Successful Implementation of Integrated Care in Slovenian Primary Care

For the purpose of celebrating the 40th anniversary of Alma Ata declaration, the WHO published a successful model of integrated patient care being performed in Slovenia. After two years, the WHO experts evaluated the success in practise during a visit to the Slovenian primary care environment. This report showed that Slovenia was a notable exception regarding developing effective primary care systems. The country has an impressive primary care which performs very well.     

Comparison of Cardiovascular Risk Screening Methods and Mortality Data among Hungarian Primary Care Population: Preliminary Results of the First Government-Financed Managed Care Program

Introduction

Besides participation in the primary prevention, screening as secondary prevention is an important requirement for primary care services. The effect of this work is influenced by the characteristics of individual primary care practices and doctors’ screening habits, as well as by the regulation of screening processes and available financial resources. Between 1999 and 2009, a managed care program was introduced and carried out in Hungary, financed by the government. This financial support and motivation gave the opportunity to increase the number of screenings.

Method

4,462 patients of 40 primary care practices were screened on the basis of SCORE risk assessment. The results of the screening were compared on the basis of two groups of patients, namely: those who had been pre-screened (pre-screening method) for known risk factors in their medical history (smoking, BMI, age, family cardiovascular history), and those randomly screened. The authors also compared the mortality data of participating primary care practices with the regional and national data.

Results

The average score was significantly higher in the pre-screened group of patients, regardless of whether the risk factors were considered one by one or in combination. Mortality was significantly lower in the participating primary practices than had been expected on the basis of the national mortality data.

Conclusion

This government-financed program was a big step forward to establish a proper screening method within Hungarian primary care. Performing cardiovascular screening of a selected target group is presumably more appropriate than screening within a randomly selected population. Both methods resulted in a visible improvement in regional mortality data, though it is very likely that with pre-screening a more cost-effective selection for screening may be obtained.     

Annals Journal Club: Causes of Persistent Dizziness in Elderly Patients in Primary Care

PURPOSE Although dizzy patients are predominantly seen in primary care, most diagnostic studies on dizziness have been performed among patients in secondary or tertiary care. Our objective was to describe subtypes of dizziness in elderly patients in primary care and to assess contributory causes of dizziness.METHODS We performed a cross-sectional diagnostic study among elderly patients in the Netherlands consulting their family physician for persistent dizziness. All patients underwent a comprehensive evaluation according to a set of diagnostic tests that were developed during an international Delphi procedure. Data for each patient were independently reviewed by a panel consisting of a family physician, a geriatrician, and a nursing home physician, which resulted in major and minor contributory causes of dizziness.RESULTS From June 2006 to January 2008, we included 417 patients aged 65 to 95 years. Presyncope was the most common dizziness subtype (69%). Forty-four percent of the patients were assigned more than 1 dizziness subtype. Cardiovascular disease was considered to be the most common major contributory cause of dizziness (57%), followed by peripheral vestibular disease (14%), and psychiatric illness (10%). An adverse drug effect was considered to be the most common minor contributory cause of dizziness (23%). Sixty-two percent of the patients were assigned more than 1 contributory cause of dizziness.CONCLUSIONS Contrary to most previous studies, cardiovascular disease was found to be the most common major cause of dizziness in elderly patients in primary care. In one-quarter of all patients an adverse drug effect was considered to be a contributory cause of dizziness, which is much higher than reported in previous studies.     

Screening Colonoscopies by Primary Care Physicians: A Meta-Analysis

PURPOSE There is currently too few endoscopists to enact a national colorectal cancer screening program with colonoscopy. Primary care physicians could play an important role in filling this shortage by offering screening colonoscopy in their practice. The purpose of this study was to examine the safety and effectiveness of colonoscopies performed by primary care physicians.     

Current approaches to obesity management in UK Primary Care: the Counterweight Programme

Background/Aims Primary care is expected to develop strategies to manage obese patients as part of coronary heart disease and diabetes national service frameworks. Little is known about current management practices for obesity in this setting. The aim of this study is to examine current approaches to obesity management in UK primary care and to identify potential gaps in care. Method A total of 141 general practitioners (GPs) and 66 practice nurses (PNs) from 40 primary care practices participated in structured interviews to examine clinician self‐reported approaches to obesity management. Medical records were also reviewed for 100 randomly selected obese patients from each practice [body mass index (BMI) ≥30 kg m^?2, n = 4000] to review rates of diet counselling, dietetic or obesity centre referrals, and use of anti‐obesity medication. Computerized medical records for the total practice population (n = 206 341, 18–75 years) were searched to examine the proportion of patients with a weight/BMI ever recorded. Results Eighty‐three per cent of GPs and 97% of PNs reported that they would raise weight as an issue with obese patients (P < 0.01). Few GPs (15%) reported spending up to 10 min in a consultation discussing weight‐related issues, compared with PNs (76%; P < 0.001). Over 18 months, practice‐based diet counselling (20%), dietetic (4%) and obesity centre (1%) referrals, and any anti‐obesity medication (2%) were recorded. BMI was recorded for 64.2% of patients and apparent prevalence of obesity was less than expected. Conclusion Obesity is under‐recognized in primary care even in these 40 practices with an interest in weight management. Weight management appears to be based on brief opportunistic intervention undertaken mainly by PNs. While clinicians report the use of external sources of support, few patients are referred, with practice‐based counselling being the most common intervention.     

Annals Journal Club: Yield of Opportunistic Targeted Screening for Type 2 Diabetes in Primary Care: The Diabscreen Study

PURPOSE In screening for type 2 diabetes, guidelines recommend targeting high-risk individuals. Our objectives were to assess the yield of opportunistic targeted screening for type 2 diabetes in primary care and to assess the diagnostic value of various risk factors.METHODS In 11 family practices (total practice population = 49,229) in The Netherlands, we conducted a stepwise opportunistic screening program among patients aged 45 to 75 years by (1) identifying high-risk individuals (=1 diabetes risk factor) and low-risk individuals using the electronic medical record, (2) obtaining a capillary fasting plasma glucose measurement, repeated on a separate day if the value was greater than 110 mg/dL, and (3) obtaining a venous sample if both capillary fasting plasma glucose values were greater than 110 mg/dL and at least 1 sample was 126 mg/dL or greater. We calculated the yield (percentage of invited patients with undiagnosed diabetes), number needed to screen (NNS), and diagnostic value of the risk factors (odds ratio and area under the receiver operating characteristic curve).RESULTS We invited for a first capillary measurement 3,724 high-risk patients seen during usual care and a random sample of 465 low-risk patients contacted by mail. The response rate was 90% and 86%, respectively. Ultimately, 101 high-risk patients (2.7%; 95% confidence interval [CI], 2.2%–3.3%; NNS = 37) and 2 low-risk patients (0.4%; 95% CI, 0.1%–1.6%; NNS = 233) had undiagnosed diabetes (P <.01). The prevalence of diabetes among patients 45 to 75 years old increased from 6.1% to 6.8% as a result. Among diagnostic models containing various risk factors, a model containing obesity alone was the best predictor of undiagnosed diabetes (odds ratio = 3.2; 95% CI, 2.0–5.2; area under the curve=0.63).CONCLUSIONS The yield of opportunistic targeted screening was fair; obesity alone was the best predictor of undiagnosed diabetes. Opportunistic screening for type 2 diabetes in primary care could target middle-aged and older adults with obesity.     

Effect of Payment Incentives on Cancer Screening in Ontario Primary Care

PURPOSE

There is limited evidence for the effectiveness of pay for performance despite its widespread use. We assessed whether the introduction of a pay-for-performance scheme for primary care physicians in Ontario, Canada, was associated with increased cancer screening rates and determined the amounts paid to physicians as part of the program.

METHODS

We performed a longitudinal analysis using administrative data to determine cancer screening rates and incentive costs in each fiscal year from 1999/2000 to 2009/2010. We used a segmented linear regression analysis to assess whether there was a step change or change in screening rate trends after incentives were introduced in 2006/2007. We included all Ontarians eligible for cervical, breast, and colorectal cancer screening.

RESULTS

We found no significant step change in the screening rate for any of the 3 cancers the year after incentives were introduced. Colon cancer screening was increasing at a rate of 3.0% (95% CI, 2.3% to 3.7%) per year before the incentives were introduced and 4.7% (95% CI, 3.7% to 5.7%) per year after. The cervical and breast cancer screening rates did not change significantly from year to year before or after the incentives were introduced. Between 2006/2007 and 2009/2010, $28.3 million, $31.3 million, and $50.0 million were spent on financial incentives for cervical, breast, and colorectal cancer screening, respectively.

CONCLUSIONS

The pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure. Policy makers should consider other strategies for improving rates of cancer screening.     

Practice Facilitation to Improve Diabetes Care in Primary Care: A Report From the EPIC Randomized Clinical Trial

PURPOSE

We investigated 3 approaches for implementing the Chronic Care Model to improve diabetes care: (1) practice facilitation over 6 months using a reflective adaptive process (RAP) approach; (2) practice facilitation for up to 18 months using a continuous quality improvement (CQI) approach; and (3) providing self-directed (SD) practices with model information and resources, without facilitation.

METHODS

We conducted a cluster-randomized trial, called Enhancing Practice, Improving Care (EPIC), that compared these approaches among 40 small to midsized primary care practices. At baseline and 9 months and 18 months after enrollment, we assessed practice diabetes quality measures from chart audits and Practice Culture Assessment scores from clinician and staff surveys.

RESULTS

Although measures of the quality of diabetes care improved in all 3 groups (all P <.05), improvement was greater in CQI practices compared with both SD practices (P <.0001) and RAP practices (P <.0001); additionally, improvement was greater in SD practices compared with RAP practices (P <.05). In RAP practices, Change Culture scores showed a trend toward improvement at 9 months (P = .07) but decreased below baseline at 18 months (P <.05), while Work Culture scores decreased from 9 to 18 months (P <.05). Both scores were stable over time in SD and CQI practices.

CONCLUSIONS

Traditional CQI interventions are effective at improving measures of the quality of diabetes care, but may not improve practice change and work culture. Short-term practice facilitation based on RAP principles produced less improvement in quality measures than CQI or SD interventions and also did not produce sustained improvements in practice culture.     

Putting People First: A Primary Health Care Success in Rural India

Background:

The World Health Report, 2008, contains a global review of primary health care on the 30th anniversary of the Declaration of Alma-Ata. The period covered by the study reported on here corresponds with that of the Report, allowing for a comparison of achievements and challenges in one primary health care centre vis-a-vis the WHO standards.

Materials and Methods:

This study uses qualitative and quantitative data from a rural primary care facility in Western Maharashtra, collected over three decades. It analyzes the four groups of reforms defined by WHO in the context of the achievements and challenges of the study facility.

Results:

According to the WHO Report, health systems in developing countries have not responded adequately to people’s needs. However, our in-depth observations revealed substantial progress in several areas, including in family planning, safe deliveries, immunization and health promotion. Satisfaction with services in the study area was high.

Conclusion:

Adequate primary health care is possible, even when all recommended WHO reforms are not fully in place.     

Quality Indicators of Primary Care Provider Engagement in Nursing Home Care

The initiative described here aims to identify quality indicators (QIs) germane to the international practice of primary care providers (PCP) in post-acute and long-term care in order to demonstrate the added value of medical providers in nursing homes (NHs). A 7-member international team identified and adapted existing QIs to the AMDA competencies for medical providers. QI sources included the ACOVE 3 Quality Indicators (2007), NH Quality Indicators (2004), NH Residential Care Quality Indicators (2002), and AGS Choosing Wisely (2014). We recruited a technical expert panel (TEP) consisting of 11 panelists from the US, Canada, and the European Union, selected for their knowledge and leadership in post-acute and long-term care. The TEP, using a RAND Modified Delphi approach, provided pre-meeting ratings, discussed items in-person for clarification, and re-rated items following discussion. When panelists rated more than 1 option for a particular QI as valid and feasible, the most stringent option was selected for inclusion in the final candidate set of QIs. Panelists confidentially rated an initial 103 items on validity and feasibility of implementation. During the meeting, panelists added 18 QIs and modified 18. In post-meeting analysis, we eliminated 7 QIs rated not valid and 11 QIs for which a more stringent QI was rated valid and feasible. This resulted in a final set of 95 QIs rated valid and feasible and 8 rated valid but not feasible. This set of QIs for PCPs in the NH identified practices in which provider engagement adds value through expertise in geriatric syndromes, employing evidence-based practice, advocating for residents, delivering person-centered care, facilitating advance care planning, and communicating effectively to coordinate care. Next steps include pilot testing and evaluating the association between adherence to QIs, PCP staffing models, and better outcomes.     

Multimorbidity in Patients Attending 2 Australian Primary Care Practices

PURPOSE

Multiple chronic conditions in a single patient can be a challenging health burden. We aimed to examine patterns and prevalence of multimorbidity among patients attending 2 large Australian primary care practices and to estimate disease severity burden using the Cumulative Illness Rating Scale (CIRS).

METHODS

Using published CIRS guidelines and a disease severity index calculated for each individual, we extracted data from the medical records of all 7,247 patients (58.5% female) seen over 6 months in 2008 who were rated for chronic conditions across 14 anatomical domains.

RESULTS

Fifty-two percent of patients had multimorbidity in 2 or more CIRS domains, ranging from 20.6% if younger than 25 years, 43.7% if aged 25 to 44 years, 75.5% if aged 45 to 64 years, 87.5% if aged 65 to 74 years, and 97.1% if aged 75 years and older. Using a cutoff of 3 or more CIRS domains, 34.5% had multimorbidity ranging from 4.8% if younger than 25 years, 22.3% if aged 25 to 44 years, 56.1% if aged 45 to 64 years, 74.6% if aged 65 to 74 years, and 92.0% if aged 75 years and older. Musculoskeletal, singularly or in combination with others, was the commonest morbidity domain. The moderate severity index category increased with increasing age.

CONCLUSIONS

Multimorbidity is a significant problem in men and women across all age-groups, and the moderate severity index increases with age. The musculoskeletal domain was most commonly affected. Mild and moderate severity index categories may underrepresent disease burden. Severity burden assessment in the primary care setting needs to take into account the severity index, as well as levels of domain severity within the index categories.     

Asthma and Chronic Obstructive Pulmonary Disease Overlap Syndrome: Doubled Costs Compared with Patients with Asthma Alone

BackgroundPatients with asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) have more rapid disease progression and more exacerbations than do those with either condition alone. Little research has been performed, however, in these patients.ObjectiveThe objective was to summarize the health care utilization, costs, and comorbidities of patients with uncontrolled asthma and patients with ACOS.MethodsThis retrospective analysis used medical and pharmacy claims from large commercial health plans. The study included patients 6 years or older with a diagnosis of asthma and one or more asthma exacerbation (index event). Patients were classified as having asthma alone or ACOS, and the two groups were matched for age, sex, region, index year, index month, and health plan type. Outcomes included rates of comorbid disease, health care utilization, and costs during the 12 months before and after the index exacerbation.ResultsAmong the matched patients with asthma (6,505 ACOS; 26,060 without COPD), mean annual all-cause health care costs were twice as high as for patients with ACOS ($22,393 vs. $11,716; P < 0.0001). Asthma-related costs, representing 29% of total costs, were nearly twice as high among patients with ACOS ($6,319 vs. 3,356; P < 0.0001). Cost differences were driven by large differences in the proportions of patients with an inpatient hospitalization (34.0% vs. 14.6%; P < 0.0001) or emergency department visit (29.6% vs. 19.9%; P < 0.0001). Nearly all prespecified comorbid conditions were more prevalent in the ACOS group.ConclusionsPatients with asthma and COPD had nearly double the health care costs as did patients with asthma without COPD. The overall disease profile of patients with asthma should be considered when managing patients, rather than treating asthma as a solitary condition.     

Functioning of family nursing in transition: an example of a small town in Poland. Are there any benefits for patients?

OBJECTIVE: To evaluate whether organizational changes in the Polish health care system affected patients' opinions about selected aspects of the quality of care provided by family nurses. DESIGN: Two independent surveys conducted in 1998 and 2002 using face-to-face interviews with structured questionnaires. SETTING AND PARTICIPANTS: The study was performed in a small town in Poland, where family physicians were introduced in 1995. The study groups consisted of two samples of patients randomly selected from those registered on the patient list. Altogether 1000 interviews were obtained in survey I (in 1998) and 1000 from another sample in survey II (in 2002). In 1998, family nurses were employed by family physicians, but in 2002 they had established their own practices and held direct contracts with the National Health Fund. RESULTS: The surveys carried out at a 4-year interval showed a significant increase in the percentage of patients reporting home visits by family nurses, both at the request of physicians and on the nurses' own initiative (from 16.3 to 45.8%, P < 0.05). Comparative analysis showed that in survey II the percentage of the respondents who were satisfied with nursing care increased from 35.8 to 53.6% (P < 0.05). CONCLUSION: Care provided by independent nurses was available to a larger group of patients. Patients were more satisfied with the services of family nurses working as independent contractors. The investigations in the present study should be supplemented by a qualitative study.     

澳大利亚初级卫生保健与全科医疗绩效考核概述

澳大利亚初级卫生保健的绩效考核主要围绕全科医疗,社区卫生、牙科服务、精神卫生、健康促进和疾病早期干预等进行。从对整个初级卫生保健的绩效考核看,相关的指标很多,但散见于不同的研究和项目中,未成体系。但针对全科医疗的绩效考核,澳大利亚全科医疗皇家学院（RACGP）进行了系统、深入的研究。RACGP从20世纪90年代起就致力于全科医疗质量标准的研发,经过不断修订,至今已发布了3个版本。RACGP的全科医疗标准以医疗服务质量和安全为导向,一级指标包括诊所服务、病人权利与需求、安全、质量改善和教育及执业管理和环境因素。这一标准对全科医生明确服务内容和标准、改善服务质量等发挥了积极作用,并成为新西兰、爱尔兰等国用于制定本国全科医疗质量标准的基础。     

Development and Validation of a Family History Screening Questionnaire in Australian Primary Care

PURPOSE

We aimed to validate a family history screening questionnaire in an Australian primary care population designed to identify people at increased risk for breast, ovarian, colorectal, and prostate cancer; melanoma; ischemic heart disease; and type 2 diabetes.

METHODS

We prospectively validated the questionnaire in 6 general practices in Perth, Western Australia among 526 patients aged 20 to 50 years who responded to a single invitation from their general practice. They completed the 15-item questionnaire before a reference standard 3-generation pedigree was obtained by a genetic counselor blinded to the questionnaire responses. We calculated diagnostic performance statistics for the questionnaire using the pedigree as the reference standard.

RESULTS

A combination of 9 questions had the following diagnostic performance, expressed as value (95% CI), to identify increased risk of any of the 7 conditions: area under the receiver operating characteristic curve 84.6% (81.2%–88.1%), 95% sensitivity (92%–98%), and 54% specificity (48%–60%). The combination of questions to detect increased risk had sensitivity of 92% (84%–99%) and 96% (93%–99%) for the 5 and 6 conditions applicable only to men and women, respectively. The specificity was 63% (28%–52%) for men and 49% (42%–56%) for women. The positive predictive values were 67% (56%–78%) and 68% (63%–73%), and the false-positive rates were 9% (0.5%–17%) and 9% (3%–15%) for men and women, respectively.

CONCLUSIONS

This simple family history screening questionnaire shows good performance for identifying primary care patients at increased disease risk because of their family history. It could be used in primary care as part of a systematic approach to tailored disease prevention.     

Implementing Asthma Guidelines Using Practice Facilitation and Local Learning Collaboratives: A Randomized Controlled Trial

PURPOSE

Guideline implementation in primary care has proven difficult. Although external assistance through performance feedback, academic detailing, practice facilitation (PF), and learning collaboratives seems to help, the best combination of interventions has not been determined.

METHODS

In a cluster randomized trial, we compared the independent and combined effectiveness of PF and local learning collaboratives (LLCs), combined with performance feedback and academic detailing, with performance feedback and academic detailing alone on implementation of the National Heart, Lung and Blood Institute’s Asthma Guidelines. The study was conducted in 3 primary care practice-based research networks. Medical records of patients with asthma seen during pre- and postintervention periods were abstracted to determine adherence to 6 guideline recommendations. McNemar’s test and multivariate modeling were used to evaluate the impact of the interventions.

RESULTS

Across 43 practices, 1,016 patients met inclusion criteria. Overall, adherence to all 6 recommendations increased (P ≤.002). Examination of improvement by study arm in unadjusted analyses showed that practices in the control arm significantly improved adherence to 2 of 6 recommendations, whereas practices in the PF arm improved in 3, practices in the LLCs improved in 4, and practices in the PF + LLC arm improved in 5 of 6 recommendations. In multivariate modeling, PF practices significantly improved assessment of asthma severity (odds ratio [OR] = 2.5, 95% CI, 1.7–3.8) and assessment of asthma level of control (OR = 2.3, 95% CI, 1.5–3.5) compared with control practices. Practices assigned to LLCs did not improve significantly more than control practices for any recommendation.

CONCLUSIONS

Addition of PF to performance feedback and academic detailing was helpful to practices attempting to improve adherence to asthma guidelines.