Long‐term effects of an education programme on the optimal use of clinical chemistry testing in primary health care

Objective: The aim of this study was to investigate whether continuing education on the optimal use of clinical chemistry testing in primary health care has had any long‐term effects on the test‐ordering behaviour of the participating physicians. Methods: The effects were monitored using 12 laboratory test ratios. Twenty‐three general practitioners at 16 primary health‐care centres in the county of Uppsala, Sweden, participated. A sign test was used to evaluate how individual physicians' test‐ordering patterns have changed during the 8 years since implementation of the educational programme. Maintained or improved ratios were interpreted as a sustained effect on the primary health‐care physician's test‐ordering habits. Results: Eleven out of 12 of the investigated ratios were the same or improved since the time of the short‐term follow‐up 6 months after the education. Conclusion: A short continuation course on optimal use of clinical chemistry assays can achieve permanent changes in the test‐ordering patterns of primary health‐care physicians. These findings highlight education as one possible means towards achieving cost‐efficiency and quality in test‐ordering.     

Informing patients on planned consultation time – a randomised controlled intervention study of consultation time in primary care

Abstract

Objective: To investigate whether patients’ pre-consultation knowledge of the time frames for the consultation influences the actual consultation time and/or patient and physician related outcomes; satisfaction and enablement.

Design: Randomised controlled blinded intervention study.

Setting: Four strategically chosen Primary Health Care Centres (PHCC:s) in Kronoberg county in Sweden participated.

Intervention: Pre-consultation information on planned consultation time. During one week in each PHCC consecutive patients were randomised to intervention group or control group, when booking an appointment with a physician.

Subjects: Patients >18?years of age.

Main outcome measures: Consultation time, patient satisfaction, patient enablement and physician satisfaction.

Results: No significant difference in consultation time was found between the intervention group and control group. No differences were seen between intervention group and control group regarding any of the other measures. Stratified data showed significantly shorter consultation time for the intervention group in one of the PHCC:s and for employed physicians. Employed physicians also rated consultations as being easier and were more satisfied with their consultations compared to non-employed physicians.

Conclusion: Information on the planned consultation time has a potential to decrease consultation time in certain settings. No negative side effects were found in this study.

• Key points

• Patients prepare before their consultation but to influence its contents and length is difficult.

• Informing patients on estimated consultation time can influence actual consultation time.

• Informing patients on planned consultation time has no adverse effects in this study.

     

Quantification of Staphylococcus aureus and Staphylococcus epidermidis on the hands of health‐care workers using a real‐time polymerase chain reaction method

Objective. The objective of this study was to test a polymerase chain reaction (PCR) assay intended as a tool for monitoring hand hygiene in hospital wards. Methods. The hands of 20 health‐care workers were sampled for 10 days using real‐time PCR for quantification of Staphylococcus aureus and S. epidermidis. Reference intervals (CI) and biological variation were evaluated using index of individuality (II) and critical difference (CD). Results. 45% of the participants were positive for S. aureus on all 10 days. Intra‐individual biological variation (CV_I) was 129% for S. aureus and 62% for S. epidermidis. Inter‐individual biological variation (CV_G) was 245% for S. aureus and 107% for S. epidermidis. II was 0.55 for S. aureus and 0.71 for S. epidermidis, indicating a high degree of individuality and limited use of the reference values. A significant individual change was determined at 374% for S. aureus and 211% for S. epidermidis. In an intervention study aimed at better hand hygiene in a ward with n participants, the difference before and after intervention is significant at CD_I/√n per cent. Conclusions. The PCR assay can be used to detect change in a group mean of S. aureus and S. epidermidis in a hospital ward, i.e. before and after an intervention to improve hand hygiene. For the individual, the change in bacteria levels needed for significance is compromised by high intra‐individual variation.     

Implementing multimodal pain rehabilitation in primary care – a health care professional perspective

Purpose: To explore professional perspectives on how to start and work with multimodal pain rehabilitation within primary healthcare.

Methods: Fourteen healthcare professionals (11 women, 3 men) were individually interviewed about their experiences of starting and working with multimodal pain. Interviews were transcribed and analyzed by qualitative content analysis. This study was part of a larger project, which aimed at evaluating multimodal pain rehabilitation in primary care.

Results: The analysis resulted in six categories. Two categories were about management engagement: putting the focus on rehabilitation and creating appropriate conditions. Three were about professional engagement: importance of driving spirits, creating a program – a process, and good teamwork – not a coincidence. The last category was about professional gain from multimodal rehabilitation (MMR): team work is enriching.

Conclusions: To enable implementation of MMR in primary care, managers on all organizational levels must take responsibility for allowing rehabilitation to be a priority. A driving spirit among the professionals facilitates the start, but the entire team is important when processing a program. Creating good teamwork requires hard work, e.g., negotiations for consensus about rehabilitation, and assumption of responsibility by each team member. Collaboration between professionals was perceived to strengthen and enhance knowledge about the patients.

• Implications for rehabilitation

• Much can be gained from conducting multimodal pain rehabilitation in primary care.

• Front line managers and those at other organizational levels must prioritize and create appropriate conditions to facilitate multimodal pain rehabilitation in primary care.

• Creation of an effective multimodal rehabilitation team requires that each team member takes responsibility, drops the focus on individual rehabilitation, seek member consensus about the content of the rehabilitation, and confer equal worth to each team member.

• The process of creating a program can be facilitated, especially at the beginning, if the team is supported by speciality pain clinics or more experienced teams.

     

Formal clinical primary health care training. Does it make a difference?

Throughout South Africa, primary clinical care is mainly provided by nurses. In line with this, most professional nurses of the former Bloemfontein local authority completed a one year "Advanced Diploma in Health Assessment, Diagnosis and Treatment" course at the University of the Free State. This study aimed to compare the clinical competencies of nurses who obtained this diploma with those who did not. The primary objective was to assess the clinical management of one chronic and one acute disease (diabetes mellitus and acute respiratory tract infections in adults, respectively) for these two groups of nurses. Relationships between quality of care and nurses' and clinics' characteristics were also examined since they could be predictors of quality of care, independent of the influence of training. We reviewed records of 286 consecutive visits for adults with diabetes and 293 consecutive visits for adults with an acute respiratory tract infection (ARTI). Nurses completed questionnaires on nurse characteristics, while the researchers obtained the information about the clinics. Recording of important generic (for ARTIs) and disease-specific steps (for diabetes) in patient management were assessed. Results for patients of "trained" and "non-trained" professionals were compared and adjusted for nurses', clinics' and patients' characteristics. There was generally little evidence of patients being thoroughly managed. Formal training was marginally associated with better care for ARTIs (p = 0.06) but not for diabetes (p = 0.47). Other factors associated with more thorough care were years of experience in curative primary health care (p = 0.006) and additional nursing degrees for ARTIs (p = 0.03) and the presence of enrolled or assistant nurses at the clinic for diabetes (p = 0.06). Fixed clinics generally performed better than mobile and satellite clinics.     

A transition program to primary health care for new graduate nurses: a strategy towards building a sustainable primary health care nurse workforce?

Background

This debate discusses the potential merits of a New Graduate Nurse Transition to Primary Health Care Program as an untested but potential nursing workforce development and sustainability strategy. Increasingly in Australia, health policy is focusing on the role of general practice and multidisciplinary teams in meeting the service needs of ageing populations in the community. Primary health care nurses who work in general practice are integral members of the multidisciplinary team – but this workforce is ageing and predicted to face increasing shortages in the future. At the same time, Australia is currently experiencing a surplus of and a corresponding lack of employment opportunities for new graduate nurses. This situation is likely to compound workforce shortages in the future. A national nursing workforce plan that addresses supply and demand issues of primary health care nurses is required. Innovative solutions are required to support and retain the current primary health care nursing workforce, whilst building a skilled and sustainable workforce for the future.

Discussion

This debate article discusses the primary health care nursing workforce dilemma currently facing policy makers in Australia and presents an argument for the potential value of a New Graduate Transition to Primary Health Care Program as a workforce development and sustainability strategy. An exploration of factors that may contribute or hinder transition program for new graduates in primary health care implementation is considered.

Summary

A graduate transition program to primary health care may play an important role in addressing primary health care workforce shortages in the future. There are, however, a number of factors that need to be simultaneously addressed if a skilled and sustainable workforce for the future is to be realised. The development of a transition program to primary health care should be based on a number of core principles and be subjected to both a summative and cost-effectiveness evaluation involving all key stakeholders.

     

Application of the ambulatory care groups in the primary care of a European national health care system: does it work?

BACKGROUND: Ambulatory Care Groups (ACGs), a US case-mix system that uses the patient as the unit of analysis, is particularly appropriate for health care systems in which physicians serve a defined list of patients. OBJECTIVE: To determine the extent to which the categorization of patients according to ACGs would account for the utilization of primary care services in a national health care system within the European Union. METHODS: Of all subjects continuously assigned to 9 physicians from public primary health care centers in Bizkaia, Basque Country (Spain) over a 12-month period, those visited at least once (n = 9,093) were included. According to the subject's age, sex, and ICD-9-CM diagnoses assigned during a year of patient-provider encounters, patients were classified by means of the ACGs system. RESULTS: Multiple linear regression analyses indicated that age and sex did not explain more than 7.1% of the variance in annual visits made by adults and 25.7% by children to primary care physicians. However, the r2 adjusted to the ACGs model was 50% and 48%, respectively, and even higher, that is 58% and 64% for another component of the system, the Ambulatory Diagnostic Groups (ADGs). CONCLUSIONS: Those results support the inadequacy of using the patient's age and sex alone to estimate physicians' workload in the primary health setting and the need to consider morbidity categories. The ACGs case-mix system is a useful tool for incorporating patients' morbidity in the explanation of the use of primary health care services in a European national health system.     

General practitioners’ views on leadership roles and challenges in primary health care: a qualitative study

Objective: To explore general practitioners’ (GPs) views on leadership roles and leadership challenges in general practice and primary health care.

Design: We conducted focus groups (FGs) with 17 GPs.

Setting: Norwegian primary health care.

Subjects: 17 GPs who attended a 5 d course on leadership in primary health care.

Results: Our study suggests that the GPs experience a need for more preparation and formal training for the leadership role, and that they experienced tensions between the clinical and leadership role. GPs recognized the need to take on leadership roles in primary care, but their lack of leadership training and credentials, and the way in which their practices were organized and financed were barriers towards their involvement.

Conclusions: GPs experience tensions between the clinical and leadership role and note a lack of leadership training and awareness. There is a need for a more structured educational and career path for GPs, in which doctors are offered training and preparation in advance.

• KEY POINTS

• Little is known about doctors’ experiences and views about leadership in general practice and primary health care. Our study suggests that:

• There is a lack of preparation and formal training for the leadership role.

• GPs experience tensions between the clinical and leadership role.

• GPs recognize leadership challenges at a system level and that doctors should take on leadership roles in primary health care.

     

Somatization, heartsink patients, or functional somatic symptoms? Towards a clinical useful classification in primary health care

Several definitions of somatization exist and try to deal with the fundamental problem that a large group of patients present with physical symptoms for which a conventional pathology cannot be identified. However, the concept remains somewhat confusing. The prevalence of somatization is high in general practice. Nevertheless, patients do not receive proper treatment and risk iatrogenic somatic fixation and harm, the doctor-patient relationship is often negatively affected and the overall healthcare system suffers from high expenditure on unnecessary physical investigations and treatments. During the last decade research has shown that somatization may be treated effectively in specialist care. Little is known about effective treatment in primary care but the Reattribution Model and the Extended Reattribution and Management Model have shown promising results. The development and evaluation of new treatment strategies is, however, hampered by the confusion of definitions and concepts. In this article an overview is presented of the various concepts relevant to the clinical work and research in primary health care. It is important to realize that somatizing patients in primary health care present a broader spectrum of severity than patients seen in a specialist setting. Hence, primary care cannot apply definitions from specialist care directly but needs a definition that also includes the mild cases. We need classifications and agreed definitions applicable in primary health care in order to develop appropriate management strategies, to predict prognosis, and to enable rigorous research concerning the large group of somatizing patients in primary health care.     

Severe disability: do primary health care nurses have a role to play?

This article focuses on the importance of primary health care nurses' involvement in the identification of children with severe disabilities, early and appropriate intervention that includes referral, as well as the provision of support to the children's caregivers. The use of multiskilling as a strategy to train nurses to fulfil this role is described. The traditional roles of community nurses are explored within the disability paradigm, with specific reference to multi-skilling. Finally, research results following the implementation of the Beginning Communication Intervention Protocol (BCIP), which uses multi-skilling as a training strategy, are described. Recommendations for further research are then provided.     

Determinants of hospitalisation rates: does primary health care play a role?

OBJECTIVE: To analyse the influence of rates of general practitioner visits on rates of hospitalisations. DESIGN: Ecological cross-sectional study of factors influencing hospitalisation rates. Aggregated data on primary care centre area level. SETTING: The county of Osterg?tland, Sweden, with 3 hospital districts and 41 primary health care centres, and the hospital district of J?nk?ping in the county of J?nk?ping, Sweden, with 11 primary health care centres. OUTCOME MEASURE: Hospitalisation rates. RESULTS: Age and rates of outpatient hospital visits were the most important factors explaining the variation in rates of hospitalisations between the primary health care centre areas. Hospital districts, socioeconomic factors and rates of GP visits also influenced the rates of hospitalisations. CONCLUSION: When evaluating the influence of primary health care on the rates of hospitalisations, both socioeconomic factors and health care structure must be taken into consideration. Doing this, the rates of GP visits correlated negatively with the rates of hospitalisations.     

District continence nurses’ experiences of their continence service in primary health care

hägglund d . (2009) Journal of Nursing Management  18, 225–233
District continence nurses’ experiences of their continence service in primary health care Aim The aim of the present study was to describe district continence nurses’ experiences of providing continence services in primary care. Background It has been stated that there is too little research on the experiences of district care nurses who provide continence services. Method Twenty-two district continence nurses answered a written questionnaire containing three open-ended main questions. A qualitative content analysis method was used to analyse the texts. Results The district continence nurses’ feelings of maintaining their professionalism were promoted by scheduled patient encounters, patients who participate in assessment of urinary incontinence (UI) and functioning teamwork. The opposite situation, nurses’ feelings of having a lesser degree of professionalism, was associated with not having scheduled patient appointments, patients not participating in assessment of UI and lack of teamwork. Conclusions The district continence nurses lacked the authority to start nurse-led continence clinics because of the lack of collaborative teamwork, an organization that did not enable nurse-led scheduled appointments and nurses’ limited view of their own profession. Implications for nursing management Primary health care managers and policy-makers need to provide an environment that enables interprofessional collaboration so that nurses’ skills can be used to advance patient services; such initiatives could enable district continence nurses to reach their full potential.     

Interprofessional postgraduate education in primary health care: Is it making a difference?

This paper explores attitudes to, and perceptions of, the impact of interprofessional postgraduate education for primary health care professionals, based on a postal survey of 153 primary health care professionals undertaking postgraduate qualifications in New Zealand. The response rate was 75% (114/153 responses); comprising 79 doctors, 28 nurses, 7 other health professionals. As a result of their postgraduate education, 92% (104/113) reported improvement in their own practice; 68% (72/106) reported a positive influence on their workplace practice. Forty-eight percent (53/111) increased their understanding of their own professional role; 79% (77/98) increased their understanding of another professional groups' skills and competencies. Twenty-two percent (25/114) perceived increased career opportunities within a year; 56% (64/114) in the longer term. Only 12% (14/114) perceived future increases in income as a result of their study. Interprofessional postgraduate qualification study for primary health care professionals in New Zealand resulted in personal and professional benefit for individuals and their clinical practice, and increased understanding about their own and other health professionals' roles. The interprofessional nature of the education was seen as positive, contributing to a modest increase in collaboration between health professional groups. Barriers to furthering participation in interprofessional learning and increasing intersectorial collaboration in the workplace are identified and discussed.     

Interprofessional postgraduate education in primary health care: is it making a difference?

This paper explores attitudes to, and perceptions of, the impact of interprofessional postgraduate education for primary health care professionals, based on a postal survey of 153 primary health care professionals undertaking postgraduate qualifications in New Zealand. The response rate was 75% (114/153 responses); comprising 79 doctors, 28 nurses, 7 other health professionals. As a result of their postgraduate education, 92% (104/113) reported improvement in their own practice; 68% (72/106) reported a positive influence on their workplace practice. Forty-eight percent (53/111) increased their understanding of their own professional role; 79% (77/98) increased their understanding of another professional groups' skills and competencies. Twenty-two percent (25/114) perceived increased career opportunities within a year; 56% (64/114) in the longer term. Only 12% (14/114) perceived future increases in income as a result of their study. Interprofessional postgraduate qualification study for primary health care professionals in New Zealand resulted in personal and professional benefit for individuals and their clinical practice, and increased understanding about their own and other health professionals' roles. The interprofessional nature of the education was seen as positive, contributing to a modest increase in collaboration between health professional groups. Barriers to furthering participation in interprofessional learning and increasing intersectorial collaboration in the workplace are identified and discussed.