Clinical outcome after ventriculoperitoneal shunt removal in an infant with hydrocephalus: The decisive role of rural primary care

Breast cancer incidence is rising among Pakistani women in the United Kingdom. However, uptake of breast screening remains low. This study aimed to improve access to breast screening for British-Pakistani women by exploring their knowledge of breast cancer and the role of primary care and community networks to support screening access amongst British-Pakistani women. We undertook a secondary qualitative analysis of 18 semi-structured interviews with British-Pakistani women from East Lancashire in the United Kingdom. Anonymized transcripts of the interviews were used for a thematic analysis. Three themes were identified in the interviewees' responses: (i) 'Women's knowledge of breasts and breast cancer', which described how a cultural taboo exists around Pakistani women's bodies and around breast cancer; (ii) 'Role of primary care', which detailed how General Practitioners can support informed decisions and offer a trusted and valued information source; (iii) 'Community engagement', which described the potential to disseminate breast-screening information through the whole community, including primary care providers, all family members and mosques. Our analysis suggested three main targets for future interventions to improve access to breast screening for British-Pakistani women: (i) co-produced strategies to increase knowledge of breasts and breast screening; (ii) greater collaboration with local General Practitioners to support women to make informed choices about screening; and (iii) community engagement involving General Practitioners and community leaders, to inform everyone - not just screening-age women - about breast cancer and screening.

A nursing historical perspective on the medical home: Impact on health care policy

BackgroundAlthough the need for integration of mental health services into primary care is well established little has been done. The outbreak of the recession found the Greek mental health system in transition. As a response to the crisis, governments implemented horizontal budget cuts instead of health reforms. This resulted in an unfavorable situation for mental health which was set once again on the sidelines of the health policy agenda. Previous studies suggest that the most prevalent disorders in the years of financial crisis in Greece are depression and anxiety while a general increase of the psychiatric morbidity is observed does not follow the population’ needs.MethodsThe present descriptive study was carried out between March and June of 2015. A convenience sample of 174 psychiatrists and psychiatry residents who met the inclusion criteria were finally selected to participate. Data were collected by using a 40-items questionnaire consisted of three sections: (a) nine questions about demographics, (b) nine questions pertaining to general aspects of administrative regulations related to primary care, (c) 22 questions about psychiatrists attitudes and perceptions towards their role in primary care. Quantitative variables are expressed as mean values, while qualitative variables as absolute and relative frequencies.ResultsThe vast majority of participants perceives the public primary care services and mental health services in their community as inadequate and considers psychiatrists’ participation in primary care as important in order to improve the detection and management rates of people demonstrating mental health symptoms. They also believe that: (a) primary care practitioners’ usually fail to detect the mental health conditions of patients; (b) their participation in primary care will decrease the social stigmatization for mental health conditions; (c) patients receiving pharmaceutical treatment for mental health problems by GPs and other primary care professionals usually fail to comply.ConclusionsRespondents in the present study are receptive to participate in primary care. They believe that their inclusion to primary care will result to decreased social stigmatization for mental health problems, increased patient’ access and improved detection and management rates for common mental health conditions.

This chapter looks at the role of primary health care in community health. Primary care, it argues, has built on its historical roots of holistic family-centered care to embrace the broader concept of population health. The chapter looks at the evolution of care models from patient/family-centered to panel management (the sum of patients being cared for by a primary care practice), to community health management. This broader concept of health necessitates collaboration with partners outside the clinical practice, including public health professionals, policymakers, schools, housing, parks and recreation, law enforcement, transportation, and food systems. The chapter describes the population and community framework and its historical role in the development of primary care, and then turns to the proposal of pragmatic approaches that busy primary care clinicians and care teams can use to integrate population health approaches into their practices.

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 POINTSLittle 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.

Patients with kidney failure on dialysis are medically and socially complex, receive care from multiple providers to manage numerous comorbidities, and therefore, are at risk for fragmented health care delivery leading to poor outcomes (1). The optimal delivery of primary care and the role of primary care providers (PCPs) for patients on dialysis remain unclear (2). Traditionally, PCPs are the central figures in the health care of their patients, with key responsibilities that include (1) establishing primary contact and entry into the medical system, (2) evaluating and providing personalized health care recommendations, and (3) referring to and coordinating with specialists. For patients on dialysis, some if not many of these responsibilities may be managed by nephrologists, largely because of how these patients interact with the medical system. Visits to the dialysis unit represent the most frequent and consistent encounters that patients on dialysis have with the health care system, and additional visits can be perceived as a burden if not accompanied by unique benefits of that care (3). In a survey of nephrologists, 90% reported providing primary care to their patients on dialysis, and more than one third of their time was dedicated to general medical care (4). However, there is varying comfort among nephrologists regarding ownership of primary care; one study demonstrated high rates of PCP involvement after dialysis initiation, with an average of 4.5 PCP visits per year and 6.9 visits per year in older, sicker patients (2). Similarly, survey studies of general medicine providers and nephrologists highlight that, although most nephrologists maintain confidence in their ability to provide primary care, both provider groups agree that the entirety of primary care should not be provided by the nephrologist alone (5). The lack of clarity regarding how primary care should be delivered, the role of PCPs, and delineation of responsibilities between PCP and nephrologist highlights a need to understand the effect of the current state of primary care delivery on clinical outcomes and to define how to provide optimal primary care for patients on dialysis. In this issue of CJASN, Silver et al. (6) examine the effect of PCPs involvement, specifically PCP continuity, in the transition of patients with kidney failure to dialysis and whether such continuity is associated with improved clinical outcomes. Their findings come at a critical moment in the reframing of care for patients on dialysis in the United States with the emergence of ESKD Seamless Care Organizations (ESCOs) in which the dialysis units and partnering nephrologists provide many of the traditional primary care functions in coordinating care. In addition, the Advancing American Kidney Care Initiative incorporates payment models in which the nephrologist assumes a more holistic approach to care delivery. The authors conducted a population-based retrospective cohort study of 19,099 adult patients who initiated hemodialysis in the province of Ontario, Canada, during the study period (2005–2014). The study used province-wide administrative databases that were linked at the patient level and included validated information on dialysis modality, with low rates of loss to follow-up (<0.5% annually). The key exposure of interest was high PCP continuity defined as both a high usual provider of care index (>75% of PCP visits with the same PCP) in the 2 years before dialysis initiation and at least one visit with the same PCP in the 90 days after dialysis initiation. Failure to meet both criteria was defined as low PCP continuity. The primary outcome was all-cause mortality during the 2 years after dialysis initiation. Secondary outcomes were all-cause hospitalization as well as disease-specific hospitalizations (including but not limited to heart failure, myocardial infarction, stroke/transient ischemic attack, sepsis, and diabetes) that were felt to be either common in patients on dialysis or amenable to PCP continuity of care. Multivariable logistic regression models were used to estimate propensity scores for high PCP continuity. Cox proportional hazards models were used to derive hazard ratios for the primary outcome as well as for the secondary outcome of disease-specific hospitalizations. Sensitivity analyses were conducted for alternative definitions of PCP involvement. The authors found that, of the 19,099 patients included in the study cohort, 6612 (35%) met both criteria for high PCP continuity, whereas 12,487 (65%) did not. Those patients with high PCP continuity were significantly older and had lower Charlson comorbidity scores than patients with low PCP continuity. The authors matched 6391 patients with high PCP continuity to an equivalent number of patients with low PCP continuity, matching on dialysis modality. There was neither a significant reduction in all-cause mortality in patients with high PCP continuity (14.5 deaths per 100 person-years versus 15.2 deaths per 100 person-years) nor a significant reduction in the rate of all-cause hospitalizations. Sensitivity analyses designed to reflect varying levels of PCP involvement continued to demonstrate no difference in results, except for a small but significant reduction in the rate of hospitalizations when the definition of PCP continuity included PCP visits for 1 year after dialysis initiation (hazard ratio, 0.89; 95% confidence interval, 0.85 to 0.93). Among disease-specific hospitalizations, the authors found a reduction in diabetes-related hospitalizations from 8.0 events per 100-person years in the low-PCP continuity group to 7.0 events per 100-person years in the high-PCP continuity group. The main strength of the study is the focus on the effect of PCP continuity on important clinical outcomes, like mortality and hospitalization. The study also benefits from the use of population-level databases. However, the authors note several important limitations, including limited generalizability to other types of health systems, lack of quality of life or mental health data, and most importantly, the absence of a standardized definition for PCP continuity of care. The definition of high PCP continuity included 2 years of consistent PCP visits and one PCP visit within 90 days after dialysis initiation, which is reasonable but somewhat arbitrary because there is no expert consensus regarding timing or type of PCP care while on dialysis. It is notable that there was a small, significant reduction in the rate of hospitalization when the definition of PCP continuity was expanded to 1 year after dialysis initiation. Notably, other studies have found that, for patients on dialysis, outpatient care can reduce the risk of readmission (7). Finally, it is unclear exactly what type of care was provided by the PCPs, if there were barriers to care (such as interoperability), and what type of communication occurred between the PCP and nephrologist. The findings of Silver et al. (6) illustrate the importance of better defining how primary care should be delivered to patients on dialysis. Wang et al. (1) conducted a systematic analysis of studies examining the role of primary care for patients on dialysis and revealed a lack of consistency regarding expectations among nephrologists, PCPs, and patients in terms of how primary care is delivered, resulting in primary care fragmentation. The consequences of the current state of undefined primary care delivery include underutilization of necessary care, duplication of care, miscommunication, and lack of coordination. Given the national interest in advancing the care of all patients with kidney disease, there is an opportunity to identify these challenges and propose innovative care delivery models. Currently, key primary care delivery barriers for patients on dialysis include (1) lack of delineation in roles between PCPs and nephrologists, (2) lack of interoperability of electronic health records, and (3) need for improved coordination and communication between PCP and nephrologist. Addressing these barriers may improve clinical outcomes distinct from visit timing and frequency. Collaborative care agreements have been proposed as a mechanism by which PCPs and specialists can codify their roles in the care of patients with kidney disease (8). For example, hepatitis B vaccination is more easily accomplished during a regularly scheduled visit to the dialysis unit, whereas planning for a colonoscopy, mammogram, or low-dose chest computed tomography (and follow-up to discuss results) is best done in the PCP office. Similarly, sharing electronic health record data is essential to ensuring that the PCP is aware of the care provided by the nephrologist and vice versa to reduce redundancy of care, avoid assumptions about care, and improve medication safety and adherence (9). The Centers for Medicare and Medicaid Services is leading efforts to advance electronic data exchange, but patients on dialysis have not been specifically referenced, which we recently highlighted as an important opportunity. Finally, ensuring coordination of care between the PCP and the nephrologist, other specialists, and varied sites of care is important to ensure high-quality holistic care delivery, particularly during periods of transition. Notably, the logistical and scheduling aspects of dialysis treatments may contribute to the marginalization of PCP care after patients transition onto dialysis. The need for improved coordination supports the evolution of ESCOs, in which coordination to improve outcomes was central to the design of the program (10). Silver et al. (6) raise the importance of not only the timing and frequency of PCP care but also, the quality of the primary care delivered. By addressing barriers to high-quality primary care and exploring innovative care delivery models that emphasize clear delineation of primary care versus nephrology responsibilities, interoperability, and coordination, there is an opportunity to advance care for patients on dialysis. It is vital to not discount primary care for the patients on dialysis, but instead, we must consider how to better integrate all care in a patient-centered care delivery model. Disclosures Dr. Mendu provides consulting services to Bayer AG unrelated to the subject matter of this article. Dr. Ahmed has nothing to disclose.

Broadening their horizons: A rural and urban nursing student exchange program in primary care

To reduce morbidity and mortality rates of cardiovascular disease, an urgent need exists to improve cardiovascular health among US adults. In 2022, the American Heart Association issued Life's Essential 8, which identifies and defines 8 health behaviors and factors that, when optimized through a combination of primary prevention, risk factor management, and effective treatments, can promote ideal cardiovascular health. Because of its central role in patient care across the life span, primary care is in a strategic position to promote Life's Essential 8 and improve cardiovascular health in the United States. High-quality primary care is person-centered, team-based, community-aligned, and designed to provide affordable optimized health care. The purpose of this scientific statement from the American Heart Association is to provide evidence-based guidance on how primary care, as a field and practice, can support patients in implementing Life's Essential 8. The scientific statement aims to describe the role and functions of primary care, provide evidence for how primary care can be leveraged to promote Life's Essential 8, examine the role of primary care in providing access to care and mitigating disparities in cardiovascular health, review challenges in primary care, and propose solutions to address challenges in achieving Life's Essential 8.

Rural primary care services have the potential to play a major role in reducing the gap in cardiovascular disease (CVD) outcomes between rural and metropolitan Australians, particularly in men at high risk of CVD. The aim of this study was to explore the self-reported behaviours and satisfaction with their general practice/practitioner of men at high risk of CVD, and attitudes of rural primary care clinicians regarding the role of primary care in CVD prevention. This observational research was addressed through survey questionnaires with rural men at high risk of CVD and semi-structured interviews with rural primary care clinicians. Fourteen rural primary care practices from towns with populations less than 25000 participated. One hundred and fifty-eight high-risk men completed the questionnaire. Their responses demonstrated poorly controlled risk factors despite a willingness to change. Alternatively, rural primary care clinicians (n=20) reported that patients were unlikely to change and that illness-based funding models inhibited cardiovascular preventive activities. Australians living in rural areas have worse CVD outcomes. In addition, there is a disparity in the assumptions of health providers and male patients at high risk of CVD in rural areas. This necessitates innovative rural primary care models that include a blended payment system that incentivises or funds preventive care alongside an emphasis on lifestyle advice, as well as an explicit strategy to influence clinician and patient behaviour to help address the disparity.

Registered nurses in primary care: A value proposition

Little research has been conducted to date on the role of primary health care (PHC) in the prevention of healthcare associated infections (HCAIs). The present article is a theoretical study of the principle of primum non nocere and aims to promote reflection on the role of PHC in HCAI prevention with emphasis on practical recommendations. The indirect and direct roles of PHC in HCAI prevention are debated in light of this guiding principle. With respect to the indirect role of PHC, we discuss the issues of hospital-centrism and ambulatory care-sensitive conditions. The article outlines a number of challenges faced by health services related to PHC's direct role in HCAI prevention, highlights seven key components of HCAI prevention programmes within the PHC sphere and provides practical recommendations for HCAI control and prevention.

ABSTRACTThis meeting was held from the 30 October to the 1 November 2018 in Almaty, Kazakhstan. The meeting brought together participants from 16 countries of central Asia, Caucasus, eastern Europe and expert speakers from western Europe and India. Participants discussed the analysis and use of data on antimicrobial medicines consumption, country experiences in enforcing legislation for prescription-only access to antibiotics, the role of primary health care (PHC) in tackling antimicrobial resistance (AMR), strategies to improving competencies of practitioners using evidence-based clinical protocols and public engagement in the responsible use of medicines. Moving toward prescription-only access to antibiotics requires that government involve, from the onset, different stakeholders, e.g. public, patients, practitioners, pharmacists and pharmaceutical industry in designing and applying policies that ensure access to antibiotics accompanied by measures that promote responsible use and limit excessive use.

Approximately 30% of general practitioner consultations are due to musculoskeletal disorders (MSKDs). Physiotherapists are trained to assess, diagnose and treat a range of MSKDs, and could provide the first point of contact for primary care patients. There is limited evidence on whether this role is acceptable to patients; however, previous research has explored advanced practitioner (AP) roles in primary care, which could inform this new initiative. This study used realist synthesis to explore factors that influence patient acceptability of AP roles in primary care. MATERIALS& METHODS: A realist synthesis was undertaken to identify initial programme theories regarding acceptability. Databases were searched to identify relevant literature. Identified studies were subject to inclusion and exclusion criteria, resulting in 38 studies included for synthesis. Theory-specific data extraction sheets were created and utilised. Data were analysed through identifying contexts, mechanisms and outcomes to formulate hypotheses. Hypotheses were validated through consultation with expert stakeholders. Eight theory areas were identified that potentially impacted on patient acceptability of the role: patient's prior experience of condition management; patient's expectations of condition management; communication; continuity of the individual practitioner; practitioner's scope of practice; accessibility; professional hierarchy and promoting the role. Nineteen hypotheses on the AP role were developed around these theory areas. Role acceptabiliy was influenced significantly by context and may change as the role develops, for instance, as waiting times change. Hypotheses will inform a subsequent realist evaluation exploring the physiotherapy AP role in primary care. Future research is needed to understand the acceptability of first contact physiotherapists delivering certain skills.

This paper reports a study of patients' accounts of the differences in nurses' and general medical practitioners' roles in primary care. Nurses are now diagnosing and treating illnesses including conducting first contact care consultations. However, the findings of international studies reporting patients' views of developments in nursing roles are not consistent. Whilst some studies report higher satisfaction following nurse consultations, others suggest that patients do not want nurses to replace general medical practitioners. Healthcare professionals' views of the boundaries of their roles have been studied, but patients' views have not been reported. Semi-structured interviews were conducted with 28 adults attending general practices for urgent 'same day' appointments during 2004. Participants were interviewed prior to their consultation with either the nurse or general medical practitioner and 19 participants were interviewed after the consultation. Data collection and analysis were concurrent, and based on the constant comparative method. Participants' views reflected traditional hierarchies in primary care. They preferred to consult with general medical practitioners if they perceived their symptoms to be serious and with nurses for minor symptoms and reassurance. They thought that nurses had more time for them and were more compassionate. Interpersonal/relational continuity of care was important and for most participants this was with a general medical practitioner who knew them. Participants trusted known practitioners; they also placed trust in professional groups and familiar structures such as the practice. New nursing services should incorporate patients' views on continuity of care provider when developing models of care delivery. Patient information leaflets in general practices should be used to explain the roles of general practitioners and nurse practitioners/practice nurses. As these roles develop further, more research is needed into all aspects of their implementation and patients' views should particularly be evaluated.

Changes in medicine domestically and globally are transforming primary care in the United States. Many have suggested that primary care is in crisis or at least at a crossroads in the United States. The Annals of Internal Medicine recently devoted much of one issue to this topic.1 Primary care for children and adolescents, however, was not addressed specifically. This article focuses on pediatrics and identifies potential roles and new models for primary care pediatrics. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 Starfield3 has defined 4 attributes of primary care including first-contact care, longitudinality, comprehensiveness, and coordination. September 11, 2001, the anthrax scare, and emerging threats such as severe acute respiratory syndrome (SARS) have brought a new focus on the importance of individual-level contacts in addressing population-level threats. Before these world events, however, primary care pediatrics was already grappling with its identity and responding to significant changes in medical systems, science, and family needs. The pace and scope of these changes are such that primary care pediatricians of the future will not be performing the same role as today. Historically, American medicine has tended to be reactive rather than proactive in defining its roles in society. However, dynamic change demands collective reflection; it is time to be proactive in assessing the needs of patients, exploring potential roles as health care providers, and developing the mechanisms to redefine the primary care pediatrician of the future. Projecting future trends requires reflection on the history of the profession of preventive pediatrics. In the 1800s, few physicians in the United States routinely … Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University Department of Pediatrics, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu