Future Primary Care Research Articles

Forgiven but not Relieved: US Physician Workforce Consequences of Changes to Public Service Loan Forgiveness.

Public Service Loan Forgiveness (PSLF) was established in 2007 for public sector and nonprofit enterprise employees to pursue educational loan forgiveness. Under PSLF, graduates are offered complete loan forgiveness after 120 qualifying monthly payments while employed at public or nonprofit institutions, including payments made during residency for physicians. In response to concerns that PSLF will heavily subsidize lawyers, doctors, and other professionals, the President's 2017 budget proposes limiting maximum forgiveness. Using data from the Association of American Medical Colleges Graduation Questionnaire (n = 55,905; response rate of 80%), we found that intended participation in PSLF among medical school graduates grew 20% per year since 2010. Future primary care physicians intend to use PSLF more than programs that were historically designed to promote primary care, such as the National Health Service Corp (NHSC). The federal government's projected cost of PSLF will reach over $316 million for 2014 graduates (net present value), approximately seven times the annual contributions from the NHSC. The proposed cap will reduce the total anticipated forgiveness by nearly two-thirds and substantially reduce subsidies for physicians. More targeted measures of loan forgiveness could be considered, such as making forgiveness contingent on pursuing specialties that society needs or practicing in shortage areas.

Looking to the future of primary care

What do you enjoy about working in primary care? The are many things I enjoy about working in primary care. I feel that we can make a massive difference to the lives of patients, their carers and families. The close relationship we have with patients is what I came into nursing for. Being a practice nurse affords me the time to know my patients, to discuss their wants and needs, and to facilitate their independence through support and patient empowerment.

New Zealand among global social media initiative leaders for primary care advocacy.

The international '#1WordforFamilyMedicine' initiative explores the identity of General Practitioners (GPs) and Family Physicians (FPs) by allowing the international Family Medicine community to collaborate on advocating for the discipline via social media. The New Zealand version attracted 83 responses on social media. Thematic analysis was performed on the responses and a 'word cloud' image was created based on an image identifying the country around the world - that of the silver fern. The '#1WorldforFamilyMedicine' project was promoted by WONCA (World Organisation of Family Doctors) globally to help celebrate World Family Doctor Day on 19 May 2015. To date, over 80 images have been created in 60 different countries on six continents. The images represent GPs' love for their profession and the community they serve. We hope that this initiative will help inspire current and future Family Medicine and Primary Care providers.

South Africa has joined a global initiative for Family Medicine advocacy

The international #1WordforFamilyMedicine initiative serves to explore the identity of family physicians and allows the international Family Medicine community to collaborate on advocating the discipline. South African family physicians provided 42 responses via a social media and online survey. Two “word cloud” images were created based on two icons recognised as being truly South African around the world – the national flag and former president Nelson Mandela. The #1WorldforFamilyMedicine initiative was promoted by the World Organization of Family Doctors across the globe to help celebrate World Family Doctor Day on 19 May 2015. To date, over 70 images have been created in 50 different countries on six continents. The images represent family physicians’ love for their profession and the community they serve. It is hoped that this initiative will help to inspire current and future Family Medicine and primary care providers.

Generational differences in practice site selection criteria amongst primary care physicians.

Background and Objectives: Generational differences are often viewed as shaping the overall attitudes and actions of different age cohorts. It is essential to understand the motivations and generational differences in primary care physicians for efforts to recruit, retain, and educate the future physician workforce. Determining what factors most influence different generations of primary care physicians when choosing a practice site is essential to build our future primary care system. This study examined generational differences in the factors that attracted primary care physicians to their current practice. Methods: A survey instrument was mailed to all active members of the North Carolina Medical Board who listed their primary occupation as a primary care specialty. The survey consisted of 24 demographic questions regarding personal and practice variables and a list of 21 reasons for choosing a practice location measured on a 7-point Likert type scale. A total of 975 surveys were returned and usable for the final analysis, for a return rate of 34.5%. Data were analyzed using regression and correlation procedures to determine attitudes of each generation and factors that significantly influenced responses. Results: While slight differences between generations did exist, the overall choices for choosing a site remained stable across generations. Personality of the practice, on-call responsibilities, ability to practice comprehensive care, and location were deemed the most important factors for all generations. Differences between various demographic groups and Family Medicine versus other primary care specialties were minor with very little alteration of the top ten items being seen between groups. Conclusion: This study indicated that there were few differences between generations regarding primary reasons for choosing a practice site. In addition, factors remained remarkably similar across different specialties, family situations, genders, and ethnic groups. Several of the top reasons that primary care physicians indicate are the most important for site selection were also potentially modifiable, such as on-call responsibilities, practice personality, and ability to practice comprehensive care. Managers, clinicians, and educators can potentially utilize this information to better prepare and recruit current and future generations of primary care physicians.

Evaluation of proficiency in using different inhaler devices among intern doctors.

Context:Doctors may have deficiencies in the ability to use different inhalers, which in turn, can result in improper technique by the patients and poorly controlled asthma and chronic obstructive pulmonary disease (COPD).Aims:To evaluate intern doctors’ proficiency in using various inhaler devices.Materials and Methods:Seventy interns were evaluated for their proficiency in using pressurized metered dose inhaler (pMDI), pMDI with spacer, rotahaler, turbuhaler, and nebulizer. A structured assessment sheet was scored for identification and preparation of device, administration, coordination, and skill of explanation on a scale of 0–5. Common errors such as failure to shake pMDI before use, inability to identify the empty device, inadequate breath holding, and failure to advise gargles after use were recorded.Results:pMDI and pMDI with spacer were identified correctly by 89% and 79% of interns. Over 90% could identify rotahaler and nebulizer whereas only 9% could identify turbuhaler. 79% and 60% could prepare pMDI and pMDI with spacer appropriately. Nebulizer preparation was performed correctly by 79% and almost all interns could not prepare turbuhaler. Only one intern administered turbuhaler correctly. About half of the participants knew the correct co-ordination for pMDI and pMDI with spacer. Two interns showed proper co-ordination in using turbuhaler. None could provide correct explanation for turbuhaler usage; whereas 76% and 70% did it for nebulizer and rotahaler, respectively. Only 43% of interns remembered to shake pMDI before use.Conclusions:Proficiency in using different inhaler devices amongst interns is poor. It is essential to provide adequate training for inhaler devices usage to medical graduates for proper management of asthma and COPD patients by those future primary care physicians and specialists.

A community based primary prevention programme for type 2 diabetes integrating identification and lifestyle intervention for prevention: the Let's Prevent Diabetes cluster randomised controlled trial

ObjectivesPrevention of type 2 diabetes (T2DM) is a priority in healthcare, but there is a lack of evidence investigating how to effectively translate prevention research into a UK primary care setting. We assessed whether a structured education programme targeting lifestyle and behaviour change was effective at preventing progression to T2DM in people with pre-diabetes. Materials and methodsForty-four general practices were randomised to receive either standard care or a 6hour group structured education programme with an annual refresher course, and regular phone contact. Participants were followed up for 3years. The primary outcome was progression to T2DM. ResultsEight hundred and eighty participants were included (36% female, mean age 64years, 16% ethnic minority group); 131 participants developed T2DM. There was a non-significant 26% reduced risk of developing T2DM in the intervention arm compared to standard care (HR 0.74, 95% CI 0.48, 1.14, p=0.18). The reduction in T2DM risk when excluding those who did not attend the initial education session was also non-significant (HR 0.65, 0.41, 1.03, p=0.07). There were statistically significant improvements in HbA1c (−0.06, −0.11, −0.01), LDL cholesterol (−0.08, −0.15, −0.01), sedentary time (−26.29, −45.26, −7.32) and step count (498.15, 162.10, 834.20) when data were analysed across all time points. ConclusionsThis study suggests that a relatively low resource, pragmatic diabetes prevention programme resulted in modest benefits to biomedical, lifestyle and psychosocial outcomes, however the reduction to the risk of T2DM did not reach significance. The findings have important implications for future research and primary care.

A viable future for primary care

Despite the despondency around primary care at the moment, Paula Marsden is optimistic about the future of the general practice workforce

Associations between behavioural risk factors and smoking, heavy smoking and future smoking among an Australian population-based sample

IntroductionTobacco smoking co-occurs with behavioural risk factors including diet, alcohol use and obesity. However, the association between behavioural risk factors and heavy smoking (>20cig/day) compared to light–moderate smoking is unknown. The link between behavioural risk factors and future smoking for both ex and current smokers is also unknown. This study sought to examine these relationships. It is hypothesised that behavioural risk factors will be more strongly associated with heavy smoking. MethodData from Wave 7 (2007) of the Household and Labour Dynamics in Australia (HILDA) survey was analysed using logistic regression to determine relationships between diet (fruit and vegetable consumption, and unhealthy diet choices), alcohol consumption, obesity and physical activity with light–moderate smoking and heavy smoking. The association between these risk factors and future smoking (2008) was assessed for current and ex-smokers (2007). ResultsObese respondents were less likely to be light/moderate smokers (RRR: 0.53; 95% CI: 0.43, 0.66) but not heavy smokers. Those who consume confectionary weekly were less likely to be light/moderate smokers (RRR: 0.73; 95% CI: 0.61, 0.87), but not heavy smokers. Smokers in 2007 were more likely to continue smoking in 2008 if they consumed 1–4 drinks per occasion (OR: 2.52; 95% CI: 1.13, 5.62). Ex-smokers in 2007 were less likely to relapse in 2008 if they consumed recommended levels of both fruit and vegetables (OR: 0.31; CI: 0.10, 0.91). ConclusionThe relationships between heavy smoking and behavioural risk factors differ from moderate–light smoking. Future primary care interventions would benefit from targeting multiple risk factors, particularly for heavy smokers.

Embracing new health professions

Nurse PrescribingVol. 13, No. 11 EditorialEmbracing new health professionsAbigail JamesAbigail JamesSearch for more papers by this authorAbigail JamesPublished Online:14 Nov 2015https://doi.org/10.12968/npre.2015.13.11.525AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Faculty of Physician Associates (2015) Frequently asked questions. http://www.fparcp.co.uk/faqs (accessed 5 November 2015) Google ScholarPrimary Care Workforce Commission (2015) The future of primary care: Creating teams for tomorrow. http://bit.ly/1Nuhn69 (accessed 5 November 2015) Google Scholar FiguresReferencesRelatedDetails 2 November 2015Volume 13Issue 11ISSN (print): 1479-9189ISSN (online): 2052-2924 Metrics History Published online 14 November 2015 Published in print 2 November 2015 Information© MA Healthcare LimitedPDF download

The importance of education for a new primary care workforce.

© 2 01 5 M A H ea lth ca re L td It is well recognised that the NHS currently faces significant financial hardship, and the increasing demand for its services, without further annual efficiencies or an increase in funding, will produce an imbalance between available resources and patient need of almost £30 billion per year by 2020–21 (NHS England, 2014). Change is needed on all three aspects of demand, efficiency and funding to sustain the current high-quality service. Ever since the publication of the NHS Plan (Department of Health (DH), 2000), DH has promoted radical change with new ways of working, new models of care and to maximise the contribution of the wide range of health professionals by working more collaboratively to ensure care is efficient, effective and cost effective. The recent focus on transformation in the acute sector has paved the way for radical change in the delivery of primary care. With several attempts to reorganise primary care, —for example, the Wanless’ review (2002) recommending a radical improvement in prevention and public health, and in 2005 the introduction of 3000 new community matrons to integrate the health and social care services (DH, 2005)—the recent publication of The future of primary care (Primary Care Workforce Commission (PCWC), 2015) proposes a much more radical reform. Drawing on the Five Year Forward View (NHS England, 2014) that identified the changes required to address the current challenges facing the NHS, The future of primary care sets out a vision for the new primary care workforce and has significant implications for the education of health and social care professionals. There is clear evidence that people are living longer, often with complex long-term conditions (Ham et al, 2012), and the media are quick to portray the changing pattern in public health with one in five adults still smoking, a third drinking too much alcohol and just under two thirds overweight or obese (NHS England, 2014). Nevertheless, there is clear acknowledgement that investment in primary care has fallen well short of investment in the acute sector, in spite of increasing expectations (PWCW 2015). If we Elizabeth Rosser

Strengthening primary health care through primary care doctors: the design of a new national Postgraduate Diploma in Family Medicine

Strengthening primary health care is a national priority in South Africa, in order to improve quality of care and health outcomes, reduce inequity and to pave the way for National Health Insurance. The World Health Organization and World Health Assembly both recommend the inclusion of a primary care doctor with postgraduate training in Family Medicine in the primary healthcare team. Currently, medical practitioners without postgraduate training, and those who may need re-orientating and upskilling for the future re-engineered primary care system, are the largest pool of doctors in South Africa. Most of these doctors are of an age and at a stage in their careers where it is unlikely that they will train to be a family physician.This article reports on a national process to design a Postgraduate Diploma in Family Medicine which will meet the learning needs of primary care doctors in both the public and private sectors as they prepare for the future.A year-long process included two national stakeholder works...

Diferencias y similitudes en la Medicina de Familia de los sistemas sanitarios en Alemania y España

An efficient primary care is of particular importance for any countries’ health care system. Many differences exist on how distinctive countries try to obtain the goal of an efficient, cost-effective primary care for its population. In this article we conducted a selective literature review, which includes both scientific and socio-political publications. The findings are complemented with the experience of a Spanish physician from Seville in her last year of training in family medicine, who completed a four months long rotation in the German health care system. We highlighted different features by comparing both countries, including their health care expenditure, the relation between primary and secondary care, the organization in the academic field and the training of future primary care physicians. It is clear that primary care in both countries plays a central role, have to deal with shortcomings, and in some points one system can learn from the other.

Shifts in the care for patients presenting in primary care with anxiety; stepped collaborative care parameters from more than a decade

BackgroundThe mental health burden on primary care is substantial and increasing. Anxiety is a major contributor. Stepped collaborative care (SCC) is implemented worldwide to improve patient outcomes, but long term real-world evaluations of SCC do not exist. Using routinely used electronic medical records from more than a decade, we investigated changes in anxiety prevalences, whether physicians made distinction between non-severe and severe anxiety, and whether these groups were referred and treated differently, both non-pharmacologically and pharmacologically. MethodsRetrospective assessment of anxiety care parameters recorded by 54 general practitioners between 2003 and 2014, in the electronic medical records of a dynamic population of 49,841–69,413 primary care patients. ResultsSubstantial shifts in anxiety care parameters have occurred. The prevalence of anxiety symptoms doubled to 0.9% and of anxiety disorders almost tripled to 1.1%. Use of ICPC codes seemed comprehensive and use of instruments to support in anxiety level differentiation increased to 13% of anxiety symptom and 7% of anxiety disorder patients in 2014. Minimal interventions were used more frequently, especially for anxiety symptoms (OR 21 [95% CI 5.1–85]). The antidepressant prescription rates decreased significantly for anxiety symptoms (OR 0.5 [95% CI 0.4–0.8]) and anxiety disorders (OR 0.6 [95% CI 0.4–0.8]). More patients were referred to psychologists and psychiatrists. ConclusionsWe found shifts in anxiety care parameters that follow the principles of SCC. Future primary care research should comprehensively assess the use of the SCC range of therapeutic options, tailored to patients with all different anxiety severity levels.

Dr Kailash Chand

We caught up with the BMA's deputy chair just after the General Election. Here, he considers the future of primary care in light of the result

Patient expectations and willingness to use primary care pharmacy services in the United Arab Emirates.

No previous studies have investigated patients' expectations of, or interest in, using primary care pharmacy services in the UAE. The study investigated primary care services that patients would use if they were provided through community pharmacies. A questionnaire was developed in English and translated to Arabic. Participants were asked to rate their likelihood of using future primary care services on a three-point Likert-type scale (very likely-unlikely). Services included screening for disease, monitoring of disease control, health advice and referral, lifestyle and preventive care, supply of printed information, counselling on medication use and side effects, patient record keeping, and pharmacist intervention in chronic disease. The questionnaire was distributed to patrons of public places by hand to eligible participants: ≥21 years, taking at least one scheduled prescription medication and having adequate Arabic or English proficiency. Areas of most interest were as follows: the pharmacist explaining how to use medications (Median = 3, interquartile range (IQR) = 1), the pharmacist advising on side effects of medications (Median = 3, IQR = 1), receiving advice on how to use devices (Median = 3, IQR = 1) and receiving printed information about medications (Median = 3, IQR = 1). Participants were least supportive of pharmacists keeping medication records (Median = 2, IQR = 1) and intervening in chronic disease management (Median = 2, IQR = 1). Participants anticipated a caring professional service by pharmacists and a pharmacy layout that allows private communication. Participants were interested in accessing enhanced primary care services by community pharmacists. Participants were more supportive of receiving information about medications, help in self-management and monitoring, and advice about disease prevention than management of chronic disease.

Have the New GP Contract and NICE guidelines improved the clinical care of people with epilepsy?

PurposeThis retrospective audit was to assess the effect of the New General Practitioner (GP) Contract and National Institute for Health and Care Excellence (NICE) guidelines on the care and management of people with epilepsy (PWE) during the period of observation from April 2004 to April 2009. MethodThe case notes of 540 people on anti-epilepsy drugs (AEDs) aged 16 years were reviewed in 13 general practices serving Ellesmere Port and Neston. ResultsForty-nine percent of people with poorly controlled epilepsy were not under shared care. Diagnostic doubt existed in 25 (5%) people. There was no evidence that the original diagnosis had been actively reviewed by the GP in any case. There were 98 (18%) women of childbearing age, in 21 of whom there was no evidence of pre-conceptual counselling ever having taken place, and 61 (62%) were not receiving folic acid routinely. Thirty-nine (7%) people were demonstrably non-compliant, whilst 74 (14%) people had prescription anomalies consisting mainly of inappropriate multi-dose regimens. ConclusionDespite marked improvements in review rates after the introduction of the New GP Contract five years previously, there are still significant unmet needs in this patient group. Clinical Commissioning Groups (CCGs) should consider funding an intermediate tier of care incorporating GPs with a special interest in epilepsy (GPwSIes) and Epilepsy Nurse Specialists (ENS) for PWE to improve and maintain existing and future primary care, as epilepsy is phased out of the Quality and Outcomes Framework (QOF).

Telemedicine and wireless devices in heart failure

Telemedicine has the potential to constitute the central element of the future primary care and become an effective means of prevention and early warning of acute exacerbation of chronic diseases. Up to now, the application of telemedicine has found a variety of difficulties, regarding the types and methods of acquisition and transmission of biological signals, the acceptance and cooperation of the patient, etc. The latest technological developments involve the combined use of wireless technologies and smartphones, for the collection and the transmission of data, and specific softwares for their automatic analysis. This paper examines some of the critical aspects in the application of new technologies for heart failure remote management.

Future of family care

The King's Fund reports on the future of primary care.

Keep it simple? Predicting primary health care costs with clinical morbidity measures

Models of the determinants of individuals’ primary care costs can be used to set capitation payments to providers and to test for horizontal equity. We compare the ability of eight measures of patient morbidity and multimorbidity to predict future primary care costs and examine capitation payments based on them. The measures were derived from four morbidity descriptive systems: 17 chronic diseases in the Quality and Outcomes Framework (QOF); 17 chronic diseases in the Charlson scheme; 114 Expanded Diagnosis Clusters (EDCs); and 68 Adjusted Clinical Groups (ACGs). These were applied to patient records of 86,100 individuals in 174 English practices. For a given disease description system, counts of diseases and sets of disease dummy variables had similar explanatory power. The EDC measures performed best followed by the QOF and ACG measures. The Charlson measures had the worst performance but still improved markedly on models containing only age, gender, deprivation and practice effects. Comparisons of predictive power for different morbidity measures were similar for linear and exponential models, but the relative predictive power of the models varied with the morbidity measure. Capitation payments for an individual patient vary considerably with the different morbidity measures included in the cost model. Even for the best fitting model large differences between expected cost and capitation for some types of patient suggest incentives for patient selection. Models with any of the morbidity measures show higher cost for more deprived patients but the positive effect of deprivation on cost was smaller in better fitting models.