GP Cluster Research Articles

Strengthening mechanism and precipitation behavior of advanced ultrahigh-strength titanium microalloy weathering steels for photovoltaic support

This study developed an 800 MPa grade ultrahigh-strength titanium microalloy weathering steel for photovoltaic support with yield and tensile strengths of 869 MPa and 956 MPa, respectively, and elongation above 12%. A comprehensive analysis was conducted to reveal the strengthening mechanisms and precipitation behavior of ultrahigh-strength weathering steel. The results illuminated that grain refinement, dislocation, and precipitation strengthening contribute 70.7% of total yield strength, the main strengthening mechanism of the ultrahigh-strength weathering steel. Notably, the average size of the elliptical TiC particles was 6.9 nm, and a long-to-short axis ratio of TiC particles ranging from 1.62 to 2.03 aligned with the theoretical shape factor of 2.16. The thermodynamic calculations agree with the experimental results, and the precipitated phase can be regarded as TiC. The precipitation kinetics indicated that optimal finishing rolling and coiling temperatures (CT) are critical for obtaining many nano-sized TiC precipitates. Compared to the CT of 630 °C, 570 °C retains more dislocations, promotes the nucleation site of TiC precipitates, and slows the post-nucleation coarsening, which is the main reason for the higher precipitation and dislocation strengthening than 630 °C. The first observation of multi-atomic layer GP clusters near precipitated phases within the ultrahigh-strength titanium microalloy weathering steel was noteworthy. The GP clusters, acting as intermediate precipitates containing Ti precipitates, keep a co-lattice relationship with the iron matrix by the dislocations around the GP clusters adjusting the mismatch. The contribution of the interaction of GP clusters and dislocations to the yield strength was estimated to be ∼53 MPa.

A trial-based economic evaluation of the CaFaSpA referral strategy for axial spondyloarthritis

Objective To assess the cost–utility from healthcare and societal perspectives of the digital CaFaSpA referral strategy (CS) for axial spondyloarthritis (axSpA) in primary care patients with chronic low back pain (CLBP). Method A cluster randomized controlled trial was performed in the Netherlands. General practice units were randomized into CS or usual care (UC). Economic evaluation was performed from the healthcare and societal perspectives within a 12-month time horizon. Outcome measures encompassed disability [Roland–Morris Disability Questionnaire (RMDQ)] and health-related quality of life (EQ-5D-3L). Direct medical (iMTA Medical Consumption Questionnaire) and indirect costs (iMTA Productivity Cost Questionnaire), including productivity loss, were evaluated. Incremental cost–utility ratios (ICURs) were calculated. Results The study included 90 GP clusters with 563 patients (CS: n = 260; UC: n = 303) (mean ± sd age 36.3 ± 7.5 years; 66% female). After 12 months, no minimal important differences in outcomes were observed for RMDQ (−0.21, 95%CI −1.52 to 1.13) or EQ-5D (−0.02, 95%CI −0.08 to 0.05). However, total costs were significantly lower in the CS group owing to lower productivity loss costs. The ICUR for RMDQ was €18,059 per point decrease and €220,457 per quality-adjusted life year increase. Conclusions Digital referral did not decrease the overall healthcare status of patients after 1 year of follow-up and appears to be more cost-effective than UC. Therefore, CS can be used as an appropriate primary care referral model for CLBP patients at risk for axSpA. This will accelerate timely provision of care by the right caregiver.

Effectiveness of coordinated care to reduce the risk of prolonged disability among patients suffering from subacute or recurrent acute low back pain in primary care: protocol of the CO.LOMB cluster-randomized, controlled study.

Low back pain (LBP) is a common musculoskeletal condition and, globally, a leading cause of years lived with disability. It leads to reduced social participation, impaired quality of life, and direct and indirect costs due to work incapacity. A coordinated approach focusing on psychosocial risk factors, active reeducation, and the early use of tools to maintain employment, may be effective for improving prognosis of patients with LBP. Primary care professionals and multidisciplinary teams, who see patients in the early stages of LBP may be in the best position to implement such a coordinated approach. We designed this study to assess a coordinated multi-faceted strategy in primary care for patients with subacute or recurrent acute LBP. The CO.LOMB study was designed as a multicentric, cluster-randomized, controlled study. Patients aged 18-60 years, with subacute or recurrent acute LBP are eligible. Patients also need to be employed (but can be on sick leave) with access to occupational health services. The clusters of GPs will be randomized (1:1) to either the Coordinated-care group or the Usual-care group. Patients will be assigned the group allocated to their GP. The healthcare professionals (GPs and associated physiotherapists) allocated to the Coordinated-care group will perform a 2-session study training. The following interventions are planned in the Coordinated-care group: exploration and management of psychosocial factors, active reeducation with a physiotherapist, the implementing of tools to maintain employment, and a reinforced cooperation between primary healthcare professionals. The primary objective is to assess the benefit of coordinated primary care to reduce disability in LBP patients at 12 months after enrollment: measure using the validated French version of the Roland Morris Disability Questionnaire. Secondary objectives include the evaluation of pain, work status, and quality of life at various time points. The study plans to enroll 500 patients in 20 GP clusters. Patients will be followed up for 12months. This study will evaluate the benefit of a coordinated multi-faceted strategy in primary care for patients with LBP. Notably whether this approach will alleviate the associated disability, attenuate pain, and promote the maintenance or return to work. NCT04826757.

Challenges in implementing GP clusters in Scotland: a qualitative study comparing the views of senior primary care stakeholders in 2016 with those in 2021.

Formation of GP clusters began in Scotland in April 2016 as part of a new Scottish GP contract. They aim to improve the care quality for local populations (intrinsic role) and the integration of health and social care (extrinsic role). To compare predicted challenges of cluster implementation in 2016 with reported challenges in 2021. Qualitative study of senior national stakeholders in primary care in Scotland. Qualitative analysis of semi-structured interviews with 12 senior primary care national stakeholders in 2016 (n = 6) and 2021 (n = 6). Predicted challenges in 2016 included balancing intrinsic and extrinsic roles, providing sufficient support, maintaining motivation and direction, and avoiding variation between clusters. Progress of clusters in 2021 was perceived as suboptimal and was reported to vary significantly across the country, reflecting differences in local infrastructure. Practical facilitation (data, administrative support, training, project improvement support, and funded time) and strategic guidance from the Scottish Government was felt to be lacking. GP engagement with clusters was felt to be hindered by the significant time and workforce pressures facing primary care. These barriers were considered as collectively contributing to cluster lead 'burnout' and loss of momentum, exacerbated by inadequate opportunities for shared learning between clusters across Scotland. Such barriers preceded, but were perpetuated by, the impact of the COVID-19 pandemic. Apart from the COVID-19 pandemic, many of the challenges reported by stakeholders in 2021 were predicted in 2016. Accelerating progress in cluster working will require renewed investment and support applied consistently across the country.

Modelling Age Hardening of Aluminium Alloys with Consideration of GP Zones or Clusters

The work reported here follows the theme of our previous research presented at the ICAA16 and ICAA17 conferences, where material models have been developed to predict the microstructure evolution and precipitation hardening of aluminium alloys during cooling and ageing. The models have two important features: one is the consideration of quenched-in vacancies and their effect on precipitation kinetics, which was discussed in past conferences; the other is the formation of GP zones or clusters and their transition to other hardening phases during ageing, which is the focus of this paper. GP zones or clusters are known to serve as precursor phases for various hardening phases. Depending on the ageing temperature being above or below the solvus temperature of the precursor phase, precipitates can either form on their own from the matrix (heterogeneous or HET type) or form on existing GP zones or clusters (homogeneous or HOM type). In the latter case, GP zones or clusters are allowed to form first from the matrix, which will later transform to their metastable counterparts. Both HET and HOM types of precipitates are considered in the current strengthening model for predicting age hardening curves for aluminium alloys. The age hardening model has been validated over a wide range of commercial aluminium alloys and demonstrated good agreement with experimental data in the form of age hardening curve and T5/T6 peak position and strength.

Primary care transformation in Scotland: qualitative evaluation of the views of national senior stakeholders and cluster quality leads.

Primary care transformation in Scotland aims to improve population health, reduce health inequalities, and reduce GP workload. Two key strategies (formalised in April 2018 in the new Scottish GP contract [Scottish General Medical Services contract], although started in early 2016) are the expansion of the multidisciplinary team (MDT) and GP cluster working. To explore progress in the implementation of the GP contract in Scotland in terms of the MDT and cluster working. Qualitative study with key national primary care stakeholders (PCSs) (n = 6) and cluster quality leads (CQLs) in clusters serving urban high deprivation areas (n = 4), urban mixed areas (n = 4), and remote and rural areas (n = 4). Semi-structured interviews with thematic analysis. There was general support for the initial aims of the new GP contract but all interviewees felt that progress on both MDT expansion and cluster working was slow, even before the pandemic. None of the CQLs (and few PCSs) felt that GP workload had reduced significantly, nor that the care of patients with complex needs had improved. Lack of time and poorly developed relationships were key barriers, as was a lack of relevant primary care data, and additional support (including guidance, administration, training, and protected time). Key PCSs and CQLs in different areas of Scotland report limited progress in primary care transformation, only partly related to the pandemic. There is a need for better workforce planning and support if the new GP contract is to succeed in transforming primary care in Scotland.

Brief lifestyle interventions for prediabetes in primary care: a service evaluation

BackgroundThe increasing number of cases of prediabetes in the UK is concerning, particularly in Wales where there is no standard programme of support. The aim of the current service evaluation was to examine the effectiveness of brief lifestyle interventions on glucose tolerance in people at risk of developing type 2 diabetes.MethodsIn this pragmatic service evaluation clinical data on people deemed at risk of developing type 2 diabetes were evaluated from two GP clusters. Patients (n = 1207) received a single 15 to 30-min, face-to-face, consultation with a health care practitioner. Interventions were assessed by changes in HbA1c and distribution across the HbA1c ranges 12 months following intervention. Statistical significance of reversion to normoglycaemia and development of diabetes were assessed through comparison with expected rates without intervention.ResultsBetween baseline and 12-month follow-up HbA1c fell from 43.85 ± 1.57 mmol/mol (6.16 ± 0.14%) to 41.63 ± 3.84 mmol/mol (5.96 ± 0.35%), a decrease of 2.22 mmol/mol (0.20%) (95% CI 2.01 (0.18%), 2.42 (0.22%); p < 0.0001). The proportion of people with normal glucose tolerance at 12 months (0.50 95%CI 0.47, 0.52) was significantly larger than the lower (0.06 (p < 0.0001) and the upper (0.19 (p < 0.0001)) estimates based on no intervention.ConclusionResults indicate significant improvement in glucose tolerance across GP clusters. The brief intervention has the potential to offer a robust and effective option to support people at risk of developing type 2 diabetes. Further research in the form of a randomised trial is needed to confirm this and identify those likely to benefit most from this intervention.

Functional somatic symptoms in youths in general practice: A cross-sectional study on prevalence, clinical management and perceived burden

ObjectiveFunctional somatic symptoms (FSS) may progress into a functional disorder if poorly managed, which may have serious implications. This cross-sectional study describes the management of youths compared to adults in general practice and estimates the prevalence of FSS in youths in this setting by comparing consultation-related aspects between youths with FSS and 1) youths with a specific diagnosis and 2) adults with FSS. MethodsWe used data from a Danish survey (2008–2009), including 3295 face-to-face consultations between GPs and patients aged 15–64 years. Patients were divided into youths (15–24 years) and adults (25–64 years) and then into subgroups according to the GPs' classifications: 1) specific diagnosis, 2) resolving symptom and 3) FSS. Logistic regression analysis was used for all comparisons, and estimates were adjusted for gender, concomitant chronic disorder and GP cluster. ResultsThe GPs more frequently ensured continuity of care in adults (AOR:0.75, 95%CI:0.61–0.92, p < 0.01) and perceived youths as less time consuming (AOR:0.58, 95%CI: 0.43–0.77, p < 0.01) and less burdensome (AOR:0.60; 95%CI: 0.45–0.81, p < 0.01) compared to adults. FSS prevalence was 4.4% in youths and 9.0% in adults. However, GPs perceived youths with FSS as more burdensome (AOR:7.77, 95%CI:2.93–20.04, p < 0.01) and more time consuming (AOR:3.98, 95%CI:1.42–11.12, p < 0.01) than youths with a specific diagnosis. No significant differences were found between youths and adults with FSS, respectively, in regards to perceived burden and consultation time. ConclusionThe results indicate age-related variations in the prevalence and clinical management of FSS in general practice. The GPs perceived both youths and adults with FSS time consuming, which underlines a need for supportive management strategies.

Lessons learned from implementing a first contact physiotherapy service via a single and dual hub model. A narrative

Purpose: GP cluster funding of first contact physiotherapy (FCP) and the complexity of the planning of FCP into individual GP practices necessitated the need to change standard provision of care utilising a single and dual hub model in two separate GP cluster areas in North East Wales. The aim of this study was to evaluate the impact of using a single or dual hub design for providing FCP care.

Implementing work-related Mental health guidelines in general PRacticE (IMPRovE): a protocol for a hybrid III parallel cluster randomised controlled trial

BackgroundThe Clinical Guideline for the Diagnosis and Management of Work-related Mental Health Conditions in General Practice (the Guideline) was published in 2019. The objective of this trial is to implement the Guideline in general practice.Trial designImplementing work-related Mental health conditions in general PRacticE is a hybrid III, parallel cluster randomised controlled trial undertaken in Australia. Its primary aim is to assess the effectiveness of a complex intervention on the implementation of the Guideline in general practice. Secondary aims are to assess patient health and work outcomes, to evaluate the cost-effectiveness of the trial, and to develop a plan for sustainability.MethodsA total of 86 GP clusters will be randomly allocated either to the intervention arm, where they will receive a complex intervention comprising academic detailing, enrolment in a community of practice and resources, or to the control arm, where they will not receive the intervention. GP guideline concordance will be assessed at baseline and 9 months using virtual simulated patient scenarios. Patients who meet the eligibility criteria (>18years, employed, and receiving care from a participating GP for a suspected or confirmed work-related mental health condition) will be invited to complete surveys about their health and work participation and provide access to their health service use data. Data on health service use and work participation compensation claim data will be combined with measures of guideline concordance and patient outcomes to inform an economic evaluation. A realist evaluation will be conducted to inform the development of a plan for sustainability.ResultsWe anticipate that GPs who receive the intervention will have higher guideline concordance than GPs in the control group. We also anticipate that higher concordance will translate to better health and return-to-work outcomes for patients, as well as cost-savings to society.ConclusionsThe trial builds on a body of work defining the role of GPs in compensable injury, exploring their concerns, and developing evidence-based guidelines to address them. Implementation of these guidelines has the potential to deliver improvements in GP care, patient health, and return-to-work outcomes.Trial registrationACTRN12620001163998, November 2020

Improving the precision of depression diagnosis in general practice: a cluster-randomized trial

BackgroundMethods to enhance the accuracy of the depression diagnosis continues to be of relevance to clinicians. The primary aim of this study was to compare the diagnostic precision of two different diagnostic strategies using the Mini International Neuropsychiatric Interview (MINI) as a reference standard. A secondary aim was to evaluate accordance between depression severity found via MINI and mean Major Depression Inventory (MDI) sum-scores presented at referral.MethodsThis study was a two-armed, cluster-randomized superiority trial embedded in the Collabri trials investigating collaborative care in Danish general practices. GPs performing case-finding were instructed always to use MDI when suspecting depression. GPs performing usual clinical assessment were instructed to detect depression as they would normally do. According to guidelines, GPs would use MDI if they had a clinical suspicion, and patients responded positively to two or three core symptoms of depression. We compared the positive predictive value (PPV) in the two groups.ResultsFifty-one GP clusters were randomized. In total, 244 participants were recruited in the case-finding group from a total of 19 GP clusters, and 256 participants were recruited in the usual clinical assessment group from a total of 19 GP clusters. The PPV of the GP diagnosis, when based on case-finding, was 0.83 (95% CI 0.78–0.88) and 0.93 (95% CI 0.89–0.96) when based on usual clinical assessment. The mean MDI sum-scores for each depression severity group indicated higher scores than suggested cut-offs.ConclusionsIn this trial, systematic use of MDI on clinical suspicion of depression did not improve the diagnostic precision compared with the usual clinical assessment of depression.Trial registrationThe trial was retrospectively registered on 07/02/2016 at ClinicalTrials.gov. No. NCT02678845.

Nonprofessional Health Workers on Primary Health Care Teams in Vulnerable Communities.

A Model Programme in primary care group practices (GP clusters) was implemented in 2013 in solo practices in Hungary.1 The practices employed—among others—nonprofessional community workers called “health mediators.” The 5-year program widened the range of primary health care services

Collaborative improvement in Scottish GP clusters after the Quality and Outcomes Framework: a qualitative study.

BackgroundScotland abolished the Quality and Outcomes Framework (QOF) in April 2016, before implementing a new Scottish GP contract in April 2018. Since 2016, groups of practices (GP clusters) have been incentivised to meet regularly to plan and organise quality improvement (QI) as part of this new direction in primary care policy.AimTo understand the organisation and perceived impact of GP clusters, including how they use quantitative data for improvement.Design and settingThematic analysis of semi-structured interviews with key stakeholders (n = 17) and observations of GP cluster meetings (n = 6) in two clusters.MethodThis analytical strategy was combined with a purposive (variation) sampling approach to the sources of data, to try to identify commonalities across diverse stakeholder experiences of working in or on the idea of GP clusters. Variation was sought particularly in terms of stakeholders’ level of involvement in improvement initiatives, and in their disciplinary affiliations.ResultsThere was uncertainty as to whether GP clusters should focus on activities generated internally or externally by the wider healthcare system (for example, from Scottish Health Boards), although the two observed clusters generally generated their own ideas and issues. Clusters operated with variable administrative/managerial and data support, and variable baseline leadership experience and QI skills. Qualitative approaches formed the focus of collaborative learning in cluster meetings, through sharing and discussion of member practices’ own understandings and experiences. Less evidence was observed of data analytics being championed in these meetings, partly because of barriers to accessing the analytics data and existing data quality.ConclusionCluster development would benefit from more consistent training and support for cluster leads in small-group facilitation, leadership, and QI expertise, and data analytics access and capacity. While GP clusters are up and running, their impact is likely to be limited without further investment in developing capacity in these areas.

In Situ Fate Mapping of Native and Stress Myelopoiesis Reveals a Unique Niche for Mono- and Dendritic Cell -Poiesis

In contrast to virtually all other tissues in the body the anatomy of differentiation in the bone marrow remains unknown. This is due to the lack of strategies to examine blood cell production in situ, which are required to better understand differentiation, lineage commitment decisions, and to define how spatial organizing cues inform tissue function. We developed approaches to image and fate map -using confetti mice- myelopoiesis in situ and generated 3D atlases of granulocyte and monocyte/dendritic cell differentiation during homeostasis and after emergency myelopoiesis induced by infection with Listeria monocytogenes. Figure 1 shows stepwise differentiation during myelopoiesis. We have found that -in imaging studies- CD11b-Ly6C-CD117+CD115+ cells are MDP; Lin-CD117+CD16/32+CD115- cells are GMP; CD11b-Ly6C+CD117+CD115+ are MOP; CD11b-CD117+CD115-Ly6C+ are GP; CD11b+CD115+Ly6Chi and CD11b+CD115+Ly6Clo cells are Ly6Chi and Ly6Clo monocytes; and MHCIIhi reticular cells are dendritic cells (DC). We used these markers to map every myeloid cell in the sternum and assessed the relationships between myeloid progenitors, their offspring and candidate niches in situ with single cell resolution. To test whether the interactions observed were specific we obtained the X, Y and Z coordinates for every hematopoietic cell in the sternum (detected using αCD45 and αTer119). We then used these coordinates to randomly place each type of myeloid cell, at the same frequencies found in vivo, through the BM to generate random distributions for each myeloid cell type. We found that myeloid progenitors do not localize with HSC indicating that they leave the HSC niche during differentiation. In the steady-state GP, MOP, and MDP are found as single cells that do not associate with each other indicating that granulo-, mono-, and dendritic cell-poiesis take place in different location. Myeloid progenitors are specifically recruited to sinusoids but are depleted near endosteum and arterioles (e.g. mean MDP distance to sinusoids, arterioles, and endosteum observed 5, 134, and 105μm vs 9, 86, and 69µm in the random simulation). GP form clusters with preneutrophils and immature neutrophils, in situ fate mapping demonstrated that these clusters are oligoclonal and that additional GP are serially recruited to the cluster as the old ones differentiate. Ly6Clo monocytes and dendritic cells are selectively enriched near MDP (2.0 DC and 4.4 Ly6Clo monocytes observed within 50µm of an MDP vs 0.9 DC and 1.8 Ly6Clo monocytes in the random simulation p=0.02 and p&amp;lt;0.0001). Fate mapping experiments demonstrated that the monocytes around MOP and monocytes and dendritic cells around the MDP are oligoclonal but are not the derived from the MOP/MDP they associate with. These indicate that Ly6Clo monocytes and DC are produced elsewhere but are then selectively recruited to regions enriched in MDP. The results above suggest that different sinusoids might be responsible for supporting different myeloid lineages. We found that dendritic cells localize to a unique subset (8% of all vessels) of colony stimulating factor 1 (CSF1, the major regulator of monopoiesis) -expressing sinusoids. Csf1 deletion in the vasculature disrupted MDP interaction with sinusoids, leading to reduced MDP numbers and differentiation ability, with subsequent loss of Ly6Clo monocytes and dendritic cells. L. monocytogenes infection dramatically changed the architecture of myelopoiesis and caused massive expansion of myeloid progenitors leading to the formation of monoclonal GP clusters and oligoclonal MOP clusters whereas MDP are still found as single cells associated with dendritic cells. Even after this massive insult granulopoiesis and mono/DC poiesis remained spatially segregated to different sinusoids. Csf1 deletion in the vasculature prevented generation of MDP and dendritic cells in response to infection. In summary we have developed strategies to image and fate map myelopoiesis in situ; revealed spatial segregation of -and distinct clonal architectures for- granulopoiesis and mono/DCpoiesis; and identified rare CSF1+ sinusoids that maintain mono/DCpoiesis in the steady-state and after infection. These data indicate that there is a specific spatial organization of definitive hematopoiesis and that local cues produced by distinct blood vessels are responsible for this organization. Figure Disclosures No relevant conflicts of interest to declare.

Progress of GP clusters 2 years after their introduction in Scotland: findings from the Scottish School of Primary Care national GP survey.

BackgroundThe concept of GP clusters is derived from 'quality circles' in general practice in Europe and Canada. GP clusters commenced across Scotland in 2016 to improve the quality of care of local populations.AimTo determine GPs' views on clusters, and the robustness of bespoke questions about them.Design & settingA cross-sectional national survey of work satisfaction of GPs in Scotland took place, which was conducted in July 2018–October 2018.MethodAn analysis of bespoke questions on GP clusters was undertaken. The questions were completed by quality leads (QLs) and all other GPs in a nationally representative sample of GPs.ResultsIn total, 2456 responses were received from 4371 GPs (56.4%). QLs reported that clusters were meeting regularly, and were friendly and well organised but not always productive. Support for cluster activity (data, health intelligence, analysis, quality improvement methods, advice, leadership, and evaluation) was suboptimal. Factor analysis identified two separate constructs (cluster meetings [CMs] and cluster support [CS]), which were minimally influenced (<2%) by GP and practice characteristics. Non-QLs (75% of all GPs) were generally satisfied with the two-way communication with the cluster QLs, but the great majority (>70%) reported no positive changes in various aspects of quality improvement. Factor analysis of these items indicated two constructs (cluster knowledge and engagement [CKE] and cluster quality improvement [CQI]), which were minimally affected by GP and practice characteristics.ConclusionGP clusters are ‘up and running’ in Scotland but are at an early stage in terms of perceived impact and appear to be in need of more support in order to improve quality of care. The bespoke questions developed on clusters have robust construct validity, suitable for future surveys.

Facilitating equal access to primary care for all: work experiences of health mediators in a primary health care model programme in Hungary

BackgroundA Primary Care Model Programme was implemented in Hungary between 2013 and 2017 in order to increase access of disadvantaged population groups to primary care and to offer new preventive services for all clients. In a country with single-handed practices, four group practices or GP clusters were created in the Programme. Six GPs comprised one cluster who together employed nonmedical health professionals and nonprofessional health mediators, the latter recruited from the serviced communities, many of them of Roma ethnicity. Health mediators were tasked by improving access of the local communities – including its vulnerable Roma members – to existing and new services. Health mediators were interviewed about their work experiences, motivation, and overall opinion as members of the clusters as part of the Programme evaluation.MethodsAs part of the Programme evaluation, structured interviews were conducted with all 40 health mediators employed at the time in the Programme. Interviews were transcribed and content analysis was carried out.ResultsThree themes emerged from the transcripts. The first focused on the health mediators’ personal characteristics such as motivation to join the Programme, the way their job increased their self-esteem, social status and health consciousness. Domains of the second theme of their work included importance of on-the-job training and of their insider knowledge of local communities, as well as their pride to have become members of the primary care team. The third theme covered overall functioning of the Programme of which they had mostly positive opinions, notwithstanding some criticism regarding procurement.ConclusionsHealth mediators had earlier worked in various European countries specifically to improve access of Roma ethnic groups to health services but the Hungarian Model Programme was globally the first in which health mediators as non-professional workers became equal members of the primary care team as employees. Their contribution and overwhelmingly positive experiences, along with their useful insights for improvement call for the establishment and funding of health mediator positions in primary care especially in areas with large numbers of disadvantaged Roma populations.

Antibiotic use and deprivation: an analysis of Welsh primary care antibiotic prescribing data by socioeconomic status.

To examine the association between socioeconomic status (SES) and antibiotic prescribing, controlling for the presence of common chronic conditions and other potential confounders and variation amongst GP practices and clusters. This was an electronic cohort study using linked GP and Welsh Index of Multiple Deprivation (WIMD) data. The setting was GP practices contributing to the Secure Anonymised Information Linkage (SAIL) Databank 2013-17. The study involved 2.9 million patients nested within 339 GP practices, nested within 67 GP clusters. Approximately 9 million oral antibiotics were prescribed between 2013 and 2017. Antibiotic prescribing rates were associated with WIMD quintile, with more deprived populations receiving more antibiotics. This association persisted after controlling for patient demographics, smoking, chronic conditions and clustering by GP practice and cluster, with those in the most deprived quintile receiving 18% more antibiotic prescriptions than those in the least deprived quintile (incidence rate ratio = 1.18; 95% CI = 1.181-1.187). We found substantial unexplained variation in antibiotic prescribing rates between GP practices [intra-cluster correlation (ICC) = 47.31%] and GP clusters (ICC = 12.88%) in the null model, which reduced to ICCs of 3.50% and 0.85% for GP practices and GP clusters, respectively, in the final adjusted model. Antibiotic prescribing in primary care is increased in areas of greater SES deprivation and this is not explained by differences in the presence of common chronic conditions or smoking status. Substantial unexplained variation in prescribing supports the need for ongoing antimicrobial stewardship initiatives.

Advanced practitioner physiotherapist as 1st point of contact in a GP cluster in Lanarkshire

Advanced practitioner physiotherapist as 1st point of contact in a GP cluster in Lanarkshire

Efficacy and cost-effectiveness of a community-based model of care for older patients with complex needs: a study protocol for a multicentre randomised controlled trial using a stepped wedge cluster design

BackgroundCommunity-dwelling older persons with complex care needs may deteriorate rapidly and require hospitalisation if they receive inadequate support for their conditions in the community.InterventionA comprehensive, multidimensional geriatric assessment with care coordination was performed in a community setting—Older Persons ENablement And Rehabilitation for Complex Health conditions (OPEN ARCH).ObjectivesThis study will assess the acceptability and determine the impact of the OPEN ARCH intervention on the health and quality of life outcomes, health and social services utilisation of older people with multiple chronic conditions and emerging complex care needs. An economic evaluation will determine whether OPEN ARCH is cost-effective when compared to the standard care.Methods/designThis multicentre randomised controlled trial uses a stepped wedge cluster design with repeated cross-sectional samples. General practitioners (GPs; n ≥ 10) will be randomised as ‘clusters’ at baseline using simple randomisation. Each GP cluster will recruit 10–12 participants. Data will be collected on each participant at 3-month intervals (− 3, 0, 3, 6 and 9 months). The primary outcome is health and social service utilisation as measured by Emergency Department presentations, hospital admissions, in-patient bed days, allied health and community support services. Secondary outcomes include functional status, quality of life and participants’ satisfaction. Cost-effectiveness of the intervention will be assessed as the change to cost outcomes, including the cost of implementing the intervention and subsequent use of services, and the change to health benefits represented by quality adjusted life years.DiscussionThe results will have direct implications for the design and wider implementation of this new model of care for community-dwelling older persons with complex care needs. Additionally, it will contribute to the evidence base on acceptability, efficacy and cost-effectiveness of the intervention for this high-risk group of older people.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12617000198325p. Registered on 6 February 2017.

Importance of comorbidities in the treatment of primary care patients with heart failure-Baseline results of the observational RECODE-HF Study.

Both non-cardiac and cardiac comorbidities are related to the prognosis of chronic heart failure (HF), but so far little is known about the impact of comorbidities on treatment difficulties in routine care. To investigate which comorbidities are associated with treatment difficulties in primary care. We hypothesized that somatic comorbidities as well as psychosocial distress are associated with treatment difficulties. In this baseline analysis of data of the observational RECODE-HF study, HF patients were recruited via primary care practices in two German sites. They received a questionnaire by mail to measure psychosocial distress. Each patient's GP was interviewed by phone regarding the patient's comorbidities and treatment difficulties. Logistic regression analyses controlled for GP cluster effects were calculated to investigate the association between comorbidities/psychosocial distress and treatment difficulties. The 3282 patients of 285 GPs included in the analysis were aged 74.2 (±10.1) years and had a mean number of 4.6 (±2.4) comorbidities. GPs reported treatment difficulties in 32.5% of the patients. Allergies/drug intolerance [odds ratio (ORs)=2.0], asthma/chronic obstructive pulmonary disease (ORs=1.4), renal insufficiency (ORs=1.3), atherosclerosis/peripheral arterial occlusive disease (ORs=1.3) and cardiac arrhythmias (ORs=1.2) as well as patient-reported psychosocial distress (ORs=1.2), HF severity (ORs=3.7-1.6) and age (ORs=0.98) were associated with treatment difficulties. Five somatic comorbidity groups as well as patient-reported psychosocial distress were significantly associated with a higher risk of GP-reported treatment difficulties. Further efforts to address comorbidities in clinical guidelines could be built on these results.