Primary Care Initiative Research Articles

The Economics of Integrated Depression Care: The University of Michigan Study

A goal of the Robert Wood Johnson Depression and Primary Care Initiative at the University of Michigan is to create and implement the clinical care and financial systems necessary to enable links between primary care and mental health specialty depression care. This paper describes the economic issues related to resources required, the mechanisms to distribute those resources, and the support that must be garnered from stakeholders. By systematic measurement and application, we assess the cost, price and selected consequences of these efforts. The study illustrates the need for both centralized and distributed capacity and support for innovative models of care.

Asthma 3+ Visit Plan: a qualitative evaluation

The Asthma 3+ Visit Plan is a Commonwealth primary care initiative to improve care for patients with moderate or severe asthma through visits to general practitioners (GP). To assess the use of, and barriers to, completing the Asthma 3+ Visit Plan in recurrent emergency department attendees; asthma knowledge, symptoms and quality of life were assessed before and after undertaking the plan. The design was a predominantly qualitative study. Consenting individuals who presented for emergency treatment for asthma were interviewed before and after completing the Asthma 3+ Visit Plan with their GP. Asthma knowledge, symptom control, quality of life and demographic information were collected and participants underwent in-depth interviews for qualitative analysis. The setting was a tertiary teaching hospital and two suburban hospitals. The participants were 20 recurrent emergency attendees with asthma. Individuals who completed the Asthma 3+ Visit Plan had significant improvements in asthma-related quality of life and asthma knowledge. Qualitative interviews revealed that recurrent emergency attendees for asthma viewed the Asthma 3+ Visit Plan favourably. A good relationship with the GP appeared integral to the success of the Asthma 3+ Visit Plan and patient recall was an important factor in plan completion. Cost was also a barrier to patients completing the plan. Our findings support the Asthma 3+ Visit Plan as a discharge strategy for recurrent emergency attendees with asthma.

Reducing perinatal mortality among Indigenous babies in Queensland: should the first priority be better primary health care or better access to hospital care during confinement?

BackgroundThe perinatal mortality rate among Indigenous Australians is still double that of the rest of the community. The aim of our study was to estimate the extent to which increased risk of low birthweight and preterm birth among Indigenous babies in Queensland account for their continuing mortality excess. If a large proportion of excess deaths can be explained by the unfavourable birthweight and gestational age distribution of Indigenous babies, then that would suggest that priority should be given to implementing primary health care interventions to reduce the risk of low birthweight and preterm birth (eg, interventions to reduce maternal smoking or genitourinary infections). Conversely, if only a small proportion is explained by birthweight and gestational age, then other strategies might need to be considered such as improving access to high-quality hospital care around the time of confinement.MethodologyPopulation-based, descriptive study of perinatal mortality rates among Indigenous and non-Indigenous babies, in Queensland, stratified by birthweight and gestational age.ResultsIndigenous babies are twice as likely to die as their non-Indigenous counterparts (rate ratio1998–2002: 2.01; 95%ci 1.77, 2.28). However, within separate strata of birth weight and gestational age, Indigenous and non-Indigenous rates are similar. The Mantel-Haenszel rate ratio adjusted for birth weight and gestational age was 1.13 (0.99, 1.28). This means that most of the excess mortality in Indigenous babies is largely due to their unfavourable birth weight and gestational-age distributions. If Indigenous babies had the same birth weight and gestational age distribution as their non-Indigenous counterparts, then the relative disparity would be reduced by 87% and 20 fewer Indigenous babies would die in Queensland each year.ConclusionOur results suggest that Indigenous mothers at high risk of poor outcome (for example those Indigenous mothers in preterm labour) have good access to high quality medical care around the time of confinement. The main reason Indigenous babies have a high risk of death is because they are born too early and too small. Thus, to reduce the relative excess of deaths among Indigenous babies, priority should be given to primary health care initiatives aimed at reducing the prevalence of low birth weight and preterm birth.

Some Recent Initiatives in Primary Newborn Care in Madhya Pradesh

Some Recent Initiatives in Primary Newborn Care in Madhya Pradesh

Innovations in Seniors' Care: Home Care/Physician Partnership

The Innovations in Seniors' Care (Primary Care Partnerships) Project was implemented in 2000 in the Calgary Health Region, Alberta, to look at integration of services for seniors. The goal was to develop a sustainable collaborative partnership between family physicians and Community Care Coordinators--RNs (Home Care). The design and model were established in Stage I of the project. Stage II addressed implementation, challenges, barriers, evaluation, learnings and successes to date. Stage III looked at refinement, revision, final evaluation of the processes and dissemination of learnings. This paper describes startup procedures and implementation (selection of participants, educational sessions, evolution of partnerships and development of the evaluation framework). As the focus of the project was quality improvement, the section on implementation will discuss how and why changes occurred in the course of the process. Key challenges related to the restructuring of Home Care, creating tools and fostering unique individualized partnerships are also discussed. The conclusion evaluates the project's benefits in relation to (1) participant satisfaction, (2) sustainability and (3) impact on the system. The initial partnerships were formed in May 2001. New partnerships continue to be developed and constitute a key strategy in the Calgary Health Region's Primary Care Initiative.

Collaborative practice in health systems change: the Nova Scotia experience with the Strengthening Primary Care Initiative.

Recently attention has been focussed on the significance of primary care to the Canadian healthcare system. Nova Scotia. Like other provinces, is seeking ways to improve the healthcare that it provides within a financially constrained publicly funded system. The Strengthening Primary Care Initiative in Nova Scotia (SPCI) was a primary care demonstration project to evaluate specific goals related to primary care. Although the provincial government conceived the SPCI, the approach to its planning and implementation was participatory and consultative. Funded through the federal Health Transition Fund (HTF) (Health Canada 2002) and the government of Nova Scotia, the SPCI involved changes in four communities over a three-year period (2000-2002). These changes included the introduction of a primary healthcare nurse practitioner in collaborative practice with one or more family physicians; remuneration of the family physician(s) with methods other than a solely fee-for-service (FFS) arrangement; and the introduction and utilization of a computerized patient medical record. The SPCI was committed to a consultative process with stakeholders, and this gave rise to several challenges. Initially there was disagreement on the requirement for nurse practitioners at each of the demonstration sites. The Minister of Health confirmed that a nurse practitioner was a required component at each demonstration site. Differences in perspectives on the role of allied health professionals in the SPCI were encountered, and the significance of the role pharmacists have in primary care was not fully appreciated until after the SPCI had started. At the time the SPCI began there was no legislation for nurse practitioners in Nova Scotia; therefore, an approval mechanism for nurse practitioner practice was authorized through the provincial regulatory bodies for nursing and medicine. Malpractice and liability issues, particularly on the part of providers who had never worked with nurse practitioners before, were an initial concern. Recruitment of nurse practitioners into the three rural sites mirrored the difficulties with recruitment of healthcare providers encountered in other parts of rural Canada. The authors discuss their perspectives on the challenges related to interdisciplinary collaboration in health systems change that were encountered during the planning and implementation of the SPCI. Although nurse practitioner Legislation has existed in Ontario and Newfoundland and Labrador for several years, many provinces are grappling with the challenges associated with the introduction of nurse practitioners and collaborative practice. This paper conveys the experience of one province and will be of interest to administrators, educators and practitioners elsewhere in Canada who are engaged in primary healthcare renewal.

Tantalus and the Tyranny of Territory: Pursuing the dream of parity in rural and metropolitan population health outcomes through primary health care programs

Many health professionals and rural health academics are motivated by the challenge of achieving equitable access to health care in rural communities with the implicit vision that fairer access to services might ultimately lead to more equitable health outcomes for people living in rural and remote settings. The purpose of this paper is to put the issue of rural and urban health outcome parity into perspective and assess recent progress towards achieving the ultimate goal of improving rural health status. I will also explore ways in which rural communities might increase their access to and use of primary health care revenue in the future to improve community health outcomes. While some improvements have been achieved across the rural health system in recent times, the fundamental problem of maintaining infrastructure to service community needs in rural areas remains as daunting as ever. Extensive evidence has now been assembled to show that rural people generally enjoy a much lower standard of health care, health outcomes and life expectancy than their urban cousins. The question underlying all of this evidence, however, is... must this always be so? Is it possible to redress the current inequities between rural and urban populations and could new primary health care initiatives, such as the Enhanced Primary Care (EPC) program, be vehicles for achieving more equitable health care arrangements and health outcomes for people living in rural communities?

Reflections on the Twenty-Fifth Anniversary of the Alma-Ata Declaration

The Alma-Ata Declaration on Primary Health Care of 1978-based on the World Health Assembly's resolution of 1977 on Health for All by the Year 2000--was a watershed in the concepts and practices of public health as a scientific discipline; it was endorsed by every country in the world, rich and poor. According to the Declaration, health is a fundamental right, to be guaranteed by the state; people should be the prime movers in shaping their health services, using and enlarging upon the capacities developed in their societies; health services should operate as an integral whole, with promotive, preventive, curative, and rehabilitative components; and any western medical technology used in non-western societies must conform to the cultural, social, economic, and epidemiological conditions of the individual countries. Since Alma-Ata, a syndicate of the rich countries and the ruling elites of the poor countries, aided by the WHO, World Bank, World Trade Organization, and other international institutions, has done much to overturn the Declaration's primary health care initiatives. The WHO's recent attempt to regain some credibility, its Commission on Macroeconomics and Health, ignored the primary health care principles of the Alma-Ata Declaration. A struggle for these principles will have to be part of the larger struggle, by like-minded individuals working in individual countries, for a just world order.

Mortality and Return to Work of Drug Abusers From Therapeutic Community Treatment 3 Years After Entry.

BACKGROUND: The outcome of therapeutic community treatment for drug abuse has been disputed with regard to mortality and rehabilitation to school or work as compared with other treatment modalities. METHOD: All patients (N = 130) admitted to a therapeutic community during 3 consecutive years (1996-1998), who had failed to stop abusing drugs after ambulatory and primary care initiatives, were assessed 1 to 4 years (mean = 36.5 months) after end of treatment. Rates of rehabilitation to school or work, changes in drug use patterns, and mortality were observed. RESULTS: Nine persons died during the observation period (the observation time to death seemed to be shorter in women than in men). The mortality rate per 100 observation years was 2.28. Among the surviving drug abusers, 39% were working or attending school at study endpoint. One fourth currently used drugs, and approximately 14% were enrolled in a methadone maintenance program. Another 13% were in treatment or prison. CONCLUSION: Drug abuse is an activity that increases the mortality rate, but among the surviving persons, a considerable number are rehabilitated, as assessed after a longer observation period. The authors suggest that this outcome could not have been attained with ambulatory general practice-driven services, even with empathic follow-up.

Small-scale rural pilot programs in chronic illness management - what next?

In recent years, rural SA has been the recipient of significant funding to support a range of new primary health care initiatives. Much of this funding, additional to normal recurrent budgets in our health system, has facilitated effective change and development through demonstration and research projects across the state. The resultant work involves programs such as: ? coordinated care trials (COAG) ? more allied health services (MAHS) ? Commonwealth regional health service initiatives (CRHS) ? quality use of medicines (QUM) ? community packages for aged care services ? Indigenous chronic disease self-management pilot programs (CDSM) ? chronic disease self-management (CDSM) programs - Sharing Health Care SA ? chronic disease self-management (CDSM) programs in Indigenous communities. In addition to the resources listed above, funding was also provided by the Commonwealth to establish the South Australian Centre for Rural and Remote Health (SACRRH) and develop the University Department of Rural Health in Whyalla. While this new funding has led to substantial developmental work in chronic illness management in particular, one needs to ask whether the time might not be right now for these hitherto small-scale change initiatives to be transformed into ongoing mainstream programs, informed and guided by research outcomes to date. Is it time to move beyond tentative chronic illness programs and into mainstream reform? We have shown that there is much to be gained, both for patients and for the system, from improved coordination of primary care services and initiatives such as self-management programs for patients with chronic conditions. Better management leads to improved patient health outcomes and can reduce demand for unplanned hospital and emergency services. Many admissions to rural hospitals requiring expensive services, in terms of infrastructure and staffing, could be either prevented, or patients could be managed more effectively in the community as part of a wider primary health care program.

Community-orientated medical practice for the University of Liverpool medical students in Morecambe Bay: the story so far

Following Mike Flanagan's article in the September 2001 issue of the journal, which concentrated on hospital-based activities, this article describes the primary care initiatives underway in respect of Liverpool University Medical School. The article covers the background and build-up to the present situation and outlines anticipated developments.

What is the role of walk-in centres in the NHS?

In April 1999 the Department of Health authorised funding for a pilot scheme of 40 NHS walk-in centres in 30 towns and cities across England,1 the first of which opened...

Improving Participation in HIV Clinical Trials: Impact of a Brief Intervention

Purpose: To determine if a brief intervention that provides information about AIDS clinical trials to HIV-infected patients at the initiation of primary care increases the participation of women, persons of color, and injection drug users (IDUs) in clinical trials. Method: 196 outpatients beginning HIV primary care at a municipal hospital were followed from September 1994 to April 1996. During the intake assessment, each patient met briefly with a research assistant who described the purpose, role, and availability of clinical trials. Contacts for further information about trials were given to patients who expressed interest. At the end of the 20-month period, enrollment rates of all patients, including women, persons of color, and IDUs, into clinical trials were compared with previously published enrollment rates of patients at the same hospital but prior to the development of this brief intervention. Results: The characteristics of the 196 HIV-infected patients were: 27% women; 47% IDUs; 14% gay/bisexual men; and 76% persons of color. Overall enrollment in AIDS clinical trials was 14.8% during the 20-month follow-up period. There was no significant difference in participation rates between males and females (p = .20), whites and persons of color (p = .71), and IDUs compared with non-IDUs (p = .90), whereas previously published data had shown significantly higher enrollment rates among males, whites, and non-IDUs. Conclusion: Providing all HIV-infected patients with information about the meaning, role, and availability of AIDS clinical trials at the initiation of HIV primary care reduces differences in participation rates by gender, race, and history of drug use.

The Evolution of the Physician's Role

CONTROVERSY CONTINUES OVER HOW PHYSICIANS SHOULD BE employed in the United States. Some workforce experts believe there is a physician oversupply, arguing that allopathic, osteopathic, and international medical graduates are all competing for limited practice opportunities in the managed care setting. Other experts have advocated the expansion of US medical school positions, claiming that physician demand has not lessened despite a perceived oversupply. Yet others continue to hold that a “maldistribution” of physicians into urban and suburban areas, rather than rural and inner-city regions, is the root of the problem. Recent data suggest that this practice disparity, the target of primary care initiatives in many medical schools, has not closed, and may even have widened. Whatever the outcome of the physician workforce debate, physicians will face a changing landscape of clinical practice roles as well as increased availability of alternate career options. Some medical graduates are choosing to reject traditional clinical roles altogether. In this issue, we explore the continuing evolution of physicians’ clinical and nonclinical roles, including additional career possibilities. The Association of American Medical Colleges has monitored medical students’ future practice patterns since 1978, polling medical students each year prior to graduation to ask them about their career plans. In this issue, Dr Richard and colleagues examine 10 years of data from the questionnaire relevant to medical student career decisions, especially those outside traditional clinical medicine. Physicians seeking an alternative path have frequently sought additional graduate or professional degrees to expand their career options. Many medical schools have responded to the demand by offering combined degree programs, traditionally in public health and health policy, and, more recently, in business and law. The juris doctor degree is one possibility that has grown in popularity in the past decade: in this issue, Matthew Howard, MD, JD, outlines the development of legal medicine and the roles that physicians with legal training can play. In this era of managed care, training in business may be an asset. Not only are some physicians seeking business knowledge to increase their proficiency in the financial affairs of medicine, but businesses are also seeking persons with MD and combined MD/PhD degrees to bring new knowledge to the workplace. Michael Ennen examines why firms are hiring physicians as consultants. What possible choices exist for medical students who decide to contribute, outside of traditional research, to the advancement of medical science? For those with patience, medical editing is a possibility. The effort that brings you JAMA and MSJAMA—long hours of editing, reediting, and copyediting—is explored by Jerome Kassirer, MD, a former editor-in-chief of the New England Journal of Medicine.

University of Texas Medical Branch at Galveston.

University of Texas Medical Branch at Galveston.

Health promotion and older people: the role of the general practitioner in Australia in promoting healthy ageing

ObjectiveThe Commonwealth Government's Enhanced Primary Care initiative supports measures to enhance the role of general practitioners (GPs) in promoting healthy ageing as part of a population health approach. This paper comments on how the health assessments can be conducted to best effect, to strengthen the role of GPs in primary care and to promote autonomy and independence in older people. MethodThe relevant literature was collated to produce a review of public health and health promotion approaches and to ascertain the effectiveness of health promotion interventions for older people. A broad definition of health promotion including primary, secondary and tertiary prevention was adopted. ResultsThe evidence base suggests there is scope for greater targeting of health promotion activities towards older people. The rationale fa the Australian GP to assume a major health promotion role with their older patients is provided. Associated barriers and enablers are discussed. ConclusionsPrevention of disability is a key public health issue. The new MBS items may enable systematic evaluation of function and assist healthy ageing for all older people, including the frail aged. An increase in the preventive advice given to older patients has the potential to increase healthy behaviours and alter health outcomes. ImplicationsThe annual health assessment items on the Medicare Benefits Schedule, by enabling the GP to focus on prevention and coordination of care, have the potential to improve the health, physical, psychological and social function of older Australians.

“Baby blues busters”; Training early childhood nurses in cognitive behavioural therapy for post-natal depression and evaluating outcome in a randomised controlled trial

Background: Post-natal Depression is a major public health problem with an increasing literature suggesting chronicity, adverse infant outcome and marital breakdown as significant consequences of this disorder. There is a remarkable paucity of randomised controlled treatment trials in this area. This study utilises the existing treatment network involved with this population in a liaison with primary care initiative, using ECNs as therapists under psychiatric supervision.Objectives: This project has two objectives, (1) to establish whether ECNs can be trained in a modified CBT for PND, (2) to compare the outcome of women treated with this therapy with “ideal standard care” using non-specific counselling by ECNs with no additional training.Methods: Five ECNs were trained in CBT and supervised weekly by a senior psychiatry registrar who had developed a CBT work-book as the basis of the therapy. All ECNs in Eastern Sydney screened women postnatally using the Edinburgh PND Scale. Those with scores over 12 wer...

The national primary mental health care initiative: Building partnerships between general practice and psychiatry services

The national primary mental health care initiative: Building partnerships between general practice and psychiatry services

Streaming into the river

The impact on health strategy of moving further towards a primary care-centred health care system in the UK is consided. Initiatives in primary eye care within a London health district illustrate the scope to extend both interprofessional care and learning. A model of network-based development is identified as a framework for delivering health strategy based on primary care. The implications for both other family health services professionals and future primary care organisational and policy developments are explored.

Initiatives in primary health care: evaluation of a South Australian program.

In 1994 the Primary Health Care Initiatives Program was established as part of the South Australian government's hospital service improvement strategy. In its first year, the program funded 34 demonstration projects, of which half were concerned with improving continuity of care and discharge planning, and half with health promotion or illness prevention. Evaluation of the program has shown that it achieved significant improvements in links and communication between the services involved, in the development of systems and procedures for facilitating discharge-planning and continuity of care, and in enhancing the capacity of organizations to undertake health promotion and illness prevention. Overall, it was not possible to determine whether the program had shortened or avoided hospital stays due to a range of factors, including the many changes occurring in the health system at the time. The program's strong emphasis on evaluation has produced a rich source of information and helped to develop the evaluation skills of project staff.