Primary Care Initiative Research Articles

Breastfeeding-Friendly Primary Care Initiative: degree of implementation in a Brazilian metropolis

OBJECTIVE: This study assessed the degree of implementation of the Breastfeeding-Friendly Primary Care Initiative in a Brazilian metropolis. METHODS: A tool with 55 items and a maximum score of 10 points, based on validated protocols, was developed for assessing the degree of implementation of the abovementioned initiative. This tool was used on a probabilistic sample of municipal primary care units in the city of Rio de Janeiro, Brazil (n=56). Managers (n=56), healthcare practitioners (n=541) and users (n=985) were interviewed. RESULTS: The mean score for the degree of implementation of the Breastfeeding-Friendly Primary Care Initiative in the study units was 5.45 (95%CI: 5.11 - 5.78), the maximum being 10.00. Existence of written guidelines and training obtained the worst scores. Breast massage and manual milk expression techniques; knowledge about contraception and the risks associated with the use of baby formulas, bottles, and pacifiers; and existence of support groups obtained intermediate scores. Provision of information and recommendations on breastfeeding rights and advantages; addressing users' worries, life experiences, and doubts; and encouraging cue feeding achieved the best scores. CONCLUSION: The proposed tool assessed the general degree of implementation of the Breastfeeding-Friendly Primary Care Initiative and of each group of actions associated with the "Ten Steps", providing information for restructuring the strategies used in Rio de Janeiro. The degree of implementation of breastfeeding promotion, protection, and support set by the initiative in this city is intermediate, with its items having been implemented to different degrees.

Degree of compliance with the ten steps of the Breastfeeding Friendly Primary Care Initiative and its association with the prevalence of exclusive breastfeeding

ObjectiveTo analyze the association between the degree of compliance with the ten steps of the Breastfeeding-Friendly Primary Care Initiative (BFPCI) and the prevalence of exclusive breastfeeding (EBF) in infants younger than six months in the city of Rio de Janeiro. MethodsThis was a cross-sectional study conducted in a representative sample of 56 primary health care units of this municipality. The assessment of compliance with the ten steps of the BFPCI was carried out by interviewing health care professionals, pregnant women, and mothers; the generated performance scores were classified into tertiles. To obtain the outcome, i.e., the EBF, a data collection questionnaire was applied to mothers of children younger than six months who were followed up at these units in November of 2007. Prevalence ratios were obtained for the EBF using Poisson regression with robust variance. ResultsThe prevalence of EBF was 47.6%. In the multivariate analysis, the upper tertile of performance showed a 34% higher prevalence of EBF (PR=1.34, 95% CI: 1.24 to 1.44) and the second tertile was 17% higher (PR=1.17, 95% CI: 1.08 to 1.27) than the first tertile. Mothers who did not work outside home had a 75% higher prevalence of EBF (PR=1.75, 95% CI: 1.53 to 2.01); assistance in a basic health unit, as opposed to a family health unit, implied a 10% higher prevalence (PR=1.10, 95% CI: 1.03 to 1.19). The prevalence of EBF decreased 1% for each day of the infant's life (PR=0.993, 95% CI: 0.992 to 0.993). ConclusionGiven the contribution of BFPCI to the practice of EBF, a greater investment in the expansion and sustainability of this initiative is recommended, as well as its association with other strategies to promote, protect, and support breastfeeding.

Improving Public Health Agency and System Performance: Fortification for Promoting Population Health and Wellness

Improving Public Health Agency and System Performance: Fortification for Promoting Population Health and Wellness

General Internal Medicine as an Engine of Innovation

Almost 10 years ago, JGIM published a seminal report from the Society of General Internal Medicine (SGIM) Task Force on the Domain of General Internal Medicine. Boldly titled “The Future of General Internal Medicine”, the report challenged the field of general internal medicine to take responsibility for addressing the “chaos and dysfunction” the Task Force believed characterized medical care at that time. Many of the innovations they proposed, including team based care, enhanced information systems, and the abandonment of the fee-for-service financing model, seemed pie-in-the-sky at the time, but are now accepted by most as essential for improving health care delivery and curbing costs. While much has changed in the past decade, in many ways, general internal medicine still stands at the crossroads. While the options may not be quite so bleak as Woody Allen suggests, general internal medicine continues to face some critical challenges in research, education and clinical practice. In this issue of JGIM, Armstrong et al. (on behalf of the 2012–2013 SGIM Council) articulate these challenges and present a vision for the future of general internal medicine. They point out that the pressure to reduce health care costs and increase value along with the historic passage of the Patient Protection and Affordable Care Act (ACA) will lead to new initiatives in primary care and GIM, featuring population management, team-based care and innovative use of electronic health records. Changes in medical education spurred by duty hours reform and enhanced workforce diversity have resulted in a shift to more training in the ambulatory setting and a shift in focus to measuring competencies rather then medical knowledge. For researchers in academic GIM, they argue that these changes bring both challenges and opportunities. GIM researchers are ideally situated to study the impact of practice transformation and payment reform that will be brought by the Affordable Care Act (ACA), but despite optimism fueled by the Patient Centered Outcomes Research Institute (PCORI), funding challenges will persist. The United States spends almost $3 trillion on health care. According to some analysts, up to 1/3 of these expenditures are wasted on inappropriate, equivocal, misapplied, or inefficient care. If just 1 % of health care payments were applied to scientific evaluation of what works and what doesn’t in health care, a pool of $30 billion would become available to generate answers our country sorely needs. Several articles in this issue of JGIM showcase the value of rigorous empirical research in evaluating innovations in health care practice and policy. The Patient Centered Medical Home (PCMH) has been touted as a solution to the current crisis in primary care, but most evaluations to date have been observational. In two related articles, Fifield, et al. describe the implementation and experimental evaluation of the PCMH model in small-medium sized practices. In their cluster-randomized trial, most practices were successful in achieving NCQA recognition, but there were few consistent differences in processes and outcomes between PCMH and control practices. An accompanying editorial by Landon puts the data in context. The PCMH has implications not just for patients and practitioners but for physicians-in-training. Chang et al. describe a consensus meeting leading to a set of 25 “entrustable professional activities” that residents will be encouraged to perform with varying degrees of independence. Some of the activities are familiar (e.g. “devise a longitudinal care plan for chronic disease”), but others (e.g., “lead an interprofessional health care team”) will require new skills and new curricula to support their development. Workforce development is key to maintaining a robust primary care infrastructure, and medical schools must do their part. Are they contributing in fair measure? An article by Choi and Ayanian suggests not. Research intensive schools produce fewer primary care graduates than their less research-intense counterparts. Lest readers be too quick to judge the Harvards of the world, a Capsule Commentary by Jackson points out that other factors besides medical school orientation (things like salary, prestige, and lifestyle) are likely to be much more important as causes of the primary care workforce crisis. Published online April 12, 2013 JGIM

Unlocking information for coordination of care in Australia: a qualitative study of information continuity in four primary health care models

BackgroundCoordination of care is considered a key component of patient-centered health care systems, but is rarely defined or operationalised in health care policy. Continuity, an aspect of coordination, is the patient’s experience of care over time, and is often described in terms of three dimensions: information, relational and management continuity. With the current health policy focus on both the use of information technology and care coordination, this study aimed to 1) explore how information continuity supports coordination and 2) investigate conditions required to support information continuity.MethodsFour diverse Australian primary health care initiatives were purposively selected for inclusion in the study. Each has improved coordination as an aim or fundamental principle. Each organization was asked to identify practitioners, managers and decision makers who could provide insight into the use of information for care coordination to participate in the study. Using in-depth semi-structured interviews, we explored four questions covering the scope and use of information, the influence of governance, data ownership and confidentiality and the influence of financial incentives and quality improvement on information continuity and coordination. Data were thematically analyzed using NVivo 8.ResultsThe overall picture that emerged across all four cases was that whilst accessibility and continuity of information underpin effective care, they are not sufficient for coordination of care for complex conditions. Shared information reduced unnecessary repetition and provided health professionals with the opportunity to access records of care from other providers, but participants described their role in coordination in terms of the active involvement of a person in care rather than the passive availability of information. Complex issues regarding data ownership and confidentiality often hampered information sharing. Successful coordination in each case was associated with responsiveness to local rather than system level factors.ConclusionsThe availability of information is not sufficient to ensure continuity for the patient or coordination from the systems perspective. Policy directed at information continuity must give consideration to the broader ‘fit’ with management and relational continuity and provide a broad base that allows for local responsiveness in order for coordination of care to be achieved.

Ethical Challenges in International Surgical Education, for Visitors and Hosts

Contributing to medical practice in developing countries has become increasingly prevalent. Primary care and preventative health initiatives have been most visible, although attention has recently shifted to surgical disease, which represents a large burden in resource-poor settings. Typically dominated by individual efforts, there is now a more concerted approach, with surgical care being included in the comprehensive primary health care plan set by the World Health Organization. Although ethical dilemmas in international surgery have been discussed sporadically in the context of specific missions from the visiting surgeon/team perspective, we are missing a comprehensive evaluation of these issues in the literature. Here we have chosen to systematically categorize ethical issues confronted while teaching and operating in a developing country into 2 broad categories: venue (i.e., host) and visitor related. For each category, topics within follow an ordinal sequence that one might use when designing a surgical education mission. Illustrative examples are provided, as well as a depiction of the ethical principles or theories involved. This article provides a discussion written from visiting and host surgeon perspectives on diverse ethical challenges for which there is limited literature, including location selection, unmet needs at home, role of sponsors, and personal gain. In addition to candid discussion and a solutions-focused approach, the reader is provided with an "ethical checklist" for international surgical education, akin to the World Health Organization surgical safety checklist, to serve as a framework for the design of surgical missions that avoid ethical pitfalls.

The Mental Health Nurse Incentive Program: reactions of general practitioners and their patients

To evaluate reactions of general practitioners (GPs) and their patients to the Mental Health Nurse Incentive Program (MHNIP). A descriptive, exploratory approach was employed using discussion groups with 25GPs and individual interviews with 19 patients receiving treatment through the MHNIP. All discussion groups and interviews were audio taped, transcribed and analysed using thematic content analysis. There was overwhelming support for the MHNIP across GP and patient groups. Patients noted that the treatment provided through the program was convenient, holistic and non-stigmatising. GPs valued the collaborative working arrangements with mental health nurses (MHNs) and highlighted the ability of these nurses to provide a wide range of interventions for patients with complex mental health problems. The collaborative working arrangement between GPs and MHNs promoted through the MHNIP was perceived to have significantly enhanced primary care services for those with mental health problems. What is known about the topic? The introduction of MHNs into GP practices under the MHNIP, a new primary care initiative, represents a major reform in the provision of primary care services for those with mental health problems. What does this paper add? This paper reports on the reactions of GPs and patients to the introduction of the MHNIP. What are the implications for practitioners? The collaborative model promoted through the program enables family doctors to play a greater role in the management of mental health conditions within the primary care setting. MHNs working with the program need considerable experience and skill in dealing with a broad range of mental health problems. In general, GPs require a better understanding of the overall program.

Determinants of childhood mortality in slums of Karachi, Pakistan.

Pakistan has an infant mortality rate (IMR) of 90.5/1000 live births, and the country's child mortality level of 117.5 is worse than in other South Asian countries. Rapid population growth combined with rural-to-urban migration has led to the creation of urban slums in which morbidity levels are usually higher than in rural populations. A study was conducted in January 1993 in 6 slums of Karachi where the Aga Khan University has operated primary health care programs since 1985. Researchers recorded the deaths of 347 children under age 5 years old due to diarrhea and acute respiratory infections (ARI) during 1989-93. 235 mothers of these children were interviewed. The following are discussed as risk factors for under-5 child mortality: the use of traditional healers, poor nutritional status, incomplete or no immunization, the quick change of healers, inappropriate child care arrangements, mother's literacy, who decides about outside treatment, short birth interval, bottle feeding, and nuclear family structure. Maternal autonomy, appropriate health-seeking behavior, and child-rearing processes identified in the study point to the need for intervention strategies which go beyond the usual primary health care initiatives and involve communities in developing social support systems for mothers.

Breastfeeding as an evaluative practice in know-how: a descriptive study

Aim: To analyze the axiological dimensions of nurses regarding breastfeeding and their reflections along with the nursing mothers, in the process of knowledge transmission. Method: A descriptive and qualitative study of 11 nurses from the Friendly Breastfeeding Primary Care Initiative of Rio de Janeiro. The data were collected by means of semi-structured interviews between January/March 2010, generating categories articulated with Max Scheler’s Theory of Values. Result: The following categories emerged: the affective bond as a value for successful breastfeeding; and breastfeeding and nutritional value and protection for the child. Discussion: To analyze the evaluative link of the act of breastfeeding between mother and child and the link related to the value of food safety also means thinking about the love and affection that, in the conception of Scheler, are absolutely unique. Conclusion: the valuation of women as individuals is seen through a totally new perspective concerning breastfeeding, as recommended by public policies regarding women’s care.

Comprehensive Primary Care Initiative Called a Gamble

Caring for the Ages is the official newspaper of AMDA and provides long-term care professionals with timely and relevant news and commentary about clinical developments and about the impact of health care policy on long-term care medicine.

Feds' Primary Care Initiative May Be a Worthwhile Gamble

Feds' Primary Care Initiative May Be a Worthwhile Gamble

Sustainability in primary care and Mental Health Integration projects in Veterans Health Administration.

To explore staff perceptions about sustainability, commitment to change, participation in change process, and information received about the change project within the Veterans Administration Primary Care and Mental Health Integration (PC-MHI) initiative and to examine differences from the Veterans Health Administration Mental Health Systems Redesign (MHSR) initiative. Surveys of change team members involved in the Veterans Affairs PC-MHI and MHSR initiatives. One-way analysis of variance examined the relationship between commitment, participation and information, and sustainability. Differences in PC-MHI sustainability were explored by location and job classification. Staff sustainability perceptions were compared with MHSR results. Sustainability differed by staff discipline. Difference between MHSR and PC-MHI existed by job function and perceptions about the change benefits. Participation in the change process and information received about the change process were positively correlated with sustainability. Staff commitment to change was positively associated with staff perceptions about the benefits of change and staff attitudes toward change. Sustainability is an important part of organizational change efforts. Change complexity seems to influence perception about sustainability and impacts staff perceptions about the benefits of change. These perceptions seem to be driven by the information received and opportunities to participate in the change process. Further research is needed to understand how information and participation influence sustainability and affect employee commitment to change.

Primary Care Initiative a Worthwhile Gamble

Primary Care Initiative a Worthwhile Gamble

Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus

There has been dramatic change in antibiotic use in English hospitals. Data from 2004 and 2009 show that the focus on reducing fluoroquinolone and second- and third-generation cephalosporin use seems to have been heeded in NHS secondary care, and has been associated with a substantial decline in hospital Clostridium difficile rates. However, there has been a substantial increase in use of co-amoxiclav, carbapenems and piperacillin/tazobactam. In primary care, antibiotic prescribing fell markedly from 1995 to 2000, but has since risen steadily to levels seen in the early 1990s. There remains a 2-fold variation in antimicrobial prescribing among English General Practices. In 2010, the NHS Atlas of Variation documented a 3-fold variation in the prescription of quinolones and an 18-fold variation in cephalosporins by Primary Care Trusts across England. There is a clear need to improve antimicrobial prescribing. This paper describes the development of new antimicrobial stewardship programmes for primary care and hospitals by the Department of Health's Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection: Antimicrobial Stewardship in Primary Care Initiative. The secondary care programme promotes the rapid prescription of the right antibiotic at the right dose at the right time, followed by active review for all patients still on antibiotics 48 h after admission. The five options available are to stop, switch to oral, continue and review again, change (if possible to a narrower spectrum) or move to outpatient parenteral antibiotic therapy. A range of audit and outcome tools has been developed, but to maintain optimal antimicrobial usage, monitoring of local and national quantitative and qualitative data on prescribing and consumption is required, linked to the development of key performance indicators in primary, secondary and tertiary care.

Lessons learned in developing community mental health care in Australasia and the South Pacific

This paper summarizes the findings for the Australasia and Pacific Region of the WPA Task Force on Steps, Obstacles and Mistakes to Avoid in the Implementation of Community Mental Health Care. We present an overview of mental health services in the region; discuss policies, plans and programmes; chart progress towards achieving community-oriented services, and detail the lessons learned.

Interview With Dr. Omar Khan, Noted Global Health Specialist

Dr. Khan has had a distinguished career in global health. He has served as a faculty member at the University of Vermont College of Medicine and Johns Hopkins University School of Public Health. He is currently a family medicine physician at Christiana Care Health System in Newark, Delaware, and is President of the Delaware Academy of Family Physicians. Dr. Khan has authored more than 55 peer-reviewed journal articles and book chapters and has conducted research and lead primary care and public health initiatives in numerous countries. Last year, Dr. Khan also coedited a book titled Megacities and Global Health sponsored by the American Public Health Association with Dr. Gregory Pappas, Deputy Health Commissioner for Washington, DC.

Organized Blood Pressure Control Programs to Prevent Stroke in Australia

High blood pressure (BP) is the most important modifiable stroke risk factor. Worldwide high BP in many people is uncontrolled or people are unaware of their BP status. We aimed to assess whether a program of organized multidisciplinary care and medication would be cost-effective for improving BP control for the prevention of stroke. A novel aspect was to simulate the intervention to match recent primary care initiatives (eg, new Medicare reimbursement items) to ensure policy relevance. Current practice and additional costs of each intervention were included using the best available evidence. The differences in the cost per quality-adjusted life year (QALY) gained for the interventions were compared against current practice. Cost-effectiveness was defined as cost per QALY gained was less than Australian dollars (AUD) 50 000 (societal perspective; reference year 2004). The robustness of estimates was assessed with probabilistic multivariable uncertainty analysis. For primary prevention, the median cost per QALY gained was AUD11 068 (95% uncertainty interval AUD5201 to AUD18 696) in those aged 75 years or older and was AUD17 359 (95% uncertainty interval AUD10 516 to AUD26 036) in those aged 55 to 84 years with ≥15% absolute risk of stroke. Primary prevention interventions were not cost-effective if aged younger than 50 years. The median cost per QALY gained for secondary prevention was AUD1811 and AUD4704, depending on which medications were modeled. Organized care for BP control targeted at specific populations offers excellent value over current practice. Organized care for secondary prevention provided the greatest benefits and strongest cost-effectiveness. Translation into clinical practice requires improved use of relevant Medicare policy in Australia.

Getting tough on pain

More than a decade after the discovery of nociceptors, physicians still have very few options for treating chronic pain. Recent research on pain perception might finally be leading to new therapeutic strategies and drugs.

Quality and safety of medication use in primary care: consensus validation of a new set of explicit medication assessment criteria and prioritisation of topics for improvement

BackgroundAddressing the problem of preventable drug related morbidity (PDRM) in primary care is a challenge for health care systems internationally. The increasing implementation of clinical information systems in the UK and internationally provide new opportunities to systematically identify patients at risk of PDRM for targeted medication review. The objectives of this study were (1) to develop a set of explicit medication assessment criteria to identify patients with sub-optimally effective or high-risk medication use from electronic medical records and (2) to identify medication use topics that are perceived by UK primary care clinicians to be priorities for quality and safety improvement initiatives.MethodsFor objective (1), a 2-round consensus process based on the RAND/UCLA Appropriateness Method (RAM) was conducted, in which candidate criteria were identified from the literature and scored by a panel of 10 experts for 'appropriateness' and 'necessity'. A set of final criteria was generated from candidates accepted at each level. For objective (2), thematically related final criteria were clustered into 'topics', from which a panel of 26 UK primary care clinicians identified priorities for quality improvement in a 2-round Delphi exercise.Results(1) The RAM process yielded a final set of 176 medication assessment criteria organised under the domains 'quality' and 'safety', each classified as targeting 'appropriate/necessary to do' (quality) or 'inappropriate/necessary to avoid' (safety) medication use. Fifty-two final 'quality' assessment criteria target patients with unmet indications, sub-optimal selection or intensity of beneficial drug treatments. A total of 124 'safety' assessment criteria target patients with unmet needs for risk-mitigating agents, high-risk drug selection, excessive dose or duration, inconsistent monitoring or dosing instructions. (2) The UK Delphi panel identified 11 (23%) of 47 scored topics as 'high priority' for quality improvement initiatives in primary care.ConclusionsThe developed criteria set complements existing medication assessment instruments in that it is not limited to the elderly, can be implemented in electronic data sets and focuses on drug groups and conditions implicated in common and/or severe PDRM in primary care. Identified priorities for quality and safety improvement can guide the selection of targets for initiatives to address the PDRM problem in primary care.

Improving primary health care services for young people experiencing psychological distress and mental health problems: a personal reflection on lessons learnt from Australia and England

Australia and England show high rates of psychological distress and mental health problems in young people. Both are high-income countries and have stated their intention to improve the delivery of health care to young people in primary care settings. Australia has an international reputation for improving care through innovative services and educational initiatives. England has taken a different direction and has concentrated more on developing policy and making recommendations to improve access for young people. To describe a Churchill Fellowship visit to Australia to observe initiatives in primary care based youth-friendly mental health care and to reflect upon the observations, comparing and contrasting with the English model. The observations and reflections presented draw on field notes from site visits and meeting with key players, accessing web resources and referring to the literature, both grey and published. Australia offers plurality in health care delivery and innovative responses to addressing youth mental health. There are two key approaches. The first is the development of services specializing in youth mental health. The second approach is to build capacity of existing primary care services to recognize the particular bio-psychosocial needs of adolescents (and their families). In contrast, England has tended to focus primarily on policy development and improving youth access. The paper draws attention to a number of political, clinical and educational developments in both Australia and England. Both countries demonstrate different strategies in response to the high levels of psychological distress in young people. Learning from colleagues in other settings can inform our own practice. Ultimately responding to young people's mental health needs is best served by youth-friendly policy which prepares clinicians for effective practice, informed by applied research and supported by adequate resources. Investment in young people's health must be a priority for us all.