Organization Of Primary Care Services Research Articles

Interventions to improve teamwork and wellbeing in primary care settings: a mixed method review

Abstract Background General practices are experiencing increasing pressures due to rising demand, declining staff numbers, and knock-on impacts on patient care. The COVID-19 pandemic has added further challenges and reinforced the importance of teamwork and organisational settings. We undertook a mixed-method systematic review to explore which interventions can improve teamwork within primary care and improve inter-sector partnerships with other health and social care services. Methods Five major bibliographic databases were systematically searched for relevant studies from inception to February 2022. We included controlled intervention study designs and linked qualitative studies. For amenable data, meta-analysis is being undertaken using random effects models taking into account the between study heterogeneity (quantified using the I2 statistic) and potential publication bias (funnel plots and Egger's test). The qualitative studies are analysed using thematic analyses. Results The original search yield of 3012 studies, of which 14 studies with 1,534 participants were include in our analyses. Most of the evaluated interventions focused on improving non-technical skills and provided evidence of improvements in the quality of teamwork in primary care. Meta-analysis and narrative synthesis is undertaken to examine the impact of the teamwork interventions on staff outcomes (team attitudes, knowledge, and functioning; wellbeing), and patient outcomes (e.g. quality of patient care, patient satisfaction/experience). Conclusions The findings provide information of immediate importance for the mental health and wellbeing and teamwork support of professionals entering primary care and for the organisation of primary care services.

Pandemic resilience and health systems preparedness: lessons from COVID-19 for the twenty-first century.

The pandemic of COVID-19 disease has acted like a stress test on every aspect of life, but particularly exposed weaknesses of health systems design and capacity. There have been similar pandemics in the past, and the threat of more frequent future pandemics in the twenty-first century is real. It is therefore important to learn the right lessons with regard to health systems preparedness and resilience. The five design features that this paper discusses are related to the organization of primary care services, planned surge capacity in secondary and tertiary care, a robust disease surveillance system that is integrated with the health management information system, adequate domestic capacity in being able to innovate and scale up production and logistics of much needed medical products and a governance approach that recognizes the importance of the health systems being able to continuously learn and adapt to meet changing needs. In addition to this, the organizational capacity of the system to deliver required services would need more investment in financial resources, and a suitable health human resource policy.

Children deserve adequately trained doctors

Abstract Children treated in different European countries continue to have very variable outcomes. Among several factors that might affect these outcomes, organisation of primary care services for children and training programmes for primary care clinicians are likely to be important factors. Children have an unquestionable right to health, safety, and wellbeing. Children have the right to access the highest possible standards of health-care services and facilities, both in primary health care and when they need specialised care. Any restriction of provision of appropriate care would contradict article 24 of the UN Convention on the Rights of the Child. Paediatric primary care is an academic and scientific discipline dealing with all issues affecting the health and wellbeing of infants, children, and adolescents from birth to adulthood in the context of their family, community, and culture. The primary clinician, ideally a paediatrician, is the first contact for children until they reach adulthood and is thus responsible for provision of comprehensive and continuing care throughout infancy, childhood, and adolescence. Paediatric care in both primary care and hospital settings needs special knowledge, ethics, empathic behaviour, and access to services, including disease prevention and health promotion. These aspects are therefore mandatory for all paediatric training both for paediatricians and family doctors. There should be a structured and accountable paediatric training programme for all doctors providing first-line care to children in primary care. When family doctors provide primary health care close collaboration with paediatricians and adequate continued training in both paediatrics and primary care is advised. Moreover, all children need timely access to professional paediatric advice.

Can the primary health care model affect the determinants of neonatal, post-neonatal and maternal mortality? A study from Brazil

BackgroundThe state of São Paulo recorded a significant reduction in infant mortality from 1990 to 2013, but the desired reduction in maternal mortality was not achieved. Knowledge of the factors with impact on these indicators would be of help in formulating public policies. The aims of this study were to evaluate the relations between socioeconomic and demographic factors, health care model and both infant mortality (considering the neonatal and post-neonatal dimensions) and maternal mortality in the state of São Paulo, Brazil.MethodsIn this ecological study, data from national official open sources were used to conduct a population-based study. The units analyzed were 645 municipalities in the state of São Paulo, Brazil. For each municipality, the infant mortality (in both neonatal and post-neonatal dimensions) and maternal mortality rates were calculated for every 1000 live births, referring to 2013. Subsequently, the association between these rates, socioeconomic variables, demographic models and the primary care organization model in the municipality were verified. For statistical analysis, we used the zero-inflated negative binomial model. Gross analysis was performed and then multiple regression models were estimated. For associations, we adopted “p” at 5%.ResultsThe increase in the HDI of the city and proportion of Family Health Care Strategy implemented were significantly associated with the reduction in both infant mortality (neonatal + post-neonatal) and maternal mortality rates. In turn, the increase in birth and caesarean delivery rates were associated with the increase in infant and maternal mortality rates.ConclusionsIt was concluded that the Family Health Care Strategy was a Primary Care organization model that contributed to the reduction in infant (neonatal + post-neonatal) and maternal mortality rates, and so did actors such as HDI and cesarean section. Thus, public health managers should prefer this model when planning the organization of Primary Care services for the population.

Changes in Quality Indicators Relating to Organization of Primary Care Services between 2007 and 2010 in São Paulo State, Brazil.

Changes in Quality Indicators Relating to Organization of Primary Care Services between 2007 and 2010 in São Paulo State, Brazil.

Trends in hospitalization due to cardiovascular conditions sensitive to primary health care.

To analyze the trend in hospitalizations for primary care-sensitive cardiovascular conditions for residents of the state of Paraná, Brazil, from 2000 to 2011. Ecological, time series study of the rates of hospitalization for cardiovascular diseases in residents aged 35-74 years old by sex, age and main diagnosis for hospitalization. Data from the Hospital Information System of the Unified Health System (SIH-SUS) and polynomial regression models for trend analyses were used. Hospitalization rates for cardiovascular conditions decreased during the period (r2 = 0.96; p < 0.001), with similar decreasing patterns for males and females, in all age ranges, although always higher for males. Although hospitalization trends for hypertension, heart failure and cerebrovascular disease decreased, angina remained stable for males and females. A downward trend in hospital admissions due to primary care-sensitive cardiovascular conditions in the state of Paraná between 2000 and 2011 may have resulted from the expansion of the health network of and the access to primary health attention, as well as other factors that influence this set of diseases, such as improved socioeconomic conditions of the population, organization of primary care services for higher age ranges and women and decrease in risk factors.

A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care

To compare the effectiveness of care delivered by nurses to the usual care delivered by general practitioners, in adult patients requesting same day appointments in primary care practices in Catalonia (Spain). Same day appointments conducted by nurses are characterized by high patient satisfaction and a high resolution index. The profile of nursing and the organization of primary care services in our country differ from other countries. Multicentre, randomized, unblinded clinical trial with two parallel groups. Patients were randomized to an intervention group (seen by nurses trained to respond to low complexity problems) or a control group (seen by the general practitioner) using an automatic probabilistic function. 38 primary care practices in Catalonia, 142 general practitioners and 155 nurses participated. Population study: ≥ 18-year-old patients who requested a same day consultation. Recruitment period: January-May, 2009. Of the 1,461 randomized patients, 92.5% completed the study. resolution of symptoms and patient satisfaction 2 weeks after the visit. Seven hundred and fifty-three patients were assigned to the intervention group and 708 to the control group. Nurses successfully solved 86.3% of the cases. We did not observe any differences in resolution of symptoms or patient satisfaction between the groups. Nurses trained specifically to resolve acute health problems of low complexity give comparable quality of care to that provided by general practitioners in terms of resolution of the problem 15 days after the visit and in patient satisfaction with the visit.

The California Challenge: Ensuring Primary Care Access for Medi-Cal Recipients under the Affordable Care Act

THE CALIFORNIA Journal of Politics & Policy Volume 3, Issue 4 The California Challenge: Ensuring Primary Care Access for Medi-Cal Recipients under the Affordable Care Act Donald A. Barr Stanford University Abstract This paper describes options for expanding access to care for California’s Medi- Cal population. Recent federal policy initiatives and an expanding set of research reports have begun to focus considerable attention on developing new models for the organization of primary care services. Initial results suggest that these innova- tive delivery models can both decrease the overall cost of care while improving the quality of care. This conclusion is especially relevant for those who provide care to Medi-Cal recipients with chronic medical conditions—the population that con- tributes by far the most to the cost of Medi-Cal. The exigencies of containing both federal and state health care expenditures for all covered populations make consid- eration of alternative modes of health care delivery an essential part of any analysis of the potential impacts of ACA, both in California and throughout the country. Keywords: medical care, Affordable Care Act, Medi-Cal, Medicaid Copyright © 2011 The Berkeley Electronic Press. All rights reserved. www.bepress.com/cjpp

Práticas em saúde no contexto de reorientação da atenção primária no Estado do Rio de Janeiro, Brasil, na visão das usuárias e dos profissionais de saúde

This evaluative study focused on expansion of the Family Health Strategy in large cities in Rio de Janeiro State, Brazil. The study analyzed the functionality of health care modalities, performance, and supply of comprehensive care itself and its link to services at other levels. The thrust of the analysis was comprehensiveness of care in the daily routine of health services, with a focus on childbearing-age women, and with pregnancy as the tracer condition. The results emerged from an analysis of focus groups with health care users and health professionals, based on: characterization of key actors; their perceptions concerning health, healthcare model, and organization of primary care services and practices. The groups suggested that the actors perceive health as identified with social determinants. Access to services and actions was differentiated in the family health unit by enrollment of the clientele and active search, and the study showed the lack of a structured network. The study indicates that work processes contemplating the social determination of health and its intersectorality can lead to expanded access to comprehensive care for childbearing-age women.

Using Logic Analysis to Evaluate Knowledge Transfer Initiatives

Models that shift more responsibility onto researchers for the process of incorporating research results into decision-making have greatly gained in popularity during the past two decades. This shift has created a new area of research to identify the best ways to transfer academic results into the organizational and political arenas. However, evaluating the utilization of information coming out of a knowledge transfer (KT) initiative remains an enormous challenge. This article demonstrates how logic analysis has proven to be a useful evaluation method to assess the utilization potential of KT initiatives. We present the case of the evaluation of the Research Collective on the Organization of Primary Care Services, an innovative experiment in knowledge synthesis and transfer. The conclusions focus not only on the utilization potential of results coming out of the Research Collective, but also on the theoretical framework used, in order to facilitate its application to the evaluation of other knowledge transfer initiatives.

Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study

BackgroundReports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract.MethodsWe analyzed data from 8,970 general practices with a total registered population of 55,522,778 patients in England and Scotland. We measured practice performance against 26 cardiovascular disease (coronary heart disease, left ventricular disease, and stroke) Quality and Outcomes Framework (QOF) indicators for patients on cardiovascular disease registers and linked this with data on practice characteristics and census data.ResultsDespite wide variations in practice list sizes and deprivation, the prevalence of was remarkably consistent, (coronary heart disease, left ventricular dysfunction, hypertension and cerebrovascular disease was 3.7%; 0.45%; 11.4% and 1.5% respectively). Achievement in quality of care for cardiovascular disease, as measured by QOF, was consistently high regardless of caseload or size with a few notable exceptions: practices with larger list sizes, higher cardiovascular disease caseloads and those in affluent areas had higher achievement of indicators requiring referral for further investigation. For example, small practices achieved lower scores 71.4% than large practices 88.6% (P < 0.0001) for referral for exercise testing and specialist assessment of patients with newly diagnosed angina.ConclusionThe volume-outcome relationship found in hospital settings is not seen between practices in the UK in management of cardiovascular disorders in primary care. Further work is warranted to explain apparently poorer quality achievement in some aspects of cardiovascular management relating to initial diagnosis and management among practices in deprived areas, smaller practices and those with a smaller caseload.

Getting a visit: How district nurses and general practitioners ‘organise’ each other in primary care

This paper examines the ways in which district nurses and general practitioners interacted and influenced each other's work within primary care services. The data presented here examine how the developments in the organisation of primary care affected the work of district nurses during a time of turbulent change. Qualitative data from 300 hours of participant observation and 40 semi-structured interviews with 33 district nurses were analysed using grounded theory, after which a literature review was undertaken. The findings from this study were interpreted using a Foucauldian notion of power and Fox's (1995) analysis of 'organisation'. The shift in power to general practitioners (GPs) has meant that they can exercise ever-increasing authority over nurses in their employ. Strict rules governed the process of inter-professional work and nurses and doctors used creative strategies to overcome the problems that existed between them. The data show that nurses could and did resist the power of GPs but this resistance generally elicited other more punishing forms of authority. Direct and indirect threats were commonplace. The data suggest that district nurses were moving into a closer, more business-like and tightly-controlled working relationship with general practitioners, through which competing discourses interplayed and circulated between GPs and district nurses in the organisation of primary care services.

Quality of primary health care in Saudi Arabia: a comprehensive review

Little is known about the quality of primary care in Saudi Arabia, despite the central role of primary care centers in Saudi health strategy. This study presents an overview of quality of primary care in Saudi Arabia, and identifies factors impeding the achievement of quality, with the aim of determining how the quality of Saudi primary care could be improved. Using a systematic search strategy, data were extracted from the published literature on quality of care in Saudi primary care services, and on barriers to achieving high-quality care. Of the 128 studies initially identified, 31 met the inclusion criteria for the review. Studies identified were diverse in methodology and focus. Components of quality were reviewed in terms of access and effectiveness of both clinical and interpersonal care. Good access and effective care were reported for certain services including: immunization, maternal health care, and control of epidemic diseases. Poor access and effectiveness were reported for chronic disease management programs, prescribing patterns, health education, referral patterns, and some aspects of interpersonal care including those caused by language barriers. Several factors were identified as determining whether high-quality care was delivered. These included management and organizational factors, implementation of evidence-based practice, professional development, use of referrals to secondary care, and organizational culture. There is substantial variation in the quality of Saudi primary care services. In order to improve quality, there is a need to improve the management and organization of primary care services. Professional development strategies are also needed to improve the knowledge and skills of staff.

Changes in patterns of knowing the patient: the case of British district nurses

British district or home nurses, have until recent years been hidden from the wider context of the British National Health Service. Policy changes in UK over the last two decades of the 20th century have increasingly focussed on Primary Care Services and district nurses (DNs) have seen substantial changes to their workload. This paper addresses the question of how the changes in the organisation of Primary Care Services affected some aspects of DNs’ work. Thus, the focus of this paper is an examination of the relationship DNs had with patients through a period of turbulent change. Knowing the patient is a central element of nursing practice. Data are presented here form a multi-site ethnographic study of DNs’ work undertaken in four purposively sampled study sites. Applying Carper's (1978) framework, the data presented here show that there has been a shifting emphasis in knowing the patient from aesthetic and personal knowing to knowing about and empirical knowing.

Liaison psychiatry in rural general practice.

The recent government health strategy document described the integration between primary and secondary care in Ireland as often poor and outlined plans to redress this deficit. In mental health care, the gradual shift away from institutions over the past four decades has resulted in the GP becoming the most frequent professional contact for people with mental disorders. However, access to specialist opinion is usually available only for the fraction of psychiatric presentations which are formally referred to the psychiatric service. On-site psychiatric liaison to primary care is commonly practised in other countries but not in Ireland. Research in the area suggests possible advantages for approaches which aim to enhance GPs' psychiatric skills while selectively encouraging referral of more serious disorders. This model has been adopted by GPs and psychiatrists in east Cavan and may be relevant to other similar settings, especially in the context of forthcoming changes in the organisation of primary care services.

Association between practice size and quality of care of patients with ischaemic heart disease: cross sectional study

Proportionally fewer inpatients die in hospitals that do more operations than in hospitals that do fewer.1 Similar associations between outcome and the size of hospitals have been found in other...

Report from University of Bristol

Professor Debbie Sharp was appointed to the foundation Chair of Primary Health Care at Bristol in 1994, initially as part of the Department of Public Health and Epidemiology. The subsequent creation of an autonomous Division of Primary Health Care, re-located within the Department of Clinical Medicine, has resulted in a signiŽcant upgrading of the academic standing of the discipline within the University. This has been achieved by increasing the ow of high quality research output from the Division and a much-enhanced contribution to the Medical School’s demanding teaching programme. The Division has been very successful in obtaining high quality external research grant funding and in obtaining research fellowships from a variety of different bodies. Primary Health Care has now achieved an enviable balance of senior:training and clinical:non-clinical staff. The Division’s research portfolio continues to show the breadth associated with a generalist area. However, activity is consolidating around several clear areas of expertise, each being developed under the auspices of one of the Division’s senior academic staff. Professor Debbie Sharp leads the focus on mental health in primary care, including projects examining aspects of post-natal depression, dementia, deliberate self-harm and depression:anxiety. Other current projects under her guidance include those researching emergency contraception, breast screening, cancer genetics, multiple sclerosis and childhood immunisation. Doctor Tom Fahey has recently been awarded the prestigious Žve-year NHS Primary Care Career Scientist award. His Želd of investigation includes decision-support, hypertension, cardiovascular disease in primary care and the treatment of acute respiratory infections. Doctor Fahey has also had great success in guiding the careers of junior research staff towards, for example, the achievement of national training fellowships. Doctor Chris Salisbury’s research interests include the organisation of primary care services, such as out-of-hours services, the development of a new health park and the establishment of walk-in centres. His research responsibilities also encompass care for children with life-threatening illnesses and schoolbased services for teenagers diagnosed with asthma. The strategy for the next Žve years is to further develop programmes of work which play to the strengths of the Division’s senior researchers alongside the ability to respond swiftly and appropriately to government initiatives. Therefore, the research portfolio will balance commissioned research and responsive funding. In line with government policy to expand the research capacity in primary care, the Division of Primary Health Care has been instrumental in developing a practice-based research network, GANG (Gloucestershire and Avon Network Group for primary care research). The primary care practitioners within the network receive education and training in research methods and participate in university initiated research. There is also a smaller group of sixteen practices with whom the Division has developed very close relationships in terms of being major collaborators with or, in some instances, co-principal investigators on major research projects. All these practices are essential players in the studies that require the participation of large populations. Health-related research is also in progress elsewhere within the University, notably in the Department of Social Medicine and the MRC Health Services Research Unit (HSRC). Several ongoing projects involve principal investigators from the HSR Division of Social Medicine. With regard to teaching, the Division remains a very active contributor to the new curriculum (introduced 1995) and now teaches across all Žve years of the curriculum. We have initiated clinical teaching in general practice in the Žrst term of Year 1 and built on this experience in each of the subsequent years. We also take overall responsibility for communication skills teaching throughout the curriculum. The Division of Primary Health Care is located in Canynge Hall on Whiteladies Road in Clifton, adjacent to the main university campus and facilities. Canynge Hall has its own library and excellent computer resources. Primary Health Care shares this

Organisation of primary care services outside normal working hours.

To determine the use and organisation of out of hours services in primary care. Telephone survey. Family health services authorities in England and Wales. Rate of use of out of hours care, methods of provision, and role of authorities. 12-25% of authorities were unable to answer one or more key questions in the survey because of insufficient information. The mean number of night visits made per unrestricted principal per 1000 patients per year was 35.3. 13 of the 19 authorities with averages above 40 covered large towns or cities. 81 authorities had at least one commercial deputising service. In 46 metropolitan districts and one other district over 75% of general practitioners had consent to use a deputising service, although not all did so. Information on cooperation between practices was limited. 22 cooperatives were recognised by the authorities, nine were not officially recognised, and a further 13 were nearing institution. Only two cooperatives were in areas with extensive use of deputising services. Methods of providing out of hours care are changing, and without good information systems family health services authorities will not be able to monitor the effect on quality and cost effectiveness of care.

Cancer screening practices of Nurse Practitioners

The Nurse Practitioner's (NP) role in providing quality primary care with emphasis on health promotion is well established. Yet the NP's actual cancer detection activities are unknown. To determine the cancer screening and detection activities of NPs in adult primary care settings, a questionnaire survey was developed from the American Cancer Society's "Guidelines for the Cancer-Related Checkup" and current cancer detection literature. The survey was distributed to primary care NPs throughout the state of Michigan (n = 97). Pearson correlation coefficients were applied to the data to establish the relationship of cancer screening practices by NPs to specific age groups and by gender. Practitioners reported significantly higher frequencies of recommended screening for adult women than for adult men. Although at a lower risk for developing cancer, younger and early middle-aged adults (19-39 years) received significantly higher frequencies of recommended screening than middle-aged and older adults. NPs believe that cancer screening and counseling are consistent with their role except in the areas of male physical exam (testes, prostate) and invasive procedures such as sigmoids for men and women. The broader implications for further research, organization of primary care services, and strategies to increase nurses' involvement in cancer screening practices are presented.