Primary Care Items Research Articles

Protocol for evaluation of enhanced models of primary care in the management of stroke and other chronic disease (PRECISE): A data linkage healthcare evaluation study.

IntroductionThe growing burden of chronic diseases means some governments have been providing financial incentives for multidisciplinary care and self-management support delivered within primary care. Currently, population-based evaluations of the effectiveness of these policies are lacking.AimTo outline the methodological approach for our study that is designed to evaluate the effectiveness (including cost) of primary care policies for chronic diseases in Australia using stroke as a case study.MethodsPerson-level linkages will be undertaken between registrants from the Australian Stroke Clinical Registry (AuSCR) and (i) Government-held Medicare Australia claims data, to identify receipt or not of chronic disease management and care coordination primary care items; (ii) state government-held hospital data, to define outcomes; and (iii) government-held pharmaceutical and aged care claims data, to define covariates. N=1500 randomly selected AuSCR registrants will be sent surveys to obtain patient experience information. In Australia, unique identifiers are unavailable. Therefore, personal-identifiers will be submitted to government data linkage units. Researchers will merge the de-identified datasets for analysis using a project identifier. An economic evaluation will also be undertaken.AnalysisThe index event will be the first stroke recorded in the AuSCR. Multivariable competing risks Poisson regression for multiple events, adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations and medication adherence for different care (policy) types. Our estimated sample size of 25,000 patients will provide 80% estimated power (ɑ>0.05) to detect a 6-8% difference in rates. The incremental costs per Quality-adjusted life years gained of community-based care following the acute event will be estimated from a health sector perspective.ConclusionCompletion of this study will provide a novel and comprehensive evaluation of the effectiveness and cost-effectiveness of Australian primary care policies. Its success will enable us to highlight the value of data-linkage for this type of research.

Using linked data to evaluate enhanced primary care policies for chronic diseases using stroke as a case study

IntroductionThe global burden of chronic diseases is large and increasing. In response, governments are investing substantial funds in innovative models of primary care, characterised by multidisciplinary care and self-management support for people with chronic conditions. Currently, large scale population-based evaluations of the effectiveness of these policies are lacking.
 Objectives and ApproachWe aim to evaluate the effectiveness and cost-effectiveness of enhanced primary care policies for chronic diseases funded through Medicare Australia using stroke as a case study. Person-level linkages from the following will be used: Australian Stroke Clinical Registry (AuSCR) to define the cohort; Australian government-held Medicare claims data to identify receipt or not of enhanced primary care items; state government-held hospital data to define outcomes; and Australian government-held pharmaceutical and aged care claims data to define covariates. In Australia, unique identifiers are not used therefore, personal-identifiers will be submitted to data linkage units and content records merged using a Project-ID.
 ResultsIdentifiers from ~25,000 AuSCR registrants (2012-2016), from Victoria and Queensland will be submitted for linkage. The index event is the first event recorded in the AuSCR. Data applications to state health departments and the Australian Institute of Health and Welfare have commenced. To obtain detailed information on patient’s primary care experience 1,500 randomly selected AuSCR registrants are being sent surveys. Multivariable analyses using a competing risks Poisson regression model for multiple events and adjusted by a propensity score, will be used to test for differences in the rates of hospital presentations. We have power (a >0.05) to detect a ≥6% difference in the number of hospital contacts between those who did and did not receive enhanced primary care. An economic evaluation will also be undertaken.
 Conclusion/ImplicationsThis is the largest stroke data linkage study in Australia. The breadth of data will provide a comprehensive evaluation of the effectiveness of enhanced primary care policies within “real world” healthcare provision. Methods will advance the use of population data linkage in healthcare evaluation where unique identifiers are unavailable.

The 'top 100' drugs and classes in England: an updated 'starter formulary' for trainee prescribers.

Prescribing is a complex skill required of doctors and, increasingly, other healthcare professionals. Use of a personal formulary can help to develop this skill. In 2006-9, we developed a core list of the 100 most commonly prescribed drugs. Our aim in the present study was to update this 'starter formulary' to ensure its continued relevance for prescriber training. We analysed large contemporary primary and secondary care datasets to identify the most frequently prescribed medicinal products. Items were classified into natural groups, broadly following their British National Formulary classification. The resulting drug groups were included in the core list if they comprised ≥0.1% prescriptions in both settings or ≥0.2-0.3% prescriptions in one setting. Drugs from emergency guidelines that did not qualify by prescribing frequency completed the list. Over 1 billion primary care items and approximately 1.8 million secondary care prescriptions were analysed. The updated list comprises 81 drug groups commonly prescribed in both settings; six from primary care; seven from secondary care; and six from emergency guidelines. Eighty-eight per cent of the formulary was unchanged. Notable changes include entry of newer anti-epileptics and dipeptidyl peptidase-4 inhibitors and exit of phenytoin and thiazolidinediones. The relative stability of the core drug list over 9 years and the current update ensure that learning based on this list remains relevant to practice. Trainee prescribers may be encouraged to use this 'starter formulary' to develop a sound basis of prescribing knowledge and skills that they can subsequently apply more widely.

How do people with diabetes describe their experiences in primary care? Evidence from 85,760 patients with self-reported diabetes from the English General Practice Patient Survey.

Developing primary care is an important current health policy goal in the U.S. and England. Information on patients' experience can help to improve the care of people with diabetes. We describe the experiences of people with diabetes in primary care and examine how these experiences vary with increasing comorbidity. Using data from 906,578 responders to the 2012 General Practice Patient Survey (England), including 85,760 with self-reported diabetes, we used logistic regressions controlling for age, sex, ethnicity, and socioeconomic status to analyze patient experience using seven items covering three domains of primary care: access, continuity, and communication. People with diabetes were significantly more likely to report better experience on six out of seven primary care items than people without diabetes after adjusting for age, sex, ethnicity, and socioeconomic status (adjusted differences 0.88-3.20%; odds ratios [ORs] 1.07-1.18; P < 0.001). Those with diabetes and additional comorbid long-term conditions were more likely to report worse experiences, particularly for access to primary care appointments (patients with diabetes alone compared with patients without diabetes: OR 1.22 [95% CI 1.17-1.28] and patients with diabetes plus three or more conditions compared with patients without diabetes: OR 0.87 [95% CI 0.83-0.91]). People with diabetes in England report primary care experiences that are at least as good as those without diabetes for most domains of care. However, improvements in primary care are needed for diabetes patients with comorbid long-term conditions, including better access to appointments and improved communication.

Talking EPC - speech pathologists' views of the Enhanced Primary Care items four years on

Allied health professionals have provided services under Enhanced Primary Care (EPC) since 2004; however, the experiences and views of AHPs about the initiative and how it has been utilised have not been well explored. We examined speech pathologists' views and experiences under EPC. A survey of speech pathologists in private practice who provide services under EPC was undertaken. Speech pathologists provide EPC services to a wide range of clients with communication and swallowing disorders. The five EPC sessions provide a 'starting point' for therapy for some clients, and supplement existing therapy for others. Speech pathologists expressed concern about the accessibility of the program, and its understanding and use in practice, but noted that the program can be valuable for clients who are able to negotiate the hurdles, and for themselves in terms of increased referrals and collaboration with general practitioners. Education around eligibility, access, and reporting requirements is needed for clients, GPs and allied health professionals in order to reduce the frustrating aspects of this program, and support its ongoing use.

An aged care liaison nurse can facilitate care planning using the Enhanced Primary Care items

An aged care liaison nurse can facilitate care planning using the Enhanced Primary Care items

Variation in levels of uptake of Enhanced Primary Care item numbers between medical practices, within Divisions of General Practice and jurisdictions

We aimed to report on variation in levels of uptake of services between medical practices across Divisions of General Practice, and jurisdictions, through the Enhanced Primary Care (EPC) program between November 1999 and October 2001.No Divisions had levels of EPC uptake outside upper control limits plus/minus three standard deviations the national level, suggesting limited substantial systematic variation relating to high uptake. Four Divisions had rates of practices providing EPC services (33.3%-67.7%)substantially lower than the national rate (81.2%). For all EPC services combined and for health assessments (HAs) there is substantial variation between practices in almost all Divisions of General Practice, and in some this is extreme. For care plans (CPs), while several Divisions show wide variation in rates across practices (and in a few there is extreme variation), in other Divisions there are very low rates of CP across all practices. For case conferences (CCs) the picture is even more extreme, and these patterns are expressed across all jurisdictions. There is substantial variation in the level of uptake of EPC services across medical practices in Australia.

General Practitioners' Collaboration with Service Coordinators: What Makes it Work? Lessons from the SA HealthPlus Coordinated Care Trial

In the past, a number of factors have been identified that discourage collaboration between GPs and other health professionals in providing care to patients with chronic illness. These include financing arrangements, lack of time and lack of knowledge of the role of other professions. This paper uses data from the independent evaluation of the SA HealthPlus Coordinated Care Trial to examine the factors that encourage and inhibit collaboration between general practitioners (GPs) and Service Coordinators (a role introduced by the trial and carried out by nurses and allied health professionals). Both quantitative and qualitative methods were used to evaluate the role of the GP and the Service Coordinator in the trial. These data were analysed to determine what factors encouraged and inhibited collaboration. Results indicated that effective communications, knowledge of and respect for each other's roles and responsibilities, and a clearly perceived benefit from collaboration were the most important predictors of successful collaboration for both parties. These results also suggest strategies for increasing the likelihood of collaboration between GPs and others such as the location of the Service Coordinator in the practice and ways of dealing with GP workloads and communication needs. These findings are relevant to recent policy initiatives including the MBS Enhanced Primary Care item numbers, the employment of practice nurses, and allied health staff via Divisions of General Practice.

Concurrent opioid dependence and mental health problems: a review of the issues for general practice.

The literature is reviewed on the issue of concurrent opioid dependence and mental health problems within the general practice setting. People with such problems have poorer personal, clinical and social outcomes than people with either mental health or drug and alcohol (D&A) problems alone. Mental health and drug services operate from different policy systems and are generally not co-ordinated with each other, leaving the onus on the patient to move effectively through health systems. The common statement that GPs are ideal health professionals to manage concurrent problems is contrasted with the evident barriers in general practice such as lack of time, knowledge, skills and confidence. Models for managing concurrent problems tend towards shared care. However, these models either have received mixed evidence (e.g. consultant-liaison psychiatry) or are amenable to development but remain untested (e.g. co-ordinated care, community health centre programs). The Enhanced Primary Care items introduced in 1999/2000 may provide an incentive for GPs to participate in shared care arrangements with other health professionals. However, there is a need for mechanisms to increase the links between GPs and other health services.