Primary Health Sector Research Articles

Geriatrician in the Practice Model of Care

Introduction: The Shoalhaven in regional Australia has an aging population with a high prevalence of dementia and insufficient geriatricians to provide a timely service to this group of patients. General Practitioners had limited experience in managing patients living with dementia with high numbers referred for recurrent review in hospital clinics. These clinic settings have different funding sources in the Australian context. Practice Change: Practices were invited to enrol in the Geriatrician in the Practice (GIP) Program. A dementia clinical nurse consultant (CNC) and geriatrician attended the general practice and ran a joint comprehensive geriatric consultation with the general practitioner and practice nurse. Eight Practices were recruited and training was provided to 15 practice nurses on cognitive assessment and to 32 General Practitioners on dementia diagnosis and management. Aim and Theory of Change: The aims of the program were to provide patients with dementia timely assessment in a familiar location, to improve the skills in primary care for the diagnosis and management of dementia and build improved relationships between the primary health and hospital sectors. It was proposed that these changes would improve the confidence of primary health practitioners to manage patients with dementia, provide improved patient satisfaction with their care experience, reduce the need for specialist review and reduce outpatient waiting times at hospital clinics. Timeline: The Program was funded in July 2015 with the first clinics commencing in November 2015. The program has been expanding with new practices included every 6 months. Highlights: The level of patient satisfaction is very high and the program has identified groups of patients who were not attending hospital clinics. The practice nurses and General Practitioners have improved confidence in the management of people living with dementia and the number of people requiring subsequent review by a geriatrician has significantly reduced. The ability of the General Practice to prioritise patients seen at the clinics has led to a more timely assessment of patients in need. Sustainability: The practice nurses have shown sufficient knowledge acquisition to not necessitate the continued regular involvement of the CNC. The Geriatrician involvement has been demonstrated to be sustainable within current funding models Transferability. There is currently consideration to expand the model to other chronic disease models of care. Conclusions: The GIP model of care has successfully lead to knowledge transfer from hospital specialist clinics to primary care. It has provided more timely assessment and greater patient satisfaction and increased available specialist time for new assessments. Discussion: The GIP model of care required initial intensive input but through knowledge transfer has provided a sustainable model of care for people living with dementia and primary care providers with a high level of patient acceptability and improved access to specialist services. It is anticipated that a hybrid model of GIP clinics and hospital based clinics will be provided in the future to accommodate patient and practitioner preferences. Lessons learned: The GIP program demonstrated that it feasible to have improved outcomes by reviewing models of care. There needs to be development of guidelines including responsibilities and roles prior to commencing such a program. A review of information technology links across the services is also recommended

Implementing a collaborative mental health care model: the MHPN

PurposeThe purpose of this paper is to describe the development and experience of the Mental Health Professionals’ Network (MHPN) in building and supporting a national interdisciplinary professional development platform in community mental health to enhance practitioner response to the needs of consumers.Design/methodology/approachThe key components of the MHPN model are described highlighting effective ways of engaging practitioners and supporting interdisciplinary practice. The MHPN has two key programs – Face-to-Face Interdisciplinary Practitioner Networks and an Online Professional Development Program.FindingsThe MHPN model has had significant uptake in communities across Australia and continues to grow. Practitioners report positive outcomes in engaging with other practitioners, improving their professional knowledge and having gained increased confidence in the provision of mental health care to patients.Practical implicationsThe progress and learnings to date offer some useful insights that can be applied to other settings to support integrated care for patients with mental health problems through enhancing collaborative care among practitioners at the primary care level.Originality/valueMHPN is a unique, national, successful platform delivering opportunities for interdisciplinary professional development in the primary mental health sector. The model is cost effective, practitioner driven, and transferable to other settings.

Early detection of oral health status and cardiometabolic risk factors among reproductive-aged women in rural areas: A cross-sectional study.

Oral health status is associated with many chronic ailments, including diseases of the cardiovascular system, diabetes, as well as pregnancy complications, such as low birth weight, preterm delivery, preeclampsia, and early pregnancy loss. The health status of reproductive-aged women is important, not only for the women themselves, but also for the health of fetus. The purpose of this study was to explore cardiometabolic risk factors, oral health status, and associated factors among reproductive-aged women. The current study is a preliminary report from a nurse-led longitudinal study, examining a health promotion program for women in a rural region of Taiwan. Participants consisted of a community-based, cross-sectional sample, involving 2547 women aged 20-49 years. A high percentage of participants were found to have cardiometabolic risk factors. More than one-quarter had ⩽24 remaining teeth. Many participants reported that they did not regularly attend dental checkups and tooth scaling, did not brush at least twice a day after meals, did not have a healthy diet, and did not exercise regularly. The results also indicated that women with <20 remaining teeth tended to be older, engaged in substance use, and displayed increased cardiometabolic risk factors. The findings indicate that reproductive-aged women show a high prevalence of tooth loss, cardiometabolic risk factors, and unhealthy habits. Nurses in the primary health sectors could reduce the consequences of these risk factors and improve oral health through the early detection and initiation of health-promoting programs that reduce risky behavior associated with cardiometabolic diseases.

Bridging the gap: An insight into dentistry

Summary: Dental and medical care are closely interlinked since certain clinical oral manifestations can provide a useful insight into underlying systemic diseases. With recent research highlighting unique ‘two-way’ relationships between systemic and oral disease processes, it is paramount medical students are aware of these. Medical school curricula scarcely cover oral disease and oral examination; the purpose of this article is to provide a foundation for further learning. A clear focus has been made on four key aspects: the core dental team, oral lesions, dental disease and oral manifestations of systemic drugs. Relevance to Medical Students: Examination of the oral cavity forms an element of the wider physical exam. Hence, an appreciation for dentistry will place medical students in a more confident position knowing that they have an understanding of oral abnormalities. This will not only encourage improved diagnoses but discourage false referrals, making a positive impact on patient care and management. Take Home Messages: Medicine and dentistry have a firm place in the primary health sector as patients share their health concerns with both their general medical practitioner and their general dental practitioner. Patient care can be greatly enhanced if a closer relationship between the two professions is fostered. This educational piece places a step in that direction by presenting to the reader an insight into the multifaceted speciality of dentistry.

Which Medical Institution Should Perform Gatekeeping in Rural China? Results from a Cross-Sectional Study

Background: China's healthcare system is developing very fast but needs a regulatory practice, which helps to improve effectiveness and efficiency. This is a problem in rural China, in particular. The government is promoting a providing system with gatekeeping and mandatory referral procedures in order to limit resulting problems. However, there exists little evidence, which of the primary healthcare facilities in rural China should be given these functions. Objective: It is this study's objective to determine the impact of the specific medical institution of an initial visit on the patients' following move through the healthcare system. On that reason, we want to find evidence which level of primary health sectors in rural China is more appropriate to perform gatekeeping and to integrate care based on referrals. The alternatives are either to prefer village clinics or township health centers. Methods: The data were collected through a cross-sectional study in 2012, which used a stratified random sampling method to select 4 counties. 420 patients who wanted to see the doctors more than 3 times during the past 6 months were included as the study sample. We described the patients' move through the healthcare system by measuring the density, dispersion and sequence of visits according to the Continuity of Care model (COC). The logistic regression model was used to determine the influence of medical institution of initial visit on patients' moves after controlling other variables. Results: We found that patients who chose the county hospital as medical institution for their initial visit had 5.88 times of the odds of high (vs. low) density, 4.17 times the odds of high (vs. low) dispersion, and 2.86 times the odds of high (vs. low) sequence of visits than those choosing village clinics as medical institution for the initial visit. However, patients choosing the county hospitals as medical institution of initial visit did not report higher density, dispersion or sequence of visit than the patients who chose the township health centers. Conclusion: For the overwhelming majority of rural areas in China, the township health centers are more appropriate to perform the gatekeeping role than village clinics are. We see that as the conclusion at least at the present stage of the system's development.

Suicidal behaviours: Prevalence estimates from the second Australian Child and Adolescent Survey of Mental Health and Wellbeing.

To (1) estimate the lifetime and 12-month prevalence of suicidal behaviours in Australian young people aged 12-17 years, (2) describe their co-morbidity with mental illness and (3) describe the co-variation of these estimates with social and demographic variables. A national random sample of children aged 4-17 years was recruited in 2013-2014. The response rate to the survey was 55% with 6310 parents and carers of eligible households participating. In addition, of the 2967 young people aged 11-17 years in these households, 89% (2653) of the 12- to 17-year-olds completed a self-report questionnaire that included questions about suicidal behaviour. In any 12-month period, about 2.4% or 41,400 young people would have made a suicide attempt. About 7.5% of 12- to 17-year-olds report having suicidal ideation, 5.2% making a plan and less than 1% (0.6%) receiving medical treatment for an attempt. The presence of a mental disorder shows the largest significant association with lifetime and 12-month suicidal behaviour, along with age, gender, sole parent family status and poor family functioning. Of young people with a major depressive disorder, 19.7% reported making a suicide attempt within the previous 12 months. There are also significant elevations in the proportions of young people reporting suicidal behaviour who have anxiety and conduct disorders. Mental disorders should be a leading intervention point for suicide prevention both in the primary health sector and in the mental health sector specifically. The associations examined here also suggest that efforts to assist sole parent and/or dysfunctional families would be worthy areas in which to target these efforts.

Programa Bolsa Família e o acompanhamento das condicionalidades na área de saúde

Resumo: Este artigo consolida resultados de uma pesquisa realizada em dez municípios brasileiros, que buscou analisar a dinâmica de acompanhamento das condicionalidades de saúde do Programa Bolsa Família. A ideia central consistiu em abordar variáveis que poderiam afetar o desempenho municipal na gestão do programa, tais como: porte populacional e magnitude da população a ser coberta; estrutura e capacidade técnico-gerencial dos municípios; oferta e organização da Atenção Básica em Saúde e arranjos intersetoriais.

Community placement for students is an important resource for the development of the primary level health sector in Nepal

Community placement for students is an important resource for the development of the primary level health sector in Nepal

When free healthcare is not free. Corruption and mistrust in Sierra Leone's primary healthcare system immediately prior to the Ebola outbreak.

Sierra Leone is one of three countries recently affected by Ebola. In debates surrounding the circumstances that contributed to the initial failure to contain the outbreak, the word 'trust' is often used: In December 2014, WHO director Margret Chan used 'lack of trust in governments'; The Lancet's Editor-in-Chief, wrote how Ebola has exposed the '… breakdown of trust between communities and their governments.' This article explores the lack of trust in public healthcare providers in Sierra Leone, predating the Ebola outbreak, apparently linked to widespread petty corruption in primary healthcare facilities. It compares four NGO-supported accountability interventions targeting Sierra Leone's primary health sector. Field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health workers and focus group discussions with primary healthcare users. Field research showed that in most clinics, women and children entitled to free care routinely paid for health services. A lack of accountability in Sierra Leone's health sector appears pervasive at all levels. Petty corruption is rife. Understaffing leads to charging for free care in order to pay clinic-based 'volunteers' who function as vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact on healthworker (mis)behaviour.

Promoting Equity in Primary Health Care

Abstract Equity in access to primary health care services is a central objective of the Swedish health care system. Yet, several reports have illustrated that disparities still exist in the primary health sector, and have increased since the beginning of the 1990s. This commentary analyzes and explains the reasons for continuing inequality in access to and utilization of primary health care services in a welfare system. Social and structural factors, communication, macrosociological aspects and health care providers’ attitudes and perceptions are discussed as substantial contributors to inequality in access to and utilization of primary health care services. In conclusion, some intervention strategies for promoting more equitable primary health care are suggested.

Health Economic Changes as a Result of Implementation of Targeted Therapy for Metastatic Renal Cell Carcinoma: National Results from DARENCA Study 2

BackgroundLimited data exist on the economic consequences of implementing targeted therapy (TT) for metastatic renal cell carcinoma (RCC) in a real-world setting. ObjectiveTo analyze health care and productivity costs for TT implementation in a national cohort of patients. Design, setting, and participantsCosts were measured per patient per year during a 2-yr follow-up during 2002–2005 (immunotherapy only) and 2006–2009 (TT implementation). All Danish patients with a diagnosis code for RCC and a procedure code for TT or immunotherapy were linked to the Danish National Patient Registry (contains information on all contacts with primary and secondary health sector). Health care and productivity costs were retrieved from the Danish case-mix system and Coherent Social Statistics, respectively. Drug costs were calculated separately from procedure codes and retail prices. Outcome measurements and statistical analysisGeneralized linear models were used to analyze costs adjusted for age, gender, and civil status. Results and limitationsA total of 439 patients were included for 2006–2009 and 192 for 2002–2005. Comparison of the health care cost per patient per year between 2006–2009 and 2002–2005 revealed lower inpatient costs (€11 899 vs €19 944, adjusted relative risk [RR] 0.64), higher outpatient costs (€14 308 vs €6209, RR 2.39), lower radiotherapy costs (€194 vs €633, RR 0.31), higher radiology costs (€676 vs €191, RR 3.73), and higher separately calculated drug costs (€12 040 vs €3103, RR 3.82, all p<0.001) for the former. Total health care costs per patient per year did not significantly differ (€27 676 vs €27 856, RR 1.05, p=0.5) between the two periods. Income from employment did not significantly differ between 2006–2009 and 2002–2005 (RR 1.11, p=0.11) and costs associated with loss of productivity were €7852 and €8265, respectively. ConclusionsA different pattern of health care costs were observed but total health care costs per patient per year did not significantly differ after implementation of TT for patients with mRCC. Patient summaryIn this nationwide study, we found changes in the pattern of health care costs for patients with metastatic kidney cancer after implementation of targeted therapy compared to an immunotherapy control period; however, total health care costs and income from employment were without significant changes.

Is integration an add-on or a new way of working for health professionals in co-located medical practices?

Introduction: Characteristically health services within the community are not separated based on illness/condition but rather on profession for example, GP services, physiotherapy clinics. In the primary health sector government policy at federal and state levels has established integrated health services. Functional and operationalised integration does not spontaneously arise from colocating health professionals. Despite primary health reforms there is no prescriptive method whereby services are integrated. For those health professionals working in a co-located primary health care environment how integrated is ‘integrated’? Practice and context: Our study examines integration at the point of service delivery, within colocated community medical practices in Australia: five different case study practices in areas of high population need. These are a purposeful mix of the state government model, Commonwealth government model (university linked Superclinic), a hybrid of state and Commonwealth model, and private for profit models. Change implemented: These practices commenced delivering co-located health services with an underlying philosphy of service integration to better address patient health outcomes (between 3 and 10 years). Objective of the change: We examine health professionals’ experience of health service integration. Targeted population: Health professionals in an integrated service delivery environment. Stakeholders engaged: Health professionals in the case study clinics. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116679– http://www.ijic.org/ Timeline: These are practices offering a range of services for between 3 and 10 years. The questionnaire was completed over a 3 week period (July 2014) and focus groups were conducted from July – September 2014. Theory/method: Our research method plan is a multiple case study (mixed methods design) of contemporary co-location service models. The case study approach incorporates close interaction with practitioners and deals with real management situations. Our data collection method was twofold; individual questionnaires designed for our research questions, and focus groups. Highlights (innovation/impact/outcomes): This is timely research with the increasing emphasis on patient centred care and recognition that more than one discipline can contribute to patient wellbeing. Health professionals varied in their expectations of integration. There was variability across the models on different components of health professional experience. Integration was described as lacking direct leadership and overt expectations of health professionals. Some infrastructure supported integration at an operational level but integration regarding patient care was relatively informal. Co-location may be the only form of health professional interface. Sustainability: Co-located services can be sustained without health professional integration because patients can continue to receive services but health professional retention and patient services can arguably be impacted by dealing with patients with multiple and chronic conditions on a longer term basis. Transferability: Outcomes of this research can be transferred and adapted across co-located health services to improve levels of integration. Conclusions: Integration as it impacts health professionals has been under-researched in colocated health services. The case study environments were not obstructive but were not making optimal use of co-located services. Discussions: Co-location is a start towards integration but health professionals see greater potential in higher levels of integration. Lessons learned: Health professionals favour integration and there are key factors that feature in their expectations of integrated health service delivery.

Neonatal survival in the Republic of Moldova – cost-effective evidence-based interventions

Aim: To estimate the number of preventable neonatal deaths based on national data.Methods: To estimate the number and proportions of avoidable neonatal deaths, we have used the same approach described by Gary L. Darmstadt, using both the official statistical data and data of some assessment studies carried out in the country.Results: According to the calculations, the highest number of neonatal deaths we are able to prevent can be obtained from the implementation of evidence-based interventions in the frame of facility-based immediate neonatal and skilled maternal care (14 death prevented at 90% of intervention coverage and 46 deaths at 99% of intervention coverage), the early neonatal mortality rate can be reduced by 7.3% and by 24%, respectively. The second place belongs to facility-based emergency obstetric and antenatal care with an equal number of deaths that could be prevented (14 cases at 90% of intervention coverage and 35 cases at 99% of coverage).Conclusions: We can conclude that due to common efforts of primary, facility-based care and public health sectors, 90% of coverage of perinatal cost-effective qualitatively implemented interventions could prevent 83 neonatal deaths (43%), while 99% of coverage could prevent 142 deaths (74%).

Evaluation of School Health Surveillance System in Baghdad Governorate

Objective(s): A descriptive evaluation study is conducted on primary health care centers, primary health sectors, health directorates in Baghdad Governorate and General Health Directorate/ Ministry of Health of November 27th 2011 to June30th 2012. Methodology: A probability multistage sample of (54) subjects which is selected of school health units. Data are collected throughout the utilization of the developed questionnaire and interview technique and keeping records of all available contacts. Interviews are conducted with the chief of school health unit in each stage level. Questionnaire has been divided into three main parts consist, in (A) especially for health directorate, in (B) for health sectors, and in (C) for primary health care centers each form contains the basic components; consists of manpower and health facilities; consists objectives, system components, resources, feedback and attributes. Results: consists prevention and behavioral indicators and disease prevalence indicators, total items of questionnaire was (217) items. Reliability of the questionnaire was determined through pilot study and validity determined through a panel of experts consists of (13) experts. Data were analyzed by using of descriptive data analysis (frequencies and percentages). The study results indicate that the system is average adequacy, simple, moderate flexible, highly acceptance, representative, low utility, unstable system. The study recommended computerizing as addition to manual documentation. Statisticians may coordinate the monthly surveillance forms. Engage the nurse in school units in primary health care centers. Involving all health institutions and centers related to school health in the surveillance system program. Conclusions: Lack of cooperation between the public and private. In the absence of mechanisms to provide feedback or disseminate data to the decision makers, the usefulness of school health surveillance system was very limited. The system adequate in primary health care centers more than health sectors and health directorates. The system has low utility in primary health centers and high ones in both health sectors and health directorate. System attributes are simple, moderate flexible, high acceptance, Representative and unstable system, moderate data quality. Recommendation: Provision of laboratory and radiological facilities and integration of their data in school surveillance. Review the surveillance forms to ensure reporting useful data. Besides enhancing representativeness of school health, there is need to have a regular feedback and information dissemination mechanism. Available data may be computerized as addition to manual documentation. Statisticians may coordinate the monthly surveillance forms. Engagement of the nurse at school units in primary health care centers. Involving all health institutions and centers related to school health in the surveillance system program. Customizing special financial of school health isolation of the general budget.

The impact of alcohol on HIV prevention and treatment for South Africans in primary healthcare.

Antiretroviral treatment (ART) has substantially reduced morbidity and mortality for HIV patients. In South Africa, with the largest ART programme globally, attention is needed not only on the further expansion of ART coverage, but also on factors which undermine its effectiveness, such as alcohol use. Given the decentralised approach of nurse-initiated and -sustained ART in the South African primary health sector, it is important to document key aspects of alcohol use to be conveyed to HIV-positive individuals and those at risk for HIV. This study comprised a narrative review of relevant literature. Alcohol acts through both behavioural and physiological pathways to impact on the acquisition, further transmission and then progression of HIV disease. Besides links to risky sex, alcohol undermines the immune system, raising susceptibility to contracting and then countering HIV and other infections. There are important drug interactions between alcohol and ART, or therapies for opportunistic infections and other co-morbidities. Moreover, alcohol undermines adherence to the medication which is essential for effective ART. Primary healthcare clinic attendees need evidence-based information on the detrimental effects of alcohol consumption on HIV infection, which ensue throughout the clinical course of HIV. This spans the role of alcohol consumption as a risk factor for HIV infection, HIV replication in infected individuals, a person's response to HIV infection and HIV treatment. Primary healthcare workers, especially nurses and HIV counsellors, require training in order to screen for and provide appropriate interventions for HIV-positive patients, those on treatment and treatment-naïve patients, who will benefit from reduced alcohol consumption or the cessation thereof.

Primary Care, Behavioral Health, and Public Health: Partners in Reducing Mental Health Stigma

The authors reflect on the role that collaboration between the primary care, behavioral health and public health sectors can play in reducing mental health stigma. They suggest that stigma against mental illness and substance abuse disorders contributes to poor health outcomes and is a major public health problem. They argue that a collaboration between primary care, behavioral health and public health is essential to achieve less stigmatized, more optimal health outcomes for all.

Health informatics community priming in a small nation: the New Zealand experience.

New Zealand (NZ) has a rapidly expanding health information technology (IT) development industry and wide-ranging use of informatics, especially in the primary health sector. The New Zealand government through the National Health IT Board (NHITB) has promised to provide shared care health records of core information for all New Zealanders by 2014. One of the major barriers to improvement in IT use in healthcare is the dearth of trained and interested clinicians, management and technical workforce. Health Informatics New Zealand (HINZ) and the academic community in New Zealand are attempting to remedy this by raising awareness of health informatics at the grass roots level via free "primer" workshops and by developing a sustainable cross-institutional model of educational opportunities. Support from the NHITB has been forthcoming, and the workshops start in early 2013. This poster presents the process, development and preliminary findings of this work.

The healthy alliances (HALL) framework: prerequisites for success

Chronic conditions are on the rise worldwide, and there is increasingly a call for the primary care and public health sectors to join forces in alliances. GPs have an important role to play in such alliances. However, successful cooperation is not as obvious as it may seem, and the sectors are not used to working together. The objective is to identify conditions and prerequisites for successful alliances. Identification of conditions and prerequisites is mainly based on stepwise analysis and iterative developments in research on collaboration processes in the area of health promotion and public health. The process as a whole resulted in the framework presented in this paper. This so-called HALL framework identifies three clusters of factors that either hinder or facilitate the success of alliances: (i) institutional factors, (ii) personal factors of participants in the alliance and (iii) factors relating to the organization of the alliance. The institutional and personal factors 'stick' to the stakeholders and are brought into the alliance. The third group refers to the lessons learned from dealing with the first two characteristics to make the alliance successful. Partners in alliances bring in personal attributes and institutional characteristics that can form obstacles to successful alliances, but, when they are addressed in a flexible and positive way, obstacles can be turned in contributory factors, leading to many potential benefits, such as collaborative learning and innovation.

Low Income and the Number of Contacts with General Practice

The purpose of this study was to examine whether there are differences in the use of general practice between citizens in low income groups and citizens with higher income after adjustment for social and health-related factors. Registers from Statistics Denmark on adult citizens of Odense Municipality in 2005 were used. Income was measured as annual equivalent disposable income and adjustment for social and health-related personal characteristics was performed using Poisson regression. Poor adults with income below 73,000 DKK have 2-3 fewer contacts with general practice annually than those with an income of 73,000-146,000 DKK, while adults with an income above 292,000 DKK have the lowest utilization of general practice of any group. The difference between the poor and those with low income was reduced to 1.5 fewer contacts after adjustment for social and health-related characteristics and further to 1,1 when a sizeable unidentified socio-economic group was omitted. Poor adults have significantly fewer contacts with general practice than adults with low or middle income. This contrasts with results from earlier studies and may be an indication of underutilization of general practice. Other explanations may be that poor citizens enter the primary health sector through other channels or that the type and quality of contacts vary between income groups, that adjustment for health or other need indicators are insufficient. Furthermore, data shortcomings such as lack of information on non-taxed income and non-taxable assets may also serve as alternative explanations.

Editorial: Reflections on Research Impact in Primary Health Care

The primary health sector has had a long-standing interest in evidence-based practice. Two decades ago the focus was on a primary health care equivalent of evidence-based medicine described by Hennen (1992, p. ix) as "self-criticism in primary care practice through research" or by Ovretveit (1998, p. 266) as "the use of best evidence in making decisions about the care of individual patients". The focus was on clinical interventions and their effects, or lack thereof. Furthermore, the aspiration to systematically use evidence in the provision of care was a central part of the quality movement in both clinical care and health service management (Ovretveit, 1992). More recently, evidence-based practice has been advancing in health services management and policy (Lin &amp; Gibson, 2003).