Delivery Of Primary Care Services Research Articles

Strategies to prevent eclampsia in a developing country: I. Reorganization of maternity services

Objective: To determine whether changes in primary and secondary care service delivery could prevent antenatal eclampsia. Method: One intervention (St. Catherine) and two control (St Ann, Manchester) parishes were chosen. The health system in St. Catherine was restructured. Primary antenatal clinics had clear instructions for referring patients to a high-risk antenatal clinic or to hospital. Guidelines were provided to high-risk clinics and the antenatal ward for appropriate treatment of hypertension and preeclampsia when induction of labor should occur. Antenatal eclampsia incidence was monitored before and during the intervention and compared with control parishes (no intervention). Each eclampsia case was investigated to identify inadequacies in the system. Results: The process resulted in better identification of women at risk. Antenatal eclampsia incidence dropped dramatically as care improved. Compared with control areas, by completion of the study, the rate was significantly lower than at the start: OR 0.19 (95% CI: 0.13–0. 27; p<0.001 trend). Antenatal admissions for hypertensive disorders declined significantly, and the number of bed days halved. Conclusion: Reorganization of maternal care can have major public health benefits and cost savings; however, women need to be alerted to recognise and act upon signs of impending eclampsia.

Organization and delivery of primary health care services in Petrópolis, Brazil

The objective of the study was to adapt and apply an instrument to measure the organizational features of the primary care system in the municipality of Petrópolis. The study compared the performance of the new Family Health Program (Programa Saúde da Família or PSF) with traditional primary care facilities using data from facility surveys and key informant interviews. The main results include: (a) the methodology was capable of distinguishing between the two types of primary care services in the municipality; (b) the PSF clinics scored higher on most dimensions of primary care, although in some areas the traditional health units had equivalent scores; and (c) data obtained from interviewing key informants was generally compatible with that obtained by conducting facility surveys. The results suggests that in spite of making important advances in primary care, the municipality of Petrópolis continues to face several challenges including the need to improve access, enforce the gatekeeper role of primary care, and improve the coordination and community orientation of both types of primary care services. The methodology could be used to set objectives and monitor progress towards improving the organization and delivery of primary care in Petrópolis and elsewhere.

A population-based study of primary care predictors of non-attendance for cervical screening.

To identify and estimate the population impact of primary care service delivery factors that independently predict non-attendance for cervical screening. Screening records of all eligible women aged 30 years and over and resident in the former Manchester Health Authority area were analysed (n=72,613). Practice-level and GP-level explanatory variables, along with area-level covariates, were obtained and merged to the study data set. Logistic regression models were used to identify factors associated with having no recorded history of attending NHS cervical screening services. A multivariate model was created to identify independent predictors of non-attendance with comprehensive adjustment for women's age, area-level socio-demographic factors, and other primary care factors. Attributable fraction estimates were used to assess the population impact of the independent predictors. Large practice size (>4,000 patients), single-handed practice, South Asian male GP, part-time GP employment status, older age and birthplace overseas, and area-level measures of deprivation and transience independently predicted non-attendance. Women born overseas and registered at larger practices were especially unlikely to have ever attended. The combined population attributable fraction estimate for the independent predictors reflecting primary care service delivery was almost 40%, and that for all variables in the final model was over 70%. Independent predictors of non-attendance reflecting general practice structure, workload and GP characteristics were identified. Although relative risks were modest, the collective population impact of these factors was considerable, which has implications for the implementation of informed targeting and the development of new screening services by Primary Care Trusts.

The role of the traditional bonesetter in primary fracture care in Nigeria.

In view of the growing interest in the management of fracture worldwide, the traditional bonesetter (TBS) practice in Nigeria was documented. To highlight the role of the TBS in primary fracture care in Nigeria. Rural. Over a 5-year period a qualitative study of the TBS settings and knowledge, diagnostic techniques and principles of fracture treatment in four TBS centres in Nigeria was carried out by active participation, on the spot assessment, interactive dialogues and oral interviews. It was found that TBS services are well preserved as a family practice, and training is by apprenticeship. Records are kept by oral tradition. There is no prescribed fee and the patronage is high. Fracture diagnosis is based on physical assessment and experience. The TBS relies solely on the conservative method of fracture treatment, and all fractures are reduced by the closed method and stabilised with an external traditional splint and a protracted period of immobilisation. The outcome of TBS treatment is good for closed fractures of the shaft of the humerus, ulna, radius and tibia, but poor for peri-articular and open fractures. Non-union, malunion, traumatic osteomyelitis and limb gangrene were the common major complications of TBS treatment. Despite criticisms and antagonism from orthodox medical practitioners TBS practice is well patronised by Nigerians. In order to guarantee safety and efficiency of the TBS practice in primary fracture care service delivery in Nigeria, there is therefore a need both to educate the community and to train the TBS.

Primary care pediatrics: 2004 and beyond.

Changes in medicine domestically and globally are transforming primary care in the United States. Many have suggested that primary care is in crisis or at least at a crossroads in the United States. The Annals of Internal Medicine recently devoted much of one issue to this topic.1 Primary care for children and adolescents, however, was not addressed specifically. This article focuses on pediatrics and identifies potential roles and new models for primary care pediatrics. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 Starfield3 has defined 4 attributes of primary care including first-contact care, longitudinality, comprehensiveness, and coordination. September 11, 2001, the anthrax scare, and emerging threats such as severe acute respiratory syndrome (SARS) have brought a new focus on the importance of individual-level contacts in addressing population-level threats. Before these world events, however, primary care pediatrics was already grappling with its identity and responding to significant changes in medical systems, science, and family needs. The pace and scope of these changes are such that primary care pediatricians of the future will not be performing the same role as today. Historically, American medicine has tended to be reactive rather than proactive in defining its roles in society. However, dynamic change demands collective reflection; it is time to be proactive in assessing the needs of patients, exploring potential roles as health care providers, and developing the mechanisms to redefine the primary care pediatrician of the future. Projecting future trends requires reflection on the history of the profession of preventive pediatrics. In the 1800s, few physicians in the United States routinely … Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University Department of Pediatrics, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu

Developing consumer involvement in rural HIV primary care programmes.

As part of a broader medical and psychosocial needs assessment in a rural region of northern California, USA, five focus groups were conducted to explore innovative approaches to creating a system of consumer involvement in the delivery of HIV primary care services in the region. A total of five focus groups (n = 30) were conducted with clients from three of five counties in the region with the highest number of HIV patients receiving primary care. Participants were recruited by their HIV case managers. They were adults living with HIV, who were receiving health care, and who resided in a rural mountain region of northern California. Group discussions explored ideas for new strategies and examined traditional methods of consumer involvement, considering ways they could be adapted for a rural environment. Recommendations for consumer involvement included a multi-method approach consisting of traditional written surveys, a formal advisory group, and monthly consumer led social support/informal input groups. Specific challenges discussed included winter weather conditions, transportation barriers, physical limitations, confidentiality concerns, and needs for social support and education. A multiple-method approach would ensure more comprehensive consumer involvement in the programme planning process. It is also evident that methods for incorporating consumer involvement must be adapted to the specific context and circumstances of a given programme.

Associate degree nursing in a community-based health center network: lessons in collaboration.

This exemplar highlights the ability of community experiences to enhance nursing students' understanding of the principles of community-based care: advocating self-care; focusing on prevention, family, culture, and community; providing continuity of care; and collaborating. An innovative teaching-practice model (i.e., a nurse-managed "network" of clinics), incorporating service-learning, was created. The Network's purposes are to provide practice sites in community-based primary care settings for student clinical rotations, increasing the awareness of the civic and social responsibility to provide quality health care for disadvantaged populations; and to reduce health disparities by increasing access to free primary health care, including health promotion and disease prevention, for disadvantaged individuals. Network clients receive free health care, referrals, and guidance to effectively obtain additional health care resources for themselves and their families. The Network is a national pioneer in modeling the delivery of primary care services through a faculty-student practice plan, with leadership emanating from a community college.

Blacklisted in the city: How stigma affects primary health care for people who inject drugs

This paper explores a current issue relating to the delivery of primary health care services for people who inject drugs. It tells the story of Living Room Primary Health Service in Melbourne?s Central Business District, and the problems experienced in trying to find a suitable space in which to operate. Despite adequate funds and a year-long search for a suitable property, the primary health service continues to work from an overcrowded space that presents many health and safety concerns for clients and workers. The issue is discussed from a symbolic interactionist perspective and draws on theories relating to stigma, deviance, and social control. The stigma experienced by people who inject drugs is described and the three forms of stigma described by Erving Goffman (1951) - physical abominations, blemishes of character and tribal stigma - are discussed and applied. Similar stigmas are described that also affect Living Room Primary Health Service, a service for the people who inject drugs. The related concept of ?passing? is also explored in relation to people who inject drugs and to the service designed to provide primary health care to them. Notions of deviance and social control are also discussed and are shown to be pertinent in understanding how people who inject drugs, and services for this group, are blacklisted in the city. This problem raises many issues regarding the public perception of drug use, stigma, social control and the delivery of health services to people who inject drugs. This paper discusses aspects of these important issues and argues that the service?s inability to secure a lease and suitable work space has more to do with the stigma and social control than money and real estate agents.

The roles and responsibilities of primary care trusts in emergency planning: a report of a major incident in Sunderland, UK

‘Shifting the balance of power: the next steps’ of February 2002 stated that PCTs would become responsible for the majority of previous Health Authority functions, including emergency planning. Chief Executives of primary care trusts (PCTs) were asked to ensure that the PCT had appropriate major incident plans and to ensure that there are mechanisms to mobilise primary care and community resources in response to a major incident. Sunderland had recently reviewed and updated an emergency response plan which it had to implement at short notice when a large WW II bomb was unearthed in the grounds of a health centre. This had a serious impact on the delivery of primary care services and the lessons learned form the basis of this report. Guidance to primary care trusts (PCTs) on emergency planning was updated by the NHS Executive in 2001 as part of the Controls Assurance Programme. The standard was as follows: ‘The organisation has planned and prepared an organised and practised response to all major incidents and emergency situations which affect the provision of normal services’. The standard mirrored the key requirements of previous NHS planning guidance. PCTs were asked to consider a range of scenarios including contingency planning, disaster planning and business continuity issues. Contingency planning involves PCT services being affected by flood or fire which result in the continuity of services being compromised. Disaster planning considers the role of the PCT within major incident planning across all of the local health community. Business continuity examines the organisational response to emergencies or to the activities of individuals or groups which may affect the stability of the PCT.

NHS Dentistry: Options for Change in context--a personal overview of a landmark document and what it could mean for the future of dental services.

The aims of this paper are to provide an impartial overview of the proposals and agenda for the future brought together in the NHS Dentistry: Options for Change document in the context of previous dental service delivery in primary care, and to start to explore what Options for Change could mean for the future of NHS dental services. Options has been described as perhaps the most radical and ground breaking opportunity for NHS dentistry to finally move forward after prolonged periods of stagnation and disharmony. The Options agenda has the potential to bring in a new style of NHS practice for dentistry, providing a way to finally get off the current 'treadmill' and to develop new NHS dental services where prevention is a priority and providing high quality dental treatment, tailored to the long term needs of the 21st century patient, is the driving aim. However, the difficulties on all sides of leaving behind decades of disputes and overcoming real access, workforce and funding issues must not be underestimated or dismissed. The report was prepared by a working group comprising representatives from the profession, of patient groups and various sections of the Department of Health in England which was brought together by the then Chief Dental Officer. The key themes and priorities for action identified in Options include: local commissioning and funding, methods of remuneration for general dental practitioners, prevention and an oral health assessment for patients, clinical pathways, information and communication technology, practice structure, development of the dental team and the patient experience. The document also contains comprehensive reports of the three Options for Change task groups making recommendations for: 1) a new deal for patients - national standards, 2) systems of delivery of dental care and 3) education, training and development of the dental team. Ways forward for delivering improved, modern, effective, preventive, patient-centred dental care have been identified. This potential can, however, only be realised if viable and sustainable agreements can be achieved to operationalise the best choices.

Epidemiology of skin diseases in school children: a study from northern India.

Little information is available about the prevalence of skin conditions among children in the general population of northern India. Low socioeconomic status, malnutrition, overcrowding, and poor standards of hygiene are important factors accounting for the distribution of skin diseases in developing countries such as India. In order to estimate the burden and relative frequency of dermatologic diseases among children in the community, we measured the point prevalence of skin conditions in 12,586 Indian school children ages 6-14 years. The overall point prevalence of one or more identifiable/apparent skin conditions was 38.8%. Of those studied, 3786 children (30%) had only one skin disease, 765 (6%) had two, and 336 (2.7%) had three skin pathologies. The most common skin conditions and their respective point prevalences were skin infections (11.4%), pityriasis alba (8.4%), dermatitis/nonspecific eczemas (5.2%), infestations (5.0%), disorders of pigmentation (2.6%), keratinization disorders (mostly keratosis pilaris) (1.3%), and nevi/hamartomas (1.1%). This study shows that skin conditions are common in children and about one-third of them are affected at any given time. The finding that more than 85% of the disorders can be grouped into fewer than eight categories is important in designing training programs for medical teams involved in the delivery of primary health care services in developing countries such as India, where about one-third of the population is less than 15 years of age.

Building research relationships with managed care organizations: Issues and strategies.

Managed care is now the dominant form of healthcare in the United States. The need for clinical research about the organization, delivery, and outcomes of primary care services in managed care models is high, yet access to managed care organizations as sites for clinical research may be problematic. The purpose of this article is to describe issues involved in obtaining access to managed care settings for clinical research and practical strategies for successful collaboration using literature review and case description. Three steps for developing collaborative relationships with managed care organizations (MCOs) are presented: 1) assessment of organizational structure, history, and culture; 2) finding common ground; and 3) project implementation. These steps are discussed within the context of MCO systems issues and a relationship-centered approach to communication between researchers and individuals from the MCO. Successful relationships with MCOs for clinical research are possible when careful attention is paid to inclusion of MCOs as collaborators in the development of the research questions and design, and as partners in the research implementation process.

Improving equity in the provision of primary health care: lessons from decentralized planning and management in Namibia.

This paper draws lessons from a review of primary health care services in Windhoek, the capital of Namibia, undertaken by a regional health management team. The review was carried out because of perceived increases in workload and inadequate staffing levels, arising from the rapid expansion of the city associated with inward migration. A survey of the utilization of government clinics was used to develop a more equitable allocation of primary health care services between localities. The survey revealed disparities between patterns of utilization of the services and the allocation of staff: the poorer localities were relatively underprovided. Decisions made centrally on resource allocation had reinforced the inequities. On the basis of the results of the review, the regional health management team redistributed nursing and medical staff and argued for a shift in the allocation of capital expenditure towards the poorer communities. The review demonstrates the potential for regional and provincial health management teams to make effective assessments of the needs of their populations and to promote the equitable delivery of primary health care services. In order to achieve this they need not only to become effective managers, but also to develop population-based planning skills and the confidence and authority to influence the allocation of resources between and within their regions and provinces.

Promoting nursing participation within primary care groups.

This article describes the evaluation of a scheme to improve communication between primary care nurses and newly established primary care groups. Findings suggest that the successes of the scheme were in part attributable to the appointment of experienced practitioners to a facilitator/link nurse role and the sustained support of the scheme by the NHS community trust. The article concludes by suggesting that, in a time of constant change within primary care, innovations such as these contribute to the development of practitioner participation in the organization and delivery of primary care services.

Measuring Primary Care Practice Performance Within an Integrated Delivery System: A Case Study

This article examines the use of an integrated performance measurement system to plan and control primary care service delivery within an integrated delivery system. We review a growing body of literature that focuses on the development and implementation of management reporting systems among healthcare providers. Our study extends the existing literature by examining the use of performance information generated by an integrated performance measurement system within a healthcare organization. We conduct our examination through a case study of the WMG Primary Care Medicine Group, the primary care medical group practice of WellSpan Health System. WellSpan Health System is an integrated delivery system that serves south central Pennsylvania and northern Maryland. Our study examines the linkage between WellSpan Health's strategic objectives and its primary care medicine group's integrated performance measurement system. The conceptual design of this integrated performance measurement system combines financial metrics with practice management and clinical operating metrics to provide a more complete picture of medical group performance. Our findings demonstrate that WellSpan Health was able to achieve superior financial results despite a weak linkage between its integrated performance measurement system and its strategic objectives. WellSpan Health achieved this objective for its primary care medicine group by linking clinical performance information to physician compensation and reporting practice management performance through the use of statistical process charts. They found that the combined mechanisms of integrated performance measurement and statistical process control charts improved organizational learning and communications between organizational stakeholders.

Models for Integrating and Managing Acute and Long-Term Care Services in Rural Areas

States and the federal government are searching for new managed-care strategies, such as capitated financing and coordinated case management, that integrate the financing and delivery of primary, acute, and long-term care services. For rural communities, the development of organizational and delivery systems, which better integrate and manage primary, acute, and long term care services, may help address long-standing problems of limited access to long-term care services. This article discusses the concept of integrated acute (medical) and long-term care service networks; model programs; challenges that health care providers, state policymakers, and others have faced in developing these new integrated structures; and the future of service-integration and coordination approaches in rural areas.

Simulation Study of an Ideal Primary Care Delivery System

Health care delivery systems have gone through rapid changes in the last decade. As a result of these changes, researchers have conducted many studies on hospital resource planning, more specifically, on hospital bed planning. In this article, the strategic emphasis is on the primary care bed needs in the state of Oklahoma. Unlike most studies, this study focuses on designing an ideal primary care service delivery system, rather than evaluating the effec tiveness of the current system. The state is parti tioned into a minimum number of primary care ser vice centers satisfying accessibility constraints to assure quality service. A simulation model of the system is used to determine the minimum number of primary care beds needed in the state to provide service at targeted service levels at these centers. The results of the ideal scenario will give health care managers and planners a new perspective and help them in making strategic planning decisions in the future.

Sample size calculations for intervention trials in primary care randomizing by primary care group: an empirical illustration from one proposed intervention trial.

Because of the central role of the general practice in the delivery of British primary care, intervention trials in primary care often use the practice as the unit of randomization. The creation of primary care groups (PCGs) in April 1999 changed the organization of primary care and the commissioning of secondary care services. PCGs will directly affect the organization and delivery of primary, secondary and social care services. The PCG therefore becomes an appropriate target for organizational and educational interventions. Trials testing these interventions should involve randomization by PCG. This paper discusses the sample size required for a trial in primary care assessing the effect of a falls prevention programme among older people. In this trial PCGs will be randomized. The sample size calculations involve estimating intra-PCG correlation in primary outcome: fractured femur rate for those 65 years and over. No data on fractured femur rate were available at PCG level. PCGs are, however, similar in size and often coterminous with local authorities. Therefore, intra-PCG correlation in fractured femur rate was estimated from the intra-local authority correlation calculated from routine data. Three alternative trial designs are considered. In the first design, PCGs are selected for inclusion in the trial from the total population of England (eight regions). In the second design, PCGs are selected from two regions only. The third design is similar to the second except that PCGs are stratified by region and baseline value of fracture rate. Intracluster correlation is estimated for each of these designs using two methods: an approximation which assumes cluster sizes are equal and an alternative method which takes account of the fact that cluster sizes vary. Estimates of sample size required vary between 26 and 7 PCGs in each intervention group, depending on the trial design and the method used to calculate sample size. Not unexpectedly, stratification by baseline value of the outcome variable decreases the sample size required. In our analyses, geographic restriction of the population to be sampled reduces between-cluster variability in the primary outcome. This leads to an increase in precision. When allowance for variable cluster size is made, the increase in precision is not as great as would be expected with equal cluster sizes. This paper highlights the usefulness of routine data in work of this kind, and establishes one of the essential prerequisites for our proposed trial and other trials using primary outcomes with similar between-PCG variation: a feasible sample size.

Barriers to Primary Healthcare for the Homeless: The General Practitioner's Perspective

Objective: The objective of this qualitative study was to examine in depth the barriers to primary healthcare for homeless people from the point of view of the general practitioner.Method: Semi-structured interviews were undertaken with twenty-five general practitioners in Birmingham, UK. The major themes in the topic guide were training, views of the homeless, practice policy and initiatives for providing primary care for the homeless.Results: Although factors relating to the practice (such as the role of the receptionist and practice workload) and to aspects of ‘the system’ (such as local and national policy) were mentioned, the major barriers related to aspects of the doctors themselves, particularly their attitudes towards homeless people and their consultation style. There also appeared to be a dichotomy in GPs’ attitudes and behaviours towards homeless patients.Conclusion: This study suggests that a major barrier to care for the homeless is the general practitioner himself, and that there may be a dichotomy in general practitioners' attitudes and consultation behaviour towards the homeless. This has implications for medical student training and methods of primary care service delivery to homeless people.

Delivery of primary care services among family planning centers: a response to managed care?

Previous case studies indicate that some family planning centers are transforming themselves into providers of primary care services, in part as a strategy to attract managed care contracts. Data for 98 family planning centers from the 1994 National Survey of Women’s Health Centers and supplementary sources are used to explore the factors associated with managed care contracting. Although some organizational-level factors are predictive, no cross-secional association was found between providing primary care and managed care contracting, which suggests family planning centers are not using primary care as a major contracting strategy.