Tracer Conditions Research Articles

Provision of services in primary care for type 2 diabetes: a qualitative study with patients, GPs, and nurses in the East of England.

BackgroundThere is little evidence on the impact of national pressures on primary care provision for type 2 diabetes from the perspectives of patients, their GPs, and nurses.AimTo explore experiences of primary care provision for people with type 2 diabetes and their respective GPs and nurses.Design and settingA qualitative primary care interview study in the East of England.MethodSemi-structured interviews were conducted, between August 2017 and August 2018, with people who have type 2 diabetes along with their respective GPs and nurses. Purposive sampling was used to select for heterogeneity in glycaemic control and previous healthcare experiences. Interviews were audio-recorded and analysed thematically. The consolidated criteria for reporting qualitative research were followed.ResultsThe authors interviewed 24 patients and 15 GPs and nurses, identifying a changing landscape of diabetes provision owing to burgeoning pressures that were presented repeatedly. Patient responders wanted GP-delivered care with continuity. They saw GPs as experts best placed to support them in managing diabetes, but were increasingly receiving nurse-led care. Nurses reported providing most of the in-person care, while GPs remained accountable but increasingly distanced from face-to-face diabetes care provision. A reluctant acknowledgement surfaced among GPs, nurses, and their patients that only minimum care standards could be maintained, with aspirations for high-quality provision unlikely to be met.ConclusionType 2 diabetes is a tracer condition that reflects many aspects of primary care. Efforts to manage pressures have not been perceived favourably by patients and providers, despite some benefits. Reframing expectations of care, by communicating solutions to both patients and providers so that they are understood, managed, and realistic, may be one way forward.

Measurement and Validation of Primary Care Nursing Indicators Based on a Wound Care Tracer Condition.

Access to both valid and reliable nursing-sensitive indicators is currently limited in primary care. The objectives were to (1) measure primary care nursing indicators using a wound care tracer condition and (2) study the associations between process and outcome indicators. We conducted a longitudinal study in an ambulatory care clinic in Quebec, Canada. The sample included 482 episodes of care. We studied 5 indicators related to processes and 3 to outcomes. Performance levels were moderately high for indicators of initial assessment and duration and low for those of continuity and education. Associations between nursing follow-up and continuity indicators and 3 outcome indicators were highly significant. Continuity and nursing follow-up are associated with improved outcomes. Increasing these indicators' performance level can improve both nursing processes and patient outcomes.

Creating performance intelligence for primary health care strengthening in Europe

BackgroundPrimary health care and its strengthening through performance measurement is essential for sustainably working towards universal health coverage. Existing performance frameworks and indicators to measure primary health care capture system functions like governance, financing and resourcing but to a lesser extent the function of services delivery and its heterogeneous nature. Moreover, most frameworks have weak links with routine information systems and national health priorities, especially in the context of high- and middle-income countries. This paper presents the development of a tool that responds to this context with the aim to create primary health care performance intelligence for the 53 countries of the WHO European Region.MethodsThe work builds-off of an existing systematic review on primary care and draws on priorities of current European health policies and available (inter)national information systems. Its development included: (i) reviewing and classifying features of primary care; (ii) constructing a set of tracer conditions; and (iii) mapping existing indicators in the framework resulting from (i). The analysis was validated through a series of reviews: in-person meetings with country-nominated focal points and primary care experts; at-distance expert reviews; and, preliminary testing with country informants.ResultsThe resulting framework applies a performance continuum in the classical approach of structures-processes-outcomes spanning 6 domains – primary care structures, model of primary care, care contact, primary care outputs, health system outcomes, and health outcomes – that are further classified by 26 subdomains and 63 features of primary care. A care continuum was developed using a set of 12 tracer conditions. A total of 139 indicators were mapped to the classification, each with an identified data source to safeguard measurability. Individual indicator passports and a glossary of terms were developed to support the standardization of the findings.ConclusionThe resulting framework and suite of indicators, coined the Primary Health Care Impact, Performance and Capacity Tool (PHC-IMPACT), has the potential to be applied in Europe, closing the gap on existing data collection, analysis and use of performance intelligence for decision-making towards primary health care strengthening.

When more is less: What explains the overuse of health care services in China?

Overuse of health care services has become an increasingly severe problem in China. However, as both academic interests and practical efforts have mainly focused on reducing underuse, our understanding of overuse is far from complete. This study aims to analyze the status of overuse of health care services in China and explore both the supply- and demand-side factors associated with overuse. We took common cold, a self-limiting viral infection which requires no injections or infusions, as a tracer condition. Based on data from the fourth and fifth Health Service Survey of Shaanxi Province, we generated an observable indicator to measure overuse: whether or not a patient received infusion treatment for common cold during outpatient visits. The statistics showed that 58.73% and 37.56% of patients had infusion treatment for common cold during outpatient visits in 2008 and 2013, respectively. Based on this dependent variable, we employed Probit analysis to investigate factors influencing the overuse of health care services. The multivariate regression results showed that on the demand side, overuse was positively associated with low health literacy, long duration of illness, large family size, and high economic status. On the supply side, overuse was relatively high in hospitals at the county level and above as well as in cities with relatively low density of health care workforce. Our results also provided some evidence for the effectiveness of health care reform policies like the essential medicines programme in reducing overuse.

Assessing the quality of primary healthcare in seven Chinese provinces with unannounced standardised patients: protocol of a cross-sectional survey

IntroductionPrimary healthcare (PHC) serves as the cornerstone for the attainment of universal health coverage (UHC). Efforts to promote UHC should focus on the expansion of access and on healthcare quality....

Tracer Methodology and the quality of care: integrative literature review.

To analyze the scientific literature about the Tracer Method in the area of nursing. Integrative literature review with 22 articles from the following databases: Latin American and Caribbean Literature in Health Sciences (LILACS); Medical Literature Analysis and Retrieval System Online(Medline/PubMed); Scientific Electronic Library Online (SciELO); Cumulative Index to Nursing & Allied Health Literature (CINAHL) and Web of Science. The search strategy included descriptors and keywords, as follows: Método Tracer, Método Traçador, Método Rastreador, Método de Avaliação, Usuário Guia amd Enfermagem correlated and combined with Boolean operators. Data was organized according to the scenarios where the method was applied, namely: health condition as a tracer condition for assessing the quality of care, compliance and non-compliance regarding the institutional protocols, reflection and training for accreditation. The Tracer Methodology is used for evaluating and improving the quality of care.

Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal and Peru

Different methodological approaches for implementation research in global health focusing on how interventions are developed, implemented and evaluated are needed. In this paper, we detail the approach developed and implemented...

How do health professionals acknowledge Web-based knowledge in pregnancy consultations?

ABSTRACTWebsites for pregnancy health are an important source of information for pregnant women, but how different cadres of health professionals value and utilize pregnant women's e-health literacy (e-HL) and Web-based knowledge in pregnancy consultations is not well understood. Using a qualitative research design and pelvic girdle pain as a tracer condition, we explored how Norwegian doctors, midwives and physiotherapists manage women's e-HL and Web-based knowledge in pregnancy consultations. The recognition of pregnant women's e-HL and Web-based knowledge differed across professional groups and produced dismissive, reactive and proactive attitudes depending on time pressure, professional identity and Internet experience.

World Health Organization and Essential Medicines

In June 2017, the World Health Organization released 20th Model List of Essential Medicines for adults and sixth Model List of Essential Medicines for children. In our commentary, we describe the changes to the Essential Medicine list, and identify deficits in excluding medicines for management of diseases with a high burden. In using tracer conditions such as cardiovascular and thromboembolic disease, mental health, and diseases of the musculoskeletal system, we highlight the absence of several medicines, which are incorporated into major clinical practice guidelines. We recommend that the World Health Organization review its process with respect to identifying disease conditions as well as evidence-based therapies.

An innovative lung model for multiple breath washout testing in health and disease

BackgroundMultiple breath washout (MBW) is a lung function test that identifies the degree of ventilation inhomogeneity (VI) in the lungs. In vitro validation of MBW devices is recommended. So far, plastic lung models for MBW validation ignored variable degrees of VI. Our primary aim was to create a plastic lung model applicable for physiological lung volumes and variable VI. MethodsA plastic box divided in two chambers was filled with water and ventilated in various lung volumes and respiratory rates. A ventilator was used for efficient gas distribution (model with low VI). An additional divider was inserted to create a model with high VI. The model was connected to commercial MBW devices and measurements were performed using different tracer gases and conditions. Primary outcome was the precision of generated functional residual capacity (FRC) and the ability to generate variable VI. The latter was estimated by lung clearance index (LCI) and expiratory phase III slopes (SIII). LCI was also compared to a mathematical model. FindingsThe intra-test variability for FRC was minimal, mean(SD) coefficient of variation 0.96(0.63)%, using different tracer gases under different conditions. Compared to the model with low VI, in the model with high VI LCI and washout SIII were significantly increased. LCI compared well to the mathematical model. InterpretationThis novel lung model shows excellent precision in lung volumes and VI estimates independent of tracer gases and conditions. The model can mimic the lungs of patients with uneven gas distribution.

A large cluster randomized trial of outcome-based pathways to improve home-based wound care

BackgroundAlthough not always recognized as a pressing health care problem, wounds are a common, complex and costly condition. The burden of treating wounds is growing rapidly due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The Integrated Client Care (ICC) Project was a multi-year initiative to develop and test a new, integrated model of wound care within the home care sector in Ontario, Canada to improve health outcomes for patients and decrease system costs.MethodsCluster randomized trial, with allocation of intervention randomized at the cluster level (14 home care centers) and analysis of outcomes based on individual-level data (patients). Primary analysis was an intention-to-treat (ITT) analysis. Two wound types, diabetic foot ulcers and pilonidal sinus, were selected as tracer conditions to assess the impact of the intervention on two different patient populations. Time to successful discharge from home care was analyzed using multivariable Cox proportional hazards regression. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented.ResultsA total of 12,063 diabetic foot ulcer patients and 1954 pilonidal sinus patient records were available for analysis. No appreciable differences were observed between patients in the control and intervention arms for either of the primary or secondary analyses in either condition group. In the diabetic foot ulcer group, 72.7% patients in the control arm and 73.6% patients in the intervention arm were discharged in the follow-up period (HR 1.05; 95% CI 0.94 to 1.17). In the pilonidal sinus group, 91.0% patients in the control arm and 89.0% patients in the intervention arm were discharged in the follow-up period (HR 0.96; 95% CI 0.82 to 1.12).ConclusionAs implemented, the ICC intervention was not effective, most likely due to failure of implementation, and is, therefore, not ready for widespread implementation in Ontario. Significant work remains to be done to correct the implementation process so that the concept of outcome-based health care can be properly evaluated.Trial registrationClinicalTrials.gov, ID: NCT01573832. Registered on 12 January 2012.

Health Insurance Scheme Performance and Effects on Health and Health Inequalities in Chile.

ABSTRACT INTRODUCTION Health systems are one determinant of health; their role is to facilitate timely and equitable access to quality services. The way in which a health system is organized can profoundly affect achievement of its objectives. The main feature of the Chilean health system is the coexistence of a public health insurance program (based on a social insurance model) with several market-based private health insurance companies. This hybrid structure provides an interesting framework for analyzing and evaluating the system’s effects on health inequalities. OBJECTIVE Assess Chilean public and private health insurance schemes’ performance and its effects on health inequalities. METHODS Public health insurance was compared with private insurance using indicators from 2013 (or the closest year) in the following domains: inputs, outputs (provider visits, discharges), outcomes (coverage) and impact (on health, quality of life, finances and patient satisfaction) as well as demographic and social determinant indicators. A conceptual framework for measuring health system performance was used. Data were obtained from administrative records and population-based surveys. RESULTS The publicly insured population had greater health care needs, was older (aging index 83.4 vs. 36.5) and poorer (17.2% vs. 1.5% below the poverty line) than the population covered by private insurers. The public insurer received average monthly funding of US$50.94 per beneficiary and spent US$51.43, while private insurers on average collected US$94.79 monthly per beneficiary, and spent US$69.63 on health services (excluding medical leave benefits). Private health insurance beneficiaries were more likely than their publicly insured counterparts to access specialized medical services (18.3% vs. 9.3%) and dentists (11.2% vs. 5.9%), have laboratory tests (18.1% vs. 4.8%), and undergo surgery (7.8% vs. 5.9%). Risk factor and disease prevalence was lower among private insurance beneficiaries for 16 of 18 tracer conditions, although age-adjusted differences were not significant. Finally, incidence of catastrophic spending was slightly lower among private insurance beneficiaries (3.7% vs. 4.2%), and a greater proportion of them were satisfied or very satisfied with the health system (37% vs. 17%). CONCLUSIONS The relative youth and better financial status of beneficiaries of private insurers is compatible with selection for lower risk. While private plans offer greater financial protection and receive higher user satisfaction ratings than the public plan, differences in financing between the two types of insurance affect availability and utilization of services. This constitutes a structural problem for the Chilean health system. There is an urgent need to move toward an integrated health system, in which incentives are aligned with social insurance objectives.

Use of standardised patients to assess quality of healthcare in Nairobi, Kenya: a pilot, cross-sectional study with international comparisons

IntroductionThe quality of clinical care can be reliably measured in multiple settings using standardised patients (SPs), but this methodology has not been extensively used in Sub-Saharan Africa. This study validates...

Mapping of research on maternal health interventions in low- and middle-income countries: a review of 2292 publications between 2000 and 2012.

BackgroundProgress in achieving maternal health goals and the rates of reductions in deaths from individual conditions have varied over time and across countries. Assessing whether research priorities in maternal health align with the main causes of mortality, and those factors responsible for inequitable health outcomes, such as health system performance, may help direct future research. The study thus investigated whether the research done in low- and middle-income countries (LMICs) matched the principal causes of maternal deaths in these settings. MethodsSystematic mapping was done of maternal health interventional research in LMICs from 2000 to 2012. Articles were included on health systems strengthening, health promotion; and on five tracer conditions (haemorrhage, hypertension, malaria, HIV and other sexually transmitted infections (STIs)). Following review of 35,078 titles and abstracts in duplicate, data were extracted from 2292 full-text publications.ResultsOver time, the number of publications rose several-fold, especially in 2004–2007, and the range of methods used broadened considerably. More than half the studies were done in sub-Saharan Africa (55.4 %), mostly addressing HIV and malaria. This region had low numbers of publications per hypertension and haemorrhage deaths, though South Asia had even fewer. The proportion of studies set in East Asia Pacific dropped steadily over the period, and in Latin America from 2008 to 2012. By 2008–2012, 39.1 % of articles included health systems components and 30.2 % health promotion. Only 5.4 % of studies assessed maternal STI interventions, diminishing with time. More than a third of haemorrhage research included health systems or health promotion components, double that of HIV research.ConclusionSeveral mismatches were noted between research publications, and the burden and causes of maternal deaths. This is especially true for South Asia; haemorrhage and hypertension in sub-Saharan Africa; and for STIs worldwide. The large rise in research outputs and range of methods employed indicates a major expansion in the number of researchers and their skills. This bodes well for maternal health if variations in research priorities across settings and topics are corrected.Electronic supplementary materialThe online version of this article (doi:10.1186/s12992-016-0189-1) contains supplementary material, which is available to authorized users.

Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study

ObjectivesThe UK's Quality and Outcomes Framework permits practices to exempt patients from financially-incentivised performance targets. To better understand the determinants and consequences of being exempted from the framework, we investigated...

Developing integrated clinical reasoning competencies indental students using scaffolded case-based learning - empirical evidence.

This study provides empirical evidence of the development of integrated clinical reasoning in the discipline-based School of Dentistry, University of Pretoria, South Africa. Students were exposed to case-based learning in comprehensive patient care (CPC) in the preclinical year of study, scaffolded by means of the four-component instructional design model for complex learning. Progress test scores of third- to fifth-year dental students, who received case-based teaching and learning in the third year (2009-2011), were compared to the scores of preceding fourth- and fifth-year cohorts. These fourth- and fifth-year cohorts received content-based teaching concurrently with their clinical training in CPC. The progress test consisted of a complex case study and 32 MCQs on tracer conditions. Students had to gather the necessary information and had to make diagnostic and treatment-planning decisions. Preclinical students who participated in the case-based teaching and learning achieved similar scores compared to final-year students who received lecture-based teaching and learning. Final-year students who participated in the case-based learning made three more correct clinical decisions per student, compared to those who received content-based teaching. Students struggled more with treatment-planning than with diagnostic decisions. The scaffolded case-based learning appears to contribute to accurate clinical decisions when compared to lecture-based teaching. It is suggested that the development of integrated reasoning competencies starts as early as possible in a dental curriculum, perhaps even in the preclinical year of study. Treatment-planning should receive particular attention.

Implementation of patient charges at primary care facilities in Kenya: implications of low adherence to user fee policy for users and facility revenue.

With user fees now seen as a major hindrance to universal health coverage, many countries have introduced fee reduction or elimination policies, but there is growing evidence that adherence to reduced fees is often highly imperfect. In 2004, Kenya adopted a reduced and uniform user fee policy providing fee exemptions to many groups. We present data on user fee implementation, revenue and expenditure from a nationally representative survey of Kenyan primary health facilities. Data were collected from 248 randomly selected public health centres and dispensaries in 2010, comprising an interview with the health worker in charge, exit interviews with curative outpatients, and a financial record review. Adherence to user fee policy was assessed for eight tracer conditions based on health worker reports, and patients were asked about actual amounts paid. No facilities adhered fully to the user fee policy across all eight tracers, with adherence ranging from 62.2% for an adult with tuberculosis to 4.2% for an adult with malaria. Three quarters of exit interviewees had paid some fees, with a median payment of US dollars (USD) 0.39, and a quarter of interviewees were required to purchase additional medical supplies at a later stage from a private drug retailer. No consistent pattern of association was identified between facility characteristics and policy adherence. User fee revenues accounted for almost all facility cash income, with average revenue of USD 683 per facility per year. Fee revenue was mainly used to cover support staff, non-drug supplies and travel allowances. Adherence to user fee policy was very low, leading to concerns about the impact on access and the financial burden on households. However, the potential to ensure adherence was constrained by the facilities’ need for revenue to cover basic operating costs, highlighting the need for alternative funding strategies for peripheral health facilities.

Integralidade no cuidado ao câncer do colo do útero: avaliação do acesso

OBJECTIVETo evaluate integrity of access to uterine cervical cancer prevention, diagnosis and treatment services.METHODSThe tracer condition was analyzed using a mixed quantitative and qualitative approach. The quantitative approach was based on secondary data from the analysis of cytology and biopsy exams performed between 2008 and 2010 on 25 to 59 year-old women in a municipality with a large population and with the necessary technological resources. Data were obtained from the Health Information System and the Regional Cervical Cancer Information System. Statistical analysis was performed using PASW statistic 17.0 software. The qualitative approach involved semi-structured interviews with service managers, health care professionals and users. NVivo 9.0 software was used for the content analysis of the primary data.RESULTSPap smear coverage was low, possible due to insufficient screening and the difficulty of making appointments in primary care. The numbers of biopsies conducted are similar to those of abnormal cytologies, reflecting easy access to the specialized services. There was higher coverage among younger women. More serious diagnoses, for both cytologies and biopsies, were more prevalent in older women.CONCLUSIONSInsufficient coverage of cytologies, reported by the interviewees allows us to understand access difficulties in primary care, as well as the fragility of screening strategies.

Hip fracture as the tracer condition.

Hip fractures represent the most severe complication of osteoporosis from the perspectives of the patient, carer, health care system and society. Given the strong association with age, numbers are set to rise significantly in the next few decades despite evidence that the age adjusted rates in some countries are either plateauing or falling. Given the almost invariable need for inpatient admission, hospital administrative data for hip fractures remain a robust measure of number of hip fractures in the community and can be extrapolated to determine the total expected number of clinical fragility fractures from the same population. Both process and outcome standards have now been developed to benchmark clinical quality in the care of patients with hip fractures and fragility fractures at other sites.

A preliminary analysis of the effect of the new rural cooperative medical scheme on inpatient care at a county hospital

BackgroundChina in 2009 committed to reach universal health coverage by promoting three forms of health insurance; NCMS for the rural population, UEBMI for formally employed urban residents and URBMI for other urban residents. NCMS has expanded to near universal coverage in rural China since launching in 2003. The objective of this study aimed to assess the effect of NCMS on inpatient care utilization from 2003 to 2012 at Longyou county hospital, Zhejiang province.MethodsThe research was conducted at Longyou county, Zhejiang province. All registered inpatient admissions from January 1, 2003, to June 30, 2012, were included in the study. The PLSQL Developer software was used to select the interesting variables in the hospital information database and saved in an Excel 2003 file. The interesting variables included the patients’ general information (name, gender, age, payment method), discharge diagnosis, length of hospital stay, and expenditure (total expenditure and out-of-pocket payment). Two common diseases (coronary arteriosclerotic disease and pneumonia) were selected as tracer conditions.Results292,400 rural residents were enrolled in the Longyou county NCMS by 2011, 95.4% of the eligible population. A total of 145,744 inpatient admissions were registered from 1 January 2003 to 30 June 2012. The proportion of inpatients covered by NCMS increased from 30.3% in 2004 to 54.2% in 2012 while the proportion of inpatients covered by UEBMI increased from 7.7% in 2003 to 14.7% in 2012. The average expenditure for UEBMI insured inpatients was higher than the average for NCMS insured inpatients, although the gap was narrowing. The average length of hospital stay increased every year for all inpatients, but was higher for UEBMI inpatients than for NCMS insured inpatients. For both tracer conditions the results were similar to the above findings.ConclusionsNCMS has improved coverage height for its enrollees and resulted in increased cost of care per inpatient admission at the county hospital. However, wide differences persist between the two insurance systems in coverage height. Both systems are associated with increasing lengths of stay and rising cost per inpatient admission. We found that around 30% of inpatients were not covered by any of the two public health insurance systems, which calls for further studies.