Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review

Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs).

SOURCES

Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files.

STUDY SELECTION

One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations.

Comprehensive Online Self-Monitoring to Support Clinicians Manage Risk of Suicide in Youth Depression

BACKGROUND

Routine monitoring of depression symptoms and suicide risk is essential for appropriate treatment planning and risk management, but not well implemented by clinicians. We developed a brief online monitoring tool to address this issue.

AIMS

To investigate whether the online tool can feasibly improve monitoring; whether it is acceptable and useful for young people and their clinicians; and to determine whether a shorter tool could be implemented.

METHOD

In a naturalistic longitudinal cohort study, 101 young people with depression completed the online tool on a tablet, prior to their consultation. Their results were immediately available to their clinician. Clients and clinicians answered questionnaires about acceptability and usefulness.

RESULTS

The tool was feasible to implement. Young people and clinicians found the tool acceptable and useful for understanding symptoms and risk. A brief three-item suicidal ideation screening measure correlated well with a validated measure of suicidal ideation.

CONCLUSION

The online tool facilitates the quick exchange of key information about suicide risk, allowing clinicians to immediately address this. This level of responsiveness is likely to improve treatment outcomes. The brief version allows full integration into clinical practice to support clinicians managing those at risk of suicide.

Can preventive care activities in general practice be sustained when financial incentives and external audit plus feedback are removed? ACCEPt-able: a cluster randomised controlled trial protocol

Background

Financial incentives and audit plus feedback on performance are two strategies commonly used by governments to motivate general practitioners (GP) to undertake specific healthcare activities. However, in recent years, governments have reduced or removed incentive payments without evidence of the potential impact on GP behaviour and patient outcomes. This trial (known as ACCEPt-able) aims to determine whether preventive care activities in general practice are sustained when financial incentives and/or external audit plus feedback on preventive care activities are removed. The activity investigated is annual chlamydia testing for 16- to 29-year-old adults, a key preventive health strategy within this age group.

Methods/design

ACCEPt-able builds on a large cluster randomised controlled trial (RCT) that evaluated a 3-year chlamydia testing intervention in general practice. GPs were provided with a support package to facilitate annual chlamydia testing of all sexually active 16- to 29-year-old patients. This package included financial incentive payments to the GP for each chlamydia test conducted and external audit plus feedback on each GP’s chlamydia testing rates. ACCEPt-able is a factorial cluster RCT in which general practices are randomised to one of four groups: (i) removal of audit plus feedback—continue to receive financial incentive payments for each chlamydia test; (ii) removal of financial incentive payments—continue to receive audit plus feedback; (iii) removal of financial incentive payments and audit plus feedback; and (iv) continue financial incentive payments and audit plus feedback. The primary outcome is chlamydia testing rate measured as the proportion of sexually active 16- to 29-year-olds who have a GP consultation within a 12-month period and at least one chlamydia test.

Discussion

This will be the first RCT to examine the impact of removal of financial incentive payments and audit plus feedback on the chlamydia testing behaviour of GPs. This trial is particularly timely and will increase our understanding about the impact of financial incentives and audit plus feedback on GP behaviour when governments are looking for opportunities to control healthcare budgets and maximise clinical outcomes for money spent. The results of this trial will have implications for supporting preventive health measures beyond the content area of chlamydia.

Trial registration

The trial has been registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12614000595617).

Scoping of models to support population-based regional health planning and management: comparison with the regional operating model in Victoria, Australia

Objective The aim of the present study was to try to understand the breadth and comprehensiveness of a regional operating model (ROM) developed within the Victorian Department of Health's North West Metropolitan Region office in Melbourne, Australia. Methods A published literature search was conducted, with additional website scanning, snowballing technique and expert consultation, to identify existing operating models. An analytical grid was developed covering 16 components to evaluate the models and assess the exhaustiveness of the ROM. Results From the 34 documents scoped, 10 models were identified to act as a direct comparator to the ROM. These concerned models from Australia (n=5) and other comparable countries (Canada, UK). The ROM was among the most exhaustive models, covering 13 of 16 components. It was one of the few models that included intersectoral actions and levers of influence. However, some models identified more precisely the planning tools, prioritisation criteria and steps, and the allocation mechanisms. Conclusions The review finds that the ROM appears to provide a wide coverage of aspects of planning and integrates into a single model some of the distinctive elements of the other models scoped. What is known about the topic? Various jurisdictions are moving towards a population-based approach to manage public services with regard to the provision of individual medical and social care. Various models have been proposed to guide the planning of services from a population health perspective. What does this paper add? This paper assesses the coverage of attributes of operating models supporting a population health planning approach to the management of services at the regional or local level. It provides a scoping of current models proposed to organise activities to ensure an integrated approach to the provision of services and compares the scoped models to a model recently implemented in Victoria, Australia. What are the implications for practitioners? This paper highlights the relative paucity of operating models describing in concrete terms how to manage medical and social services from a population perspective and encourages organisations that are accountable for securing population health to clearly articulate their own operating model. It outlines strengths and potential gaps in current models.

Frequent callers to telephone helplines: new evidence and a new service model

BACKGROUND

This paper describes a program of work designed to inform a service model to address a challenge for telephone helplines, namely frequent callers.

METHODS

We conducted a systematic literature review and four empirical studies that drew on different data sources-(a) routinely collected calls data from Lifeline, Australia's largest telephone helpline; (b) data from surveys/interviews with Lifeline frequent callers; (c) data from the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) study; and (d) data from Australia's National Survey of Mental Health and Wellbeing.

RESULTS

Frequent callers represent 3 % of callers but make 60 % of calls. They are isolated and have few social supports but are not "time wasters"; they have major mental and physical health problems and are often in crisis. They make use of other services for their mental health problems. The circumstances under which they use telephone helplines vary, but current service models reinforce their calling behaviour.

CONCLUSIONS

The findings point to a service model that might better serve the needs of both frequent callers and other callers. The model involves offering frequent callers an integrated, tailored service in which they are allocated a dedicated and specially trained telephone crisis supporter (TCS), and given set calling times. It also involves promoting better linkages between telephone helplines and other services that provide mental health care, particularly general practitioners (GPs) and other primary care providers. The next step is to refine and test the model.

Equity of access to primary healthcare for vulnerable populations: the IMPACT international online survey of innovations

BACKGROUND

Improving access to primary healthcare (PHC) for vulnerable populations is important for achieving health equity, yet this remains challenging. Evidence of effective interventions is rather limited and fragmented. We need to identify innovative ways to improve access to PHC for vulnerable populations, and to clarify which elements of health systems, organisations or services (supply-side dimensions of access) and abilities of patients or populations (demand-side dimensions of access) need to be strengthened to achieve transformative change. The work reported here was conducted as part of IMPACT (Innovative Models Promoting Access-to-Care Transformation), a 5-year Canadian-Australian research program aiming to identify, implement and trial best practice interventions to improve access to PHC for vulnerable populations. We undertook an environmental scan as a broad screening approach to identify the breadth of current innovations from the field.

METHODS

We distributed a brief online survey to an international audience of PHC researchers, practitioners, policy makers and stakeholders using a combined email and social media approach. Respondents were invited to describe a program, service, approach or model of care that they considered innovative in helping vulnerable populations to get access to PHC. We used descriptive statistics to characterise the innovations and conducted a qualitative framework analysis to further examine the text describing each innovation.

RESULTS

Seven hundred forty-four responses were recorded over a 6-week period. 240 unique examples of innovations originating from 14 countries were described, the majority from Canada and Australia. Most interventions targeted a diversity of population groups, were government funded and delivered in a community health, General Practice or outreach clinic setting. Interventions were mainly focused on the health sector and directed at organisational and/or system level determinants of access (supply-side). Few innovations were developed to enhance patients' or populations' abilities to access services (demand-side), and rarely did initiatives target both supply- and demand-side determinants of access.

CONCLUSIONS

A wide range of innovations improving access to PHC were identified. The access framework was useful in uncovering the disparity between supply- and demand-side dimensions and pinpointing areas which could benefit from further attention to close the equity gap for vulnerable populations in accessing PHC services that correspond to their needs.

The CORE study protocol: a stepped wedge cluster randomised controlled trial to test a co-design technique to optimise psychosocial recovery outcomes for people affected by mental illness in the community mental health setting

INTRODUCTION

User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness.

METHODS

An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point.

ETHICS AND DISSEMINATION

The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry ACTRN12614000457640.

Factors associated with smoking and smoking cessation among primary care patients with depression: a naturalistic cohort study

Purpose

– People with a history of depression are more likely to smoke and less likely to achieve abstinence from smoking long term. The purpose of this paper is to understand the factors associated with smoking and smoking cessation among patients with depression.

Design/methodology/approach

– This paper reports on smoking prevalence and cessation in a cohort of 789 primary care attendees with depressive symptoms (Centre for Epidemiologic Studies Depression Scale score of=16) recruited from 30 randomly selected Primary Care Practices in Victoria, Australia in 2005.

Findings

– At baseline, 32 per cent of participants smoked. Smokers were more likely to be male, unmarried, receive government benefits, have difficulty managing on available income, have emphysema, a chronic illness, poor self-rated health, to have more severe depressive and anxiety symptoms, to be taking anti-depressants, to be hazardous drinkers, to report suicidal ideation and to have experienced childhood physical or sexual abuse. At 12 months, 20 participants reported quitting. Females and people with good or better self-rated health were significantly more likely to have quit, while people with a chronic illness or suicidal ideation were less likely to quit. Smoking cessation was not associated with increases in depression or anxiety symptoms. Only six participants remained quit over four years.

Practical implications

– Rates of smoking were high, and long-term cessation was low among primary care patients with depressive symptoms. Primary care physicians should provide additional monitoring and support to assist smokers with depression quit and remain quit.

Originality/value

– This is the first naturalistic study of smoking patterns among primary care attendees with depressive symptoms.

Do Australian general practitioners believe practice nurses can take a role in chlamydia testing? A qualitative study of attitudes and opinions

BACKGROUND

Chlamydia notifications continue to rise in young people in many countries and regular chlamydia testing is an important prevention strategy. Although there have been initiatives to increase testing in primary care, none have specifically investigated the role of practice nurses (PNs) in maximising testing rates. PNs have previously expressed a willingness to be involved, but noted lack of support from general practitioners (GPs) as a barrier. We sought GPs' attitudes and opinions on PNs taking an expanded role in chlamydia testing and partner notification.

METHODS

In the context of a cluster randomised trial in mostly rural towns in 4 Australian states, semi structured interviews were conducted with 44 GPs between March 2011 and July 2012. Data relating to PN involvement in chlamydia testing were thematically analysed using a conventional content analysis approach.

RESULTS

The majority of GPs interviewed felt that a role for PNs in chlamydia testing was appropriate. GPs felt that PNs had more time for patient education and advice, that patients would find PNs easier to talk to and less intimidating than GPs, and that GPs themselves could benefit through a reduction in their workload. Although GPs felt that PNs could be utilised more effectively for preventative health activities such as chlamydia testing, many raised concerns about how these activities would be renumerated whilst some felt that existing workload pressures for PNs could make it difficult for them to expand their role. Whilst some rural GPs recognised that PNs might be well placed to conduct partner notification, they also recognised that issues of patient privacy and confidentiality related to living in a "small town" was also a concern.

CONCLUSION

This is the first qualitative study to explore GPs' views around an increased role for PNs in chlamydia testing. Despite the concerns raised by PNs, these findings suggest that GPs support the concept and recognise that PNs are suited to the role. However issues raised, such as funding and remuneration may act as barriers that will need to be addressed before PNs are supported to make a contribution to increasing chlamydia testing rates in general practice.

Frequent callers to crisis helplines: who are they and why do they call?

OBJECTIVE

Frequent callers present a challenge for crisis helplines, which strive to achieve optimal outcomes for all callers within finite resources. This study aimed to describe frequent callers to Lifeline (the largest crisis helpline in Australia) and compare them with non-frequent callers, with a view to furthering knowledge about models of service delivery that might meet the needs of frequent callers.

METHOD

Lifeline provided an anonymous dataset on calls made between December 2011 and May 2013. We assumed calls from the same (encrypted) phone number were made by the same person, and aggregated call level data up to the person level. Individuals who made 0.667 calls per day in any period from 1 week to the full 549 days for which we had data (i.e. 4.7 calls in 7 days, 20 calls in 30 days, 40 calls in 60 days, etc.) were regarded as frequent callers.

RESULTS

Our analysis dataset included 411,725 calls made by 98,174 individuals, 2594 (2.6%) of whom met our definition of frequent callers. We identified a number of predictors of being a frequent caller, including being male or transgender, and never having been married. The odds increased with age until 55-64 years, and then declined. Suicidality, self-harm, mental health issues, crime, child protection and domestic violence issues all predicted being a frequent caller.

CONCLUSIONS

Collectively, frequent callers have a significant impact on crisis lines, and solutions need to be found for responding to them that are in everybody's best interests (i.e. the frequent callers themselves, other callers, telephone crisis supporters who staff crisis lines, and those who manage crisis lines). In striking this balance, the complex and multiple needs of frequent callers must be taken into account.

Improving chlamydia knowledge should lead to increased chlamydia testing among Australian general practitioners: a cross-sectional study of chlamydia testing uptake in general practice

Background

Female general practitioners (GPs) have higher chlamydia testing rates than male GPs, yet it is unclear whether this is due to lack of knowledge among male GPs or because female GPs consult and test more female patients.

Methods

GPs completed a survey about their demographic details and knowledge about genital chlamydia. Chlamydia testing and consultation data for patients aged 16-29 years were extracted from the medical records software for each GP and linked to their survey responses. Chi-square tests were used to determine differences in a GP’s knowledge and demographics. Two multivariable models that adjusted for the gender of the patient were used to investigate associations between a GP and their chlamydia testing rates ― Model 1 included GPs’ characteristics such as age and gender, Model 2 excluded these characteristics to specifically examine any associations with knowledge.

Results

Female GPs were more likely than male GPs to know when to re-test a patient after a negative chlamydia test (18.8% versus 9.7%, p = 0.01), the correct symptoms suggestive of PID (80.5% versus 67.8%, p = 0.01) and the correct tests for diagnosing PID (57.1% versus 42.6%, p = 0.01). Female GPs tested 6.5% of patients, while male GPs tested 2.2% (p < 0.01). Model 1 found factors associated with chlamydia testing were being a female GP (OR = 2.5, 95% CI: 1.9, 3.3) and working in a metropolitan clinic (OR = 3.2; 95% CI: 2.4, 4.3). Model 2 showed that chlamydia testing increased as knowledge of testing guidelines improved (3-5 correct answers – AOR = 2.0, 95% CI: 1.0, 4.2; 6+ correct answers – AOR = 2.9, 95% CI: 1.4, 6.2).

Conclusions

Higher rates of chlamydia testing are strongly associated with GPs who are female, based in a metropolitan clinic and among those with more knowledge of the recommended guidelines. Improving chlamydia knowledge among male GPs may increase chlamydia testing.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0584-2) contains supplementary material, which is available to authorized users.

Depression and multimorbidity: a cross-sectional study of 1,751,841 patients in primary care

BACKGROUND

Depression is common in many chronic physical health disorders, but the nature and extent of physical health comorbidities in depression, particularly within large population-based samples of patients, and how these comorbidities relate to factors such as age, sex, and social deprivation, are unknown. We aimed to assess the nature and extent of multiple physical health comorbidities in primary care patients with depression within a large and representative Scottish dataset.

METHOD

This study was a cross-sectional secondary data analysis of 314 primary care practices in Scotland (from the Primary Care Clinical Informatics Unit at the University of Aberdeen, Scotland, March 31, 2007), including 143,943 people with depression and 1,280,435 controls. The outcomes assessed were 32 common chronic physical health conditions, adjusted for age, sex, and social deprivation. Depression was defined as a Read code for depression recorded within last year and/or 4 or more antidepressant prescriptions (excluding low-dose tricyclic antidepressants) within the last year.

RESULTS

Individuals in primary care with depression were more likely than individuals without depression to have every one of the 32 comorbid physical conditions we assessed, even after adjusting for age, sex, and deprivation. The depression group was also significantly more likely to have multiple levels of comorbidity, including 2 physical health conditions (OR = 1.55; 95% CI, 1.53-1.58), 3 physical health conditions (OR = 1.84; 95% CI, 1.81-1.87), 4 physical health conditions (OR = 2.06; 95% CI, 2.01-2.11; P < .001), and 5 or more physical health conditions (OR = 2.65; 95% CI, 2.59-2.71; P < .001).

CONCLUSION

Depression in primary care is associated with a very wide range of physical health comorbidities and considerable medical burden. The nature and extent of this multimorbidity and the important association with social deprivation have not been previously described within a large and representative dataset of routine primary care data. Our findings have important implications for the integrated management of depression and physical health problems in the United Kingdom and throughout the world.

Visions of generalism - what does the future hold?

Support for generalism is underpinned by more than 100 years of writings and these writings point to writers and thinkers who have grappled with the tensions between generalism and specialism since ancient Egyptian times. Taking a historical stance we make the case that generalism is here to stay. But, what does the future hold? We outline some ideas for growing generalism in the wake of smart technologies, personalised medicine and the deluge of ever increasing health information.

The challenges of real-world implementation of web-based shared care software: the HopSCOTCH Shared-Care Obesity Trial in Children

BACKGROUND

E-health initiatives hold promise to improve shared-care models of health care. In 2008-2011 we developed and trialled web-based software to facilitate a randomised trial of a shared-care approach for childhood obesity involving General Practitioners (GPs) working with tertiary specialists. We describe the software's development, implementation and evaluation, and make recommendations for future e-health initiatives. The web-based software was designed with the goals of allowing both GPs and specialists to communicate and review patient progress; integrating with existing GP software; and supporting GPs to deliver the structured intervention. Specifically, we aimed to highlight the challenges inherent in this process, and report on the extent to which the software ultimately met its implementation and user aims.

METHODS

The study was conducted at the Royal Children's Hospital and 22 general practices across Melbourne, Australia. Participants comprised 30 GPs delivering the shared-care intervention. Outcomes included the following. (1) GPs' pre-specified software requirements: transcribed from two focus groups and analysed for themes using content analysis. (2) Software implementation and performance based on the experience of the research team and GPs. (3) GP users' evaluation collected via questionnaire. (4) Software usage collected via GP questionnaire and qualified through visual inspection of the software meta-data.

RESULTS

Software implementation posed difficult and at times disabling technological barriers (e.g. out-dated hardware, poor internet connections). The software's speed and inability to seamlessly link with day-to-day software was a source of considerable frustration. Overall, GPs rated software usability as poor, although most (68%) felt that the structure and functionality of the software was useful. Recommendations for future e-health initiatives include thorough scoping of IT systems and server speed, testing across diverse environments, automated pre-requisite checks and upgrades of processors/memory where necessary, and user-created usernames and passwords.

CONCLUSIONS

GPs are willing to embrace novel technologies to support their practice. However, implementation remains challenging mainly for technical reasons, and this precludes further evaluation of potential user-specific barriers. These findings could inform future e-health ventures into shared-care, and highlight the need for an appropriate infrastructure.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN126080000553.