Increasing the Capacity of Primary Care Through Enabling Technology

Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in England

BACKGROUND

Little is known about the clinical characteristics of children and parents affected by intimate partner violence (IPV) presenting in health-care settings. We examined the associations between family adversities, health characteristics, and IPV in children and parents using linked electronic health records (EHRs) from primary and secondary care between 1 year before and 2 years after birth (the first 1000 days). We compared parental health problems in in children and parents with and without recorded IPV.

METHODS

We developed a population-based birth cohort of children and parents (aged 14-60 years) in England, comprising linked EHRs from mother-child pairs (with no identified father) and mother-father-child triads. We followed the cohort across general practices (Clinical Practice Research Datalink GOLD), emergency departments, outpatient visits, hospital admissions, and mortality records. Family adversities included 33 clinical indicators of parental mental health problems, parental substance misuse, adverse family environments, and high-risk child maltreatment-related presentations. Parental health problems included 12 common comorbidities, ranging from diabetes and cardiovascular diseases to chronic pain or digestive diseases. We used adjusted and weighted logistic-regression models to estimate the probability of IPV (per 100 children and parents) associated with each adversity, and period prevalences of parental health problems associated with IPV.

FINDINGS

We included 129 948 children and parents, comprising 95 290 (73·3%) mother-father-child triads and 34 658 (26·7%) mother-child pairs only between April 1, 2007, and Jan 29, 2020. An estimated 2689 (2·1%) of 129 948 children and parents (95% CI 2·0-2·3) had recorded IPV and 54 758 (41·2%; 41·5-42·2) had any family adversity between 1 year before and 2 years after birth. All family adversities were significantly associated with IPV. Most parents and children with IPV had recorded adversities (1612 [60·0%] of 2689) before their first IPV recording. The probability of IPV was 0·6 per 100 children and parents (95% CI 0·5-0·6) with no adversity, increasing to 4·4 per 100 children per parents (4·2-4·7) with one adversity, and up to 15·1 per 100 parents and children (13·6-16·5) with three of more adversities. Mothers with IPV had a significantly higher prevalence of both physical (73·4% vs 63·1%, odds ratio [OR] 1·6, 95% CI 1·4-1·8) and mental health problems (58·4% vs 22·2%, OR 4·9, 4·4-5·5) than mothers without IPV. Fathers with IPV had a higher prevalence of mental health problems (17·8% vs 7·1%, OR 2·8, 2·4-3·2) and similar prevalences of physical health problems than those without IPV (29·6% vs 32·4%, OR 0·9, 0·8-1·0).

INTERPRETATION

Two in five of the children and parents presenting to health care had recorded parental mental health problems, parental substance misuse, adverse family environments, or high-risk presentations of maltreatment in the first 1000 days. One in 22 children and parents with family adversity also had recorded IPV before age 2 years. Primary and secondary care staff should safely ask about IPV when parents or children present with family adversity or health problems associated with IPV, and respond appropriately.

FUNDING

NIHR Policy Research Programme.

The Effects of the Use of Patient-Accessible Electronic Health Record Portals on Cancer Survivors’ Health Outcomes: Cross-sectional Survey Study

Background

In the past decade, patient-accessible electronic health record (PAEHR) systems have emerged as an important tool for health management both at the hospital level and individual level. However, little is known about the effects of PAEHR portals on the survivorship of patients with chronic health conditions (eg, cancer).

Objective

This study aims to investigate the effects of the use of PAEHR portals on cancer survivors’ health outcomes and to examine the mediation pathways through patient-centered communication (PCC) and health self-efficacy.

Methods

Data for this study were derived from the Health Information National Trends Survey (HINTS 5, Cycle 4) collected from February 2020 to June 2020. This study only involved respondents who reported having been diagnosed with cancer (N=626). Descriptive analyses were performed, and the mediation models were tested using Model 6 from the SPSS macro PROCESS. Statistically significant relationships among PAEHR portal use, PCC, health self-efficacy, and physical and psychological health were examined using bootstrapping procedures. In this study, we referred to the regression coefficients generated by min-max normalization as percentage coefficients (bp). The 95% bootstrapped CIs were used with 10,000 resamplings.

Results

No positive direct associations between PAEHR portal use and cancer survivors’ health outcomes were found. The results supported the indirect relationship between PAEHR portal use and cancer survivors’ psychological health via (1) PCC (bp=0.029; β=.023, 95% CI .009-.054), and (2) PCC and health self-efficacy in sequence (bp=0.006; β=.005, 95% CI .002-.014). Besides, the indirect association between PAEHR portal use and cancer survivors’ physical health (bp=0.006; β=.004, 95% CI .002-.018) via sequential mediators of PCC and health self-efficacy was also statistically acknowledged.

Conclusions

This study offers empirical evidence about the significant role of PAEHR portals in delivering PCC, improving health self-efficacy, and ultimately contributing to cancer survivors’ physical and psychological health.

Perceived technology use, attitudes, and barriers among primary care nurses

BACKGROUND

In primary healthcare, health information technology has the potential to facilitate the delivery of healthcare services by improving quality of care, efficiency and patient safety. However, little is known about the uptake and technology acceptance among primary healthcare nurses.

AIM

The aim of this study was to describe health information technology acceptance and use among primary healthcare nurses.

SETTING

Primary healthcare centres in the Western Cape.

METHODS

A quantitative descriptive survey was conducted with a sample of 160 nurses working in primary healthcare for more than 6 months, using a self-administered questionnaire based on the technology acceptance model constructs. Eighteen primary healthcare centres were randomly selected with a sample of 160 using nonprobability purposive sampling.

RESULTS

Ninety-three (58.1%) respondents completed the survey. Three-quarters of the respondents reported positive attitudes, positive perceptions of usefulness and ease of use towards the use of health information technology. Barriers of access and training were reported by 75%, with around half the respondents reporting poor computer and information accessing skills. Health information technology use was varied, with high ratings for seeking and using and low ratings of ability to use health information technology for patient administration and management. Health information technology use was predicted by perceptions of ease of use.

CONCLUSION

This research presents a mixed picture of acceptance of technology among primary healthcare nurses and highlights the lack of access to computers and Internet in these settings.

CONTRIBUTION

This study contributes to the field of technology acceptance among primary healthcare nurses.

Experiences and Expectations of the Characteristics of Friendly Primary Health Services from the Perspective of Men: A Phenomenological Qualitative Study

Inadequate men's engagement with health services may be influenced by unmet needs and demands of the local men's community. This study aimed to explore men's experiences with primary health services and their expectations of the characteristics of friendly primary health services, from the perspective of men in Kelantan, Malaysia. A qualitative study using in-depth interviews was conducted with 15 men from six primary health facilities in Kelantan, Malaysia, who were selected based on maximum variation sampling. The data were transcribed and analyzed using the thematic analysis method. The study found that experiences with the existing primary health services were categorized into four subthemes: provision of health services, health promotion delivery, attributes of healthcare providers, and the physical environment of the health facilities. Meanwhile, the expectations of the characteristics of friendly primary health services were categorized into four subthemes: meeting the needs of men in primary health services, approaching men through effective health promotion strategies, standards of a healthcare provider from the viewpoint of men, and a comfortable physical environment for men. Prior experiences hugely influenced men's expectations of friendly primary health services. Men want these health service characteristics customized to meet their needs, allowing them to use health services with confidence and comfort. Thus, to strengthen primary health services for men, it is essential to comprehend their prior experiences with and expectations of the services.

Utilization of Text Messages to Supplement Rounding Communication: a Randomized Feasibility Study

BACKGROUND

Fragmented communication with patients and families during hospitalizations often leaves patients confused about the daily plan.

OBJECTIVE

To pilot a supplemental text message-based platform for improving bidirectional communication about the clinical plan and patients' goals.

DESIGN

Randomized controlled trial PARTICIPANTS: Thirty adult patients, thirty caregivers of pediatric patients, and the interns caring for them on inpatient general medicine and pediatric services.

INTERVENTIONS

Patients and caregivers were texted or emailed daily to report their personal goal and assess their understanding of the team's clinical plan. Interns were texted daily to report the team's clinical plan and to assess their understanding of the patient's personal goal.

MAIN MEASURES

Primary outcomes were feasibility, defined as survey response rates, and acceptability. Secondary outcomes were patient comprehension of the clinical plan, trainee comprehension of the patient's goal, patient-centered communication scores, and educational satisfaction scores.

KEY RESULTS

Thirty adult patients, thirty caregivers of pediatric patients, fourteen general medicine interns, and six general pediatric interns enrolled. Intervention feasibility was met, with survey response rates of 80% for general medicine trainees, 67% for general pediatric trainees, 58% for adult patients, and 70% for caregivers. Patients and caregivers in the intervention arm had higher understanding of medication changes (76% vs 50%, p = 0.02) and new consultations (90% vs 61%, p = 0.002). Interns had higher understanding of patients' goals in the intervention arm (93% vs 40%, p < 0.001), particularly for adult patients (97% vs 17%, p < 0.001). Caregivers rated communication higher regarding information to help make decisions (p = 0.04). Interviews demonstrated high acceptability.

CONCLUSIONS

Our text message-based communication intervention was feasible and acceptable to all involved participants, with preliminary signals of efficacy. The intervention may contribute to improved understanding of medication changes and new consultations, as well as help in making decisions. A large, randomized efficacy trial of this intervention is warranted. Graphical abstract.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review

The COVID-19 pandemic has led health systems to increase the use of tools for monitoring and triaging patients remotely. In this systematic review, we aim to assess the effectiveness and safety of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. We searched five databases (MEDLINE, Embase, Global Health, medRxiv, and bioRxiv) from database inception to April 15, 2021, and included feasibility studies, clinical trials, and observational studies, including preprints. We found 561 studies, of which 13 were included in our narrative synthesis. These 13 studies were all observational cohorts and involved a total of 2908 participants. A meta-analysis was not feasible owing to the heterogeneity of the outcomes reported in the included studies. Our systematic review substantiates the safety and potential of pulse oximetry for monitoring patients at home with COVID-19, identifying the risk of deterioration and the need for advanced care. The use of pulse oximetry can potentially save hospital resources for patients who might benefit the most from care escalation; however, we could not identify explicit evidence for the effect of RPM with pulse oximetry on health outcomes compared with other monitoring models such as virtual wards, regular monitoring consultations, and online or paper diaries to monitor changes in symptoms and vital signs. Based on our findings, we make 11 recommendations across the three Donabedian model domains and highlight three specific measurements for setting up an RPM system with pulse oximetry.

Exploring the perspectives of primary care providers on use of the electronic Patient Reported Outcomes tool to support goal-oriented care: a qualitative study

BACKGROUND

Digital health technologies can support primary care delivery, but clinical uptake in primary care is limited. This study explores enablers and barriers experienced by primary care providers when adopting new digital health technologies, using the example of the electronic Patient Reported Outcome (ePRO) tool; a mobile application and web portal designed to support goal-oriented care. To better understand implementation drivers and barriers primary care providers' usage behaviours are compared to their perspectives on ePRO utility and fit to support care for patients with complex care needs.

METHODS

This qualitative sub-analysis was part of a larger trial evaluating the use of the ePRO tool in primary care. Qualitative interviews were conducted with providers at the midpoint (i.e. 4.5-6 months after ePRO implementation) and end-point (i.e. 9-12 months after ePRO implementation) of the trial. Interviews explored providers' experiences and perceptions of integrating the tool within their clinical practice. Interview data were analyzed using a hybrid thematic analysis and guided by the Technology Acceptance Model. Data from thirteen providers from three distinct primary care sites were included in the presented study.

RESULTS

Three core themes were identified: (1) Perceived usefulness: perceptions of the tool's alignment with providers' typical approach to care, impact and value and fit with existing workflows influenced providers' intention to use the tool and usage behaviour; (2) Behavioural intention: providers had a high or low behavioural intention, and for some, it changed over time; and (3) Improving usage behaviour: enabling external factors and enhancing the tool's perceived ease of use may improve usage behaviour.

CONCLUSIONS

Multiple refinements/iterations of the ePRO tool (e.g. enhancing the tool's alignment with provider workflows and functions) may be needed to enhance providers' usage behaviour, perceived usefulness and behavioural intention. Enabling external factors, such as organizational and IT support, are also necessary to increase providers' usage behaviour. Lessons from this study advance knowledge of technology implementation in primary care.

TRIAL REGISTRATION

Clinicaltrials.gov Identified NCT02917954. Registered September 2016, https://www.clinicaltrials.gov/ct2/show/study/NCT02917954.

Internet use and health in higher education students: a scoping review

The amount of time spent online has increased over the last decade among higher education students. Students engage in online activities related to studies, work, leisure, entertainment and electronic services (e-services) use. The Internet is also used for health-related matters. The increase in the use of the Internet has influenced students' health, especially mental and physical health and well-being. This scoping review scrutinizes the literature between 2015 and 2020 (N = 55) on the association between Internet use and health in higher education students. A methodological framework, outlined by Arksey and O'Malley, was applied to conduct this review. Systematic searches were carried out in the CINAHL, PubMed and Scopus databases and in the available grey literature. For the data, a thematic analysis by Braun and Clarke was utilized. Two major themes of 'Health-promoting Internet use' and 'Health-threatening Internet use' emerged and are described in this review.

The Impact of Technology-Enabled Care Coordination in a Complex Mental Health System: A Local System Dynamics Model

Background

Prior to the COVID-19 pandemic, major shortcomings in the way mental health care systems were organized were impairing the delivery of effective care. The mental health impacts of the pandemic, the recession, and the resulting social dislocation will depend on the extent to which care systems will become overwhelmed and on the strategic investments made across the system to effectively respond.

Objective

This study aimed to explore the impact of strengthening the mental health system through technology-enabled care coordination on mental health and suicide outcomes.

Methods

A system dynamics model for the regional population catchment of North Coast New South Wales, Australia, was developed that incorporated defined pathways from social determinants of mental health to psychological distress, mental health care, and suicidal behavior. The model reproduced historic time series data across a range of outcomes and was used to evaluate the relative impact of a set of scenarios on attempted suicide (ie, self-harm hospitalizations), suicide deaths, mental health–related emergency department (ED) presentations, and psychological distress over the period from 2021 to 2030. These scenarios include (1) business as usual, (2) increase in service capacity growth rate by 20%, (3) standard telehealth, and (4) technology-enabled care coordination. Each scenario was tested using both pre– and post–COVID-19 social and economic conditions.

Results

Technology-enabled care coordination was forecast to deliver a reduction in self-harm hospitalizations and suicide deaths by 6.71% (95% interval 5.63%-7.87%), mental health–related ED presentations by 10.33% (95% interval 8.58%-12.19%), and the prevalence of high psychological distress by 1.76 percentage points (95% interval 1.35-2.32 percentage points). Scenario testing demonstrated that increasing service capacity growth rate by 20% or standard telehealth had substantially lower impacts. This pattern of results was replicated under post–COVID-19 conditions with technology-enabled care coordination being the only tested scenario, which was forecast to reduce the negative impact of the pandemic on mental health and suicide.

Conclusions

The use of technology-enabled care coordination is likely to improve mental health and suicide outcomes. The substantially lower effectiveness of targeting individual components of the mental health system (ie, increasing service capacity growth rate by 20% or standard telehealth) reiterates that strengthening the whole system has the greatest impact on patient outcomes. Investments into more of the same types of programs and services alone will not be enough to improve outcomes; instead, new models of care and the digital infrastructure to support them and their integration are needed.

The next three epochs: Health system challenges amidst and beyond the COVID-19 era

The COVID-19 pandemic has brought to light tremendous gaps and issues faced by health systems globally. Commendable effort has been made to retain continuity of care for non-COVID-19 patients amidst the pandemic, particularly using technology-enhanced models of care. However, these efforts are not sufficient to tackle the impending challenges that health systems around the world will face next: (1) vaccine uptake and hesitancy; (2) a mental health crisis; and (3) post-COVID-19 migration. In this letter to the editor, explanation of why each of these issues is concerning and how each subsequent issue grows in severity is provided. Particular focus on the issue of post-COVID-19 migration is made, as this challenge is quite pressing to health systems but has yet to be explored thoroughly in the literature. Possible strategies for health system planners to consider are provided in this letter. Strategies include involving stakeholders such as patients and clinicians in deliberations and deployment of interventions, focussing efforts on adapting primary health systems, and building on technology-enhanced models of care where possible. By adhering to the recommendations made in this letter, health systems may be able to proactively deal with the identified challenges before they become crises of their own, post COVID-19.

Transforming Interprofessional Roles During Virtual Health Care: The Evolving Role of the Medical Assistant, in Relationship to National Health Profession Competency Standards

Introduction:

Medical assistants (MAs) were once limited to obtaining vital signs and office work. Now, MAs are foundational to team-based care, interacting with patients, systems, and teams in many ways. The transition to Virtual Health during the COVID-19 pandemic resulted in a further rapid and unique shift of MA roles and responsibilities. We sought to understand the impact of this shift and to place their new roles in the context of national professional competency standards.

Methods:

In this qualitative, grounded theory study we conducted semi-structured interviews with 24 MAs at 10 primary care sites at a major academic medical center on their experiences during the shift from in-person to virtual care. MAs were selected by convenience sample. Coding was done in Dedoose version 8.335. Consensus-based inductive and deductive approaches were used for interview analysis. Identified MA roles were compared to national MA, Institute of Medicine, physician, and nursing professional competency domains.

Results:

Three main themes emerged: Role Apprehension, Role Expansion, and Adaptability/Professionalism. Nine key roles emerged in the context of virtual visits: direct patient care (pre-visit and physical care), panel management, health systems ambassador, care coordination, patient flow coordination, scribing, quality improvement, and technology support. While some prior MA roles were limited by the virtual care shift, the majority translated directly or expanded in virtual care. Identified roles aligned better with Institute of Medicine, physician, and nursing professional competencies, than current national MA curricula.

Conclusions:

The transition to Virtual Health decreased MA’s direct clinical work and expanded other roles within interprofessional care, notably quality improvement and technology support. Comparison of the current MA roles with national training program competencies identified new leadership and teamwork competencies which could be expanded during MA training to better support MA roles on inter-professional teams.

Assisted Living: Optimal Person-Environment Fit

Assisted living (AL) is a well-established alternative to nursing homes, promoting autonomy and choice in a residential environment. This article examines the opportunities that AL affords for older adults and areas for further research to optimize the fit between resident needs and the AL environment. The model of person-environment fit provides an organizing framework for our commentary. The environment of AL emphasizes choice, independence, and privacy. The acuity of health care needs in AL residents has evolved since its inception. Unlike earlier residents, many today live with multiple chronic conditions and need for functional supports. Regulated by states, there is high variability in oversight, staffing, and resources available in AL. Families play an important role in supporting residents, yet expectations for their engagement may not be clear. Descriptive research abounds but there is a need for more sophisticated approaches to understanding how the AL environment can provide optimal supports for older adults, across all states and across income and racial/ethnic groups. There are several methodological challenges to AL research, including the high variability among AL settings and across states, the lack of common data elements, and difficulty accessing representative samples. With the popularity of AL as an option, it will be important to continue to examine how this environment can evolve to meet the changing needs of the resident population, while balancing the elements of autonomy and affordability. [Research in Gerontological Nursing, 14(1), 5-12.].

Multicomponent interventions for enhancing primary care: a systematic review

Background

Many countries have implemented interventions to enhance primary care to strengthen their health systems. These programmes vary widely in features included and their impact on outcomes.

Aim

To identify multiple-feature interventions aimed at enhancing primary care and their effects on measures of system success — that is, population health, healthcare costs and utilisation, patient satisfaction, and provider satisfaction (quadruple-aim outcomes).

Design and setting

Systematic review and narrative synthesis.

Method

Electronic, manual, and grey-literature searches were performed for articles describing multicomponent primary care interventions, providing details of their innovation features, relationship to the ‘4Cs’ (first contact, comprehensiveness, coordination, and continuity), and impact on quadruple-aim outcomes. After abstract and full-text screening, articles were selected and their quality appraised. Results were synthesised in a narrative form.

Results

From 37 included articles, most interventions aimed to improve access, enhance incentives for providers, provide team-based care, and introduce technologies. The most consistent improvements related to increased primary care visits and screening/preventive services, and improved patient and provider satisfaction; mixed results were found for hospital admissions, emergency department visits, and expenditures. The available data were not sufficient to link interventions, achievement of the 4Cs, and outcomes.

Conclusion

Most analysed interventions improved some aspects of primary care while, simultaneously, producing non-statistically significant impacts, depending on the features of the interventions, the measured outcome(s), and the populations being studied. A critical research gap was revealed, namely, in terms of which intervention features to enhance primary care (alone or in combination) produce the most consistent benefits.

Telemedicine Services Provided to Medicare Beneficiaries by Otolaryngologists Between 2010 and 2018

Importance

Clinicians are increasingly adopting telemedicine in an effort to expand patient access and efficiently deliver care. However, the extent to which otolaryngologists provide telemedicine services is unclear.

Objective

To characterize recent trends in the use of telemedicine by otolaryngologists to deliver care to Medicare beneficiaries.

Design, Setting, and Participants

A retrospective cross-sectional analysis was conducted between January 1, 2010, and December 31, 2018, using publicly available Medicare Physician/Supplier Procedure Summary data on physicians practicing in the field of otolaryngology and benchmark specialties (dermatology and psychiatry) that provided telemedicine services to Medicare beneficiaries.

Main Outcomes and Measures

Primary outcomes were the mean annual number of telemedicine services delivered per active physician and mean annual payment per active physician for these services. Secondary outcomes included the number, setting, and complexity of telemedicine services.

Results

Between 2010 and 2018, otolaryngologists provided 2127 total telemedicine services (7 unique service types) to Medicare beneficiaries and received $88 574 in total payment for these services. During this period, the mean number of telemedicine services increased at a compound annual growth rate (CAGR) of 11.0%, and the mean Medicare payment per otolaryngologist increased at a CAGR of 21.8%. In comparison, telemedicine use during this period generally increased at a higher rate in the fields of dermatology (mean number of services per active physician at CAGR of 13.0%; mean Medicare payment per active physician at CAGR of 12.5%) and psychiatry (mean number of services per active physician at CAGR of 25.8%; mean Medicare payment per active physician at CAGR of 26.6%). In 2018, outpatient evaluation and management visits accounted for most telemedicine services provided (337 of 353 [95.5%]) and the payments received ($17 542.13 of $18 470.47 [95.0%]) by otolaryngologists. In contrast, physicians in other specialties also provided substantial portions of telemedicine services in the inpatient (psychiatry, 18 403 of 198 478 [9.3%]; dermatology, 231 of 1034 [22.3%]) and skilled nursing facility settings (psychiatry, 14 690 of 198 478 [7.4%]; dermatology, 46 of 1034 [4.4%]).

Conclusions and Relevance

This study suggests that the extent to which otolaryngologists used telemedicine to deliver care to Medicare beneficiaries between 2010 and 2018 was rare. Although there was relative growth in the use of telemedicine by otolaryngologists during this period, absolute growth remained low. Policy makers and provider organizations should support otolaryngologists in the adoption of telemedicine technologies, especially while coronavirus disease 2019 (COVID-19) viral suppression efforts necessitate prolonged restriction of physical clinic throughput.

Strengthening Primary Health-Care Services to Help Prevent and Control Long-Term (Chronic) Non-Communicable Diseases in Low- and Middle-Income Countries

The prevalence of long-term (chronic) non-communicable diseases (NCDs) is increasing globally due to an ageing global population, urbanization, changes in lifestyles, and inequitable access to healthcare. Although previously more common in high- and upper-middle-income countries, lower-middle-income countries (LMICs) are more affected, with NCDs in LMICs currently accounting for 85–90% of premature deaths among 30–69 years old. NCDs have both high morbidity and mortality and high treatment costs, not only for the diseases themselves but also for their complications. Primary health care (PHC) services are a vital component in the prevention and control of long-term NCDs, particularly in LMICs, where the health infrastructure and hospital services may be under strain. Drawing from published studies, this review analyses how PHC services can be utilized and strengthened to help prevent and control long-term NCDs in LMICs. The review finds that a PHC service approach, which deals with health in a comprehensive way, including the promotion, prevention, and control of diseases, can be useful in both high and low resource settings. Further, a PHC based approach also provides opportunities for communities to better access appropriate healthcare, which ensures more significant equity, efficiency, effectiveness, safety, and timeliness, empowers service users, and helps healthcare providers to achieve better health outcomes at lower costs.

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Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study

BACKGROUND

Approximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore.

METHODS

This study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare.

RESULTS

Despite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time. Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients. Although providers could equip patients with self-management and lifestyle-related guidelines, patients' actions are influenced by multiple factors, including work requirements, beliefs and environment.

CONCLUSIONS

There were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.

Cocreation of a digital patient health hub to enhance education and person-centred integrated care post hip fracture: a mixed-methods study protocol

INTRODUCTION

Older people with hip fractures often require long-term care and a crucial aspect is the provision of quality health information to patients and their carers to support continuity of care. If patients are well informed about their health condition and caring needs, particularly posthospital discharge into the community setting, this may support recovery and improve quality of life. As internet and mobile access reach every household, it is possible to deliver a new model of service using a digital education platform as a personal health hub where both patients and their providers of care can establish a more efficient information integration and exchange process. This protocol details proposed research, which aims to develop a 'model of care' by using a digital health solution that will allow delivery of high quality and patient-centred information, integrated into the existing process delivered within the community setting.

METHODS AND ANALYSIS

This phase of the study uses a pragmatic mixed-methods design and a participatory approach through engagement of patients, their carers and healthcare providers from multiple disciplines to inform the development of a digital health platform. Quantitative methods will explore health literacy and e-health literacy among older people with hip fractures admitted to the two public tertiary care hospitals in Adelaide, South Australia. Qualitative methods will provide an understanding of aspects of content and context required for the digital health platform to be developed in order to deliver quality health information. The study will use appropriate theoretical frameworks and constructs to guide the design, analysis and overall conduct of the research study. The scope of the study intends to ultimately empower patients and their carers to improve self-management and to better use coordinated services at the community level. This could prevent further falls including associated injuries or new fractures; reduce new hospital admissions and improve confidence and engagement by limiting the psychologically restrictive 'fear of falls'.

ETHICS AND DISSEMINATION

The study has been approved by the Human Research Ethics Committee of the Central Adelaide Local Health Network, South Australia (SA) Health, Government of South Australia and the University of Adelaide Human Research Ethics Committee. Findings from the study will be published in suitable peer-reviewed journals and disseminated through workshops or conferences.

Public health information systems for primary health care in India: A situational analysis study

Introduction:

Information communication technology (ICT) based health information systems (HISs) are expected to transform health system functionality. The present study was aimed to evaluate HISs in India with a focus on primary health care (PHC).

Methodology:

The study used a qualitative method to evaluate and understand various ICT-based HIS implemented at the state/union territory (UT) level in India. After initial scoping research on HIS through literature search and observation, in-depth interviews of key informants at various levels (programme managers, analysts, co-ordinators, data entry operator and health care providers) was carried out to have an insight on the user experience of these systems. An inductive applied thematic coding of qualitative data was done for analysing the data.

Results:

Multiple applications have been developed under national health programmes to meet the health information needs, but at present, there is a limited role of these HISs in enhancing the effectiveness of comprehensive PHC. Many of these systems are proprietary-based, and the long-term sustainability and integration of these systems remain a challenge.

Conclusion:

A change is required in the approach to design a HIS that will cater to the needs of PHC. Moreover, HIS should be people-centred rather than technology-centric with focus on integration and sustainability.

Tinkering at the margins: evaluating the pace and direction of primary care reform in Ontario, Canada

BACKGROUND

Primary care reform has been on the political agenda in Canada and many industrialized countries for several decades; it is widely seen as the foundation for broader health system transformation. Federal investments in primary care, including major cash transfers to provinces and territories as part of a 10-year health care funding agreement in 2004, triggered waves of primary care reform across Canada. Nevertheless, Commonwealth Fund surveys show, Canada continues to lag behind other industrialized nations with respect to timely access to care, electronic medical record use and audit and feedback for quality improvement in primary care. This paper evaluates the pace and direction of primary care reform as well as the extent of resulting change in the organization and delivery of primary care in Ontario, Canada's most populous province.

METHODS

Qualitative and quantitative methods were used for this study. A literature review was conducted to analyze the core dimensions of primary care reform, the history of reform in Ontario, and the extent to which different dimensions are integrated into Ontario's models. Quantitative data on the number of family physicians/general practitioners and patients enrolled in these models was examined over a 10-year period to determine the degree of change that has taken place in the organization and delivery of primary care in Ontario.

RESULTS

There are 11 core reform dimensions that individually and collectively shift from conventional primary care toward the more expansive vision of primary health care. Assessment of Ontario's models against these core dimensions demonstrate that there has been little substantive change in the organization and delivery of primary care over 10 years in Ontario.

CONCLUSIONS

Primary care reform is a multi-dimensional construct with different reform models bundling core dimensions in different ways. This understanding is important to move beyond the rhetoric of "reform" and to critically assess the pace and direction of change in primary care in Ontario and in other jurisdictions. The conceptual framework developed in this paper can assist decision-makers, academics and health care providers in all jurisdictions in evaluating the pace of change in the primary care sector, as well as other sectors.

Improving patient portal enrolment in an academic resident continuity clinic: quality improvement made simple

Electronic health record patient portal usage has been associated with improvement in chronic disease parameters, patient functional status and patient satisfaction. Our institution’s patient portal is a secure, online health management tool that connects patients to portions of their electronic health record.

Our quality improvement project aimed to increase patient portal enrolment significantly in our Internal Medicine resident patient panels.

This study was conducted in a large, multisite health system in Kansas City, Kansas that serves a diverse patient population. Our clinic includes 65 resident patient panels. We followed a subset of 16 resident patient panels in this quality improvement project. A baseline audit showed that 35% of the 1628 patients in these panels were enrolled in the patient portal system. A standardised, nurse-initiated portal sign-up process following patient rooming was implemented. Initial results indicated a 9.6% increase in patient portal sign-up at the end of the first 4-week cycle. We then implemented educational sessions for our clinic nurses as well as attending physicians, and achieved a 15.1% increase from baseline to the end of the second 4-week cycle, resulting in 86 patient portal activations (p<0.01).

Resident physicians worked with clinic nurse partners in two formats for this project. Nurses assigned to patient rooming for residents during the clinic sessions being studied (rooming nurses) initiated the portal sign-up process. Nurses assigned to partner with the resident for longitudinal patient care management, anchor nurses, worked with residents on items such as phone messages or portal messages. Semi-structured interviews of the four anchor nurses aligned with the 16 residents were conducted at the end of the study and revealed that nursing staff perceived increased patient portal activity to be associated with a decrease in nursing workload and an increase in patient engagement.

Readiness to use telemonitoring in diabetes care: a cross-sectional study among Austrian practitioners

Background

Telemonitoring services could dramatically improve the care of diabetes patients by enhancing their quality of life while decreasing healthcare expenditures. However, the potential for implementing innovative treatment options in the Austrian public and private health system is not known yet. Thus, we analyzed the readiness to use telemonitoring in diabetes care among Austrian practitioners.

Methods

We conducted an online survey among a purposive sample of Austrian practitioners (n = 41) using an adapted German version of the practitioner telehealth readiness assessment tool. We assessed three readiness domains for telemonitoring in the context of diabetes care, i.e. core readiness, engagement readiness, and structural readiness, and validated the German tool using principal components analysis.

Results

Study subjects perceived themselves as open to innovations and also expressed optimistic attitudes towards telemonitoring in general and offering telemonitoring-based services for their patients. Participants achieved a medium average readiness level for telemonitoring (58.2, 95% CI 53.9–62.5) and were thus in a good position to use telemonitoring, although some arguments may adversely affected its use. The top three perceived benefits of telemonitoring were enhanced quality of treatment, better therapy adjustment, and reduced travel and waiting times for patients. The top three barriers were reduced personal communication, practitioner time expenditure and equally placed poor financial compensation as well as data security and privacy issues.

Conclusion

Our data revealed that Austrian practitioners showed a quite moderate readiness to use telemonitoring in diabetes care. To further advance telemonitoring readiness among all pillars of diabetes care in Austria, joint efforts among healthcare stakeholders are required to overcome existing financial, organizational, and technical obstacles.

Multifactorial e- and mHealth interventions for cardiovascular disease primary prevention: Protocol for a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Cardiovascular diseases (CVD) are a leading cause of mortality and disease burden. Preventative interventions to augment the population-level adoption of health lifestyle behaviours that reduce CVD risk are a priority. Face-to-face interventions afford individualisation and are effective for improving health-related behaviours and outcomes, but they are costly and resource intensive. Electronic and mobile health (e- and mHealth) approaches aimed at modifying lifestyle risk factors may be an effective and scalable approach to reach many individuals while preserving individualisation. This systematic review aims to (a) determine the effectiveness of multifactorial e- and mHealth interventions on CVD risk and on lifestyle-related cardiometabolic risk factors and self-management behaviours among adults without CVD; and (b) describe the evidence on adverse events and on the cost-effectiveness of these interventions.

METHODS

Methods were detailed prior to the start of the review in order to improve conduct and prevent inconsistent decision making throughout the review. This protocol was prepared following the PRISMA-P 2015 statement. MEDLINE, CINAHL, Embase, PsycINFO, Web of Science, Cochrane Public Health Group Specialised Register and CENTRAL electronic databases will be searched between 1991 and September 2019. Eligibility criteria are: (a) population: community-dwelling adults; (b) intervention/comparison: randomised controlled trials comparing e- or mHealth CVD risk preventative interventions with usual care; and (c) outcomes: modifiable CVD risk factors. Selection of study reports will involve two authors independently screening titles and abstracts, followed by a full-text review of potentially eligible reports. Two authors will independently undertake data extraction and assess risk of bias. Where appropriate, meta-analysis of outcome data will be performed.

DISCUSSION

This protocol describes the pre-specified methods for a systematic review that will provide quantitative and narrative syntheses of current multifactorial e- and mHealth CVD preventative interventions. A systematic review and meta-analysis will be conducted following the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions and reported according to PRISMA guidelines.

Clinical Examination Component of Telemedicine, Telehealth, mHealth, and Connected Health Medical Practices

Telemedicine and telehealth are the practices of medicine at a distance. Performing the equivalent of a complete clinical examination by telemedicine would be unusual. However, components of a more traditional clinical examination are part of the telemedicine workup for specific conditions. Telemedicine clinical examinations are facilitated, and enhanced, through the integration of a class of medical devices referred to as telemedicine peripherals (eg, electronic stethoscopes, tele-ophthalmoscopes, video-otoscopes, and so forth). Direct-to-consumer telehealth is a rapidly expanding segment of the health care service industry.

Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors?

OBJECTIVE

Patients with multiple chronic conditions face many stressors (e.g. financial, safety, transportation stressors) that are rarely prioritized for discussion with the primary care provider (PCP). In this pilot randomized controlled trial we examined the effects of a novel technology-based intervention called Customized Care on stressor disclosure.

METHODS

The main outcomes were stressor disclosure, patient confidence and activation, as assessed by self-report and observational methods (transcribed and coded audio-recordings of the office visit).

RESULTS

Sixty patients were enrolled. Compared with care as usual, intervention patients were 6 times more likely to disclose stressors to the PCP (OR=6.16, 95% CI [1.53, 24.81], p=0.011) and reported greater stressor disclosure confidence (exp[B]=1.06, 95% CI [1.01, 1.12], p=0.028). No differences were found in patient activation or the length of the office visit.

CONCLUSION

Customized Care improved the likelihood of stressor disclosure without affecting the length of the PCP visit.

PRACTICE IMPLICATIONS

Brief technology-based interventions, like Customized Care could be made available through patient portals, or on smart phones, to prime patient-PCP discussion about difficult subjects, thereby improving the patient experience and efficiency of the visit.

Disruptive Models in Primary Care: Caring for High-Needs, High-Cost Populations

Starfield and colleagues have suggested four overarching attributes of good primary care: "first-contact access for each need; long-term person- (not disease) focused care; comprehensive care for most health needs; and coordinated care when it must be sought elsewhere." As this series on reinventing primary care highlights, there is a compelling need for new care delivery models that would advance these objectives. This need is particularly urgent for high-needs, high-cost (HNHC) populations. By definition, HNHC patients require extensive attention and consume a disproportionate share of resources, and as a result they strain traditional office-based primary care practices. In this essay, we offer a clinical vignette highlighting the challenges of caring for HNHC populations. We then describe two categories of primary care-based approaches for managing HNHC populations: complex case management, and specialized clinics focused on HNHC patients. Although complex case management programs can be incorporated into or superimposed on the traditional primary care system, such efforts often fail to engage primary care clinicians and HNHC patients, and proven benefits have been modest to date. In contrast, specialized clinics for HNHC populations are more disruptive, as care for HNHC patients must be transferred to a multidisciplinary team that can offer enhanced care coordination and other support. Such specialized clinics may produce more substantial benefits, though rigorous evaluation of these programs is needed. We conclude by suggesting policy reforms to improve care for HNHC populations.