The community-oriented primary care experience in the United kingdom

A Cost-Effectiveness Analysis of Comprehensive Smoking-Cessation Interventions Based on the Community and Hospital Collaboration

Background

The prevalence of cigarette smoking in China is high and the utilization of smoking cessation clinics is very low. Multicomponent smoking cessation interventions involving community and hospital collaboration have the potential to increase the smoking cessation rate. However, the cost-effectiveness of this intervention model is unknown.

Methods

We conducted a smoking cessation intervention trial in 19 community health service centers in Beijing, China. A cost-effectiveness analysis was performed from a societal perspective to compare three strategies of smoking cessation: no intervention (NI), pharmacological intervention (PI), and comprehensive intervention (CI) (PI plus online health promotion). A Markov model, with a time horizon of 20 years, was used to simulate the natural progression of estimated 10,000 male smokers. A cross-sectional survey was conducted to obtain data on costs and quality-adjusted life years (QALYs) by using the five-level EuroQol-5-dimension (EQ-5D-5L) questionnaire. Probabilistic sensitivity analysis was performed to explore parameters of uncertainty in the model.

Results

A total of 680 participants were included in this study, including 283 in the PI group and 397 in the CI group. After 6 months of follow-up, the smoking cessation rate reached 30.0% in the CI group and 21.2% in the PI group. Using the Markov model, compared with the NI group, the intervention strategies of the PI group and the CI group were found to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of $535.62/QALY and $366.19/QALY, respectively. The probabilistic sensitivity analysis indicated that the CI strategy was always the most cost-effective intervention.

Conclusion

CI for smoking cessation, based in hospital and community in China, is more cost-effective than PI alone. Therefore, this smoking cessation model should be considered to be implemented in healthcare settings.

Translating Planetary Health Principles Into Sustainable Primary Care Services

Global anthropogenic environmental degradations such as climate change are increasingly recognized as critical public health issues, on which human beings should urgently act in order to preserve sustainable conditions of living on Earth. "Planetary Health" is a breakthrough concept and emerging research field based on the recognition of the interdependent relationships between living organisms-both human and non-human-and their ecosystems. In that regards, there have been numerous calls by healthcare professionals for a greater recognition and adoption of Planetary Health perspective. At the same time, current Western healthcare systems are facing their limits when it comes to providing affordable, equitable and sustainable healthcare services. Furthermore, while hospital-centrism remains the dominant model of Western health systems, primary care and public health continue to be largely undervalued by policy makers. While healthcare services will have to adapt to the sanitary impacts of environmental degradations, they should also ambition to accompany and accelerate the societal transformations required to re-inscribe the functioning of human societies within planetary boundaries. The entire health system requires profound transformations to achieve this, with obviously a key role for public health. But we argue that the first line of care represented by primary care might also have an important role to play, with its holistic, interdisciplinary, and longitudinal approach to patients, strongly grounded in their living environments and communities. This will require however to redefine the roles, activities and organization of primary care actors to better integrate socio-environmental determinants of health, strengthen interprofessional collaborations, including non-medical collaborations and more generally develop new, environmentally-centered models of care. Furthermore, a planetary health perspective translated in primary care will require the strengthening of synergies between institutions and actors in the field of health and sustainability.

Functional Status among Polymedicated Geriatric Inpatients at Discharge: A Population-Based Hospital Register Analysis

This study explored and compared the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge. We used a cross-sectional registry of geriatric patients' hospital records from a multi-site public hospital center in Switzerland. The analysis included all inpatients aged 65 years old or more admitted between 1 January 2015 and 31 December 2017 (n = 53,690), of whom 67.5% were polymedicated at hospital discharge, 52.1% were women (n = 18,909), and 42.7% were 75-84 years old (n = 15,485). On average, the polymedicated patients' hospital lengths of stay were six days longer, they presented with more than three comorbidities, and they were prescribed more than nine medications at hospital discharge (p < 0.001). They showed more frequent general mobility decline (43.2% vs. 41.9%), gait disorders (46.2% vs. 43%), fatigue (48.6% vs. 43.4%) and dependence on lower-body care (49.7% vs. 47.6%), and presented a higher malnutrition risk (OR = 1.411; 95%CI 1.263-1.577; p < 0.001). However, the non-polymedicated inpatients had proportionally more physical and cognitive impairments. The comparison of the functional status of polymedicated and non-polymedicated geriatric inpatients at hospital discharge is important for clinicians trying to identify and monitor those who are most vulnerable to functional decline, and to design targeted strategies for the prevention of functional impairment and related adverse health outcomes.

Health promotion and disease prevention in general practice and primary care: a scoping study

This paper reports the findings of a scoping review on the organisation and delivery of health improvement activities in general practice and the primary healthcare team. The project was designed to examine who delivers these interventions, where they are located, what approaches are developed in practices and how individual practices and the primary healthcare team organise such public health activities and how these contribute to health improvement. Our focus was on health promotion and prevention activities and aimed to identify the current extent of knowledge about the health improvement activities in general practice and the wider primary healthcare team. Many of the research studies reviewed had some details about the type, process, location or who provided the intervention. Little attention is paid in the literature to examining the impact of the organisational context on the way services are delivered or how this affects the effectiveness of health improvement interventions in general practice. We found that the focus of attention is mainly on individual prevention approaches with practices engaging in both primary and secondary prevention. Although many GPs do not take a population approach and focus on individual patients some do see health promotion as an integral part of practice – whether as individual approaches to primary or secondary health improvement or as a practice-based approach to improving the health of their patients. Based on our analysis we conclude that there is insufficient good evidence to support many of the health improvement interventions undertaken in general practice and primary care.

Evaluation and mechanism for outcomes exploration of providing public health care in contract service in rural China: a multiple-case study with complex adaptive systems design

BACKGROUND

The Chinese government has increased the funding for public health in 2009 and experimentally applied a contract service policy (could be seen as a counterpart to family medicine) in 15 counties to promote public health services in the rural areas in 2013. The contract service aimed to convert village doctors, who had privately practiced for decades, into general practitioners under the government management, and better control the rampant chronic diseases. This study made a rare attempt to assess the effectiveness of public health services delivered under the contract service policy, explore the influencing mechanism and draw the implications for the policy extension in the future.

METHODS

Three pilot counties and a non-pilot one with heterogeneity in economic and health development from east to west of China were selected by a purposive sampling method. The case study methods by document collection, non-participant observation and interviews (including key informant interview and focus group interview) with 84 health providers and 20 demanders in multiple level were applied in this study. A thematic approach was used to compare diverse outcomes and analyze mechanism in the complex adaptive systems framework.

RESULTS

Without sufficient incentives, the public health services were not conducted effectively, regardless of the implementation of the contract policy. To appropriately increase the funding for public health by local finance and properly allocate subsidy to village doctors was one of the most effective approaches to stimulate health providers and demanders' positivity and promote the policy implementation. County health bureaus acted as the most crucial agents among the complex public health systems. Their mental models influenced by the compound and various environments around them led to the diverse outcomes. If they could provide extra incentives and make the contexts of the systems ripe enough for change, the health providers and demanders would be receptive to the transition of the policy.

CONCLUSIONS

The innovative fund raising measures could be taken by relatively developed counties of China to conduct public health services. Policymakers could take systems thinking as a useful tool to design plans and predict the unintended outcomes during the process of public health reforms.

A re-emerging political space for linking person and community through primary health care

PURPOSE

The goal of the study was to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities.

METHODS

Thirteen semistructured interviews were conducted in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard-defining organizations with influence over healthcare reform policies and implementation. Interviews were recorded; an editing and immersion-crystallization analysis approach was used to identify themes.

RESULTS

Four themes were identified: (1) affirmation of primary care as the foundation of a more effective healthcare system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas.

CONCLUSIONS

Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

A reemerging political space for linking person and community through primary health care

OBJECTIVES

We sought to understand how national policy key informants perceive the value and changing role of primary care in the context of emerging political opportunities.

METHODS

We conducted 13 semistructured interviews in May 2011 with leaders of federal agencies, think tanks, nonprofits, and quality standard-defining organizations with influence over health care reform policies and implementation. We recorded the interviews and used an editing and immersion-crystallization analysis approach to identify themes.

RESULTS

We identified 4 themes: (1) affirmation of primary care as the foundation of a more effective health care system, (2) the patient-centered medical home as a transitional step to foster practice innovation and payment reform, (3) the urgent need for an increased focus on community and population health in primary care, and (4) the ongoing need for advocacy and research efforts to keep primary care on public and policy agendas.

CONCLUSIONS

Current efforts to reform primary care are only intermediate steps toward a system with a greater focus on community and population health. Transformed and policy-enabled primary care is an essential link between personalized care and population health.

A scoping literature review of collaboration between primary care and public health

AIM

The purpose of this scoping literature review was to determine what is known about: 1) structures and processes required to build successful collaborations between primary care (PC) and public health (PH); 2) outcomes of such collaborations; and 3) markers of their success.

BACKGROUND

Collaboration between PC and PH is believed to enable more effective individual and population services than what might be achieved by either alone.

METHODS

The study followed established methods for a scoping literature review and was guided by a framework that identifies systemic, organizational and interactional determinants for collaboration. The review was restricted to articles published between 1988 and 2008. Published quantitative and qualitative primary studies, evaluation research, systematic and other types of reviews, as well as descriptive accounts without an explicit research design, were included if they addressed either the structures or processes to build collaboration or the outcomes or markers of such collaboration, and were published in English.

FINDINGS

The combined search strategy yielded 6125 articles of which 114 were included. Systemic-level factors influencing collaboration included: government involvement, policy and fit with local needs; funding and resource factors, power and control issues; and education and training. Lack of a common agenda; knowledge and resource limitations; leadership, management and accountability issues; geographic proximity of partners; and shared protocols, tools and information sharing were influential at the organizational level. Interpersonal factors included having a shared purpose; philosophy and beliefs; clear roles and positive relationships; and effective communication and decision-making strategies. Reported benefits of collaboration included: improved chronic disease management; communicable disease control; and maternal child health. More research is needed to explore the conditions and contexts in which collaboration between PC and PH makes most sense and potential gains outweigh the associated risks and costs.

Competence, respect and trust: key features of successful interprofessional nurse-doctor relationships

Professional relationships between doctors and nurses have often been seen as problematic, a barrier to effective collaborative practice, yet little is known about the intrinsic nature of such relationships in the primary care context. This study set out to explore roles of, and relationships between, nurses and doctors currently working in New Zealand primary care settings. Using a qualitative methodology, data were collected using in-depth interviews with 18 individual nurses and doctors working in primary care settings in Wellington, New Zealand. Doctors' and nurses' perceptions of their own and each others' roles, and the perceived relationships between individuals from both disciplinary groups were explored, using principles of naturalistic enquiry in a mixed method of analysis. The study findings indicate that effective interprofessional relationships between individual doctors and nurses can, and often do, exist in New Zealand primary care settings, although they are not universal. The identification and separation of vocational and business roles, and the development of professional identity, form the basis for a theory of trust development in nurse-doctor interprofessional relationships in New Zealand primary care. Professional identity is related to demonstration of professional competence, in turn related to development of mutual interprofessional respect and enduring interprofessional trust.

Integrating public health and primary care

PURPOSE

Improved health and social outcomes would be possible with better coordination and collaboration between public health and primary care. The purpose of this study is to identify linkages between these health sectors with the aim of informing a forward-looking policy approach to integrate public health functions in primary care.

METHODS

We searched national and international journals and the grey literature for relevant papers and reports published from January 1999 to December 2003. The final set of documents provided broad coverage of the topic, with emphasis on national and international representation and a special focus on disease surveillance, health promotion, accident and illness prevention and chronic diseases.

RESULTS

Three main findings emerged from this study. First, there is a need to understand and clearly articulate the roles and functions of public health and primary care in Canada. Second, the main areas of overlap between these sectors are health surveillance, health promotion and prevention of disease and injury. Third, based on an international literature search, we identified 10 models that demonstrate how these sectors can be integrated; five of them were developed in Canada.

CONCLUSIONS

National and international evidence and a variety of working models support the integration of public health functions in primary care. Canada has been a leader in developing models of integrated health systems that combine individualized approaches to influence personal health behaviour and community approaches to influence the health of the population. These integration models could be further developed through a focus on the common need of primary care and public health to address the health implications of the ever-present risk of emerging infectious diseases in Canada.

Discussion Suppers as a Means for Community Engagement

PURPOSE

This paper describes how Lehigh Valley Hospital and Health Network (LVHHN), a large tertiary care urban hospital, used discussion suppers as a means for community engagement designed to lead to community health improvement. An overview of the implementation of the project is described.

PROJECT

In 1996, with an awareness of the need to address population-based health improvement, the Dorothy Rider Pool Health Care Trust and LVHHN undertook a multiyear, multidimensional effort to improve health and quality of life in the Lehigh Valley of Pennsylvania. Data were obtained via a series of community and health assessments. Action-Oriented Community Diagnosis and the Behavioral Risk Factor Surveillance System survey, a national instrument, are 2 assessments discussed. The community was engaged through a series of discussion suppers in which community data were shared in a friendly, interactive fashion. The process included community definition of priorities from the data and the subsequent determination of corresponding actions (programs).

CONCLUSIONS

The success of these activities demonstrates the discussion suppers were an effective approach and that data can be shared with rural areas in ways that build partnerships and provide a basis for joint actions. This is increasingly important as communities expect our health care systems to provide care both within the hospital as well as outside its walls.

Medical training in community medicine: a comprehensive, academic, service-based curriculum

The University of Pennsylvania's Family Practice Residency includes a significant community medicine component in order to accomplish the goals of addressing the health-related needs of the university's neighbors; exposing residents to the knowledge, skills and attitudes necessary to address the health needs of a community; and encouraging health careers with a community focus. It is my belief that these goals further the agenda of the National Institute of Medicine and Healthy People 2000 and 2010. Longitudinal and block community medicine experiences were established to accomplish these goals. This article describes and discusses three measurable outcomes of this curriculum: (1) individual resident projects, (2) resident class projects and (3) significant career foci in community medicine among resident graduates. I believe that our community medicine program exemplifies medical training in a community setting and furthers the national health agenda.

Community-oriented primary care: new relevance in a changing world

Since its inception in rural, pre-apartheid South Africa, community-oriented primary care (COPC) has intrigued and informed public health and primary care leaders worldwide. COPC has influenced such programs as the US community health center movement, the general practice movement in the United Kingdom, and recent reforms in the public health system of South Africa. We provide a global overview of COPC, tracing its conceptual roots, reviewing its many manifestations, and exploring its future prospects as an organizational paradigm for the democratic organization of community health services. We examine the pitfalls and paradoxes of COPC and suggest its future utility. COPC has important values and methods to offer disparate but powerful movements in public health worldwide.