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Petrovic B, Bender JL, Liddy C, Afkham A, McGee SF, Morgan SC, Segal R, O’Brien MA, Julian JA, Sussman J, Urquhart R, Fitch M, Schneider ND, Grunfeld E. Implementation of a Web-Based Communication System for Primary Care Providers and Cancer Specialists. Curr Oncol 2023; 30:3537-3548. [PMID: 36975482 PMCID: PMC10047665 DOI: 10.3390/curroncol30030269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/03/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
Healthcare providers have reported challenges with coordinating care for patients with cancer. Digital technology tools have brought new possibilities for improving care coordination. A web- and text-based asynchronous system (eOncoNote) was implemented in Ottawa, Canada for cancer specialists and primary care providers (PCPs). This study aimed to examine PCPs' experiences of implementing eOncoNote and how access to the system influenced communication between PCPs and cancer specialists. As part of a larger study, we collected and analyzed system usage data and administered an end-of-discussion survey to understand the perceived value of using eOncoNote. eOncoNote data were analyzed for 76 shared patients (33 patients receiving treatment and 43 patients in the survivorship phase). Thirty-nine percent of the PCPs responded to the cancer specialist's initial eOncoNote message and nearly all of those sent only one message. Forty-five percent of the PCPs completed the survey. Most PCPs reported no additional benefits of using eOncoNote and emphasized the need for electronic medical record (EMR) integration. Over half of the PCPs indicated that eOncoNote could be a helpful service if they had questions about a patient. Future research should examine opportunities for EMR integration and whether additional interventions could support communication between PCPs and cancer specialists.
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Affiliation(s)
- Bojana Petrovic
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Jacqueline L. Bender
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Cancer Rehabilitation and Survivorship, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON M5G 2C4, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Clare Liddy
- Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON K1G 5Z3, Canada
| | - Amir Afkham
- Ontario Health East, Ottawa, ON K1J 1J8, Canada
| | - Sharon F. McGee
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Scott C. Morgan
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
- Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - Roanne Segal
- The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada
| | - Mary Ann O’Brien
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Jim A. Julian
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Jonathan Sussman
- Department of Oncology, Faculty of Health Sciences, McMaster University, Hamilton, ON L8V 5C2, Canada
| | - Robin Urquhart
- Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS B3H 1V7, Canada
- Department of Surgery, Nova Scotia Health, Halifax, NS B3H 2Y9, Canada
| | - Margaret Fitch
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5T 1P8, Canada
- CanIMPACT Patient Advisory Committee, Toronto, ON M5G 1V7, Canada
| | | | - Eva Grunfeld
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M7, Canada
- Ontario Institute for Cancer Research, Toronto, ON M5G 1N8, Canada
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Radhakrishnan A, Reyes-Gastelum D, Abrahamse P, Gay B, Hawley ST, Wallner LP, Chen DW, Hamilton AS, Ward KC, Haymart MR. Physician Specialties Involved in Thyroid Cancer Diagnosis and Treatment: Implications for Improving Health Care Disparities. J Clin Endocrinol Metab 2022; 107:e1096-e1105. [PMID: 34718629 PMCID: PMC8852205 DOI: 10.1210/clinem/dgab781] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 02/07/2023]
Abstract
CONTEXT Little is known about provider specialties involved in thyroid cancer diagnosis and management. OBJECTIVE Characterize providers involved in diagnosing and treating thyroid cancer. DESIGN/SETTING/PARTICIPANTS We surveyed patients with differentiated thyroid cancer from the Georgia and Los Angeles County Surveillance, Epidemiology and End Results registries (N = 2632, 63% response rate). Patients identified their primary care physicians (PCPs), who were also surveyed (N = 162, 56% response rate). MAIN OUTCOME MEASURES (1) Patient-reported provider involvement (endocrinologist, surgeon, PCP) at diagnosis and treatment; (2) PCP-reported involvement (more vs less) and comfort (more vs less) with discussing diagnosis and treatment. RESULTS Among thyroid cancer patients, 40.6% reported being informed of their diagnosis by their surgeon, 37.9% by their endocrinologist, and 13.5% by their PCP. Patients reported discussing their treatment with their surgeon (71.7%), endocrinologist (69.6%), and PCP (33.3%). Physician specialty involvement in diagnosis and treatment varied by patient race/ethnicity and age. For example, Hispanic patients (vs non-Hispanic White) were more likely to report their PCP informed them of their diagnosis (odds ratio [OR]: 1.68; 95% CI, 1.24-2.27). Patients ≥65 years (vs <45 years) were more likely to discuss treatment with their PCP (OR: 1.59; 95% CI, 1.22-2.08). Although 74% of PCPs reported discussing their patients' diagnosis and 62% their treatment, only 66% and 48%, respectively, were comfortable doing so. CONCLUSIONS PCPs were involved in thyroid cancer diagnosis and treatment, and their involvement was greater among older patients and patients of minority race/ethnicity. This suggests an opportunity to leverage PCP involvement in thyroid cancer management to improve health and quality of care outcomes for vulnerable patients.
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Affiliation(s)
| | - David Reyes-Gastelum
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Paul Abrahamse
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Brittany Gay
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sarah T Hawley
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Lauren P Wallner
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Debbie W Chen
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ann S Hamilton
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90089, USA
| | - Kevin C Ward
- Department of Epidemiology, Emory University, Atlanta, GA 30322, USA
| | - Megan R Haymart
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
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Bosongo S, Chenge F, Mwembo A, Criel B. L’influence des prestations des médecins à la première ligne de soins sur le système intégré de district sanitaire à Kisangani, République Démocratique du Congo: une étude qualitative. Pan Afr Med J 2021; 39:215. [PMID: 34630827 PMCID: PMC8486932 DOI: 10.11604/pamj.2021.39.215.25737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 07/14/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION in the DRC, doctors, formerly absent, are increasingly being employed as primary care physicians, in particular but not exclusively in urban areas. This study describes and analyses the impact of primary care physician services on the integrated district health system in Kisangani, DRC. METHODS in the third quarter of 2018, we conducted 40 semi-structured interviews of health district stakeholders (population, nurses, doctors, managers) selected in a reasoned way. Questions focused on doctors' motivation, their package of activities and the perceptions of other district stakeholders on their front-line services. Data were analysed using the thematic content analysis. RESULTS the services of primary care physicians were a de facto but they were unplanned and unsupported. This derived largely from doctors' need for professional integration. This seemed to improve treatment acceptability but limited their financial accessibility. It was associated with an uncontrolled expansion of the activity packages and caused competition between first-line and second-line physicians. CONCLUSION physician services are a challenge and an opportunity to strengthen first-line care while preserving complementarity with second-line care. A (re)definition of first-line physicians' role and activity package is then required. Hence, the need to improve the dialogue between different health system actors in order to (re)define consensually a model of first-line care adapted to match physicians' needs.
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Affiliation(s)
- Samuel Bosongo
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Faculté de Médecine et Pharmacie, Université de Kisangani, Kisangani, République Démocratique du Congo
| | - Faustin Chenge
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, République Démocratique du Congo
| | - Albert Mwembo
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Ecole de Santé Publique, Université de Lubumbashi, Lubumbashi, République Démocratique du Congo
| | - Bart Criel
- Centre de Connaissances en Santé au Congo, République Démocratique du Congo
- Institut de Médecine Tropicale d´Anvers, Antwerpen, Belgique
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Yu CH, McCann M, Sale J. "In my age, we didn't have the computers": Using a complexity lens to understand uptake of diabetes eHealth innovations into primary care-A qualitative study. PLoS One 2021; 16:e0254157. [PMID: 34234368 PMCID: PMC8263251 DOI: 10.1371/journal.pone.0254157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 06/21/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Shared decision-making is a central component of person-centred care and can be facilitated with the use of patient decision aids (PtDA). Barriers and facilitators to shared decision-making and PtDA use have been identified, yet integration of PtDAs into clinical care is limited. We sought to understand why, using the concepts of complexity science. METHODS We conducted 60-minute in-depth interviews with patients with diabetes, primary care physicians, nurses and dietitians who had participated in a randomized controlled trial examining the impact of MyDiabetesPlan (an online goal-setting PtDA). Relying on a qualitative description approach, we used a semi-structured interview guide to explore participants' experiences with using MyDiabetesPlan and how it was integrated into the clinical encounter and clinical care. Audiotapes were transcribed verbatim, then coded independently by two analysts. FINDINGS 17 interviews were conducted (5 physicians, 3 nurses, 2 dietitians, 7 patients). Two themes were developed: (1) MyDiabetesPlan appeared to empower patients by providing tailored patient-important information which engaged them in decision-making and self-care. Patients' use of MyDiabetesPlan was however impacted by their competing medical conditions, other life priorities and socioeconomic context. (2) MyDiabetesPlan emphasized to clinicians a patient-centred approach that helped patients assume greater ownership for their care. Clinicians' use of MyDiabetesPlan was impacted by pre-existing clinical tools/workplans, workflow, technical issues, clinic administrative logistics and support, and time. How clinicians adapted to these barriers influenced the degree to which MyDiabetesPlan was integrated into care. CONCLUSIONS A complexity lens (that considers relationships between multiple components of a complex system) may yield additional insights to optimize integration of PtDA into clinical care. A complexity lens recognizes that shared decision-making does not occur in the vacuum of a clinical dyad (patient and clinician), and will enable us to develop a family of interventions that address the whole process, rather than individual components. TRIAL REGISTRATION ClinicalTrials.gov NCT02379078.
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Affiliation(s)
- Catherine H. Yu
- Division of Endocrinology & Metabolism, Department of Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
| | - Maggie McCann
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joanna Sale
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE To quantify the impact of Medicaid enrollment on access to care and adherence to recommended preventive services. DATA SOURCE 2005-2015 Medical Expenditure Panel Survey Household Component. STUDY DESIGN We examined several access measures and utilization of several preventive services within the past year and within the time frame recommended by the United States Preventive Services Task Force, if more than a year. We estimated local average treatment effects of Medicaid enrollment using a new, two-stage regression model developed by Nguimkeu, Denteh, and Tchernis. This model accounts for both endogenous and underreported Medicaid enrollment by using a partial observability bivariate probit regression as the first stage. We identify the model with an exogenous measure of Medicaid eligibility, the simulated Medicaid eligibility rate by state, year, and parents vs childless adults. A wide range of changes in Medicaid eligibility occurred during the time period studied. DATA COLLECTION/EXTRACTION METHODS Sample of low-income, nonelderly adults not receiving disability benefits. PRINCIPAL FINDINGS Medicaid enrollment decreased the probability of having unmet needs for medical care by 7.5 percentage points and the probability of experiencing delays getting prescription drugs by 7.7 percentage points. Medicaid enrollment increased the probability of having a usual source of care by 16.5 percentage points, the probability of having a routine checkup by 17.1 percentage points, and the probability of having a flu shot in past year by 12.6 percentage points. CONCLUSION Medicaid enrollment increased access to care and use of some preventive services. Additional research is needed on impacts for subgroups, such as parents, childless adults, and the smaller and generally older populations for whom screening tests are recommended.
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Affiliation(s)
- Steven C. Hill
- Division of Research & ModelingCenter for Financing, Access, and Cost TrendsAgency for Healthcare Research & QualityDepartment of Health and Human ServicesRockvilleMarylandUSA
| | - Salam Abdus
- Division of Research & ModelingCenter for Financing, Access, and Cost TrendsAgency for Healthcare Research & QualityDepartment of Health and Human ServicesRockvilleMarylandUSA
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Gracey K, Martin S, Reidy J. Palliative Care During Public Health Emergencies: Examples from the COVID-19 Pandemic. Am Fam Physician 2020; 102:312-315. [PMID: 32866361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Kristina Gracey
- University of Massachusetts Medical School, UMass Memorial Health Care, Department of Family Medicine and Community Health, Worcester, MA, USA
| | - Stephen Martin
- University of Massachusetts Medical School, UMass Memorial Health Care, Department of Family Medicine and Community Health, Worcester, MA, USA
| | - Jennifer Reidy
- University of Massachusetts Medical School, UMass Memorial Health Care, Department of Family Medicine and Community Health, Worcester, MA, USA
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Affiliation(s)
| | - Louise Fleming
- Imperial College London, London, UK
- Department of Paediatrics, Royal Brompton Hospital, London, UK
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Mirhoseiny S, Geelvink T, Martin S, Vollmar HC, Stock S, Redaelli M. Does task delegation to non-physician health professionals improve quality of diabetes care? Results of a scoping review. PLoS One 2019; 14:e0223159. [PMID: 31603900 PMCID: PMC6788697 DOI: 10.1371/journal.pone.0223159] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective As a result of unhealthy lifestyles, reduced numbers of healthcare providers are having to deal with an increasing number of diabetes patients. In light of this shortage of physicians and nursing staff, new concepts of care are needed. The aim of this scoping review is to review the literature and examine the effects of task delegation to non-physician health professionals, with a further emphasis on inter-professional care. Research design and methods Systematic searches were performed using the PubMed, Embase and Google Scholar databases to retrieve papers published between January 1994 and December 2017. Randomised/non-randomised controlled trials and studies with a before/after design that described the delegation of tasks from physicians to non-physicians in diabetes care were included in the search. This review is a subgroup analysis that further assesses all the studies conducted using a team-based approach. Results A total of 45 studies with 12,092 patients met the inclusion criteria. Most of the interventions were performed in an outpatient setting with type-2 diabetes mellitus patients. The non-physician healthcare professionals involved in the team were nurses, pharmacists, community health workers and dietitians. Most studies showed significant improvements in glycaemic control and high patient satisfaction, while there were no indications that the task delegation affected quality of life scores. Conclusions The findings of the review suggest that task delegation can provide equivalent glycaemic control and potentially lead to an improvement in the quality of care. However, this review revealed a lack of clinical endpoints, as well as an inconsistency between the biochemical outcome parameters and the patient-centred outcome parameters. Given the vast differences between the individual healthcare systems used around the world, further high-quality research with an emphasis on long-term outcome effects and the expertise of non-physicians is needed.
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Affiliation(s)
- Sanas Mirhoseiny
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Tjarko Geelvink
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Stephan Martin
- Faculty of Medicine, University of Düsseldorf, Düsseldorf, Germany
- West-German Center of Diabetes and Health, Düsseldorf Catholic Hospital Group, Düsseldorf, Germany
| | - Horst Christian Vollmar
- Department of General Practice, Faculty of Medicine, Ruhr-Universität Bochum, Gebäude MAFO 1/61, Bochum, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Marcus Redaelli
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- * E-mail:
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Kroth PJ, Morioka-Douglas N, Veres S, Babbott S, Poplau S, Qeadan F, Parshall C, Corrigan K, Linzer M. Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout. JAMA Netw Open 2019; 2:e199609. [PMID: 31418810 PMCID: PMC6704736 DOI: 10.1001/jamanetworkopen.2019.9609] [Citation(s) in RCA: 162] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
IMPORTANCE Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs). OBJECTIVES To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem. DESIGN, SETTING, AND PARTICIPANTS This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019. MAIN OUTCOMES AND MEASURES Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions. RESULTS Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout. CONCLUSIONS AND RELEVANCE Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.
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Affiliation(s)
| | | | | | | | - Sara Poplau
- Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | | | | | - Kathryne Corrigan
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Mark Linzer
- Minneapolis Medical Research Foundation, Minneapolis, Minnesota
- Hennepin County Medical Center, Minneapolis, Minnesota
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Klueh MP, Sloss KR, Dossett LA, Englesbe MJ, Waljee JF, Brummett CM, Lagisetty PA, Lee JS. Postoperative opioid prescribing is not my job: A qualitative analysis of care transitions. Surgery 2019; 166:744-751. [PMID: 31303324 DOI: 10.1016/j.surg.2019.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/08/2019] [Accepted: 05/29/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Persistent opioid use is common after surgical procedures, and postoperative opioid prescribing often transitions from surgeons to primary care physicians in the months after surgery. It is unknown how surgeons currently transition these patients or the preferred approach to successful coordination of care. This qualitative study aimed to describe transitions of care for postoperative opioid prescribing and identify barriers and facilitators of ideal transitions for potential intervention targets. METHODS We conducted a qualitative study of surgeons and primary care physicians at a large academic healthcare system using a semi-structured interview guide. Transcripts were independently coded using the Theoretical Domains Framework to identify underlying determinants of physician behaviors. We mapped dominant themes to the Behavior Change Wheel to propose potential interventions targeting these behaiors. RESULTS Physicians were interviewed between July 2017 and December 2017 beyond thematic saturation (n = 20). Surgeons report passive transitions to primary care physicians after ruling out surgical complications, and these patients often bounce back to the surgeon when primary care physicians are uncertain of the cause of ongoing pain. Ideal practices were identified as setting preoperative expectations and engaging in active transition for postoperative opioid prescribing. We identified 3 behavioral targets for multidisciplinary intervention: knowledge (guidelines for coordination of care), barriers (utilizing support staff for active transition), and professional role (incentive for multidisciplinary collaboration). CONCLUSION This qualitative study identifies potential interventions aimed at changing physician behaviors regarding transitions of care for postoperative opioid prescribing. Implementation of these interventions could improve coordination of care for patients with persistent postoperative opioid use.
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Affiliation(s)
- Michael P Klueh
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; University of Michigan Medical School, Ann Arbor, MI
| | - Kenneth R Sloss
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | | | - Michael J Englesbe
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI.
| | - Jennifer F Waljee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
| | - Chad M Brummett
- Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI; Department of Anesthesiology, Michigan Medicine, Ann Arbor, MI
| | - Pooja A Lagisetty
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jay S Lee
- Department of Surgery, Michigan Medicine, Ann Arbor, MI; Michigan Opioid Prescribing Engagement Network (OPEN), Ann Arbor, MI
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Freeman PR, Curran GM, Drummond KL, Martin BC, Teeter BS, Bradley K, Schoenberg N, Edlund MJ. Utilization of prescription drug monitoring programs for prescribing and dispensing decisions: Results from a multi-site qualitative study. Res Social Adm Pharm 2019; 15:754-760. [PMID: 30243575 PMCID: PMC6417986 DOI: 10.1016/j.sapharm.2018.09.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/08/2018] [Accepted: 09/13/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) track the dispensing of prescription-controlled substances with the goal of mitigating misuse and diversion. Authorized users query the PDMP for controlled substance prescription histories at the point of care. Despite widespread implementation of PDMPs, there is much not known about how PDMPs influence prescribing and dispensing decisions. OBJECTIVES The objective of this study was to investigate how primary care providers (PCPs) and pharmacists utilize PDMPs when making prescribing and dispensing decisions. METHODS Data from in-depth, qualitative interviews with PCPs (n = 48) and community pharmacists (n = 60) across four states- Arkansas, Idaho, Kentucky, and Washington were analyzed for themes around PDMP use. RESULTS Both PCPs and pharmacists reported that PDMPs are key tools for aiding prescribing and dispensing decisions. PCPs reported variable use of PDMPs with most querying the PDMP when there are "red flags" and fewer reporting having clinic policies that direct PDMP use. Primary care providers in Kentucky reported more consistent and routine use of the PDMP as a result of a state law that mandates query prior to the initial prescribing of Schedule II controlled substances. Community pharmacists practicing in chain pharmacies reported formal policies requiring PDMP query prior to dispensing opioids, while utilization of PDMPs by pharmacists practicing in independently-owned pharmacies was more variable. Pharmacists and PCPs reported barriers to PDMP use, such as having to "log in on a separate machine" and perceived that PDMP utility could be improved by integrating it within pharmacy dispensing systems and electronic health records. CONCLUSIONS Pharmacists and PCPs reported the importance of PDMP information to aid their prescribing and dispensing decisions. Efforts to enhance state PDMP programs should consider processes that seamlessly integrate all available controlled substance prescription history for a given patient at the point of care so that PDMP utility for prescribing and dispensing decisions is maximized.
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Affiliation(s)
- Patricia R Freeman
- University of Kentucky College of Pharmacy, 789 South Limestone Street, Lexington, KY, 40536, USA.
| | - Geoffrey M Curran
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, USA; Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, USA
| | - Karen L Drummond
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, USA; Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, USA
| | - Bradley C Martin
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, USA; Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR, 72114, USA
| | - Benjamin S Teeter
- University of Arkansas for Medical Sciences, 4301 West Markham St., #522-4, Little Rock, AR, 72205-7199, USA
| | - Katharine Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA, 98101, USA
| | - Nancy Schoenberg
- University of Kentucky College of Medicine, 125 Medical Behavioral Science Office Building, Lexington, KY, 40536-0086, USA
| | - Mark J Edlund
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC, 27709-2194, USA
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Maharani C, Djasri H, Meliala A, Dramé ML, Marx M, Loukanova S. A scoping analysis of the aspects of primary healthcare physician job satisfaction: facets relevant to the Indonesian system. Hum Resour Health 2019; 17:38. [PMID: 31146752 PMCID: PMC6543658 DOI: 10.1186/s12960-019-0375-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/12/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Although there is extensive literature on the different aspects of physician job satisfaction worldwide, existing questionnaires used to measure job satisfaction in developed countries (e.g., the Job Satisfaction Scale) do not capture the aspects specific to Indonesian primary healthcare physicians. This is especially true considering the 2014 healthcare system reform, which led to the implementation of a national social health insurance scheme in Indonesia that has significantly changed the working conditions of physicians. Therefore, the current study aimed to identify aspects of primary care physician job satisfaction featured in published literature and determine those most suitable for measuring physician job satisfaction in light of Indonesia's recent reforms. METHODS A scoping literature review of full-text articles published in English between 2006 and 2015 was conducted using the PubMed, Psycinfo, and Web of Science databases. All aspects of primary care physician job satisfaction included in these studies were identified and classified. We then selected aspects mentioned in more than 5% of the reviewed papers and identified those most relevant to the post-reform Indonesian context. RESULTS A total of 440 articles were reviewed, from which 23 aspects of physicians' job satisfaction were extracted. Sixteen aspects were deemed relevant to the current Indonesian system: physical working conditions, overall job satisfaction, patient care/treatment, referral systems, relationships with colleagues, financial aspects, workload, time of work, recognition for good work, autonomy, opportunity to use abilities, relationships with patients, their families, and community, primary healthcare facilities' organization and management style, medical education, healthcare systems, and communication with health insurers. CONCLUSION Considering the recent reforms of the Indonesian healthcare system, existing tools for measuring job satisfaction among physicians must be revised. Future research should focus on the development and validation of new measures of physician job satisfaction based on the aspects identified in this study.
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Affiliation(s)
- Chatila Maharani
- Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
- Department of Public Health, Universitas Negeri Semarang, Semarang, Indonesia
| | - Hanevi Djasri
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Andreasta Meliala
- Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Mohamed Lamine Dramé
- Success in Africa, Conakry University Medical Faculty based think tank, Conakry, Guinea
| | - Michael Marx
- Heidelberg Institute of Global Health, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
| | - Svetla Loukanova
- Department of General Practice and Implementation Research, Medical Faculty, University Hospital Heidelberg, Heidelberg University, Heidelberg, Germany
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Ziegler E, Valaitis R, Yost J, Carter N, Risdon C. "Primary care is primary care": Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario. PLoS One 2019; 14:e0215873. [PMID: 31009508 PMCID: PMC6476519 DOI: 10.1371/journal.pone.0215873] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/09/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario. METHODS A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered. RESULTS Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners' roles, and the need for more training and education in transgender care for practitioners. CONCLUSIONS Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.
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Affiliation(s)
- Erin Ziegler
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Ruta Valaitis
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Jennifer Yost
- M. Louise Fitzpatrick School of Nursing, Villanova University, Villanova, Pennsylvania, United States of America
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Cathy Risdon
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Pallarés-Carratalá V, Divisón Garrote JA, Prieto Díaz MA, García Matarín L, Seoane Vicente MC, Molina Escribano F, Velilla Zancada S, Rey Aldana D, Cinza Sanjurjo S, Santos Altozano C, Górriz JL, Alonso Moreno FJ, Polo García J, Barquilla García A, Beato Fernández P, Escobar Cervantes C. [Positioning for the management of arterial hypertension in Primary Care from the critical analysis of the American (2017) and European (2018) guidelines. Spanish Society of Primary Care Physicians (SEMERGEN)]. Semergen 2019; 45:251-272. [PMID: 31005506 DOI: 10.1016/j.semerg.2019.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/04/2019] [Indexed: 11/30/2022]
Abstract
The Scientific Societies of Primary Care, being the area in which there is a considerable prevalence of Arterial Hypertension (AHT), need to periodically evaluate the international guidelines for its management. This is particularly relevant when disparate guidelines make it difficult to make decisions in daily clinical practice. The present document has as its aim to analyse the changes and new developments proposed in the guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA 2017), as well as in the guidelines of the European Society of Cardiology and European Society of Hypertension (ESC/ESH 2018). An analysis will be made of any differences, limitations, and their applicability to Primary Care in Spain. Finally, the most relevant available and appropriate information is extracted and integrated in order to homogenise the care of the hypertensive patient, from a critical, but also a reasoned, perspective. The discrepancies between the recommendations in such essential aspects as the management of the disease, require the compiling and critical analysis of the information that enables us as scientific society, interested in providing all PC physicians with the most relevant, and at the same time, sensible, recommendations of all the guidelines.
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Affiliation(s)
- V Pallarés-Carratalá
- Unidad de Vigilancia de la Salud, Unión de Mutuas, Castellón, España; Departamento de Medicina, Universitat Jaume I, Castellón, España.
| | - J A Divisón Garrote
- Centro de Salud Casas Ibañez, Casas Ibáñez, Albacete, España; Cátedra de Medicina de Familia SEMERGEN, Universidad Católica San Antonio de Murcia, Murcia, España.
| | | | | | | | - F Molina Escribano
- Centro de Salud Casas Ibañez, Consultorio Balsa de Ves, Balsa de Ves, Albacete, España
| | | | - D Rey Aldana
- Centro de Salud A Estrada, A Estrada, Pontevedra, España
| | - S Cinza Sanjurjo
- Cátedra SEMERGEN, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España; Centro de Salud Porto do Son, Porto de Son, A Coruña, España
| | | | - J L Górriz
- Servicio de Nefrología, Hospital Clínico de Valencia, Valencia, España; Departamento de Medicina, Facultad de Medicina, Universidad de Valencia, Valencia, España
| | | | - J Polo García
- Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
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Kouri A, Kaplan A, Boulet LP, Gupta S. New evidence-based tool to guide the creation of asthma action plans for adults. Can Fam Physician 2019; 65:103-106. [PMID: 30765356 PMCID: PMC6515492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To improve the use of asthma action plans (AAPs) among primary care physicians. SOURCES OF INFORMATION In a 2017 article, recent asthma guidelines and adult studies (January 2010 to March 2016) addressing acute loss of asthma control were reviewed to develop an evidence-based tool to help guide physicians in creating AAPs to maximize adherence and minimize errors. Evidence supporting the effects of AAPs is level I. Evidence supporting the recommendations in the tool ranges from level I to consensus. MAIN MESSAGE A lack of knowledge about and training in creating appropriate AAP content is an important barrier to the use of AAPs, as is the fact that instructions provided by asthma guidelines are often difficult to integrate into real-world practice. In order to address these issues, a freely accessible, practical, evidence-based tool has recently been created, addressing both the knowledge and the practical barriers to AAP creation. This tool has been formatted as a printable bedside chart for the point of care, but could also be integrated into a computerized electronic decision support system in the future. CONCLUSION Asthma action plans, in conjunction with asthma education and regular follow-up, can improve patients' symptoms and quality of life and reduce hospitalization. This novel point-of-care tool provides practical advice on how to complete AAPs to improve patients' asthma self-management.
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Affiliation(s)
- Andrew Kouri
- Clinical fellow in the Division of Respirology in the Department of Medicine at the University of Toronto in Ontario.
| | - Alan Kaplan
- Chair of the Board of Directors for the Family Physician Airways Group of Canada and Clinical Lecturer in the Department of Family and Community Medicine at the University of Toronto
| | - Louis-Philippe Boulet
- Respirologist in the Institut universitaire de cardiologie et de pneumologie de Québec of Laval University in Quebec city, Que
| | - Samir Gupta
- Associate Scientist with the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St Michael's Hospital in Toronto
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Perry D, Orrantia E, Garrison S. Treating opioid use disorder in primary care. Can Fam Physician 2019; 65:117. [PMID: 30765361 PMCID: PMC6515501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Danielle Perry
- Master's degree candidate and Knowledge Translation Expert with the PEER (Patients, Experience, Evidence, Research) Group in the Department of Family Medicine at the University of Alberta in Edmonton
| | - Eliseo Orrantia
- Rural family physician for the Marathon Family Health Team in Ontario and Associate Professor at the Northern Ontario School of Medicine
| | - Scott Garrison
- Associate Professor in the Department of Family Medicine at the University of Alberta
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Abstract
The speech language pathologist has a vital management role in patients with voice and swallow concerns, as well as stroke patients and patients with fluency problems. This article summarizes the variety of speech and swallow rehabilitation that adult patients may require or seek. The case examples allow the reader to base the clinical decision-making process within the context of a patient presentation and elucidate the role of speech and language pathology services for the primary care provider in order to refer patients with symptoms and concerns to the right provider early in their medical care.
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Affiliation(s)
- Kristine Pietsch
- Department of Otolaryngology, Johns Hopkins University, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA
| | - Tiffany Lyon
- Department of Speech and Language Pathology, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Vaninder K Dhillon
- Department of Otolaryngology, Johns Hopkins University, 601 North Caroline Street, 6th Floor, Baltimore, MD 21287, USA; Department of Otolaryngology Head and Neck Surgery, Johns Hopkins University, National Capital Region, 6420 Rockledge Drive, Suite 4920, Bethesda, MD 20817, USA.
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[Scientific professional associations and guidelines' preparation process.]. Recenti Prog Med 2018; 109:457-8. [PMID: 30394405 DOI: 10.1701/3010.30082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Clinical guidelines are a valuable tool for doctors: they are the "type of document" most downloaded from publishers' websites and the "type of article" most cited in scientific literature. They are also an important driver of health system expenditure. To avoid conflicts of interest and to overcome an overly specialized approach, guidelines should not be prepared by scientific professional associations involved in the subject addressed. The preparation process of guidelines should be coordinated by expert methodologists and should include primary care physicians, experts from other disciplines (bioethics, health economics, etc.) and patient representatives.
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Signorelli C, Wakefield CE, Fardell JE, Foreman T, Johnston KA, Emery J, Thornton-Benko E, Girgis A, Lie HC, Cohn RJ. The Role of Primary Care Physicians in Childhood Cancer Survivorship Care: Multiperspective Interviews. Oncologist 2018; 24:710-719. [PMID: 30171066 DOI: 10.1634/theoncologist.2018-0103] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/16/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Primary care physicians (PCPs) are well placed to provide holistic care to survivors of childhood cancer and may relieve growing pressures on specialist-led follow-up. We evaluated PCPs' role and confidence in providing follow-up care to survivors of childhood cancer. SUBJECTS, MATERIALS, AND METHODS In Stage 1, survivors and parents (of young survivors) from 11 Australian and New Zealand hospitals completed interviews about their PCPs' role in their follow-up. Participants nominated their PCP for an interview for Stage 2. In Stage 2, PCPs completed interviews about their confidence and preparedness in delivering childhood cancer survivorship care. RESULTS Stage 1: One hundred twenty survivors (36% male, mean age: 25.6 years) and parents of young survivors (58% male survivors, survivors' mean age: 12.7 years) completed interviews. Few survivors (23%) and parents (10%) visited their PCP for cancer-related care and reported similar reasons for not seeking PCP-led follow-up including low confidence in PCPs (48%), low perceived PCP cancer knowledge (38%), and difficulty finding good/regular PCPs (31%). Participants indicated feeling "disconnected" from their PCP during their cancer treatment phase. Stage 2: Fifty-one PCPs (57% male, mean years practicing: 28.3) completed interviews. Fifty percent of PCPs reported feeling confident providing care to childhood cancer survivors. PCPs had high unmet information needs relating to survivors' late effects risks (94%) and preferred a highly prescriptive approach to improve their confidence delivering survivorship care. CONCLUSION Improved communication and greater PCP involvement during treatment/early survivorship may help overcome survivors' and parents' low confidence in PCPs. PCPs are willing but require clear guidance from tertiary providers. IMPLICATIONS FOR PRACTICE Childhood cancer survivors and their parents have low confidence in primary care physicians' ability to manage their survivorship care. Encouraging engagement in primary care is important to promote holistic follow-up care, continuity of care, and long-term surveillance. Survivors'/parents' confidence in physicians may be improved by better involving primary care physicians throughout treatment and early survivorship, and by introducing the concept of eventual transition to adult and primary services. Although physicians are willing to deliver childhood cancer survivorship care, their confidence in doing so may be improved through better communication with tertiary services and more appropriate training.
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Affiliation(s)
- Christina Signorelli
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's & Children's Health, UNSW Sydney, New South Wales, Australia
| | - Claire E Wakefield
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's & Children's Health, UNSW Sydney, New South Wales, Australia
| | - Joanna E Fardell
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's & Children's Health, UNSW Sydney, New South Wales, Australia
| | - Tali Foreman
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's & Children's Health, UNSW Sydney, New South Wales, Australia
| | - Karen A Johnston
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's & Children's Health, UNSW Sydney, New South Wales, Australia
| | - Jon Emery
- Centre for Cancer Research and Department of General Practice, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victorian Comprehensive Cancer Centre, Victoria, Australia
| | - Elysia Thornton-Benko
- Bondi Road Doctors, Bondi Junction, New South Wales, Australia
- Wellac Lifestyle: Wellness After, And during Cancer, New South Wales, Australia
| | - Afaf Girgis
- Centre for Oncology Education and Research Translation, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, New South Wales, Australia
| | - Hanne C Lie
- Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Norway
- Department of Paediatric Medicine, Children's and Adolescents Division, Oslo University Hospital, Norway
| | - Richard J Cohn
- Kids Cancer Centre, Sydney Children's Hospital, Randwick, New South Wales, Australia
- School of Women's & Children's Health, UNSW Sydney, New South Wales, Australia
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Hisham R, Liew SM, Ng CJ. A comparison of evidence-based medicine practices between primary care physicians in rural and urban primary care settings in Malaysia: a qualitative study. BMJ Open 2018; 8:e018933. [PMID: 30002004 PMCID: PMC6082445 DOI: 10.1136/bmjopen-2017-018933] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 05/03/2018] [Accepted: 06/01/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE This study aimed to compare the evidence-based practices of primary care physicians between those working in rural and in urban primary care settings. RESEARCH DESIGN Data from two previous qualitative studies, the Front-line Equitable Evidence-based Decision Making in Medicine and Creating, Synthesising and Implementing evidence-based medicine (EBM) in primary care studies, were sorted, arranged, classified and compared with the help of qualitative research software, NVivo V.10. Data categories were interrogated through comparison between and within datasets to identify similarities and differences in rural and urban practices. Themes were then refined by removing or recoding redundant and infrequent nodes into major key themes. PARTICIPANTS There were 55 primary care physicians who participated in 10 focus group discussions (n=31) and 9 individual physician in-depth interviews. SETTING The study was conducted across three primary care settings-an academic primary care practice and both private and public health clinics in rural (Pahang) and urban (Selangor and Kuala Lumpur) settings in Malaysia. RESULTS We identified five major themes that influenced the implementation of EBM according to practice settings, namely, workplace factors, EBM understanding and awareness, work experience and access to specialist placement, availability of resources and patient population. Lack of standardised care is a contributing factor to differences in EBM practice, especially in rural areas. CONCLUSIONS There were major differences in the practice of EBM between rural and urban primary care settings. These findings could be used by policy-makers, administrators and the physicians themselves to identify strategies to improve EBM practices that are targeted according to workplace settings.
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Affiliation(s)
- Ranita Hisham
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Su May Liew
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chirk Jenn Ng
- Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Sequist TD, Holliday AM, Orav EJ, Bates DW, Denker BM. Physician and patient tools to improve chronic kidney disease care. Am J Manag Care 2018; 24:e107-e114. [PMID: 29668213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To determine if electronic health record (EHR) tools and patient engagement can improve the quality of chronic kidney disease (CKD) care. STUDY DESIGN Randomized controlled trial. METHODS We enrolled 153 primary care physicians caring for 3947 high-risk and 3744 low-risk patients with stage III CKD across 13 ambulatory health centers in eastern Massachusetts. Intervention physicians received a set of electronic alerts during office visits recommending risk-appropriate CKD care. Patients of intervention physicians also received tailored educational mailings. For high-risk patients, we assessed for a visit with a nephrologist and prescription of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) during the 12-month study period. For low-risk patients, we assessed for a urine microalbumin screening and prescription of an ACE inhibitor or ARB during the 12-month study period. RESULTS Among high-risk patients, those in the intervention arm were significantly more likely to have an office visit with a nephrologist compared with those in the control arm (45% vs 34%; P <.001). Among low-risk patients, those in the intervention arm were significantly more likely than those in the control arm to have received urine microalbumin testing (45% vs 21%; P <.001). There was no difference between the intervention and control arms in rates of prescription of an ACE inhibitor or ARB in either the high-risk patient group (76% vs 79%; P = .17) or the low-risk patient group (64% vs 65%; P = .57). CONCLUSIONS A combined program of EHR tools and patient engagement improved some areas of CKD care, but substantial gaps remain.
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LaGrandeur W, Armin J, Howe CL, Ali-Akbarian L. Survivorship care plan outcomes for primary care physicians, cancer survivors, and systems: a scoping review. J Cancer Surviv 2018; 12:334-347. [PMID: 29332213 DOI: 10.1007/s11764-017-0673-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/22/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE With the focus on survivorship care-coordination between oncology and primary care providers (PCPs), there is a need to assess the research regarding the use of survivorship care plans (SCPs) and determine emerging research areas. We sought to find out how primary care physicians have been involved in the use of SCPs and determine SCP's effectiveness in improving care for cancer survivors. In this scoping review, we aimed to identify gaps in the current research and reveal opportunities for further research. METHODS We followed the methodology for scoping studies which consists of identifying the research question, locating relevant studies, selecting studies, charting the data, and collating, summarizing, and reporting the results. RESULTS Out of 5375 original articles identified in the literature search, 25 met the inclusion/exclusion criteria. Eight articles examined PCP-only related outcomes, eight examined survivor-only related outcomes, eight examined mixed outcomes between both groups, and one examined system-based outcomes. Findings highlighted several areas where SCPs may provide benefits, including increased confidence among PCPs in managing the care of survivors and increased quality of life and well-being for survivors. This research also highlighted the need for careful consideration of SCP mode of delivery and content in order to maximize their utility to patients and providers. CONCLUSIONS Based on the findings of this review, SCPs may benefit providers and health care systems, but the benefits to patients remain unclear. Further research on the potential benefits of SCPs to particular patient populations is warranted. IMPLICATIONS FOR CANCER SURVIVORS SCPs appear to be beneficial to PCPs in improving overall quality of care. However, more work needs to be done to understand the direct impact on cancer survivors.
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Affiliation(s)
- Weston LaGrandeur
- University of Arizona College of Medicine, 1733 E Silver Street, Tucson, AZ, 85719, USA.
| | - Julie Armin
- Department of Family & Community Medicine, University of Arizona, 1450 N. Cherry Ave, Tucson, AZ, 85719, USA
| | - Carol L Howe
- Department of Family & Community Medicine, University of Arizona Health Sciences Library, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ, 85724-5079, USA
| | - Leila Ali-Akbarian
- Department of Family & Community Medicine, University of Arizona Cancer Center, University of Arizona, 1450 N. Cherry Ave, Tucson, AZ, 85719, USA
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Parlier AB, Galvin SL, Thach S, Kruidenier D, Fagan EB. The Road to Rural Primary Care: A Narrative Review of Factors That Help Develop, Recruit, and Retain Rural Primary Care Physicians. Acad Med 2018; 93:130-140. [PMID: 28767498 DOI: 10.1097/acm.0000000000001839] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
PURPOSE To examine the literature documenting successes in recruiting and retaining rural primary care physicians. METHOD The authors conducted a narrative review of literature on individual, educational, and professional characteristics and experiences that lead to recruitment and retention of rural primary care physicians. In May 2016, they searched MEDLINE, PubMed, CINAHL, ERIC, Web of Science, Google Scholar, the Grey Literature Report, and reference lists of included studies for literature published in or after 1990 in the United States, Canada, or Australia. The authors identified 83 articles meeting inclusion criteria. They synthesized results and developed a theoretical model that proposes how the findings interact and influence rural recruitment and retention. RESULTS The authors' proposed theoretical model suggests factors interact across multiple dimensions to facilitate the development of a rural physician identity. Rural upbringing, personal attributes, positive rural exposure, preparation for rural life and medicine, partner receptivity to rural living, financial incentives, integration into rural communities, and good work-life balance influence recruitment and retention. However, attending medical schools and/or residencies with a rural emphasis and participating in rural training may reflect, rather than produce, intention for rural practice. CONCLUSIONS Many factors enhance rural physician identity development and influence whether physicians enter, remain in, and thrive in rural practice. To help trainees and young physicians develop the professional identity of a rural physician, multifactorial medical training approaches aimed at encouraging long-term rural practice should focus on rural-specific clinical and nonclinical competencies while providing trainees with positive rural experiences.
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Affiliation(s)
- Anna Beth Parlier
- A.B. Parlier was research project coordinator, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina, at the time of writing. As of August 2017, she will be a graduate student, Psychology Department, Virginia Commonwealth University, Richmond, Virginia. S.L. Galvin is director of research, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina, and adjunct assistant professor, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina. S. Thach is director of clinical and community outreach, Western North Carolina Rural Health Initiative, Mountain Area Health Education Center, Asheville, North Carolina. D. Kruidenier is research and clinical librarian, Center for Research, Mountain Area Health Education Center, Asheville, North Carolina. E.B. Fagan is chief education officer, Mountain Area Health Education Center (MAHEC), assistant program director, Family Medicine Residency Program, MAHEC, and assistant medical director, Department of Family Medicine, MAHEC, Asheville, North Carolina. He is also associate professor, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
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Hadjipetrou A, Anyfantakis D, Galanakis CG, Kastanakis M, Kastanakis S. Colorectal cancer, screening and primary care: A mini literature review. World J Gastroenterol 2017; 23:6049-6058. [PMID: 28970720 PMCID: PMC5597496 DOI: 10.3748/wjg.v23.i33.6049] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/19/2017] [Accepted: 08/02/2017] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is a common health problem, representing the third most commonly diagnosed cancer worldwide and causing a significant burden in terms of morbidity and mortality, with annual deaths estimated at 700000. The western way of life, that is being rapidly adopted in many regions of the world, is a well discussed risk factor for CRC and could be targeted in terms of primary prevention. Furthermore, the relatively slow development of this cancer permits drastic reduction of incidence and mortality through secondary prevention. These facts underlie primary care physicians (PCPs) being assigned a key role in health strategies that enhance prevention and prompt diagnosis. Herein, we review the main topics of CRC in the current literature, in order to better understand its pathogenesis, risk and protective factors, as well as screening techniques. Furthermore, we discuss preventive and screening policies to combat CRC and the crucial role served by PCPs in their successful implementation. Relevant articles were identified through electronic searches of MEDLINE and through manual searches of reference lists.
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Affiliation(s)
- Athanasios Hadjipetrou
- Primary Health Care Centre of Kissamos, Chania, 73400 Crete, Greece
- First Department of Surgery, Saint George General Hospital of Chania, 73300 Crete, Greece
| | - Dimitrios Anyfantakis
- Primary Health Care Centre of Kissamos, Chania, 73400 Crete, Greece
- First Department of Surgery, Saint George General Hospital of Chania, 73300 Crete, Greece
| | | | - Miltiades Kastanakis
- First Department of Surgery, Saint George General Hospital of Chania, 73300 Crete, Greece
| | - Serafim Kastanakis
- Department of Internal Medicine, Saint George General Hospital of Chania, 73300 Crete, Greece
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Prestes M, Gayarre MA, Elgart JF, Gonzalez L, Rucci E, Paganini JM, Gagliardino JJ. Improving diabetes care at primary care level with a multistrategic approach: results of the DIAPREM programme. Acta Diabetol 2017. [PMID: 28624898 DOI: 10.1007/s00592-017-1016-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To present results, 1 year postimplementation at primary care level, of an integrated diabetes care programme including systemic changes, education, registry (clinical, metabolic, and therapeutic indicators), and disease management (DIAPREM). METHODS We randomly selected and trained 15 physicians and 15 nurses from primary care units of La Matanza County (intervention-IG) and another 15 physicians/nurses to participate as controls (control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for 1 year; both groups used structured medical records. Patients in IG had quarterly clinical appointments, whereas those in CG received traditional care. Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions. RESULTS After 12 months, the dropout rate was significantly lower in IG than in CG. Whereas in IG HbA1c, blood pressure and lipid profile levels significantly decreased, no changes were recorded in CG. Drug prescriptions showed no significant changes in IG except a decrease in oral monotherapy. CONCLUSIONS DIAPREM is an expedient and simple multistrategic model to implement at the primary care level in order to decrease patient dropout and improve control and treatment adherence, and quality of care of people with diabetes.
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MESH Headings
- Adult
- Aged
- Blood Pressure
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/therapy
- Education, Medical, Continuing/organization & administration
- Education, Medical, Continuing/standards
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Physicians, Primary Care/education
- Physicians, Primary Care/organization & administration
- Physicians, Primary Care/standards
- Practice Patterns, Physicians'/organization & administration
- Practice Patterns, Physicians'/standards
- Primary Health Care/methods
- Primary Health Care/organization & administration
- Primary Health Care/standards
- Quality Improvement/organization & administration
- Registries
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Affiliation(s)
- Mariana Prestes
- CENEXA Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET), Facultad de Ciencias Médicas (UNLP), 60 y 120, 1900, La Plata, Argentina
| | - Maria A Gayarre
- Coordinadora del PRODIABA, Secretaría de Salud, Municipalidad de La Matanza, San Justo, Argentina
| | - Jorge F Elgart
- CENEXA Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET), Facultad de Ciencias Médicas (UNLP), 60 y 120, 1900, La Plata, Argentina
| | - Lorena Gonzalez
- CENEXA Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET), Facultad de Ciencias Médicas (UNLP), 60 y 120, 1900, La Plata, Argentina
- Escuela de Economía de la Salud y Administración de Organizaciones de Salud, Facultad de Ciencias Económicas (UNLP), La Plata, Argentina
| | - Enzo Rucci
- CENEXA Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET), Facultad de Ciencias Médicas (UNLP), 60 y 120, 1900, La Plata, Argentina
- III-LIDI, Facultad de Informática, Universidad Nacional de La Plata, La Plata, Argentina
| | - Jose M Paganini
- INUS. Centro Interdisciplinario Universitario para la Salud, Facultad de Ciencias Médicas (UNLP), La Plata, Argentina
| | - Juan J Gagliardino
- CENEXA Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET), Facultad de Ciencias Médicas (UNLP), 60 y 120, 1900, La Plata, Argentina.
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Higuera L, Carlin C. A comparison of retrospective attribution rules. Am J Manag Care 2017; 23:e180-e185. [PMID: 28817293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To compare the performance of methods to retrospectively attribute patients to provider systems by comparing the fraction attributed and the stability of assignment over time. STUDY DESIGN Retrospective cross-sectional study. METHODS Descriptive statistics are used to measure the fraction of patients attributed and stability of attribution from year to year. This study uses a panel of administrative claims data (2010-2011). Attribution rules were defined by unit of measure (count of physician visits, dollars paid), type of providers (primary care physicians [PCPs], all physicians), type of encounters (all visits, evaluation and management visits only), and level of concentration of care (majority, plurality). We created 32 retrospective attribution rules, spanning PCP-only rules, all-physician rules, hierarchical rules based on PCPs then all physicians, and lookback rules based on current-year PCP visits then prior-year experience. RESULTS All methods exhibit a tradeoff between stability of attribution and fraction of the population attributed. This tradeoff is minimized when PCP-based rules are supplemented by a 1-year lookback when the current-year experience does not result in attribution. CONCLUSIONS We recommend using this lookback method when multiple years of data are available. In absence of multiple years of data, PCP-based rules maximize stability; hierarchical rules result in a greater fraction attributed with less loss of stability than simple all-provider rules.
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Affiliation(s)
- Lucas Higuera
- Medica Research Institute, 401 Carlson Pkwy, Mail Route CW105, Minnetonka, MN 55305. E-mail:
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Abstract
Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis.
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Affiliation(s)
- T Sánchez-Sagrado
- Delegación territorial de Sanidad y Bienestar Social, Segovia, España.
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Douglas HE, Wood F. Burns dressings. Aust Fam Physician 2017; 46:94-97. [PMID: 28260266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Burn injuries are common and costly; each year, there are more than 200,000 cases, costing the Australian community $150 million. Management of smaller burn injuries in the community can be improved by appropriate first aid, good burn dressings and wound management. This can reduce the risk of the burn becoming deeper or infected, and can potentially reduce the requirement for specialist review or surgery. OBJECTIVE The objective of this article is to provide healthcare professionals with information about the pathophysiology of burn wound progression. This information includes the aims of burn wound dressings and indications for different types of dressings in different burn depths, advantages of blister debridement, and the reasoning behind advice given to patients after healing of the burn wound. DISCUSSION This article provides a framework used by the State Burn Service of Western Australia, by which clinicians can understand the needs of a specific burn wound and apply these principles when choosing an appropriate burn dressing for their patient. Every intervention in the journey of a patient with a burn injury affects their eventual outcome. By managing all burn injuries effectively at every single step, we can reduce burn injury morbidity as a community.
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Wynter S, Grigg C. Lisfranc injuries. Aust Fam Physician 2017; 46:116-119. [PMID: 28260272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Injury to the tarsometatarsal joint is a relatively rare occurrence that is commonly missed, leading to debilitating outcomes. For this reason, it is considered a red flag in general practice. OBJECTIVE This article reviews the current literature on tarsometatarsal injuries and describes clinical assessment, imaging and management. DISCUSSION Lisfranc injuries refer to the displacement of the metatarsals from the tarsus, with special attention placed on the second tarsometa-tarsal joint and Lisfranc ligament. These injuries can occur in numerous circumstances, such as motor vehicle accidents, crush inju-ries and falls. Indirect mechanisms include axial force through the foot or twisting on a plantar flexed foot. Suggestive examination signs include plantar ecchymosis, mid-foot pain and positive findings in the provocative tests described in the article. Weight-bearing radiographs are vital for diagnosis. Correct and prompt management is key to avoiding posttraumatic arthritis, a devastating but common complication of Lisfranc injuries.
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Pearson S, Stewart M, Bateson D. Implanon NXT: Expert tips for best-practice insertion and removal. Aust Fam Physician 2017; 46:104-108. [PMID: 28260268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND The single rod etonogestrel contraceptive implant is available in Australia as Implanon NXT. It is a highly effective, long-acting reversible contraceptive method, which is suitable for most women across the reproductive lifespan. OBJECTIVE This article provides practical advice for clinicians who already insert and remove the contraceptive implant, as well as advice for those who have not yet acquired this procedural skill. DISCUSSION Contraceptive implant procedures are usually performed in the general practice setting. Clinicians can support women in making an informed choice to have an implant by providing information about their benefits, side effects and risks, and timely access to insertion. Training in the procedures and compliance with procedural instructions are essential to minimise risks, including deep insertion and damage to neurovascular structures.
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Vikraman J, Donath S, Hutson Ao JM. Undescended testes: Diagnosis and timely treatment in Australia (1995-2014). Aust Fam Physician 2017; 46:152-158. [PMID: 28260279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Routine primary care checks in infants and prepubertal boys aim for early detection and intervention of undescended testes (UDT). Congenital and acquired UDT cause infertility, and congenital UDT also increases testicular cancer risk. We examined 20 years of Australian orchidopexy data (1995-2014) to explore the national orchidopexy operation rates over time. METHODS Orchidopexy and population data were collected from the Australian Bureau of Statistics (ABS) for 1995-2014, and census data for each age group were also collected. Poisson regressions were used to analyse the data. RESULTS For patients aged DISCUSSION: The rate of orchidopexy per age has decreased in patients aged 5-14 years over the past 20 years, possibly indicating that acquired UDT is not being diagnosed and treated in some boys, risking infertility in adulthood.
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Johnson K, Pulley L. Interest in Treatment of Patients with Sickle Cell Disease: A Brief Survey of Arkansas Physicians. J Ark Med Soc 2017; 113:160-163. [PMID: 30085462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Sikel Cell Diseas (SCD) is a genetic blood disorder that disproportionatley affects the African American population. In a heavily rural state like Arkansas, manging SCD in patients requires having an expensive network of physicians willing to treat them. A survey was faxed to 1312 primary care physicians in Arkansas to determine the physician population currently treating and interested in treating patients with SCD. With a 13% response rate, results show that 21.5% of respondents currently rtreat patients with SCD, 32.6% are interested in treating patients with SCD. Most respondents reported that SCD patients never come to their practice for care.
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Netter Epstein W. Revisiting Incentive-Based Contracts. Yale J Health Policy Law Ethics 2017; 17:1-59. [PMID: 29756755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Incentive-based pay is rational, intuitive, and popular. Agency theory tells us that a principal seeking to align its incentives with an agent's should be able to simply pay the agent to achieve the principal's desired results. Indeed, this strategy has long been used across diverse industries-from executive compensation to education, professional sports to public service-but with mixed results. Now a new convert to incentive compensation has appeared on the scene: the United States' behemoth health-care industry. In many ways, the incentive mismatch story is the same. Insurance companies and employers are concerned about constraining the cost of care, and patients are concerned about quality of care. Physicians lack an adequate financial incentive to pay attention to either. Health care's recent move away from the traditional fee-for-service compensation model to incentive pay is perhaps unsurprising. But there is a problem: mixed preliminary evidence and potential mal-effects on vulnerable third-party patients. This Article employs a new lens-the legal and behavioral literature on optimal contract specificity-to suggest why incentive pay is problematic and why the health-care experience will be no different than other industries. The use of incentive pay is a change in contractdrafting strategy, a decision to write a more detailed, control-based contract rather than one that relies on discretion. The contracts literature suggests that this strategy will only work well where simple compliance is the goal rather than creativity or innovation. The health industry will not succeed in implementing incentive pay better than other industries have. What it needs is to recognize the limits of incentive pay and implement it sparingly. The new Trump Administration may be particularly primed to heed this call.
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Dulong De Rosnay C, Tai T, Pasche O. [It all started with a simple symptom and then… Basic palliative medical tools for primary care physicians]. Rev Med Suisse 2016; 12:1858-1863. [PMID: 28696624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The treatment of symptoms in palliative care is of primary importance, though this in itself is not sufficient for the relief of all aspects of a patient's suffering. Pain, dyspnea, or anxiety cannot be reduced to a single somatic characteristic, the psychological implications and the consequences on the patient's daily life being of paramount importance. A respect with regard to certain basic principles, and a full knowledge of the main therapeutic approaches available, allow for a better initial management of the symptoms.To this end we propose references as a memory aid while pointing out that the apparition of complex elements or instability in this type of case justifies having recourse to a specialised structure.
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Affiliation(s)
| | - Tony Tai
- Equipe mobile de soins palliatifs du Réseau santé Nord Broye, avenue de Thienne 2, 1350 Orbe
| | - Olivier Pasche
- ForOm NV, rue d'Entremonts 11, 1400 Yverdon-les-Bains
- PMU, 1011 Lausanne
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Pichonnaz C, Milliet J, Farron A, Luthi F. [Update on the postsurgical shoulder rotator cuff rehabilitation]. Rev Med Suisse 2016; 12:1278-1283. [PMID: 28665563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Primary care physicians play a crucial role in rehabilitation following rotator cuff surgery. This synthesis paper aims to address essential issues of postsurgical rehabilitation, based on recent recommendations. The rehabilitation comprises 4 phases, which are determined by the tendon healing process.For each phase, this article presents the stage of tendon healing, the allowed mechanical constraints, the exercise and physiotherapy modalities, the possible activities and the potential complications. Information and counseling to support the patient implication in the rehabilitation are also detailed. This article contributes to an enhanced comprehension of the healing process, which is a prerequisite for appropriate follow-up and efficient complication detection.
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Affiliation(s)
- Claude Pichonnaz
- Haute école de santé Vaud (HESAV), Beaumont 21, 1011 Lausanne
- Service de chirurgie orthopédique et de traumatologie, CHUV, 1011 Lausanne
| | - José Milliet
- Service de chirurgie orthopédique et de traumatologie, CHUV, 1011 Lausanne
| | - Alain Farron
- Service de chirurgie orthopédique et de traumatologie, CHUV, 1011 Lausanne
| | - François Luthi
- Service de médecine physique et de réadaptation, Département de l'appareil locomoteur, CHUV et Université de Lausanne, 1011 Lausanne
- Clinique romande de réadaptation, Service de réadaptation de l'appareil locomoteur, Av. Grand-Champsec 90, 1950 Sion
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Bhalla S, Unnikrishnan R, Srivastava R, Tandon N, Mohan V, Prabhakaran D. Innovation in capacity building of primary-care physicians in diabetes management in India: a new slant in medical education. Lancet Diabetes Endocrinol 2016; 4:200-202. [PMID: 26868978 DOI: 10.1016/s2213-8587(15)00514-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 12/15/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Sandeep Bhalla
- Centre for Control of Chronic Conditions, Public Health Foundation of India (New Delhi), Gurgaon 122002, India
| | - Ranjit Unnikrishnan
- Dr Mohan's Diabetes Specialities Centre, Chennai, India; Madras Diabetes Research Foundation, Chennai, India
| | - Rahul Srivastava
- Centre for Control of Chronic Conditions, Public Health Foundation of India (New Delhi), Gurgaon 122002, India
| | - Nikhil Tandon
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Viswanathan Mohan
- Dr Mohan's Diabetes Specialities Centre, Chennai, India; Madras Diabetes Research Foundation, Chennai, India
| | - Dorairaj Prabhakaran
- Centre for Control of Chronic Conditions, Public Health Foundation of India (New Delhi), Gurgaon 122002, India.
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Besse C, Berset DG, Studer R, Quarroz S, Praz-Christinaz SM, Rivier G, Barlet-Ghaleb C, Danuser B, Bonsack C. [Multidisciplinary consultation "Suffering at work": an experience in western Switzerland]. Rev Med Suisse 2016; 12:276-279. [PMID: 26999999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Mental health problems at work constitute a challenge in the clinical feld, as well in the professional, the economic and the public health perspective. The total costs they generate in Switzerland are equivalent to 3.2% of the Swiss gross domestic product and they very often lead to dismissal. The vast majority of people are treated by their primary care physician. The Institute for Work and Health features a specialized consultation on the topic of suffering at work, offering the primary care physicians a pluridisciplinary advice or support, in a collaborative care prospect. Its action, adapted to each situation's needs, goes from an advice to a referral to specialists that can strengthen the network on a long-term basis (mental health follow-up, supported employment program, legal or social advice).
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Zemishlany Z. Integrating Mental Health into Primary Care. Isr Med Assoc J 2016; 18:124-125. [PMID: 26979007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Avny O, Nahum KC, Michnick T, Teitelbaum T, May D. Psychiatric Collaboration Models in Israel. Isr Med Assoc J 2016; 18:71-75. [PMID: 26978996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We present a literature review of collaborative enterprises between psychiatrists and primary care physicians in Israel and other countries. Also described are local psychiatric liaison initiatives in Israel, as well as landmark studies of collaborative psychiatric care. These studies demonstrate the superiority of community psychiatric liaison models in the treatment of patients suffering from depressive anxiety disorders and somatization disorder. In light of the mental health reform process currently underway in Israel, it is important to develop, implement and assess such liaison models.
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Casalino LP, Chen MA, Staub CT, Press MJ, Mendelsohn JL, Lynch JT, Miranda Y. Large Independent Primary Care Medical Groups. Ann Fam Med 2016; 14:16-25. [PMID: 26755779 PMCID: PMC4709151 DOI: 10.1370/afm.1890] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/19/2015] [Accepted: 11/08/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE In the turbulent US health care environment, many primary care physicians seek hospital employment. Large physician-owned primary care groups are an alternative, but few physicians or policy makers realize that such groups exist. We wanted to describe these groups, their advantages, and their challenges. METHODS We identified 21 groups and studied 5 that varied in size and location. We conducted interviews with group leaders, surveyed randomly selected group physicians, and interviewed external observers-leaders of a health plan, hospital, and specialty medical group that shared patients with the group. We triangulated responses from group leaders, group physicians, and external observers to identify key themes. RESULTS The groups' physicians work in small practices, with the group providing economies of scale necessary to develop laboratory and imaging services, health information technology, and quality improvement infrastructure. The groups differ in their size and the extent to which they engage in value-based contracting, though all are moving to increase the amount of financial risk they take for their quality and cost performance. Unlike hospital-employed and multispecialty groups, independent primary care groups can aim to reduce health care costs without conflicting incentives to fill hospital beds and keep specialist incomes high. Each group was positively regarded by external observers. The groups are under pressure, however, to sell to organizations that can provide capital for additional infrastructure to engage in value-based contracting, as well as provide substantial income to physicians from the sale. CONCLUSIONS Large, independent primary care groups have the potential to make primary care attractive to physicians and to improve patient care by combining human scale advantages of physician autonomy and the small practice setting with resources that are important to succeed in value-based contracting.
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Affiliation(s)
- Lawrence P Casalino
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Melinda A Chen
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | | | - Matthew J Press
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Jayme L Mendelsohn
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | | | - Yesenia Miranda
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
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Viall S, Jain S, Chapman K, Ah Mew N, Summar M, Kirmse B. Short-term follow-up systems for positive newborn screens in the Washington Metropolitan Area and the United States. Mol Genet Metab 2015; 116:226-30. [PMID: 26549574 DOI: 10.1016/j.ymgme.2015.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/02/2015] [Accepted: 11/03/2015] [Indexed: 11/29/2022]
Abstract
For most inherited metabolic disorders on newborn screening (NBS) panels, prompt, expert confirmation and treatment are critical to optimize clinical outcomes for children with inherited metabolic diseases (IMD). In the Washington Metropolitan Area (WMA), 3 different short-term follow-up (STFU) systems exist for linking infants with positive newborn screens for IMD to appropriate specialty care. We diagrammed the STFU systems for the District of Columbia, Maryland and Virginia and calculated clinically relevant intervals of time between NBS collection and diagnosis/treatment initiation. We also surveyed representatives from 48 other state NBS programs to classify the STFU systems in the rest of the country. We found that in the WMA the STFU system that did not include the IMD specialist at the same time as the primary care provider (PCP) was associated with a longer median collection-to-specialist contact interval for true positive NBS for critical diagnoses (p=0.013). Nationally, 25% of state NBS programs report having a STFU system that does not include the IMD specialist at the same time as the PCP. In conclusion, there is variability among the STFU systems employed by NBS programs in the US which may lead to delays in diagnosis confirmation and treatment. National standards for STFU systems that include early involvement of an IMD specialist for all presumed positive NBS results may decrease the collection-to-specialist contact interval which could improve clinical outcomes in children with IMD.
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Affiliation(s)
- Sarah Viall
- Children's National Health System and George Washington University, Washington, DC, United States.
| | - Sneha Jain
- Virginia Commonwealth University, Richmond, VA, United States
| | - Kimberly Chapman
- Children's National Health System and George Washington University, Washington, DC, United States
| | - Nicholas Ah Mew
- Children's National Health System and George Washington University, Washington, DC, United States
| | - Marshall Summar
- Children's National Health System and George Washington University, Washington, DC, United States
| | - Brian Kirmse
- Children's National Health System and George Washington University, Washington, DC, United States; University of Mississippi Medical Center, Jackson, MS, United States
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Cornuz J, Auer R, Neuner-Jehle S, Humair JP, Jacot-Sadowski I, Cardinaux R, Battegay E, Zeller A, Zoller M, Biedermann A, Rodondi N. [Swiss recommendations for the check-up in the doctor's office]. Rev Med Suisse 2015; 11:1936-1942. [PMID: 26672259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Prevention and screening of diseases belong to the role of each primary care physician. Recommendations have been developed in the EviPrev programme, which brings together members of all five academic ambulatory general internal medicine centers in Switzerland (Lausanne, Bern, Geneva, Basel and Zürich). Several questions must be addressed before realising a prevention intervention: Do we have data demonstrating that early intervention or detection is effective? What are the efficacy and adverse effects of the intervention? What is the efficiency (cost-effectiveness) of the intervention? What are the patient's preferences concerning the intervention and its consequences? The recommendations aim at answering these questions independently, taking into account the Swiss context and integrating the patient's perspective in a shared decision-making encounter.
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Matter M, Châtelain D. [Interdisciplinary health care team: yes! drunken bathtub: no!]. Rev Med Suisse 2015; 11:1776. [PMID: 26591797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Kaushal R, Edwards A, Kern LM. Association between the patient-centered medical home and healthcare utilization. Am J Manag Care 2015; 21:378-386. [PMID: 26167704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The patient-centered medical home (PCMH) model of primary care is being implemented widely, with unclear effects on healthcare utilization. How much any effect is driven by electronic health records (EHRs), a core component of PCMHs, is unknown. Our objective was to determine any association between the PCMH model and healthcare utilization and to isolate that effect from any by the EHR alone. STUDY DESIGN We conducted a prospective cohort study (2008-2010) of 275 primary care physicians and 230,593 patients in the Hudson Valley, a multi-payer region in New York state with predominantly small practices. METHODS We considered 3 groups: physicians who implemented Level III PCMHs in 2009, as per the National Committee for Quality Assurance, all of whom also used EHRs (n = 92); physicians using paper medical records (n = 119); and physicians using EHRs without the PCMH (n = 64). We used negative binomial regression to determine associations between study group and change over time for each of 7 utilization measures, adjusting for 10 physician characteristics. RESULTS For every 100 patients whose physicians transformed to PCMHs, there were 21 fewer specialist visits over time compared with patients whose physicians used paper records (P = .03), and 22 fewer specialist visits over time compared with patients whose physicians used EHRs without the PCMH (P = .05). There were no significant differences over time in primary care visits, radiology tests, laboratory tests, emergency department visits, admissions, or readmissions. CONCLUSIONS The PCMH was associated with a significant decrease in the rate of specialist visits, the most expensive type of ambulatory visit, 1 year after PCMH implementation.
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Niv Y, Dickman R, Levi Z, Neumann G, Ehrlich D, Bitterman H, Dreiher J, Cohen A, Comaneshter D, Halpern E. Establishing an integrated gastroenterology service between a medical center and the community. World J Gastroenterol 2015; 21:2152-8. [PMID: 25717251 PMCID: PMC4326153 DOI: 10.3748/wjg.v21.i7.2152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 07/18/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.
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Barr P. APP HAPPY Keeping up with the patients. Hosp Health Netw 2015; 89:18. [PMID: 30277338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Stempniak M. PCP EXCELLENCE 10 traits shared by the country's best primary care practices. Hosp Health Netw 2015; 89:16. [PMID: 30277337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Affiliation(s)
- Allan H Goroll
- From the Division of General Internal Medicine, Massachusetts General Hospital, Boston
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Briot P, Bréchat PH, Reiss-Brennan B, Cannon W, Bréchat N, Teil A. [Integrated care delivery system for mental illness: A case study of Intermountain Healthcare (USA)]. Sante Publique 2015; 27:S199-S208. [PMID: 26168633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Mental health is a public health priority among chronic diseases in France and the United States. Although there is room for progress in France, the experience of Intermountain Healthcare (IH), Utah, in the United States can provide convincing experimental data. AIM To identify the lessons learned from IH clinical integration of mental health specialists in primary care practices called "Mental Health Integration" (MHI) which might be useful in France. METHODS This research is based on qualitative analysis of data derived from collaborative work with IH experts, literature searches, and item queries on the 3 objectives of the Triple Aim of the Institute for Healthcare Improvement (IHI). RESULTS The MHI programme was developed to achieve IHI T riple AIM improving user satisfaction; improving access of care and the health of the population; reducing health care costs per capita. By integrating mental health specialists within a multidisciplinary team headed by primary care physicians and working under the same roof with care managers and support staff, the MHI model enhances the process of the Chronic Care Model. Furthermore MHI has become the foundation for team-based care centered on the patient and theirfamily over the continuum of care by offering a global and structured evidenced-based care process. Prevention and integration of specialized care have been developed. Users and their families are co-responsible for their health. Discussion: Evaluation is systematic and based on specific indicators. The efficiency and clinical and organizational effectiveness created generate savings for health insurance as well as improved access to care and health equality.
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McEvoy VR. Why 'metrics' overload is bad medicine. Mo Med 2015; 112:32-33. [PMID: 25812271 PMCID: PMC6170082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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