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Background: On average, people with schizophrenia and psychosis die 13-30 years sooner than the general population (World Psychiatry 10 (1):52-77, 2011). Mental and physical health care is often provided by different organisations, different practitioners and in different settings which makes collaborative care difficult. Research is needed to understand and map the impact of new collaborative ways of working at the primary/secondary care interface (PloS One 7 (5); e36468). The evaluation presented in this paper was designed to explore the potential of a Community and Physical Health Co-ordinator role (CPHC) (CPHCs were previously Care Co-ordinators within the Community Mental Health Team, Community in the title CPHC refers to Community Mental Health) and Multi-Disciplinary Team (MDT) meetings across primary and community care, with the aim of improving collaboration of mental and physical health care for service users with Severe Mental Illness (SMI). Methods: Data collection took place across five general practices (GPs) and a Community Mental Health Team (CMHT) in the Northwest of England, as part of a process evaluation. Semi-structured interviews were conducted with a purposive sample of GP staff (n= 18) and CMHT staff (n=4), a focus group with CMHT staff (n=8) and a survey completed by 13 CMHT staff, alongside cardiovascular risk data and MDT actions. Framework analysis was used to manage and interpret data. Results: The results from the evaluation demonstrate that a CPHC role and MDT meetings are effective mechanisms for improving the collaboration and co-ordination of physical health care for SMI service users. The findings highlight the importance of embedding and supporting the CPHC role, with an emphasis on protected time and continuing professional roles and integrating multiple perspectives through MDT meetings. Considering the importance of physical health care for SMI service users and the complex environment, these are important findings for practitioners, researchers and policy makers in the field of primary care and mental health. Conclusion: There is an increasing focus on integration and collaborative working to ensure the delivery of quality care across the whole patient pathway, with a growing need for professionals to work together across service and professional boundaries. The introduction of a two pronged approach to collaboration has shown some important improvements in the management of physical health care for service users with SMI. [ABSTRACT FROM AUTHOR]

Background: The potential value of expanding the Practice Nurse role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. The purpose of this review was to systematically examine published literature to identify existing and potential roles of Practice Nurse's in the delivery of care to people affected by dementia and to describe the characteristics and effectiveness of nurse interventions in dementia models of care. Methods: The PRISMA statement guided the systematic review of the quantitative and qualitative evidence for roles and characteristics of the Practice Nurse in the delivery of dementia care. A comprehensive literature search of seven electronic databases and Google scholar identified relevant original research published in English between January 2000 and January 2019. Thirteen articles met the inclusion criteria and were extracted into the Covidence software for analysis. Results: The heterogeneity of the included studies purpose, design and outcomes measures and the diversity in health systems and primary care nurses scope of practice made it difficult to synthesise the findings and draw conclusions. The heterogeneity did, however, provide important insights into the characteristics of roles undertaken by nurses working in the general practice setting, which were potentially beneficial to people living with dementia and their support person. These included patient accessibility to the Practice Nurse, early recognition and management of cognitive changes, care management and collaboration with the General Practitioner. Limitations of the provision of dementia care by Practice Nurses included a lack of definition of the role, inadequate dementia specific training, time constraints and poor communication with General Practitioners. Conclusions: Embedding an evidence-based model that describes the role of the Practice Nurse in dementia care provision has the potential to increase early recognition of cognitive impairment and more appropriate primary care management of dementia. Systematic review registration: PROSPERO 2018 CRD42018088191. [ABSTRACT FROM AUTHOR]

Background: Chronic disease management presents enormous challenges to the primary care workforce because of the rising epidemic of cardiovascular risk factors. The chronic care model was proven effective in improving chronic disease outcomes in developed countries, but there is little evidence of its effectiveness in developing countries. The aim of this study was to evaluate the effectiveness of the EMPOWER-PAR intervention (multifaceted chronic disease management strategies based on the chronic care model) in improving outcomes for type 2 diabetes mellitus and hypertension using readily available resources in the Malaysian public primary care setting. This paper presents the study protocol. Methods/Design: A pragmatic cluster randomised controlled trial using participatory action research is underway in 10 public primary care clinics in Selangor and Kuala Lumpur, Malaysia. Five clinics were randomly selected to provide the EMPOWER-PAR intervention for 1 year and another five clinics continued with usual care. Each clinic consecutively recruits type 2 diabetes mellitus and hypertension patients fulfilling the inclusion and exclusion criteria over a 2-week period. The EMPOWER-PAR intervention consists of creating/strengthening a multidisciplinary chronic disease management team, training the team to use the Global Cardiovascular Risks Self-Management Booklet to support patient care and reinforcing the use of relevant clinical practice guidelines for management and prescribing. For type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving HbA1c < 6.5%. For hypertension without type 2 diabetes mellitus, the primary outcome is the change in the proportion of patients achieving blood pressure < 140/90 mmHg. Secondary outcomes include the proportion of patients achieving targets for serum lipid profile, body mass index and waist circumference. Other outcome measures include medication adherence levels, process of care and prescribing patterns. Patients' assessment of their chronic disease care and providers' perceptions, attitudes and perceived barriers in care delivery and cost-effectiveness of the intervention are also evaluated. Discussion: Results from this study will provide objective evidence of the effectiveness and cost-effectiveness of a multifaceted intervention based on the chronic care model in resource-constrained public primary care settings. The evidence should instigate crucial primary care system change in Malaysia. Trial Registration: ClinicalTrials.gov NCT01545401 [ABSTRACT FROM AUTHOR]

Background: An ageing population and high levels of multimorbidity increase rates of GP and specialist consultations. Constraints on health care funding are leading to additional pressure for the adoption of safe and cost-effective alternatives to specialist care, in some cases by shifting services to primary care. Discussion: In this paper we argue, having searched for evidence on approaches to shifting care for some people with cardiovascular problems from secondary to primary care, that a collaborative, multidisciplinary approach is required to achieve high quality outcomes from cardiovascular care in the primary care setting. Simply transferring patients from specialist care to management by primary care teams is likely to lead to worse outcomes than services that involve both specialists and primary care teams together, in planned and effectively managed systems of care. The care of patients with certain chronic conditions in the community, if appropriately organised, can achieve the same health outcomes as ambulatory care by hospital specialists. However, shared care by GPs and specialists for patients with chronic heart failure after discharge from hospital can deliver better patient survival. The existing models of shared care include specialists working in an ambulatory care setting (in Central and Eastern Europe) or in hospital based outreach clinics, and cardiology care organised by GPs in the UK and Australia, which have demonstrated reductions in referral rates. Summary: Current research supports the idea of the management of certain chronic health conditions in primary care based on the integration of GPs and specialists into multidisciplinary teams, based on availability of reliable evidence about cost-effectiveness, health care outcomes, patient preference and incentives for GPs. Evaluation of such schemes is mandatory, however, to ensure that the expected benefits do materialise. [ABSTRACT FROM AUTHOR]

Background: Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services. Methods: A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached. Results: Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on ‘as needed’ basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS’ perceived 4 important ‘needs’ in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support. Conclusions: Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community. [ABSTRACT FROM AUTHOR]

Background: A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? Discussion: Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a 'complex intervention' (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. Summary: Answers to the complex problem of multi-morbidity won't come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity. [ABSTRACT FROM AUTHOR]

Background: Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. Methods: This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. Results : The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives--re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. Conclusions: The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare. [ABSTRACT FROM AUTHOR]

Background: We sought to characterize how the term "missed opportunities" is reported in the literature in the context of immunization rates and to assess how missed opportunities can be operationalized. Methods: Peer-reviewed literature searches were conducted in April - May, 2015, to answer: "What methods research studies used to operationalize missed opportunities to vaccinate?" A meta-narrative review methodology was used. Results: Seven studies met inclusion criteria. The methodologies for quantifying missed opportunities fell into two general categories based on: 1. the number of healthcare encounters per patient without appropriate vaccination services, defined as a number of visits per patient with no vaccination related services (Missed opportunities per patient); 2. vaccination status as "non-vaccinated" among a group of patients who had a healthcare encounter where the vaccination should/could have had happened (Missed opportunities per population). Conclusions: Our study provided an initial overview of the methods reported in the literature, and concluded that the quantifiable missed opportunity holds promise as a measurable outcome (variable) for research and quality improvement projects aimed to increase adult immunization recommendation and uptake in primary care. [ABSTRACT FROM AUTHOR]

Background: Accreditation is a widely employed quality assurance concept in health care and the survey visit is the central method for assessing participating organisations' compliance with accreditation standards. Despite this, research on the survey visit as a method for assessing compliance is scarce. In Denmark a mandatory accreditation programme was introduced for general practice clinics in 2016. We performed a qualitative, explorative study of the reflections and actions of surveyors and general practice professionals (GPs and staff) concerning the production of information about compliance with the accreditation standards in relation to the survey visit. Methods: We conducted qualitative interviews with GPs and staff from general practices in two Danish regions before and after their survey visit. We also interviewed the surveyors. We observed survey visits to qualify the interviews and analysis. All interviews were audio recorded, transcribed, and analysed using an integrative approach. Results: The surveyors combined documents, questioning of the professionals, and visual impressions of the clinic to assess compliance. They sought to de-dramatise the survey visit and to generate a natural conversation with attention to workflows. Trust in the professionals' statements was fundamental to the surveyors' approach, and they were confident in their ability to assess compliance. Their level of scrutiny was influenced by their observations and the quality of documents. The general practice professionals had generally sought to comply with the standards and to give an authentic portrait of the clinic. The few cases of misrepresention concerned standards that the professionals found too excessive. Conclusion: The validity of the survey visit as a method to assess compliance was highly dependent on the professionals' willingness to convey a realistic picture of their practice. Since they were generally willing to do so, the trust-based approach seemed suitable for identifying cases of non-compliance caused by insufficient understanding of the standards. However, it can be difficult for the surveyors to detect when the professionals engage in misrepresentation due to disagreements with the standards. Thus, when adopting a trust-based approach to the survey visit, it seems particularly important to ensure that the professionals view the standards as meaningful and manageable. [ABSTRACT FROM AUTHOR]

Background: Integrated primary care teams are ideally positioned to support the mental health care needs arising during the COVID-19 pandemic. Understanding how COVID-19 has affected mental health care delivery within primary care settings will be critical to inform future policy and practice decisions during the later phases of the pandemic and beyond. The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams' delivery of mental health care. Methods: A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analysed using thematic analysis. Results: We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers. Conclusions: From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care's capacity for mental health care for the duration of the pandemic and beyond. [ABSTRACT FROM AUTHOR]

Background: Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. Methods: We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. Results: We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. Conclusions: We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care. [ABSTRACT FROM AUTHOR]

Background: The present study describes how primary care can be improved for patients with multimorbidity, based on the evaluation of a patient-centered care (PCC) improvement program designed to foster the eight PCC dimensions (patient preferences, information and education, access to care, physical comfort, coordination of care, continuity and transition, emotional support, and family and friends). This study characterizes the interventions implemented in practice as part of the PCC improvement program and describes the experiences of healthcare professionals and patients with the resulting PCC delivery. Methods: This study employed a mixed-methods design. Semi-structured interviews were conducted with nine general practitioners and nurse practitioners from seven primary care practices in Noord-Brabant, the Netherlands, that participated in the program (which included interventions and workshops). The qualitative interview data were examined using thematic analysis. A longitudinal survey was conducted with 138 patients with multimorbidity from these practices to assess perceived improvements in PCC and its underlying dimensions. Paired sample t tests were performed to compare survey responses obtained at a 1-year interval corresponding to program implementation. Results: The PCC improvement program is described, and themes necessary for PCC improvement according to healthcare professionals were generated [e.g. Aligning information to patients' needs and backgrounds, adapting a coaching role]. PCC experiences of patients with multimorbidity improved significantly during the year in which the PCC interventions were implemented (t = 2.66, p = 0.005). Conclusion: This study revealed how primary PCC can be improved for patients with multimorbidity. It emphasizes the importance of investing in PCC improvement programs to tailor care delivery to heterogenous patients with multimorbidity with diverse care needs. This study generates new perspectives on care delivery and highlights opportunities for its improvement according to the eight dimensions of PCC for patients with multimorbidity in a primary care setting. [ABSTRACT FROM AUTHOR]

Background: Rural settings in low- and middle-income countries are bedeviled with poverty and high disease burden, and lack adequate resources to deliver quality healthcare to the population. Drug shortage and inadequate number and skill-mix of healthcare providers is very common in rural health facilities. Hence, rural healthcare providers have no choice but to be innovative and introduce some strategies to cope with health delivery challenges at the health centre levels. This study explored how and why rural healthcare providers cope with clinical care delivery challenges at the health centre levels in Ghana. Methods: This study was a multiple case studies involving three districts: Bongo, Kintampo North, and Juaboso districts. In each case study district, a cross-sectional design was used to explore the research question. Purposive sampling technique was used to select study sites and the study participants. The authors conducted 11 interviews, 9 focus group discussions (involving 61 participants), and 9-week participant observation (in 3 health centres). Transcription of the voice-recordings was done verbatim, cleaned and imported into the Nvivo version 11 platform for analysis. Data was analysed using the inductive content analysis approach. Ethical clearance was granted by the Ethics Review Committee of the Ghana Health Service. Results: The study found three main coping strategies (borrowing, knowledge sharing and multi-tasking). First, borrowing arrangements among primary health care institutions help to address the periodic shortage of medical supplies at the health centres. Secondly, knowledge sharing among healthcare providers mitigates skills gap during service delivery; and finally, rural healthcare providers use multi-tasking to avert staff inadequacy challenges during service delivery at the health centre levels. Conclusion: Borrowing, knowledge sharing, and multi-tasking are coping strategies that are sustaining and potentially improving health outcomes at the district levels in Ghana. We recommend that health facilities across all levels of care in Ghana and other settings with similar challenges could adopt and modify these strategies in order to ensure quality healthcare delivery amidst delivery challenges. [ABSTRACT FROM AUTHOR]

Background: GPs are under considerable pressure providing routine care. However, they may not be the most appropriate professionals to manage getting patients back to work, and keeping them there. Objective: To test the feasibility of delivering occupational therapy-led vocational clinics (OTVoc) to provide return to work advice and support for people with musculoskeletal conditions and mental health problems, in primary care. Methods: Prospective mixed methods study in two primary care centres (eight GP surgeries). We collected anonymised service level data on all patients receiving OTVoc. Next, patient participants who met inclusion criteria and consented, undertook baseline and 3-month follow-up assessments. Interviews were also conducted to explore stakeholders' views- GPs, Nurse Practitioners, Front Desk Staff, Occupational Therapists, patients and their employers about OTVoc- and included study eligibility, referral, experiences and attitudes to return to work. Data were analysed using descriptive statistics and thematic analysis. Results: The majority of standardized measures showed some improvement over the study period: the sickness absence rate dropped from 71 to 15% and use of GP 'fit' notes reduced from 76 to 6%. Interview data indicated positive attitudes to OTVoc, the use of the fit note and the Allied Health Professions Health and Work Reports (AHP H&WRs). GPs felt that OTVoc reduced their workload. Conclusion: Further research is feasible and warranted. OTVoc was positively received and stakeholders believed it was effective in getting patients back to work or preparing for their return. There was enthusiasm for extending service eligibility criteria, suggesting potential for further development and evaluation. [ABSTRACT FROM AUTHOR]

Background: Pharmacological and behavioural treatments for alcohol use disorders (AUDs) are effective but the uptake is limited. Primary care could be a key setting for identification and continuous care for AUD due to accessibility, low cost and acceptability to patients. We aimed to synthesise the literature regarding differential models of care for the management of AUD in primary health care settings. Methods: We conducted a systematic review of articles published worldwide (1998-present) using the following databases; Medline, PsycINFO, Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials and Embase. The Grey Matters Tool guided the grey literature search. We selected randomised controlled trials evaluating the effectiveness of a primary care model in the management of AUD. Two researchers independently assessed and then reached agreement on the included studies. We used the Cochrane risk of bias tool 2.0 for the critical appraisal. Results: Eleven studies (4186 participants) were included. We categorised the studies into 'lower' versus 'higher' intensity given the varying intensity of clinical care evaluated across the studies. Significant differences in treatment uptake were reported by most studies. The uptake of AUD medication was reported in 5 out of 6 studies that offered AUD medication. Three studies reported a significantly higher uptake of AUD medication in the intervention group. A significant reduction in alcohol use was reported in two out of the five studies with lower intensity of care, and three out of six studies with higher intensity of care. Conclusion: Our results suggest that models of care in primary care settings can increase treatment uptake (e.g. psychosocial and/or pharmacotherapy) although results for alcohol-related outcomes were mixed. More research is required to determine which specific patient groups are suitable for AUD treatment in primary health care settings and to identify which models and components are most effective. Trial Registration: PROSPERO: CRD42019120293. [ABSTRACT FROM AUTHOR]

Background: Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care. Methods: This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively. Results: Data from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70–4.36), multimorbid (OR 1.37; 95%-CI 1.24–1.51; p < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15–1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72–3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09–1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04–1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30–0.41; p < 0.001) were prescribed or changed less frequently in NP consultations. Conclusions: Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care. [ABSTRACT FROM AUTHOR]

Background: Transitioning from pediatric care to adult-oriented care at age 18 (the age of transfer in most countries and jurisdictions) is a complex process for adolescents and young adults affected by chronic physical health and/or mental health conditions. The role of primary health care (PHC) providers for this population is poorly understood. Perspectives from these providers, such as family physicians and other members of the primary care team, have not been explored in depth. Methods: A total of 18 participants (e.g., family physicians, social workers, nurses) were recruited from 6 Primary Care Networks in Calgary, Alberta, Canada. Semi-structured individual interviews were conducted, and transcribed verbatim. A qualitative description approach was used to analyze the data, and included thematic analysis. Results: Five distinct, yet overlapping, roles of primary health care providers for adolescents and young adults transitioning to adult care resulted from our analysis: (1) being the "common thread" (continuous accessible care); (2) caring for the "whole patient" (comprehensive care); (3) "knowing families" (family-partnered care); (4) "empowering" adolescents and young adults to develop "personal responsibility" (developmentally-appropriate care); and (5) "quarterbacking" care (coordination of specialist and/or community-based care). Participants identified potential benefits of these roles for adolescents and young adults transitioning to adult care, and barriers in practice (e.g., lack of time, having minimal involvement in pediatric care). Conclusions: Input from family physicians, who follow their patients across the lifespan and provide the majority of primary care in Canada, are critical for informing and refining recommended transition practices. Our findings provide insights, from PHC providers themselves, to bolster the rationale for primary care involvement during transitions from pediatric specialty and community-based care for AYAs. Solutions to overcome barriers for integrating primary care and specialty care for adolescents and young adults need to be identified, and tested, with input from key stakeholders. [ABSTRACT FROM AUTHOR]

Background: With the increasing double burden of communicable and non-communicable diseases (NCDs) in sub-Saharan Africa, health systems require new approaches to organise and deliver services for patients requiring long-term care. There is increasing recognition of the need to integrate health services, with evidence supporting integration of HIV and NCD services through the reorganisation of health system inputs, across system levels. This study investigates current practices of delivering and implementing integrated care for chronically-ill patients in rural Malawi, focusing on the primary level. Methods: A qualitative study on chronic care in Phalombe district conducted between April 2016 and May 2017, with a sub-analysis performed on the data following a document analysis to understand the policy context and how integration is conceptualised in Malawi; structured observations in five of the 15 district health facilities, selected purposively to represent different levels of care (primary and secondary), and ownership (private and public). Fifteen interviews with healthcare providers and managers, purposively selected from the above facilities. Meetings with five non-governmental organisations to study their projects and support towards chronic care in Phalombe. Data were analysed using a thematic approach and managed in NVivo. Results: Our study found that, while policies supported integration of various disease-specific programmes at point of care, integration efforts on the ground were severely hampered by human and health resource challenges e.g. inadequate consultation rooms, erratic supplies especially for NCDs, and an overstretched health workforce. There were notable achievements, though most prominent at the secondary level e.g. the establishment of a combined NCD clinic, initiating NCD screening within HIV services, and initiatives for integrated information systems. Conclusion: In rural Malawi, major impediments to integrated care provision for chronically-ill patients include the frail state of primary healthcare services and sub-optimal NCD care at the lowest healthcare level. In pursuit of integrative strategies, opportunities lie in utilising and expanding community-based outreach strategies offering multi-disease screening and care with strong referral linkages; careful task delegation and role realignment among care teams supported with proper training and incentive mechanisms; and collaborative partnership between public and private sector actors to expand the resource-base and promoting cross-programme initiatives. [ABSTRACT FROM AUTHOR]

Background: Normalisation Process Theory (NPT) provides a framework to understand how interventions are implemented, embedded, and integrated in healthcare settings. Previous reviews of published literature have examined the application of NPT across international healthcare and reports its benefits. However, given the distinctive clinical function, organisational arrangements and the increasing management of people with a wide variety of conditions in primary care settings in the United Kingdom, it is important to understand how and why authors utilise and reflect on NPT in such settings to inform and evaluate implementation processes. Methods: A systematic review of peer-reviewed literature using NPT in primary care settings in the United Kingdom (UK) was conducted. Eight electronic databases were searched using replicable methods to identify articles published between January 2012 and April 2018. Data were analysed using a framework approach. Results: Thirty-one articles met the inclusion criteria. Researchers utilised NPT to explore the implementation of interventions, targeting a wide range of health services and conditions, within primary care settings in the UK. NPT was mostly applied qualitatively; however, a small number of researchers have moved towards mixed and quantitative methods. Some variation was observed in the use of NPT constructs and sub-constructs, and whether and how researchers undertook modification to make them more relevant to the implementation process and multiple stakeholder perspectives. Conclusion: NPT provides a flexible framework for the development and evaluation of complex healthcare interventions in UK primary care settings. This review updates the literature on NPT use and indicates that its application is well suited to these environments, particularly in supporting patients with long-term conditions and co-morbidities. We recommend future research explores the receipt of interventions by multiple stakeholders and suggest that authors reflect on justifications for using NPT in their reporting. [ABSTRACT FROM AUTHOR]

Background: Obesity is a major risk factor behind some of the most common problems encountered in primary care. Although effective models for obesity treatment have been developed, the 'reach' of these interventions is poor and only a small fraction of primary care patients receive evidence-based treatment. The purpose of this study is to identify factors that impact the uptake (reach) of an evidence-based obesity treatment program within the context of a pragmatic cluster randomized controlled trial comparing three models of care delivery. Methods: Recruitment and reach were evaluated by the following measures: 1) mailing response rates, 2) referral sources among participants contacting the study team, 3) eligibility rates, 4) participation rates, and 5) representativeness based on demographics, co-morbid conditions, and healthcare utilization of 1432 enrolled participants compared to > 17,000 non-participants from the clinic-based patient populations. Referral sources and participation rates were compared across study arms and level of clinic engagement. Results: The response rate to clinic-based mailings was 13.2% and accounted for 66% of overall program recruitment. An additional 22% of recruitment came from direct clinic referrals and 11% from media, family, or friends. Of those screened, 87% were eligible; among those eligible, 86% enrolled in the trial. Participation rates did not vary across the three care delivery arms, but were higher at clinics with high compared to low provider involvement. In addition, clinics with high provider involvement had a higher rate of in clinic referrals (33% versus 16%) and a more representative sample with regards to BMI, rurality, and months since last clinic visit. However, across clinics, enrolled participants compared to non-participants were older, more likely to be female, more likely to have had a joint replacement but less likely to have CVD or smoke, and had fewer hospitalizations. Conclusions: A combination of direct patient mailings and in-clinic referrals may enhance the reach of primary care behavioral weight loss interventions, although more proactive outreach is likely necessary for men, younger patients, and those at greater medial risk. Strategies are needed to enhance provider engagement in referring patients to behavioral weight loss programs. Trial registration: clnicialtrials.gov NCT02456636. Registered May 28, 2015, https://www.clinicaltrials.gov/ct2/results?cond=&term=RE-POWER&cntry=&state=&city=&dist=. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is a serious heart arrhythmia associated with devastating outcomes such as stroke. Inequitable rural AF care may put patients at risk. Virtually delivered specialty AF care offers a viable option, but stakeholder perceptions of this option within the context of rural AF care is unknown. The study purpose was to obtain patient and primary care physician perspectives of rural AF care and virtually delivered AF care as a potential option. Methods: Using a mixed methods design, AF patients (n = 101) and physicians (n = 15) from three rural communities participated in focus groups and/or surveys. Focus group data were thematically analyzed, survey data were descriptively analyzed, and data were triangulated. Results: Findings captured patients' and physicians' perceptions of prioritized, needs, concerns and problems in AF management, available/unavailable services, and their ideas about virtual AF care. Patients and physicians identified eclectic problems in managing AF. Overall, patients felt ill informed about managing their AF and their most salient problems related to fatigue, exercise intolerance, weight maintenance, sleep apnea, and worry about stroke and bleeding. Physicians found treating patients with co-morbidities and cognitive decline problematic and balancing risks related to anticoagulation challenging. Patients and physicians identified education as a pressing need, which physicians lacked time and resources to meet. Despite available rural services, access to primary and cardiology care was a recurring challenge, and emergency department (ED) use highly contentious but often the only option for accessing care. Physicians' managed AF care and varied in the referrals they made, often reserving them for complex situations to avoid patient travel. Patients and providers supported a broad approach to virtual AF care, tailored to an inclusive rural patient demographic. Conclusions: The study offered valuable physician and patient perspectives on AF care in rural communities including diverse management challenges, gaps in access to primary and specialty services that made ED an often used but contentious option. Findings point to the potential value of virtual care designed to reach patients with AF across the spectrum and geared to local contexts that preserve the vital role of primary care physicians in AF care in their communities. [ABSTRACT FROM AUTHOR]

Background: Low patient satisfaction with the quality of out-of-hours primary care (OOH-PC) has been linked with several individual and organizational factors. However, findings have been ambiguous and may not apply to the Danish out-of-hours (OOH) setting in which general practitioners (GPs) perform the initial telephone triage. This study aimed to identify patient-related, GP-related and organizational factors associated with low patient satisfaction. Methods: The study was based on data from a 1-year population-based survey of OOH-PC (LV-KOS) in the Central Denmark Region in 2010-2011. GPs on OOH duty completed an electronic questionnaire in the OOH computer system, and the registered patients received a subsequent postal questionnaire focusing on contact evaluation, waiting time, demographic characteristics and general self-perceived health. Associations were analysed using multivariable logistic regression with dissatisfaction as the dependent variable. Results: The patient response rate was 50.6%. For all contact types, 82.5% of the patients were satisfied with the OOH-PC service. More patients were dissatisfied with telephone consultations than with clinic consultations or home visits (8.5% vs. 6.0% and 4.3%, respectively). Contacts assessed by the GP as 'not severe' were associated with dissatisfaction for telephone consultations and home visits. Poor general self-perceived health was associated with dissatisfaction for all contact types. Living in urban areas was associated with dissatisfaction for telephone consultations, while unacceptable waiting time was associated with dissatisfaction for all contact types. Conclusions: We found a high level of patient satisfaction with the OOH-PC service. The only factors affecting patient satisfaction across all contact types were unacceptable waiting time and poor general self-perceived health. For the other investigated factors, patient satisfaction depended on the type of contact. Generally, patients contacting for GP-assessed non-severe health problem and patients living in urban areas were more dissatisfied. [ABSTRACT FROM AUTHOR]

Background: Facing rising inequities and poorer accessibility of physicians in rural areas, new healthcare delivery structures are being considered to support local healthcare in German communities. To better understand perspectives on and attitudes towards different supplementary models, we examined attitudes among local politicians in the German federal state of Lower Saxony towards the suitability of supplementary care models. Methods: As part of a cross-sectional study, we surveyed local politicians in Lower Saxony at the local authority and district levels (n = 449) by mail questionnaire. We asked for an assessment of four potential supplementary healthcare models at the local level: the use of trained medical assistants, patients' buses, mobile physicians' offices, and telemedicine. Results: The response rate was 71.0% for mayors (n = 292) and 81.6% (n = 31) for county administrators. In summary, 72.4% of respondents supported the use of trained medical assistants, 48.9% voted for patients' buses, 22.0% for mobile physicians' offices, and 13.9% for telemedicine. Except for telemedicine, the politicians' approval of the supplementary models in rural areas was higher than in urban areas. The assessment regarding the suitability of each model was not significantly connected with indicators of a positively or negatively assessed local healthcare situation. The analyses showed that the use of trained medical assistants was associated with the positive effects of division of labor and potential to relieve physicians. In contrast, there was skepticism about technical support via telemedicine, mostly due to concerns about its unsuitability for elderly people and the potential lower quality of healthcare delivery. Conclusion: Local politicians widely accept the use of trained medical assistants, whereas the applicability of technical solutions such as telemedicine is perceived with skepticism. Therefore, the knowledge gap between evidence for and prejudices against telemedicine needs to be addressed more effectively. Reasons for the assessments of the presented models are more likely traceable to personal views than to assessments of the actual estimated local primary care situation. [ABSTRACT FROM AUTHOR]

Background: Patients as real healthcare system users are important observers of primary care and are able to provide reliable information about the quality of care. The aim of this study was to explore the patients' experiences and their level of satisfaction with the process and outcomes of care provided by primary care physicians in Poland and to identify the characteristics of the patients, their physicians, and facilities associated with patient satisfaction. Methods: The study is based on data from the Polish part of the Quality and Costs of Primary Care in Europe (QUALICOPC) cross-sectional, questionnaire-based study. In Poland, a nationally representative sample of 220 PC physicians and 1980 of their patients were recruited to take part in the study. As a study tool we used 3 out of 4 QUALICOPC questionnaires: "Patient Experience", "PC Physician" and "Fieldworker" questionnaires. Results: The areas of the best quality perceived by Polish PC patients are: equity, accessibility of care and quality of service. Coordination and comprehensiveness of care are evaluated relatively worse. The patients' and their physicians' characteristics have a limited influence on patient satisfaction and experiences with Polish primary care. Conclusions: Primary health care in Poland is of good overall quality as perceived by the patients. Study participants were at most satisfied with accessibility and equity of care and less satisfied with coordination and comprehensiveness of care. Longer patient-doctor relationship and older age of patients were found as the most influential determinants of higher satisfaction. However, variables used in this study poorly explain the overall level of satisfaction. Further research is needed to identify the other determinants of patient satisfaction in the Polish population. Rural practices deserve additional attention due to highest proportions of both extremely satisfied and dissatisfied patients. [ABSTRACT FROM AUTHOR]

Background: Patients from rural and urban regions should have equitable access to health care. In Germany, the physician-patient-ratio and the supply of medical services vary greatly between urban and rural areas. The aim of our study was to explore the regional variations of the perceived health care problems in ambulatory care from the perspective of affected professionals and laypersons i.e. general practitioners and their patients. Methods: We conducted 27 focus groups with general practitioners (n = 65) and patients (n = 145) from urban areas, environs and rural areas in northern Germany. Discussions were facilitated by two researchers using a semi-structured guideline. The transcripts were content analyzed using deductive and inductive categories. Results: General practitioners and patients reported problems due to demographic change and patient behaviour, through structural inequalities and the ambulatory reimbursement system as well as with specialist care and inpatient care. A high physician density, associated with high competition between general practitioners, a high fluctuation of patients and a low status of general practitioners were the main problems reported in urban areas. In contrast, participants from rural areas reported an insufficient physician density, a lack of young recruits in primary care and a resulting increased workload as problematic. All regions are concerned with subjectively inadequate general practitioners' budgets, insufficiently compensated consultations and problems in the cooperation with specialists and inpatient care institutions. Most problems were mentioned by GPs and patients alike, but some (e.g. high competition rates in urban regions and problems with inpatient care) were only mentioned by GPs. Conclusions: While many problems arise in urban regions as well as in rural regions, our results support the notion that there is an urgent need for action in rural areas. Possible measures include the support of telemedicine, delegation of medical services and reoccupation of vacant practices. The attractiveness of working in rural areas for general practitioners, specialists and clinicians must be increased by consolidating and expanding rural infrastructure (e.g. child care and cultural life). The above mentioned results also indicate that the ambulatory reimbursement system should be examined regarding the reported inequalities. Measures to further enhance the cooperation between general practitioners, specialists and inpatient care should be taken to solve supra-regionally reported problems. Problems showing regional variations indicate the need for measures to balance these variations between the regions. This is the first German study to analyze subjective views of the stakeholders concerned on regionally variating problems in ambulatory care. Further studies are needed to quantify the extent of the identified problems and differences. A corresponding survey is currently under way. [ABSTRACT FROM AUTHOR]

Background: Depression is a common health condition affecting up to a third of patients attending primary care, where most of the care for people with depression is provided. Adequate recognition of depression is the critical step in the path to effective care, particularly in low income countries. As part of the Programme for Improving Mental healthcare (PRIME), a project supporting the implementation of integrated mental healthcare in primary care, we evaluated the level of recognition of depression by clinicians working in primary care in rural Ethiopia prior to in service training. We hypothesised that the detection rate of depression will be under 10% and that detection would be affected by gender, education and severity of depression. Methods: Cross-sectional survey in eight health centres serving a population of over 160,000 people. A validated version of the 9-item patient health questionnaire (PHQ-9) was administered as an indicator of probable depression. In addition, primary care clinicians completed a clinician encounter form. Participants were consecutive primary care attendees aged 18 years and above. Results: A total of 1014 participants were assessed. Primary care clinicians diagnosed 13 attendees (1.3%) with depression. The PHQ9 prevalence of depression at a cut-off score of ten was 11.5% (n = 117), of whom 5% (n = 6/117) had received a diagnosis of depression by primary care clinicians. Attendees with higher PHQ scores and suicidality were significantly more likely to receive a diagnosis of depression by clinicians. Women (n = 9/13) and participants with higher educational attainment were more likely to be diagnosed with depression, albeit non-significantly. All cases diagnosed with depression by the clinicians had presented with psychological symptoms. Conclusion: Although not based on a gold standard diagnosis, over 98% of cases with PHQ-9 depression were undetected. Failure of recognition of depression may pose a serious threat to the scale up of mental healthcare in low income countries. Addressing this threat should be an urgent priority, and requires a better understanding of the nature of depression and its presentation in rural low-income primary care settings. [ABSTRACT FROM AUTHOR]

Background: Chronic diseases, primarily cardiovascular disease, respiratory disease, diabetes and cancer, are the leading cause of death and disability worldwide. In sub-Saharan Africa (SSA), where communicable disease prevalence still outweighs that of non-communicable disease (NCDs), rates of NCDs are rapidly rising and evidence for primary healthcare approaches for these emerging NCDs is needed. Methods: A systematic review and evidence synthesis of primary care approaches for chronic disease in SSA. Quantitative and qualitative primary research studies were included that focused on priority NCDs interventions. The method used was best-fit framework synthesis. Results: Three conceptual models of care for NCDs in low- and middle-income countries were identified and used to develop an a priori framework for the synthesis. The literature search for relevant primary research studies generated 3759 unique citations of which 12 satisfied the inclusion criteria. Eleven studies were quantitative and one used mixed methods. Three higher-level themes of screening, prevention and management of disease were derived. This synthesis permitted the development of a new evidence-based conceptual model of care for priority NCDs in SSA. Conclusions: For this review there was a near-consensus that passive rather than active case-finding approaches are suitable in resource-poor settings. Modifying risk factors among existing patients through advice on diet and lifestyle was a common element of healthcare approaches. The priorities for disease management in primary care were identified as: availability of essential diagnostic tools and medications at local primary healthcare clinics and the use of standardized protocols for diagnosis, treatment, monitoring and referral to specialist care. [ABSTRACT FROM AUTHOR]

Background: Primary care is the cornerstone of healthcare reform with policies across jurisdictions promoting interdisciplinary team working. The effective implementation of such health policies requires understanding the perspectives of all actors. However, there is a lack of research about health professionals' views of this process. This study compares Primary Healthcare Professionals' perceptions of the effectiveness of the Primary Care Strategy and Primary Care Team (PCT) implementation in Ireland. Methods: Design and Setting: e-survey of (1) General Practitioners (GPs) associated with a Graduate Medical School (N = 100) and (2) Primary Care Professionals in 3 of 4 Health Service Executive (HSE) regions (N = 2309). After piloting, snowball sampling was used to administer the survey. Descriptive analysis was carried out using SPSS. Ratings across groups were compared using non-parametric tests. Results: There were 569 responses. Response rates varied across disciplines (71 % for GPs, 22 % for other Primary Healthcare Professionals (PCPs). Respondents across all disciplines viewed interdisciplinary working as important. Respondents agreed on lack of progress of implementation of formal PCTs (median rating of 2, where 1 is no progress at all and 5 is complete implementation). GPs were more negative about the effectiveness of the Strategy to promote different disciplines to work together (median rating of 2 compared to 3 for clinical therapists and 3.5 for nurses, P = 0.001). Respondents identified resources and GP participation as most important for effective team working. Protected time for meetings and capacity to manage workload for meetings were rated as very important factors for effective team working by GPs, clinical therapists and nurses. A building for co-location of teams was rated as an important factor by nurses and clinical therapists though GPs rated it as less important. Payment to attend meetings and contractual arrangements were considered important factors by GPs but not by nurses or clinical therapists. Conclusion: PCPs and GPs agree there is limited PCT implementation. GPs are most negative about this implementation. There is some disagreement about which resources are most important for effective PCT working. These findings provide valuable data for clinicians and policy makers about implementation of interdisciplinary teams in primary care. [ABSTRACT FROM AUTHOR]

Background: Medication error is a frequent, harmful and costly patient safety incident. Research to date has mostly focused on medication errors in hospitals. In this study, we aimed to identify the main causes of, and solutions to, medication error in primary care. Methods: We used a novel priority-setting method for identifying and ranking patient safety problems and solutions called PRIORITIZE. We invited 500 North West London primary care clinicians to complete an open-ended questionnaire to identify three main problems and solutions relating to medication error in primary care. 113 clinicians submitted responses, which we thematically synthesized into a composite list of 48 distinct problems and 45 solutions. A group of 57 clinicians randomly selected from the initial cohort scored these and an overall ranking was derived. The agreement between the clinicians' scores was presented using the average expert agreement (AEA). The study was conducted between September 2013 and November 2014. Results: The top three problems were incomplete reconciliation of medication during patient 'hand-overs', inadequate patient education about their medication use and poor discharge summaries. The highest ranked solutions included development of a standardized discharge summary template, reduction of unnecessary prescribing, and minimisation of polypharmacy. Overall, better communication between the healthcare provider and patient, quality assurance approaches during medication prescribing and monitoring, and patient education on how to use their medication were considered the top priorities. The highest ranked suggestions received the strongest agreement among the clinicians, i.e. the highest AEA score. Conclusions: Clinicians identified a range of suggestions for better medication management, quality assurance procedures and patient education. According to clinicians, medication errors can be largely prevented with feasible and affordable interventions. PRIORITIZE is a new, convenient, systematic, and replicable method, and merits further exploration with a view to becoming a part of a routine preventative patient safety monitoring mechanism. [ABSTRACT FROM AUTHOR]

Background: In 2006 The Dutch Health Care system changed to a market oriented system. The GP remuneration changed from ±2/3 capitation patients and 1/3 private patients before 2006 to a mixed payment scheme. From 2006 onward every patient was insured and the GP received partly capitation, partly fees for consultations and for specific services. This change coincided with many other organisational changes in General Practice care. Our research question was if during the years after 2006 patient experiences of Dutch family practice had changed. We also wanted to explore the influence of patient and practice characteristics on patient experiences. Data on patient experiences were available from 2007 to 2012. Method: In a series of annual cross sectional patient surveys the performance of GPs and practices was measured. Patient sampling took place as a part of the Dutch accreditation program in 1657 practices involving 2966 GPs. Patients' experiences, gender, age, health status, and number of annual consultations were documented as well as the type and location of practices. Linear regression analysis was used to examine time trends in patient experiences and the impact of patient and practice characteristics. Results: 78,985 patients assessed the performance of 2966 GPs, and 45,773 patients assessed the organisation of 1657 practices. The number of patients with positive experiences increased significantly between 2007 and 2012; respectively 4.8 % for GPs (beta 0.20 and p < 0.0001) and 6.6 % for practices (beta 0.10, p < 0.004). Higher age, having no chronic illness, more frequent consultations and attending single-handed practices, predicted better patient experiences. Conclusions: In our evaluation of patient experiences with general practice care from 2007 to 2012 we found an increase of 4.8 % for GPs and 6.6 % for practices respectively. This improvement is significant. While no direct causation can be made, possible explanations may be found in the various reforms in Dutch family practice since 2006. More insight is needed into key determinants of this improvement before policymakers and care providers can attribute the improvement to these reforms. [ABSTRACT FROM AUTHOR]

Background: Significant challenges exist within primary care services in the United Kingdom (UK). These include meeting current demand, financial pressures, an aging population and an increase in multi-morbidity. Psychological services also struggle to meet waiting time targets and to ensure increased access to psychological therapies. Innovative ways of delivering effective primary care and psychological services are needed to improve health outcomes. Summary: In this article we argue that integrated care models that incorporate behavioural health care are part of the solution, which has seldom been argued in relation to UK primary care. Integrated care involves structural and systemic changes to the delivery of services, including the co-location of multi-disciplinary primary care teams. Evidence from models of integrated primary care in the United States of America (USA) and other higher-income countries suggest that embedding continuity of care and collaborative practice within integrated care teams can be effective in improving health outcomes. The Behavioural Health Consultant (BHC) role is integral to this, working psychologically to support the team to improve collaborative working, and supporting patients to make changes to improve their health across management of long-term conditions, prevention and mental wellbeing. Patients' needs for higher-intensity interventions to enable changes in behaviour and self-management are, therefore, more fully met within primary care. The role also increases accessibility of psychological services, delivers earlier interventions and reduces stigma, since psychological staff are seen as part of the core primary care service. Although the UK has trialled a range of approaches to integrated care, these fall short of the highest level of integration. A single short pilot of integrated care in the UK showed positive results. Larger pilots with robust evaluation, as well as research trials are required. There are clearly challenges in adopting such an approach, especially for staff who must adapt to working more collaboratively with each other and patients. Strong leadership is needed to assist in this, particularly to support organisations to adopt the shift in values and attitudes towards collaborative working. Conclusions: Integrated primary care services that embed behavioural health as part of a multi-disciplinary team may be part of the solution to significant modern day health challenges. However, developing this model is unlikely to be straight-forward given current primary care structures and ways of working. The discussion, developed in this article, adds to our understanding of what the BHC role might consist off and how integrated care may be supported by such behavioural health expertise. Further work is needed to develop this model in the UK, and to evaluate its impact on health outcomes and health care utilisation, and test robustly through research trials. [ABSTRACT FROM AUTHOR]

Background: Multimorbidity is a highly prevalent health problem, which may reduce adherence, produce conflicts in treatment, and is not yet supported by evidence-based clinical recommendations. Many older people suffer from more than one chronic disease as well as from chronic pain. There is some evidence that disease management can become more complex if multimorbid patients suffer from chronic pain. In order to better consider the patients' comorbidity spectrum in clinical pain treatment recommendations, evidence is needed regarding which disease combinations are frequently related with the presence of chronic pain. Therefore, our aim is to identify diseases and disease combinations in a multimorbid population, which are associated with the patient-reported presence of chronic pain. Methods: Analyses are based on cross-sectional data of the MultiCare Cohort Study, an observational cohort study based on interviews with 3189 multimorbid patients aged 65+, randomly selected from 158 practices, and their GPs. The response rate was 46.2 %. Data were collected in GP interviews and comprehensive patient interviews. Diseases and disease combinations associated with chronic pain were identified by CART (classification and regression tree) analyses performed separately for both genders. 46 chronic conditions were used as predictor variables and a dichotomized score from the Graded Chronic Pain Scale was used as outcome variable. Results: About 60 % of the study participants were female. Women more often reported chronic pain than men. The most important predictor of a higher pain level in the female population was chronic low back problems, especially if combined with chronic gastritis, hyperuricemia/gout, cardiac insufficiency, neuropathies or depression. Regarding the pain level the male population was also divided best by chronic low back problems, especially if combined with intestinal diverticulosis, neuropathies or chronic ischemic heart disease. Conclusions: Our analyses are a first step in identifying diseases and disease combinations that are related to chronic pain. The most important condition seems to be low back problems. Back pain and pain in other body regions seems to be interrelated with cardiometabolic conditions. In women, psychosocial issues like depression also seem to be relevant. Trial registration: ISRCTN89818205. [ABSTRACT FROM AUTHOR]

Background: Choice of urine sampling technique in urinary tract infection may impact diagnostic accuracy and thus lead to possible over- or undertreatment. Currently no evidence-based consensus exists regarding correct sampling technique of urine from women with symptoms of urinary tract infection in primary care. The aim of this study was to determine the accuracy of urine culture from different sampling-techniques in symptomatic non-pregnant women in primary care. Methods: A systematic review was conducted by searching Medline and Embase for clinical studies conducted in primary care using a randomized or paired design to compare the result of urine culture obtained with two or more collection techniques in adult, female, non-pregnant patients with symptoms of urinary tract infection. We evaluated quality of the studies and compared accuracy based on dichotomized outcomes. Results: We included seven studies investigating urine sampling technique in 1062 symptomatic patients in primary care. Mid-stream-clean-catch had a positive predictive value of 0.79 to 0.95 and a negative predictive value close to 1 compared to sterile techniques. Two randomized controlled trials found no difference in infection rate between mid-stream-clean-catch, mid-stream-urine and random samples. Conclusions: At present, no evidence suggests that sampling technique affects the accuracy of the microbiological diagnosis in non-pregnant women with symptoms of urinary tract infection in primary care. However, the evidence presented is in-direct and the difference between mid-stream-clean-catch, mid-stream-urine and random samples remains to be investigated in a paired design to verify the present findings. [ABSTRACT FROM AUTHOR]

Background: The number of people with multiple chronic conditions demanding primary care services is increasing. To deal with the complex health care demands of these people, professionals from different disciplines collaborate. This study aims to explore influential factors regarding interprofessional collaboration related to care plan development in primary care. Methods: A qualitative study, including four semi-structured focus group interviews (n = 4). In total, a heterogeneous group of experts (n = 16) and health care professionals (n = 15) participated. Participants discussed viewpoints, barriers, and facilitators regarding interprofessional collaboration related to care plan development. The data were analysed by means of inductive content analysis. Results: The findings show a variety of factors influencing the interprofessional collaboration in developing a care plan. Factors can be divided into 5 key categories: (1) patient-related factors: active role, self-management, goals and wishes, membership of the team; (2) professional-related factors: individual competences, domain thinking, motivation; (3) interpersonal factors: language differences, knowing each other, trust and respect, and motivation; (4) organisational factors: structure, composition, time, shared vision, leadership and administrative support; and (5) external factors: education, culture, hierarchy, domain thinking, law and regulations, finance, technology and ICT. Conclusions: Improving interprofessional collaboration regarding care plan development calls for an integral approach including patient- and professional related factors, interpersonal, organisational, and external factors. Further, the leader of the team seems to play a key role in watching the patient perspective, organising and coordinating interprofessional collaborations, and guiding the team through developments. The results of this study can be used as input for developing tools and interventions targeted at executing and improving interprofessional collaboration related to care plan development. [ABSTRACT FROM AUTHOR]

Background: Technological advances in clinical data capturing and storage systems have led to recent attempts at disease surveillance and region specific population health planning through regularly collected primary care administrative clinical data. However the accuracy and comprehensiveness of primary care health records remain questionable. Methods: We aimed to explore the perceptions and experiences of general practice staff in maintaining accurate patient health data within clinical software used in primary care settings of regional NSW. Focus groups were conducted with general practitioners, practice nurses and practice administrative staff from 17 practices in the Illawarra-Shoalhaven region of the state of New South Wales (NSW) in Australia that had participated in the Sentinel Practices Data Sourcing (SPDS) project - a general practice based chronic disease surveillance and data quality improvement study. A total of 25 respondents that included 12 general practitioners (GPs) and 13 practice staff participated in the 6 focus groups. Focus groups were audio-recorded and transcribed verbatim. Thematic analysis of the data was undertaken. Results: Five key themes emerged from the data. Firstly, the theme of resourcing data management raised issues of time constraints, the lack of a dedicated data management role and the importance of multidisciplinary involvement, including a data champion. The need for incentives was identified as being important to motivate ongoing commitment to maintaining data quality. However, quality of software packages, including coding issues and software limitations and information technology skills were seen as key barriers. The final theme provided insight into the lessons learnt from the project and the increased awareness of the importance of data quality amongst practice staff. Conclusion: The move towards electronic methods of maintaining general practice patient records offers significant potential benefits in terms of both patient care and monitoring of health status and health needs within the community. However, this study has reinforced the importance of human factors in the maintenance of such datasets. To achieve optimal benefits of electronic health and medical records for patient care and for population health planning purposes, it is extremely essential to address the barriers that clinicians and other staff face in maintaining complete and correct primary care patient electronic health and medical information. [ABSTRACT FROM AUTHOR]

Background: Canadians' health care-seeking behaviour for physical and mental health issues was examined using the international Quality and Cost of Primary Care (QUALICOPC) survey that was conducted in 2013 in Canada. Method: This study used the cross-sectional Patient Experiences Survey collected from 7260 patients in 759 practices across 10 Canadian provinces as part of the QUALICOPC study. A Responsive Care Scale (RCS) was constructed to reflect the degree of health care-seeking behaviour across 11 health conditions. Using several patient characteristics as independent variables, four multiple regression analyses were conducted. Results: Patients' self-reports indicated that there were gender differences in health care-seeking behaviour, with women reporting they visited their primary care provider to a greater extent than did men for both physical and mental health concerns. Overall, patients were less likely to seek care for mental health concerns in comparison to physical health concerns. For both women and men, the results of the regressions indicated that age, illness prevention, trust in physicians and chronic conditions were important factors when explaining health care-seeking behaviours for mental health concerns. Conclusion: This study confirms the gender differences in health care-seeking behaviour advances previous research by exploring in detail the variables predicting differences in health care-seeking behaviour for men and women. The variables were better predictors of health care-seeking behaviour in response to mental health concerns than physical health concerns, likely reflecting greater variation among those seeking mental health care. This study has implications for those working to improve barriers to health care access by identifying those more likely to engage in health care-seeking behaviours and the variables predicting health care-seeking. Consequently, those who are not accessing primary care can be targeted and policies can be developed and put in place to promote their health care-seeking behavior. [ABSTRACT FROM AUTHOR]

Background: Although conditions for high quality cardiovascular risk management in primary care in the Netherlands are favourable, there still remains a gap between practice guideline recommendations and practice. The aim of the current study was to identify determinants of cardiovascular primary care in the Netherlands. Methods: We performed a qualitative study, using semi-structured interviews with healthcare professionals and patients with established cardiovascular diseases or at high cardiovascular risk. A framework analysis was used to cluster the determinants into seven domains: 1) guideline factors, 2) individual healthcare professional factors, 3) patient factors, 4) professional interaction, 5) incentives and recourses, 6) mandate, authority and accountability, and 7) social, political and legal factors. Results: Twelve healthcare professionals and 16 patients were interviewed. Healthcare professionals and patients mentioned a variety of factors concerning all seven domains. Determinants of practice according to the health care professionals were related to communication between healthcare professionals, patients' lack of knowledge and self-management, time management, market mechanisms in the Dutch healthcare system and motivational interviewing skills of healthcare professionals. Patients mentioned determinants related to their knowledge of risk factors for cardiovascular diseases, medication adherence and self-management as key determinants. A key finding is the mismatch between healthcare professionals' and patients' views on patient's knowledge and self-management. Conclusions: Perceived determinants of cardiovascular risk management were mainly related to patient behaviors and (but only for health professionals) to the healthcare system. Though health care professionals and patients agree upon the importance of patients' knowledge and self-management, their judgment of the current state of knowledge and self-management is entirely different. [ABSTRACT FROM AUTHOR]

Background: Biological and sociocultural differences between men and women may play an important role in medical treatment. Little is known about the awareness of these differences among general practitioners (GPs) and if they consider such differences in their medical practice. The aim of this study was to explore GPs' perception of sex and gender aspects in medical treatment. Methods: We conducted five focus group discussions (FGDs) with 29 physicians (mainly GPs) in Sweden. A discussion guide with semi-structured questions was used. All FGDs were audio-recorded and transcribed word-by-word. Data were analysed through inductive thematic analysis with no predetermined categories. Results: Three main categories emerged from the data. The first category emphasised GPs' experiences of sex and gender differences in diagnosing and assessment of clinical findings. Medical treatment in men and women was central in the second category. The third category emphasised GPs' knowledge of sex differences in drug therapy. Conclusions: The GPs stated they had little knowledge of sex and gender differences in drug treatment, but gave multiple examples of how the patient's sex affects the choice of treatment. Sex and gender aspects were considered in diagnosing and in the treatment decision. However, once the decision to treat was made the choice of drug followed recommendations by local Drug and Therapeutics Committee, which were perceived to be evidence-based. In the analysis we found a gap between perceived and expressed knowledge of sex and gender differences in drug treatment indicating a need of education about this to be included in the curriculum in medical school and in basic and specialist training for physicians. Education could also be a tool to avoid stereotypical thinking about male and female patients. [ABSTRACT FROM AUTHOR]

Background: Health systems organized as networks and coordinated by the Primary Health Care (PHC) may contribute to the improvement of clinical care, sanitary conditions, satisfaction of patients and reduction of local budget expenditures. The aim of this study was to adapt and validate a questionnaire - COPAS - to assess the coordination of Integrated Health Service Delivery Networks by the Primary Health Care. Methods: A cross sectional approach was used. The population was pooled from Family Health Strategy healthcare professionals, of the Alfenas region (Minas Gerais, Brazil). Data collection was performed from August to October 2013. The results were checked for the presence of floor and ceiling effects and the internal consistency measured through Cronbach alpha. Construct validity was verified through convergent and discriminant values following Multitrait-Multimethod (MTMM) analysis. Results: Floor and ceiling effects were absent. The internal consistency of the instrument was satisfactory; as was the convergent validity, with a few correlations lower then 0.30. The discriminant validity values of the majority of items, with respect to their own dimension, were found to be higher or significantly higher than their correlations with the dimensions to which they did not belong. Conclusion: The results showed that the COPAS instrument has satisfactory initial psychometric properties and may be used by healthcare managers and workers to assess the PHC coordination performance within the Integrated Health Service Delivery Network. [ABSTRACT FROM AUTHOR]

Background: Socioeconomic deprivation is associated with inequalities in health care and outcomes. Despite concerns that the Quality and Outcomes Framework pay-for-performance scheme in the UK would exacerbate inequalities in primary care delivery, gaps closed over time. Local schemes were promoted as a means of improving clinical engagement by addressing local health priorities. We evaluated equity in achievement of target indicators and practice income for one local scheme. Methods: We undertook a longitudinal survey over four years of routinely recorded clinical data for all 83 primary care practices. Sixteen indicators were developed that covered five local clinical and public health priorities: weight management; alcohol consumption; learning disabilities; osteoporosis; and chlamydia screening. Clinical indicators were logit transformed from a percentage achievement scale and modelled allowing for clustering of repeated measures within practices. This enabled our study of target achievements over time with respect to deprivation. Practice income was also explored. Results: Higher practice deprivation was associated with poorer performance for five indicators: alcohol use registration (OR 0.97; 95 % confidence interval 0.96,0.99); recorded chlamydia test result (OR 0.97; 0.94,0.99); osteoporosis registration (OR 0.98; 0.97,0.99); registration of repeat prednisolone prescription (OR 0.98; 0.96,0.99); and prednisolone registration with record of dual energy X-ray absorptiometry (DEXA) scan/referral (OR 0.92; 0.86,0.97); practices in deprived areas performed better for one indicator (registration of osteoporotic fragility fracture (OR 1.26; 1.04,1.51). The deprivation-achievement gap widened for one indicator (registered females aged 65-74 with a fracture referred for a DEXA scan; OR 0.97; 0.95,0.99). Two other indicators indicated a similar trend over two years before being withdrawn (registration of fragility fracture and over-75 s with a fragility fracture assessed and treated for osteoporosis risk). For one indicator the deprivation-achievement gap reduced over time (repeat prednisolone prescription (OR 1.01; 1.01,1.01). Larger practices and those serving more affluent areas earned more income per patient than smaller practices and those serving more deprived areas (t = -3.99; p =0.0001). Conclusions: Any gaps in achievement between practices were modest but mostly sustained or widened over the duration of the scheme. Given that financial rewards may not reflect the amount of work undertaken by practices serving more deprived patients, future pay-for-performance schemes also need to address fairness of rewards in relation to workload. [ABSTRACT FROM AUTHOR]

Background Strategies to improve care coordination between primary and hospital care do not always have the desired results. This is partly due to incomplete understanding of the key concepts of care coordination. An in-depth analysis of existing theoretical frameworks for the study of care coordination identified 14 interrelated key concepts. In another study, these 14 key concepts were further explored in patients? experiences. Additionally, ?patient characteristics? was identified as a new key concept in patients? experiences and the previously identified key concept ?quality of relationship? between healthcare professionals was extended to ?quality of relationship? with the patient. Together, these 15 interrelated key concepts resulted in a new theoretical framework. The present study aimed at improving our understanding of the 15 previously identified key concepts and to explore potentially previous unidentified key concepts and the links between these by exploring how healthcare professionals experience care coordination. Methods A qualitative design was used. Six focus groups were conducted including primary healthcare professionals involved in the care of patients who had breast cancer surgery at three hospitals in Belgium. Data were analyzed using constant comparative analysis. Results All 15 previously identified key concepts of care coordination were further explored in healthcare professionals? experiences. Links between these 15 concepts were identified, including 9 newly identified links. The concept ?external factors? was linked with all 6 concepts relating to (inter)organizational mechanisms; ?task characteristics?, ?structure?, ?knowledge and information technology?, ?administrative operational processes?, ?cultural factors? and ?need for coordination?. Five of these concepts related to 3 concepts of relational coordination; ?roles?, ?quality of relationship? and ?exchange of information?. The concept of ?task characteristics? was only linked with ?roles? and ?exchange of information?. The concept ?patient characteristics? related with the concepts ?need for coordination? and ?patient outcome?. Outcome was influenced by ?roles?, ?quality of relationship? and ?exchange of information?. Conclusions External factors and the (inter)organizational mechanism should enhance ?roles? and ?quality of relationship? between healthcare professionals and with the patient as well as ?exchange of information?, and setting and sharing of common ?goals? to improve care coordination and quality of care. [ABSTRACT FROM AUTHOR]

Background Health coaching is a new intervention offering a one-on-one focused self-management support program. This study implemented a health coaching pilot in primary care clinics in Eastern Ontario, Canada to evaluate the feasibility and acceptability of integrating health coaching into primary care for patients who were either at risk for or diagnosed with diabetes. Methods We implemented health coaching in three primary care practices. Patients with diabetes were offered six months of support from their health coach, including an initial face-to-face meeting and follow-up by email, telephone, or face-to-face according to patient preference. Feasibility was assessed through provider focus groups and qualitative data analysis methods. Results All three sites were able to implement the program. A number of themes emerged from the focus groups, including the importance of physician buy-in, wide variation in understanding and implementing of the health coach role, the significant impact of different systems of team communication, and the significant effect of organizational structure and patient readiness on Health coaches' capacity to perform their role. Conclusions It is feasible to implement health coaching as an integrated program within small primary care clinics in Canada without adding additional resources into the daily practice. Practices should review their organizational and communication processes to ensure optimal support for health coaches if considering implementing this intervention. [ABSTRACT FROM AUTHOR]

Background: The Quebec primary health care delivery system has experienced numerous reforms over the last 15 years. In this study, we sought to examine how managers and primary care providers made sense of the creation of successive new primary care organizational forms. Methods: We conducted a longitudinal qualitative case study in a primary care practice group located in Montreal, Quebec, for over 6 years (2002 to 2008). The data sources for the study include 31 semi-structured interviews with key informants, in-situ observations of group meetings, as well as documents and field notes. Textual material was submitted to narrative and metaphor analysis. Results: The core metaphor of the journey came from a set of stories in which the members of this primary care group depicted the processes undertaken towards developing a multidisciplinary cooperative practice, which include an uneasy departure, uncertainty about the destination, conflict among members who jump ship or stay on board, negotiations about the itinerary, and, finally, enduring challenges in leading the way and being pioneers of change in the organization of primary care in their institutional context. Identification with the initial family medicine unit identity was persistent over time, but successive reforms further enriched its meaning as it became a multidisciplinary primary care practice pioneering organizational change. Conclusions: In order to support primary care reforms in complex institutional fields, this study proposes that decision-makers undertake a journey in which they recognize both the need to capitalize existing meaningful and legitimated organizational identities, as well as the necessity for collective leadership in the management of multiple organizational identities over time. [ABSTRACT FROM AUTHOR]

Background: Mass media plays an important role in communicating about health research and services to patients, and in shaping public perceptions and decisions about health. Healthcare professionals also play an important role in providing patients with credible, evidence-based and up-to-date information on a wide range of health issues. This study aims to explore primary care nurses' experiences of how mass media influences frontline healthcare. Methods: In-depth telephone interviews were carried out with 18 primary care nurses (nine health visitors and nine practice nurses) working in the United Kingdom (UK). Interviews were recorded and transcribed. The data was analysed using thematic analysis, with a focus on constant comparative analysis. Results: Three themes emerged from the data. First, participants reported that their patients were frequently influenced by controversial health stories reported in the media, which affected their perceptions of, and decisions about, care. This, in turn, impinged upon participants' workloads as they had to spend additional time discussing information and reassuring patients. Second, participants also recalled times in their own careers when media reports had contributed to a decline in their confidence in current healthcare practices and treatments. Third, the participants in this study suggested a real need for additional resources to support and expand their own media literacy skills, which could be shared with patients. Conclusion: In an ever expanding media landscape with greater reporting on health, nurses working in the primary care setting face increasing pressure to effectively manage media stories that dispute current health policies and practices. These primary care nurses were keen to expand their media literacy skills to develop critical autonomy in relation to all media, and to facilitate more meaningful conversations with their patients about their health concerns and choices. [ABSTRACT FROM AUTHOR]

Background: As primary care practices evolve into medical homes, there is an increasing need for effective models to shift from visit-based to population-based strategies for care. However, most medical teams lack tools and training to manage panels of patients. As part of a study comparing different approaches to panel management at the Manhattan and Brooklyn campuses of the VA New York Harbor Healthcare System, we created a toolkit of strategies that non-clinician panel management assistants (PMAs) can use to enhance panel-wide outcomes in smoking cessation and hypertension. Methods: We created the toolkit using: 1) literature review and consultation with outside experts, 2) key informant interviews with staff identified using snowball sampling, 3) pilot testing for feasibility and acceptability, and 4) further revision based on a survey of primary care providers and nurses. These steps resulted in progressively refined strategies for the PMAs to support the primary care team. Results: Literature review and expert consultation resulted in an extensive list of potentially useful strategies. Key informant interviews and staff surveys identified several areas of need for assistance, including help to manage the most challenging patients, providing care outside of the visit, connecting patients with existing resources, and providing additional patient education. The strategies identified were then grouped into 5 areas - continuous connection to care, education and connection to clinical resources, targeted behavior change counseling, adherence support, and patients with special needs. Conclusions: Although panel management is a central aspect of patient-centered medical homes, providers and health care systems have little guidance or evidence as to how teams should accomplish this objective. We created a toolkit to help PMAs support the clinical care team for patients with hypertension or tobacco use. This toolkit development process could readily be adapted to other behaviors or conditions. [ABSTRACT FROM AUTHOR]

Background: Fragmentation within health care systems may negatively impact the quality of chronic disease patient care. We sought to evaluate the relationship between care management processes (CMP), integration of services, and blood pressure (BP) control among diabetic patients. Methods: Retrospective chart reviews were performed for a random sample of adult diabetic hypertensive patients (n = 2,162) from 28 physician organizations in the United States (US). A modified version of the Physician Practice Connection Readiness Survey (PPC-RS) was completed by the chief medical officer at each site. The PPC-RS measured health system organization, delivery system redesign, decision support, clinical information systems, and self-management support, and an integration scale measured structure, functions, and financial risk. Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients. Results: Approximately 39.9% of diabetic patients had controlled BP. Mean total PPC score across sites was 55, with highest mean scores for health system organization (81), followed by design support (60), clinical information systems (57), self-management support (39), and delivery system redesign (39). Mean integration score was 46 (SD 27, range 4-93), and means of subscores were 64 for structure, 33 for financial risk, and 42 for function. Clinical information systems subscore was correlated with uncontrolled BP (r = -0.38, p < 0.05), while association with total PPC score was strong but not significant at p < 0.05 (r = -0.32). Total integration score and the structure subscore were significantly correlated with BP control (r = 0.38, p < 0.05, and r = 0.49, p < 0.01). Conclusions: This study suggests that CMP and service integration may be associated with better outcomes in diabetes, though results were mixed and limited by a small number of participating sites. Primary care implementation of integrated electronic medical records may have a beneficial effect on patient outcomes for diabetes and other chronic diseases. [ABSTRACT FROM AUTHOR]

Background: Mental health problems are common and are associated with increased disability and health care costs. Problem-Solving Treatment (PST) delivered to these patients by nurses in primary care might be efficient. The aim of this study was to evaluate the cost-effectiveness of PST by mental health nurses compared with usual care (UC) by the general practitioner for primary care patients with mental health problems. Methods: An economic evaluation from a societal perspective was performed alongside a randomized clinical trial. Patients with a positive General Health Questionnaire score (score ≥ 4) and who visited their general practitioner at least three times during the past 6 months were eligible. Outcome measures were improvement on the Hospital Anxiety and Depression Scale and QALYs based on the EQ-5D. Resource use was measured using a validated questionnaire. Missing cost and effect data were imputed using multiple imputation techniques. Bootstrapping was used to analyze costs and cost-effectiveness of PST compared with UC. Results: There were no statistically significant differences in clinical outcomes at 9 months. Mean total costs were €4795 in the PST group and €6857 in the UC group. Costs were not statistically significantly different between the two groups (95% CI -4698;359). The cost-effectiveness analysis showed that PST was cost-effective in comparison with UC. Sensitivity analyses confirmed these findings. Conclusions: PST delivered by nurses seems cost-effective in comparison with UC. However, these results should be interpreted with caution, since the difference in total costs was mainly caused by 3 outliers with extremely high indirect costs in the UC group. Trial registration: Nederlands Trial Register ISRCTN51021015 [ABSTRACT FROM AUTHOR]

Background: Pharmacists have expanded their roles and responsibilities as a result of primary health care reform. There is currently no consensus on the core competencies for pharmacists working in these evolving practices. The aim of this study was to develop and validate competencies for pharmacists’ effective performance in these roles, and in so doing, document the perceived contribution of pharmacists providing collaborative primary health care services. Methods: Using a modified Delphi process including assessing perception of the frequency and criticality of performing tasks, we validated competencies important to primary health care pharmacists practising across Canada. Results: Ten key informants contributed to competency drafting; thirty-three expert pharmacists replied to a second round survey. The final primary health care pharmacist competencies consisted of 34 elements and 153 sub-elements organized in seven CanMeds-based domains. Highest importance rankings were allocated to the domains of care provider and professional, followed by communicator and collaborator, with the lower importance rankings relatively equally distributed across the manager, advocate and scholar domains. Conclusions: Expert pharmacists working in primary health care estimated their most important responsibilities to be related to direct patient care. Competencies that underlie and are required for successful fulfillment of these patient care responsibilities, such as those related to communication, collaboration and professionalism were also highly ranked. These ranked competencies can be used to help pharmacists understand their potential roles in these evolving practices, to help other health care professionals learn about pharmacists’ contributions to primary health care, to establish standards and performance indicators, and to prioritize supports and education to maximize effectiveness in this role. [ABSTRACT FROM AUTHOR]

Background: Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KV Å) and SNOMED CT. Methods: Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed. Results: 417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions. Conclusions: Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT. Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care. [ABSTRACT FROM AUTHOR]

Background: Bridging the knowledge-to-practice gap in health care is an important issue that has gained interest in recent years. Implementing new methods, guidelines or tools into routine care, however, is a slow and unpredictable process, and the factors that play a role in the change process are not yet fully understood. There is a number of theories concerned with factors predicting successful implementation in various settings, however, this issue is insufficiently studied in primary health care (PHC). The objective of this article was to apply implementation theory to identify key factors influencing the adoption of an innovation being introduced in PHC in Sweden. Methods: A qualitative study was carried out with staff at six PHC units in Sweden where a computer-based test for lifestyle intervention had been implemented. Two different implementation strategies, implicit or explicit, were used. Sixteen focus group interviews and two individual interviews were performed. In the analysis a theoretical framework based on studies of implementation in health service organizations, was applied to identify key factors influencing adoption. Results: The theoretical framework proved to be relevant for studies in PHC. Adoption was positively influenced by positive expectations at the unit, perceptions of the innovation being compatible with existing routines and perceived advantages. An explicit implementation strategy and positive opinions on change and innovation were also associated with adoption. Organizational changes and staff shortages coinciding with implementation seemed to be obstacles for the adoption process. Conclusion: When implementation theory obtained from studies in other areas was applied in PHC it proved to be relevant for this particular setting. Based on our results, factors to be taken into account in the planning of the implementation of a new tool in PHC should include assessment of staff expectations, assessment of the perceived need for the innovation to be implemented, and of its potential compatibility with existing routines. Regarding context, we suggest that implementation concurrent with other major organizational changes should be avoided. The choice of implementation strategy should be given thorough consideration. [ABSTRACT FROM AUTHOR]