Search

The quality of primary medical care was assessed by studying the events leading to 686 emergency admissions of patients from our hospital-based primary care practice. Independent physician reviewers determined that 59 (9 percent) of the admissions were potentially preventable; 40 were due to iatrogenic factors including inadequate follow-up and adverse drug reactions, 12 were due to lack of patient compliance, and seven were due to both iatrogenesis and noncompliance. Adverse drug reactions were the most common cause of iatrogenesis, and warfarin was the drug that most commonly caused an adverse reaction. Inadequate follow-up of abnormal physical findings, symptoms, and laboratory test results was also important. Patients with preventable admissions had more medical diagnoses (4.9 versus 4.1, p less than 0.01), were prescribed more medications (4.5 versus 3.7, p less than 0.01), and were older (66.5 years versus 60.2 years, p less than 0.01) than patients whose admissions were not preventable. It is concluded that a small percentage of emergency hospitalizations may be preventable and that systematic review of emergency hospitalizations may provide a means of measuring the quality of primary medical care.

The establishment, organization, and operation of a pharmaceutical component within a primary care facility is delineated. This setting allows the pharmacist an opportunity to provide innovative clinical services. A mechanism of reimbursement is suggested which rewards the pharmacist for performing functions not directly related to the dispensing activity. The indications are that this arrangement could be financially feasible for a group practice including a pharmacist and one or two physicians.

EPSDT is the means the federal government has selected to force the states to seek out poor children who are out of the mainstream of medical care and to offer them preventive services. The use of periodic screening exams (as defined in the Program Regulations Guide) is an untried method of providing health care and may be unsuccessful, but fortunately the states have been given much freedom in program design and future modification. Major obstacles at present are the absence of specific goals at the state level, and a lack of commitment by state governments and administrators to provide adequate funds and direction for a successful program. Inadequate health resources in inner cities and rural areas, the lack of outreach workers, and a low priority for health care on the part of the consumer all add to the problem. If EPSDT is successfnl in screening out children with problems and then providing diagnosis and treatment for them, it will be a major achievement. If it takes the next step and places children in a continuing primary care facility, it will be a significant advance in achieving the Academy's goal-the attainment by all children of their full potential for physical, emotional, and social health.

This study aims to compare the use and cost of objective and subjective measures of adherence to pediatric antiretroviral treatment in a primary care facility in South Africa. In a 1-month longitudinal study of 53 caregiver-child dyads, pharmacy refill (PR), measurement of returned syrups (RS), caregiver self-report (3DR) and Visual Analogue Scale (VAS) were compared to Medication Event Monitoring System (MEMS). Adherence was 100% for both VAS and 3DR; by PR and RS 100% and 103%, respectively. MEMS showed that 92% of prescribed doses were administered, but only 66% of these within the correct 12-hourly interval. None of the four measures correlated significantly with MEMS. MEMS data suggest that timing of doses is often more deviant from prescribed than expected and should be better addressed when monitoring adherence. Of all, MEMS was by far the most expensive measure. Alternative, cheaper electronic devices need to be more accessible in resource-limited settings.

Introduction of a computerized printout ("mini record") containing problems and therapies, and listing visits between regularly scheduled ones to a primary care facility, resulted in improved recognition of problems and therapies. Recognition both of the occurrence of the visits which had been made elsewhere and the content of those visits was not improved, even though the mini record listed the dates and place of visit. Recognition was improved more in situations where the practitioners in the primary care clinic changed than when the practitioner remained the same individual who had seen the patient at the previous visit to the primary care clinic. Coordination of care is an essential ingredient of primary care. Recognition of all information generated by patients in a series of visits is evidence of coordination. Continuity (whether achieved by continuity of practitioner or by medical records) is one means of attaining better coordination. In a previous study we showed that continuity of practitioner improves coordination. This study shows that a technologic innovation consisting of an alteration in medical records facilitates coordination, but only with regard to certain aspects of care. Explanations for this finding are postulated.

The activities of a clinical pharmacist within a primary care facility are measured in a time-motion study. This type of practice allows the pharmacist an opportunity to provide many patient-care services normally unavailable at community pharmacies. The innovative services are described in detail to establish how they produce savings of physician time and to imply how they improve patient care. The activities of the clinical pharmacist are compared to those of the community pharmacist. The indications are that a significant difference exists between the activities of the community pharmacist and a clinical pharmacist working within the office of a physician.

The number of patients with chronic illness is increasing worldwide. These patients usually receive care from a primary care facility. The Patient Assessment of Chronic Illness Care (PACIC) is a tool that is increasingly used in several countries to measure how the patients perceive the care they receive. The goal of this validation study is to provide and validate an extended version of the tool, the PACIC+ questionnaire, in Thailand. In this observational validation study, patients with type 2 diabetes from the outpatient clinic at a university hospital in Thailand completed the PACIC+ at the clinic. For follow-up, they received the questionnaire per mail after four weeks. The Thai PACIC+ comprises 26 items, which map onto 5 subscales and a summary score related to the Chronic Care Model (CCM) and 5 subscales and a summary score related to the 5A model, a counseling model for behavioral changes. Data-analysis focused on the use of most extreme answering categories (> 15%), internal consistency (Cronbach’s alpha), and test-retest reliability. An exploratory factor analysis (EFA) was performed for the CCM and the 5A model separately to examine the factor structure. A total of 151 patients participated. The average age of the sample was 63 ± 9 years (range 29–86 years). Fifty-three percent of the respondents were female. In the Delivery System subscale, 20% of patients reported the highest possible value; in all other subscales, relative frequencies of the most extreme categories did not exceed 15%. Cronbach’s alpha per subscale varied from 0.58 to 0.81, while that of the summary scores were 0.89 and 0.91. The mean difference from the test-retest varied from − 0.06 to 0.17 across subscales. The Kaiser-Meyer-Olkin criterion for sampling adequacy (KMO) was good for both models as well as the Bartlett’s test for sphericity p. While the factor loadings in rotated factor solution showed good concordance with the CCM, concordance was not as good for the 5A model, especially for the subscales “Assess” and “Advice”. A validated Thai version of the PACIC+ is now available to measure how the patients perceive the care they receive.

Background With support from USAID-funded projects, the Dominican Republic (DR) started organizing a unified pharmaceutical system (SUGEMI) in 2010. Implementing SUGEMI included developing standard operating procedures (SOPs) for all system components, appointing personnel for national and regional pharmaceutical units, and training on-site staff responsible for pharmaceutical supply management. Strengthening and sustaining SUGEMI is now dependent on in-depth training of public health system staff responsible for supply management functions.