Development
Creating a ‘reverse’ integrated primary and mental healthcare clinic for those with serious mental illness
- Alexandros Maragakis, Ragavan Siddharthan, Jill RachBeisel, Cassandra Snipes
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- Published online by Cambridge University Press:
- 20 November 2015, pp. 421-427
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Individuals with serious mental illness (SMI) are more likely to experience preventable medical health issues, such as diabetes, hyperlipidemia, obesity, and cardiovascular disease, than the general population. To further compound this issue, these individuals are less likely to seek preventative medical care. These factors result in higher usage of expensive emergency care, lower quality of care, and lower life expectancy. This manuscript presents literature that examines the health disparities this population experiences, and barriers to accessing primary care. Through the identification of these barriers, we recommend that the field of family medicine work in collaboration with the field of mental health to implement ‘reverse’ integrated care (RIC) systems, and provide primary care services in the mental health settings. By embedding primary care practitioners in mental health settings, where individuals with SMI are more likely to present for treatment, this population may receive treatment for somatic care by experts. This not only would improve the quality of care received by patients, but would also remove the burden of managing complex somatic care from providers trained in mental health. The rationale for this RIC system, as well as training and policy reforms, are discussed.
Evaluation of a faecal calprotectin care pathway for use in primary care
- James Turvill, Shaun O’Connell, Abigail Brooks, Karen Bradley-Wood, James Laing, Swaminathan Thiagarajan, David Hammond, Daniel Turnock, Alison Jones, Ruchit Sood, Alex Ford
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- Published online by Cambridge University Press:
- 22 February 2016, pp. 428-436
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Background
National Institute for Health and Care Excellence have recommended faecal calprotectin (FC) testing as an option in adults with lower gastrointestinal symptoms for whom specialist investigations are being considered, if cancer is not suspected and it is used to support a diagnosis of inflammatory bowel disease (IBD) or irritable bowel syndrome. York Hospital and Vale of York Clinical Commissioning Group have developed an evidence-based care pathway to support this recommendation for use in primary care. It incorporates a higher FC cut-off value, a ‘traffic light’ system for risk and a clinical management pathway.
ObjectivesTo evaluate this care pathway.
MethodsThe care pathway was introduced into five primary care practices for a period of six months and the clinical outcomes of patients were evaluated. Negative and positive predictive values (NPV and PPV) were calculated. GP feedback of the care pathway was obtained by means of a web-based survey. Comparator gastroenterology activity in a neighbouring trust was obtained.
ResultsThe care pathway for FC in primary care had a 97% NPV and a 40% PPV. This was better than GP clinical judgement alone and doubled the PPV compared with the standard FC cut-off (<50 mcg/g), without affecting the NPV. In total, 89% of patients with IBD had an FC>250 mcg/g and were diagnosed by ‘straight to test’ colonoscopy within three weeks. The care pathway was considered helpful by GPs and delivered a higher diagnostic yield after secondary care referral (21%) than the conventional comparator pathway (5%).
ConclusionsA care pathway for the use of FC that incorporates a higher cut-off value, a ‘traffic light’ system for risk and supports clinical decision making can be achieved safely and effectively. It maintains the balance between a high NPV and an acceptable PPV. A modified care pathway for the use of FC in primary care is proposed.
Research
Sickness certification for common mental disorders and GP return-to-work advice
- Mark Gabbay, Chris Shiels, Jim Hillage
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- Published online by Cambridge University Press:
- 10 March 2016, pp. 437-447
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Aim
To report the types and duration of sickness certification for different common mental disorders (CMDs) and the prevalence of GP advice aimed at returning the patient to work.
BackgroundIn the United Kingdom, common mental health problems, such and depression and stress, have become the main reasons for patients requesting a sickness certificate to abstain from usual employment. Increasing attention is being paid to mental health and its impact on employability and work capacity in all parts of the welfare system. However, relatively little is known about the extent to which different mental health diagnoses impact upon sickness certification outcomes, and how the GP has used the new fit note (introduced in 2010) to support a return to work for patients with mental health diagnoses.
MethodsSickness certification data was collected from 68 UK-based general practices for a period of 12 months.
FindingsThe study found a large part of all sickness absence certified by GPs was due to CMDs (29% of all sickness absence episodes). Females, younger patients and those living in deprived areas were more likely to receive a fit note for a CMD (compared with one for a physical health problem). The highest proportion of CMD fit notes were issued for ‘stress’. However, sickness certification for depression contributed nearly half of all weeks certified for mental health problems. Only 7% of CMD fit notes included any ‘may be fit’ advice from the GP, with type of advice varying by mental health diagnostic category. Patients living in the most socially deprived neighbourhoods were less likely to receive ‘may be fit’ advice on their CMD fit notes.
Exploring practical approaches to maximising data quality in electronic healthcare records in the primary care setting and associated benefits. Report of panel-led discussion held at SAPC in July 2014
- Sheena Dungey, Simon Glew, Barbara Heyes, John Macleod, A. Rosemary Tate
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- Published online by Cambridge University Press:
- 18 January 2016, pp. 448-452
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Background
Electronic healthcare records provide information about patient care over time which not only affords the opportunity to improve patient care directly through effective monitoring and identification of care requirements but also offers a unique platform for both clinical and service-model research essential to the longer-term development of the health service. The quality of the recorded data can, however, be variable and can compromise the validity of data use both for primary and secondary purposes.
ObjectivesIn order to explore the challenges and benefits of and approaches to recording high quality primary care electronic records, a Clinical Practice Research Datalink (CPRD) sponsored workshop was held at the Society of Academic Primary Care (SAPC) conference in 2014 with the aim of engaging GPs and other data users.
MethodsThe workshop was held as a structured discussion, led by an expert panel and focused around three questions: (1) What are the data quality priorities for clinicians and researchers? How do these priorities differ or overlap? (2) What challenges might GPs face in provision of good data quality both for treating their patients and for research? Do these aims conflict? (3) What tools (such as data metrics and visualisations or software components) could assist the GP in improving data quality and patient management and could this tie in with analytical processes occurring at the research stage?
ResultsThe discussion highlighted both overlap and differences in the perceived data quality priorities and challenges for different user groups. Five key areas of focus were agreed upon and recommendations determined for moving forward in improving quality.
ConclusionsThe importance of good high quality electronic healthcare records has been set forth along with the need for a practical user-considered and collaborative approach to its improvement.
Primary health care registered nurses’ types in implementation of health promotion practices
- Virpi Maijala, Kerttu Tossavainen, Hannele Turunen
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- Published online by Cambridge University Press:
- 23 November 2015, pp. 453-463
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Aim
This study aimed to identify and reach consensus among primary health care participants [registered nurses (RNs) who receive clients, directors of nursing, senior physicians, health promotion officers, and local councillors] on the types of service provider that RNs who receive clients represent in the implementation of health promotion practices in primary health care in Eastern Finland.
BackgroundThere is an increasing focus on public health thinking in many countries as the population ages. To meet the growing needs of the health promotion practices of populations, advance practice has been recognized as effective in the primary health care setting. The advance practice nurses share many common features, such as being RNs with additional education, possessing competencies to work independently, treating clients in both acute and primary care settings, and applying a variety of health promotion practices into nursing.
MethodsThe two-stage modified Delphi method was applied. In round one, semi-structured interviews were conducted among primary health care participants (n=42) in 11 health centres in Eastern Finland. In round two, a questionnaire survey was conducted in the same health centres. The questionnaire was answered by 64% of those surveyed (n=56). For data analysis, content analysis and descriptive statistics were used.
FindingsThis study resulted in four types of service provider that RNs who receive clients represented in the implementation of health promotion practices in the primary health care setting in Eastern Finland. First, the client-oriented health promoter demonstrated four dimensions, which reached consensus levels ranging between 82.1 and 89.3%. Second, the developer of health promotion practices comprised four dimensions, which reached consensus levels between 71.4 and 85.7%. Third, the member of multi-professional teams of health promotion practices representing three dimensions, with consensus levels between 69.6 and 82.1%. Fourth, the type who showed interest towards health policy reached a consensus level of 55.4% in this study.
District nurses’ experiences of preventive home visits to 75-year-olds in Stockholm: a qualitative study
- Annica Lagerin, Lena Törnkvist, Ingrid Hylander
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- Published online by Cambridge University Press:
- 01 December 2015, pp. 464-478
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Aims
This study had two aims: to describe the dialogue between district nurses (DNs) and older people in preventive home visits (PHVs) from the perspective of the DNs, and to identify barriers to and facilitators of this dialogue as perceived by the DNs.
BackgroundThe number of older people is rapidly increasing in all western countries, and as people’s age increases, the probability that they will have multiple diseases also increases. Planned actions are therefore needed to promote health and prevent diseases among older people so they can remain in good health and live in their homes for as long as possible. In Sweden, PHVs to 75-year-olds by DNs are one such action.
MethodsThis qualitative study included five group interviews with 20 DNs. Data were analysed with qualitative content analysis.
FindingsDNs’ experiences of barriers to and facilitators of a successful health dialogue were sorted into five domains. Together, these domains provided a systematic description of the interaction between the DN and the older person in the PHV. The domains included: establishing trustful contact, conducting a structured interview, making an overall assessment, proposing health-promoting activities and offering follow-up. The barriers and facilitators could be related to the older person, the DN or the home environment. The latent content of the interviews was evident in three themes that were related to the DNs’ experiences of barriers and facilitators. These themes illustrated professional dilemmas that the DNs had to resolve to achieve the purpose of the PHV. The study demonstrates that the interaction between a DN and an older person in a PHV can be described as a complex social process in which the DN balances a personal and professional approach, combines a person-oriented and a task-oriented approach and employs both a salutogenic and pathogenic perspective.
How to support patients who are crying in palliative home care: an interview study from the nurses’ perspective
- Kerstin Rydé, Katarina Hjelm
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- Published online by Cambridge University Press:
- 02 March 2016, pp. 479-488
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Aim
The aim of this study was to explore how nurses can support patients who are crying in a palliative home care context.
BackgroundIn palliative care the nurse has a central role in the team whose duty it is to create a sense of security and trust, as well as to give comfort and support the patients. The nurse’s responsibility is to identify different needs of the patients for support and develop a relationship with them. Patients may express their pain, anxiety, fear and suffering by crying. No studies have been found which focus on how nurses can support patients who are crying in different ways and crying for different reasons.
MethodsA qualitative explorative study was performed. Semi-structured interviews were held with eight nurses aged 32–63 years (Median 40) working in Swedish palliative home care. The data were analysed using Qualitative Content analysis.
FindingsIt was reported that the nurse should meet and confirm the patient during different types of crying episodes and should also be able to alternate between being close and physically touching the in such close contact with the patients, the nurse can provide emotional support by showing empathy, merely being present and letting the patients cry as much as they want. When the crying finally stops, the nurse can support the person by speaking with them, showing sensitivity, humility and respect for the patient’s wishes. A few examples of the patients’ need for information or practical support emerged. The nurse can emotionally support the person who is crying by just being present, confirming, showing empathy, offering a chance to talk and showing respect for their individual needs and the different ways they may cry.
Physiotherapy as a first point of contact in general practice: a solution to a growing problem?
- Rob W. Goodwin, Paul A. Hendrick
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- Published online by Cambridge University Press:
- 06 June 2016, pp. 489-502
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Aim
To evaluate the clinical effectiveness, patient satisfaction and economic efficacy of a physiotherapy service providing musculoskeletal care, as an alternative to GP care.
BackgroundThere is a growing demand on general practice resources. A novel ‘1st Line Physiotherapy Service’ was evaluated in two GP practices (inner city practice, university practice). Physiotherapy, as a first point of contact, was provided as an alternative to GP care for patients with musculoskeletal complaints.
ParticipantsA convenience cohort sample of over 500 patients with a musculoskeletal complaint was assessed within the physiotherapy service. For the economic evaluation a cohort of 100 GP patients was retrospectively reviewed.
MethodClinical outcome measures were collected at assessment, one and six months following assessment. Patient satisfaction was collected at assessment. An economic evaluation was undertaken on the physiotherapy cohort of patients and compared to a retrospective cohort of patients (n=100) seen by a GP. This evaluation considered only the health care perspective (primary and secondary care). Societal issues such as absence from employment were not considered.
ResultsThere were no adverse events associated with the physiotherapy service. Patients reported high levels of satisfaction with the physiotherapy service. Patients managed within the 1st Line Physiotherapy Service demonstrated clinical improvements (EQ-5D-5L, Global Rating of Change) at the six-month point. There was a statistically significant difference in favour of the physiotherapy groups using a non-parametric bootstrap test; inner city practice, mean difference in costs=£538.01 (P =0.006; 95% CI; £865.678, £226.98), university practice mean difference in costs=£295.83 (P=0.044; 95% CI; £585.16, £83.69).
ConclusionThe limitations of this pragmatic service evaluation are acknowledged. Nevertheless, the physiotherapy service appears to provide a safe and efficacious service. The service is well received by patients. There appear to be potential financial implications to the health economy. Physiotherapists, as a first point of contact for patients with musculoskeletal-related complaints, could contribute to the current challenges faced in primary care.
Training mid-level health cadres to improve health service delivery in rural Bangladesh
- Lal B. Rawal, Kawkab Mahmud, Sheikh Md. S. Islam, Rashidul A. Mahumud, Md. Nuruzaman, Syed M. Ahmed
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- Published online by Cambridge University Press:
- 31 March 2016, pp. 503-513
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Introduction
In recent years, the government of Bangladesh has encouraged private sector involvement in producing mid-level health cadres including Medical Assistants (MAs). The number of MAs produced has increased significantly. We assessed students’ characteristics, educational services, competencies and perceived attitudes towards health service delivery in rural areas.
MethodsWe used a mixed method approach using quantitative (questionnaire survey) and qualitative (key informant interviews and roundtable discussion) methods. Altogether, five public schools with 238 students and 30 private schools with 732 students were included. Statistical analyses were performed using STATA v-12. Qualitative data were analyzed thematically.
FindingsThe majority of the students in both public (66%) and private medical assistant training schools (MATS) (61%) were from rural backgrounds. They spent the majority of their time in classroom learning (public 45% versus private 42%) and the written essay exam was the common form of a students’ performance assessment. Compared with students of public MATS, students of private MATS were more confident in different aspects of educational areas, including managing emerging health needs (P<0.001); evidence-based practice (P=0.002); critical thinking and problem solving (P=0.02), and use of IT/computer skills (P<0.001). Students were aware of not having adequate facilities in rural areas (public 71%, private 65%), but they perceived working in rural areas will offer several benefits, including use of learnt skills; friendly rural people; and opportunities for real-life problem solving, etc.
ConclusionThis study provides a current picture of MATS students’ characteristics, educational services, competencies and perception towards working in rural areas. The MA students in both private and public sectors showed a greater level of willingness to serve in rural health facilities. The results are promising to improve health service delivery, particularly in rural and hard-to-reach areas of Bangladesh.
Tobacco use and self-reported morbidity among rural Indian adults
- Anamitra Barik, Rajesh Kumar Rai, Abhijit Chowdhury
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- Published online by Cambridge University Press:
- 21 April 2016, pp. 514-523
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Aim
To measure the prevalence of self-reported morbidity and its associated factors among adults (aged ⩾15 years) in a select rural Indian population.
BackgroundSelf-reporting of smoking has been validated as population-based surveys using self-reported data provide reasonably consistent estimates of smoking prevalence, and are generally considered to be sufficiently accurate for tracking the general pattern of morbidity associated with tobacco use in populations. However, to gauge the true disease burden using self-reported morbidity data requires cautious interpretation.
MethodsDuring 2010–2011, a cross-sectional survey was conducted under the banner of the Health and Demographic Surveillance System, Birbhum, an initiative of the Department of Health and Family Welfare, Government of West Bengal, India. With over 93.6% response rate from the population living in 12 300 households, this study uses the responses from 16 354 individuals: 8012 smokers, and 8333 smokeless tobacco users. Smokers and smokeless tobacco users were asked whether they have developed any morbidity symptoms due to smoking, or smokeless tobacco use. Bivariate, as well as multivariate logistic regression analyses were deployed to attain the study objective.
FindingsOver 20% of smokers and over 9% of smokeless tobacco users reported any morbidity. Odds ratio (OR) with 95% confidence interval (CI) estimated using logistic regression shows that women are less likely to report any morbidity attributable to smoking (OR: 0.69; CI: 0.54–0.87), and more likely to report any morbidity due to smokeless tobacco use (OR: 1.68; CI: 1.36–2.09). Non-Hindus have higher odds, whereas the wealthiest respondents have lower odds of reporting any morbidity. With a culturally appropriate intervention to change behaviour, youth (both men and women) could be targeted with comprehensive tobacco cessation assistance programmes. A focussed intervention could be designed for unprocessed tobacco users to curb hazardous effects of tobacco use.
Short Report
Quantification of diabetes consultations by the main primary health care nurse groups in Auckland, New Zealand
- Barbara Daly, Bruce Arroll, Nicolette Sheridan, Timothy Kenealy, Robert Scragg
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- Published online by Cambridge University Press:
- 08 January 2016, pp. 524-529
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Background: Diabetes prevalence continues to increase, with most diabetes patients managed in primary care. Aim: This report quantifies the number of diabetes consultations undertaken by primary healthcare nurses in Auckland, New Zealand. Methods: Of 335 primary healthcare nurses randomly selected, 287 (86%) completed a telephone interview in 2006–2008. Findings: On a randomly sampled day (from the past seven) for each nurse, 42% of the nurses surveyed (n=120) consulted 308 diabetes patients. From the proportion of nurses sampled in the study, it is calculated that the number of diabetes patients consulted by primary healthcare nurses per week in Auckland between September 2006 and February 2008 was 4210, with 61% consulted by practice, 23% by specialist and 16% by district nurses. These findings show that practice nurses carry out the largest number of community diabetes consultations by nurses. Their major contribution needs to be incorporated into future planning of the community management of diabetes.