Primary Care

Primary Care

  • Clare M Carolan added an answer:
    What are the barriers and facilitators to reporting errors in primary care?

    Patient safety reporting systems despite their limitations are great source of deriving insights into the delivery of safer care. Over the last 10 years, the national reporting and learning system has accrued over 10 million reports of patient safety incidents in England and Wales; most are from hospitals. Why does primary care especially in general practice lag behind?

    Clare M Carolan · University of Stirling

    Hi,

    I’m not entirely familiar with the patient safety initiative and the process of error reporting in England & Wales but I would envisage that GPs utilise SEAs within practice as their primary mechanism for reporting errors, i.e. local reporting mechanisms. Could it be that there is a perception the current national system is not responsive to the needs of primary care and hence why it is not used?

    It might be worthwhile comparing and contrasting the approach to patient safety in Scotland administered via the Scottish Patient Safety Programme (SSPS).  See http://www.scottishpatientsafetyprogramme.scot.nhs.uk/about-us or contact them to discuss further.

    Also Paul Bowie and Carl de Wet have just published a very comprehensive text  'Safety and Improvement in Primary Care' which might provide further insights.

    See http://www.amazon.co.uk/Safety-Improvement-Primary-Care-Essential/dp/1846195802

  • Yacov Fogelman added an answer:
    What are the best indicators to use when assessing safe opioid prescribing in a primary care chart review?

    I would like to start some research on whether primary care opioid prescribing for chronic non-cancer pain meets current guidelines, especially for patient safety. There are too many recommendations in our guidelines to use all of them, some are more/less important, and some are difficult to operationalize for a chart review or ongoing quality improvement.  I have seen some initial work on quality/safety indicators for opioid prescribing by others in unpublished and grey literature.  Does anyone know which would be the best to use, and where/how this is being measured?

    Yacov Fogelman · Technion - Israel Institute of Technology

    I liked Vahid presenting  "opioid risk tool' .Patients with anxiety or depression are more likely than others to have opioids prescribed, yet have less analgesic benefit, are more prone to medication misuse, and are more likely to use psychoactive drugs. A few studies have suggested that lifestyle factors such as smoking and obesity are predictors of opioid misuse or early opioid prescriptions for pain. Certain opioid prescribing patterns raise important safety concerns. For example, co-prescribing of opioids and benzodiazepines is recognized as a risk for unintentional overdose and death , but the frequency of such prescribing in routine care is not well characterized.

    Given these uncertainties, it is important to better understand which patients are most likely to receive opioids and whether certain patient characteristics are associated with long-term use. There is also a need for better data on related health services consumption and patient safety concerns (such as co-prescription of sedative-hypnotics),.In my view as a family physician with unofficial subspecialty in pain medicine this latter group of patients are at risk and should be reassessed by their primary care provider.

  • Should we routinely screen for depression?

    Depression is a mood disorder that affects the way a person feels, thinks or behaves, which may impair social or occupational functioning, also depression is common in primary care and hospital settings, but it is often not recognised by healthcare professionals. Because depression is potentially treatable, there has been interest in screening patients who present to primary care settings. This has led to calls for screening programmes to aid detection and management.
    Multiple recommendations for clinicians for screening for depression in adults have been published. But the existing evidence on depression screening recommendations are far from unanimously accepted.

    Sheikh Mohammed Shariful Islam · Ludwig-Maximilian-University of Munich

    Depression should be screened routinely in primary care especially for those suffering from chronic conditions like diabetes, cardiovascular diseases, cancers and other diseases. Simple and easy tools are available that primary care physicians and trained nurses can use such as patient health questionnaire-9 (PHQ-9).

  • What are the most reliable measures (indicators) of treatment adherence in metabolic syndrome?
    We are looking at predicting adherence to medical and behavioral health care recommendations among individuals with metabolic syndrome. I'm curious if anyone might be able to provide personal insight into specific indicators (behavioral or otherwise) that have been effective/reliable in quantifying the construct of treatment adherence?
    Sheikh Mohammed Shariful Islam · Ludwig-Maximilian-University of Munich

    We used Morisky's 8 scale medication adherence tool to measure adherence among patients with type 2 diabetes in Bangladesh. It is a easy tool to use in clinical and research settings.

  • Gerrit J Hiddink added an answer:
    Professional performance of PNs in lifestyle counselling in primary care practice in your country?

    Tasks and professional performance of PNs in lifestyle counselling in primary care practice will be different per country, I suppose. What about your country?

    Gerrit J Hiddink · Wageningen University

    The abbreviation PNs means Practice Nurses

  • Chai Eng Tan added an answer:
    How does nursing home care to elderly patients living in their own homes work?
    I´m a spanish primary care nurse and I'm interested in how nursing home care to elderly patients living in their own homes works in different countries.
    I appreciate your information.
    Chai Eng Tan · Hospital Universiti Kebangsaan Malaysia (HUKM)

    For the first question:

    The plan for domiciliary care under the Ministry of Health Malaysia is to be executed by the primary care team (currently being piloted in several states before nationwide implementation).  Postnatal home visits have been long established by the maternal and child health section of the public primary care clinics.  I am also a family medicine specialist who happens to have an interest in home care, and thus, am working together with the nurses to develop the service further.  In Singapore, it is also run by the Family Medicine / primary care unit. 

     

    For the second question:

    For the home care service offered by the teaching hospital I'm working in, patients referred to us are patients who have reasonable logistic difficulty to come to the hospital / clinic for nursing procedures, staying within the catchment area, and agreeable to the terms of service.  These include stroke patients, patients with spinal cord injuries, cerebral palsy, diabetic foot ulcers, post-amputation etc. 

     

    For the third question:

    Services offered are nursing procedures such as changing Ryle's tube, changing urinary catheters and suprapubic catheters, wound dressing, caregiver education and monitoring of blood pressure and capillary blood glucose.  We are working to extend our services and now we include doctors doing house calls for complex cases, and in future may coordinate with rehabilitation or dietetic services.  However, due to logistics, it is still very challenging to coordinate services from various other departments.  Our services are partially subsidized as our teaching hospital is under the purvey of the Ministry of Education, whereas clinics under teh Ministry of Health offer their services at an even more highly subsidized rates.  We don't have the facility for telemonitoring at the moment.  So I do envy the Australians as described by Ms Franks above. 

  • William R Hazzard added an answer:
    Who should treat elderly patients in a community? Their primary care physician or a specialist in geriatrics?
    Geriatric medicine is a distinct medical specialty with vast specific knowledge accumulated over the last 30 years. On the other side most present primary care community physicians have not been exposed to systematic geriatric education. How could this gap be bridged?
    William R Hazzard · Wake Forest School of Medicine

    To Jenice in particular (but all who may read this): Thanks for your efforts within the hard-working, futuristic (but currently much maligned) VA, where I worked as director of Geriatrics & Extended Care ar VA Puget Sound from 2000-2010): I could not agree more. I would only suggest substitution of  "gerontologize" for "geriatricize". Gerontologize rolls off the tongue more easliy, plus it encompasses all we do and know as a scientific discipline that studies and values life from conception through death as well as caring for those nearing the end of their lives. Good luck! Bill

  • Terry Richmond added an answer:
    Do you have any information on successful implementations of fall-prevention strategies in your country?
    We will be looking at the implementation of the fall-prevention strategies in the acute sector, primary care and nursing homes.
    Terry Richmond · Kingston General Hospital

    Daily mobility assessments and falls risk assessments by nursing staff .Identification of falls risk patients with use of falling star logos.Daily walking program by 2 personal care assistants on all patients over 65yrs admitted to medicine program that come from home,retirement home or rehab.Frequent audits.Daily discussuins of mobility status and falls risk at board rounds. 

  • Are there any review articles on integration of sleep medicine in a primary care setting?
    There are several studies on integrating mental health services in primary care. I am interested in integrating sleep medicine services in a primary care setting.
    Pandi-Perumal Seithikurippu Ratnas · Somnogen Canada Inc
    Here is the first edition of Primary Care Sleep Medicine:

    http://link.springer.com/book/10.1007%2F978-1-59745-421-6

    Second edition will be released in few months!
  • Orgenes E. Lema asked a question:
    Is there any evidence of link between banned cosmetics use and maternal mortality?
    The world is struggling with MDG 5. In developing countries like Tanzania, a comprehensive strategy has been put in place during the last 20 years involving many aspects such as family planning, education to prevent teenage pregnancies, focused antenatal care (where up to 95% of pregnant mothers attend antenatal care), increasing skilled labour attendance (over 51% of all deliveries now attended by trained midwife), addressing PPH (use of misoprostol) and even training on post abortion care. Despite the efforts, the reduction in maternal mortality does not seem to match achievements in the implementation of these interventions and overall improvement on the services. Furthermore, in urban settings, we still see a number of unexplainable maternal mortalities despite readily availability of the services provides through these national interventions. Thre is political will and even our President is now tasking Regional and District Administrative Officers to investigate the maternal deaths. Obviously, it is time to think beyond the box. Is there any evidence that exposure to dangerous chemicals such as mercury compunds, triclosan, lead acetate, phthalates, oxybenzene, etc via persistent use of banned prodiucts e.g. food, cosmetics etc contribute to maternal mortality? Would a survey to attempt to establish the relationship (if it exists) be useful?
  • Aoife Lawton added an answer:
    What are the visual, clinical and verbal barriers and facilitators to disclosure of domestic violence in a primary care setting?
    I'm looking for research around patient engagement in primary care - GP setting. Specifically around domestic violence discovery and disclosure.
    Aoife Lawton · Health Service Executive
    Dear Daniel and Jeanettte, the author has now published her Thesis.
    I thought you might be interested in it. It is openly accessible in our repository, available at http://www.lenus.ie/hse/handle/10147/316150
  • Paul Silverston added an answer:
    Protocols or 'gut feeling' for safe assessement of apparently minor illnesses?
    Silverston's timely and excellent article refocuses the attention, in minor illness consultations, on excluding and/or safety netting for the unexpected serious illness, presenting before classical signs and symptoms have developed.He emphasises the importance of taking 'vital signs' observations including pulse oximetry. Diagnosis is often described as a art as well as a science, which I take to mean a certain amount of tacit experience and 'gut instinct' is involved.How do we strike a balance between objectively reassuring signs , and an instinct, either in the clinician or the patient or carer, that "something isn't right" ? Should we now abandon 'instinct' and rely only on signs and protocols? Or should we use instinct as an additional positive predictor, whilst no longer relying on it as a negative predictor of serious illness?
    Paul Silverston · Anglia Ruskin University
    Indeed. The problem is that it takes time to hone one's antennae, both in terms of acquiring the knowledge base and through clinical experience, so algorithmic responses are easier to teach and there are fewer "grey" areas in clinical decision-making as a result. Whilst medicine may be hard to practice, it is no less hard to teach!
  • Tim Noonan added an answer:
    Are you familiar with the notion of complementary and alternative medicine more than conventional primary care?
    Conventional medicine prides itself on being science-based, and shuns alternative medicine for being "unproven," however, many of the non-communicable diseases have been taken care of successfully by alternative medicine. Conventional medicine is still behind and it will send your health into a downward spiral.
    Tim Noonan · STAT Medical Transport
    "Eg desferrioxamine has been around for about 48 years as an iron chelator, I would consider that safe and effective (not withstanding, as with all drugs there can be side effects)."

    That is not evidence of safety or efficacy.

    Please provide some valid evidence.

    The macrolide antibiotics have been around for decades, which would be evidence of safety and efficacy according to your earlier mentioned standard.

    I have been critical of the rampant use of antibiotics, but they remain popular. The side effects are not really new.

    This is why we need to have high standards for evidence. Too many treatments are used without good evidence that the treatment is better than a similar drug with a better safety profile.

    Again, we need to raise our standards, not lower them.

    "I could go on, but I think it is incumbent upon all of us to be open minded and not follow slavishly."

    Why should we open our minds - if that means endangering our patients with treatments that are not safe and do not work?

    "We need to use what works, and saying a treatment does not work because it is a CAM is not an accurate statement."

    Here is what I wrote. If you want to quote me, go ahead, but do not make up statements that I did not make.

    "I include everything that does not have evidence of safety and efficacy - efficacy of improved outcomes that matter, not just surrogate endpoint outcomes.

    I hold alternative medicine to the same standard, but there does not appear to be anything of benefit to patients from alternative medicine."

    CAM is not useless because it is CAM, it is useless because there is no evidence that it works. Provide valid evidence and I will change my mind about any particular treatment that has valid evidence that it improves outcomes.

    If we cannot have an honest discussion among ourselves, how can our patients expect us to be honest with them?

    :-)
  • Ravi Managuli asked a question:
    Point of care ultrasound - any thoughts?
    Point of care ultrasound is a buzzword these days especially due to low-cost hand held (tablet/smartphone-based) ultrasound systems being available in the market. ER is one example of point-of-care. Are primary care physicians using ultrasound in their routine exams? Are they willing to perform exam even if there is no reimbursement just for the benefit of patients?
  • Susan Walker asked a question:
    Has extending general practice opening hours beyond a normal 'working week' i.e. 8-6pm Monday to Friday, 9-12 Saturday been shown to improve care?
    The UK government is experimenting with encouraging General Practitioners to extend their surgery hours beyond the normal working week to improve access and quality of care. Whilst this may improve access for the employed, I am sceptical about whether it will improve quality of care, or access, for those who are least well resourced or most in need. Does anyone know of any high quality studies which have looked at this? I am especially interested in how 'quality of care' might be operationalised in this context. Any thoughts, opinions or personal experiences would also be welcome.
  • Patricia Grace-Farfaglia added an answer:
    How are EHRs influencing the safety of ambulatory care?
    Positively? Negatively? What is the evidence? What works? What doesn't? What is inspirational? What is a hazard? How do we know and what evidence do we have? If we don't have the evidence, how should we get it?
    Patricia Grace-Farfaglia · University of Connecticut
    I found your question intriguing. I was an EPIC software trainer and Go Live support consultant for an implementation in Connecticut in 2012. I found the experience exhausting, but I learned so much about the impact of data on patient management. One role I had was enforcer for the medication & problem list (meaningful use criteria) for admission, transfer to a new unit, and discharge. This required cooperation between the patient/family, ER, resident, nursing, and the physician of record's office. Our physician offices were the first to adopt EPIC. Once the whole suite of modules went live, it required rethinking the CPOE screens and workflow of patient care. Much of this occurred in real-time. You could not discharge a patient from the system without medication review and sign-off. Since that was a new practice, it led to many instances where my diplomatic skills were put to the test. But to the credit of the organization, we had an abundance of experienced support personnel 24/7 for the first 2 months to decrease any impact on patient safety. If you want to do a study, the EPIC trainers would be a good group for a qualitative interview. Many of them have been part of the training and implementation for several healthcare systems. You can find them on LinkedIn...a great source for a purposeful sample. For the large hospital systems with affiliate physician practices, the data you seek for a patient safety study can be de-identified and made available. Our medical center at UCONN has already started putting some data into RedCap (web based research database) and R2D2 (research registry and d-identified database).
  • David Palacios-Martínez added an answer:
    Somebody knows anything about BIT´s annual world congress of endobolism (http://www.bitlifesciences.com/wce2014/)?
    I have been invited as a speaker. I have previously participated as a speaker at Spanish and international conferences, but never before in a conference in Asia or paying for being a speaker. Has anybody had any experience about this conference or this organizer? Thanks you all.
    David Palacios-Martínez · Comunidad de Madrid
    Hi Mrs Gade,
    I have not found any significant aditional information about BIT´s annual world congress of endobolism 2014. It seems to be a new conference.
    Sincerely,
    David.
  • Marsha Green added an answer:
    Does anyone know of good papers regarding implementation of clinical decision support systems in primary care?
    Looking at good (and bad!) examples of successful CDSS implementation in primary care/general practice
    Marsha Green · College of St. Scholastica
    Take a look at the Institute for Clinical Systems Improvement (ICSI) website - this is a collaborative program which conducts process improvement/standardization/protocols focused on delivering guidelines for multiple clinical topics that are related to primary care.
  • Rodney P Jones added an answer:
    Does a long time series of deaths in Scotland shed light on what is happening in urgent care?
    Analysis of a time series of monthly deaths in Scotland from 1990 to 2012 shows evidence for a series of infectious like events which also appear to be linked to increases in ED attendance, medical admissions and a wobble in the gender ratio.

    http://www.bmijournal.org/index.php/bmi/article/viewFile/167/117

    Is this the missing piece of information explaining what is happening in urgent health care?

    Your comments and thoughts would be welcome.
    Rodney P Jones · Healthcare Analysis & Forecasting, Camberley, UK
    Have submitted some more work which suggests that the transmission of the agent reaches a minimum in the summer suggesting Vitamin D is of vital importance. This is somewhat timely given the explosion of studies demonstrating the beneficial effects of vitamin D against mortality and morbidity. So until we can all come up with a better solution (immunization or low cost anti-viral) vitamin D for the elderly seems a sensible first step.
  • Fernando A. Alonso López added an answer:
    Can someone tell me how or if they are incorporating Spirometry in their primary care offices?
    HEDIS guidelines require us to do Spirometry to gauge the severity of COPD, preferably when the patient is not suffering an acute exacerbation. Would someone share with me how they are addressing that guideline?
    Fernando A. Alonso López · Servicio Cántabro de Salud
    We have 2 nurses with skills about spirometry to make all our health center need. Using an spirometer and calibration bubble all the weeks
  • Aziz Sheikh added an answer:
    How can we improve patient's safety in the Middle East Region?
    The incidence of preventable adverse events, errors and near misses is relatively high in developing countries. Can you share some successful programs to improve patient's safety by improving systems?
    Aziz Sheikh · The University of Edinburgh
    You may find it useful to take a look at this recent paper on global safety priorities for primary care: http://www.ncbi.nlm.nih.gov/pubmed/24260028
  • Joanne Pike added an answer:
    Are you aware of exemplar models of community based primary health care and/or integrated models of care for older adults with multimorbidities?
    I'm particularly interested in models that span multiple health and/or social care sectors.
    Joanne Pike · Glyndwr University
    Here in Wales we have a case management approach, whereby District Nurses and Case managers (nurses with an advanced practice qualification - at Masters level) work within an intergrated team. But there are many variations of this still, and it is an evolving service. The services are targeted at those living at home with multiple morbidities. The model is a development of the 'Evercare' or Kaiser Permenante model. Try this address for the strategic approach being taken. I know it's dated, but there have been progress reports published on the net.
    http://www.wales.nhs.uk/documents/serviceplane.pdf
  • James Harris added an answer:
    Can someone send me the the beck anxiety inventory for primary care 7 item self report instrument?
    Typically a 7 item self-report instrument
    James Harris · University of Phoenix
    David,

    Many Thanks! Have a good weekend; best, James
  • George Dowswell added an answer:
    Sexual dysfunction following cancer and cancer treatment: European perspectives on primary care service provision?
    I suspect that there's lots of good practice across Europe but that it is not being translated between settings and healthcare systems. Is anyone working on improving primary care diagnosis and treatment of sexual dysfunction? There are networks for primary care, cancer, sexual dysfunction but what about a network for primary care identification and treatment of sexual dysfunction following cancer?

    Such a network could engage clinicians from primary, secondary and tertiary care, not only with an interest in cancer, academics from a range of disciplines, patients and patient groups, policy makers.
    George Dowswell · University of Birmingham
    Thank you - Yesterday someone mentioned to me that HTA had funded a study at UCL so I really appreciate your helpful message - I was going to chase this up when I had found out a little more. You've made it easy now. George
  • Rahul Alam added an answer:
    How can I obtain GP/PALS/PCT/CCG complaints data?
    Has anyone had any experience in trying to obtain patient level complaints data from any of the above organisations?
    Rahul Alam · The University of Manchester
    Hi,

    That's really helpful - thank you. I'll pursue both these avenues.
    Many thanks again.
    Rahul Alam
  • Ezequiel R. Rodriguez Rey added an answer:
    How widespread is the trend to higher emergency department attendances?
    There has been recent alarm in the UK regarding a rapid increase in ED attendances which I suspect is far wider than just the UK. Any observations from elsewhere in the world?
  • Helena Britt added an answer:
    What are your thoughts on using computer aided diagnosis/differential diagnosis generators (DDx) - Patient net or SkyNet?
    Do clinicians routinely use differential diagnosis generators in primary/secondary care? We are undertaking a systematic literature review of their utility and trying to ascertain their feasability in UK General practice. Are they likely to be helpful or be a hindrance?
    Helena Britt · University of Sydney
    Dobn;t use them in Aus. Select a term from an interface terminology, whihc may be differential. Proivding a list of terms used by GPs is more frutiful thatn generating differential diagnoses in my view.
  • Juan M Mendive asked a question:
    Primary prevention of depression - can anyone help?
    Primary care environment to prevent depression from opportunistic approach. What is the quality of life implication of that?

About Primary Care

The primary research focus is on the prevention, early diagnosis and management of common illness in general practice - particularly childhood infection, cancer, cardiovascular disease and stroke. Primary care has recently developed a new stream of clinical research which seeks to improve the conceptual understanding and effectiveness of early and more reliable diagnosis and monitoring in a number of chronic diseases. The primary aim is that Primary care has an international reputation for developing innovative methods of research synthesis and research use to ensure that research findings change clinical practice.

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