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Lord, Bill, Emily Andrew, Amanda Henderson, David J. Anderson, Karen Smith, and Stephen Bernard. "Palliative care in paramedic practice: A retrospective cohort study." Palliative Medicine 33, no. 4 (February 5, 2019): 445–51. http://dx.doi.org/10.1177/0269216319828278.
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Background: Paramedics may be involved in the care of patients experiencing a health crisis associated with palliative care. However, little is known about the paramedic’s role in the care of these patients. Aim: To describe the incidence and nature of cases attended by paramedics and the care provided where the reason for attendance was associated with a history of palliative care. Design: This is a retrospective cohort study. Setting/participants: Adult patients (aged >17 years) attended by paramedics in the Australian state of Victoria between 1 July 2015 and 30 June 2016 where terms associated with palliative care or end of life were recorded in the patient care record. Secondary transfers including inter-hospital transport cases were excluded. Results: A total of 4348 cases met inclusion criteria. Median age was 74 years (interquartile range 64–83). The most common paramedic assessments were ‘respiratory’ (20.1%), ‘pain’ (15.8%) and ‘deceased’ (7.9%); 74.4% ( n = 3237) were transported, with the most common destination being a hospital (99.5%, n = 3221). Of those with pain as the primary impression, 359 (53.9%) received an analgesic, morphine, fentanyl or methoxyflurane, and 356 (99.2%) were transported following analgesic administration. Resuscitation was attempted in 98 (29.1%) of the 337 cases coded as cardiac arrest. Among non-transported cases, there were 105 (9.6%) cases where paramedics re-attended the patient within 24 h of the previous attendance. Conclusion: Paramedics have a significant role in caring for patients receiving palliative care. These results should inform the design of integrated systems of care that involve ambulance services in the planning and delivery of community-based palliative care.
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Mitra, Biswadev, Stephen Bernard, Dashiell Gantner, Brian Burns, Michael C. Reade, Lynnette Murray, Tony Trapani, et al. "Protocol for a multicentre prehospital randomised controlled trial investigating tranexamic acid in severe trauma: the PATCH-Trauma trial." BMJ Open 11, no. 3 (March 2021): e046522. http://dx.doi.org/10.1136/bmjopen-2020-046522.
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IntroductionHaemorrhage causes most preventable prehospital trauma deaths and about a third of in-hospital trauma deaths. Tranexamic acid (TXA), administered soon after hospital arrival in certain trauma systems, is an effective therapy in preventing or managing acute traumatic coagulopathy. However, delayed administration of TXA appears to be ineffective or harmful. The effectiveness of prehospital TXA, incidence of thrombotic complications, benefit versus risk in advanced trauma systems and the mechanism of benefit remain uncertain.Methods and analysisThe Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (The PATCH-Trauma study) is comparing TXA, initiated prehospital and continued in hospital over 8 hours, with placebo in patients with severe trauma at risk of acute traumatic coagulopathy. We present the trial protocol and an overview of the statistical analysis plan. There will be 1316 patients recruited by prehospital clinicians in Australia, New Zealand and Germany. The primary outcome will be the eight-level Glasgow Outcome Scale Extended (GOSE) at 6 months after injury, dichotomised to favourable (GOSE 5–8) and unfavourable (GOSE 1–4) outcomes, analysed using an intention-to-treat (ITT) approach. Secondary outcomes will include mortality at hospital discharge and at 6 months, blood product usage, quality of life and the incidence of predefined adverse events.Ethics and disseminationThe study was approved by The Alfred Hospital Research and Ethics Committee in Victoria and also approved in New South Wales, Queensland, South Australia, Tasmania and the Northern Territory. In New Zealand, Northern A Health and Disability Ethics Committee provided approval. In Germany, Witten/Herdecke University has provided ethics approval. The PATCH-Trauma study aims to provide definitive evidence of the effectiveness of prehospital TXA, when used in conjunction with current advanced trauma care, in improving outcomes after severe injury.Trial registration numberNCT02187120.
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Armstrong, Brent, Odette Levesque, Jonathan B. Perlin, Cathy Rick, and Gordon Schectman. "Reinventing Veterans Health Administration: Focus on Primary Care." Journal of Healthcare Management 50, no. 6 (November 2005): 399–409. http://dx.doi.org/10.1097/00115514-200511000-00009.
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Post, Edward P., and William W. Van Stone. "Veterans Health Administration Primary Care-Mental Health Integration Initiative." North Carolina Medical Journal 69, no. 1 (January 2008): 49–52. http://dx.doi.org/10.18043/ncm.69.1.49.
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Vedsted, Peter, David Weller, Alina Zalounina Falborg, Henry Jensen, Jatinderpal Kalsi, David Brewster, Yulan Lin, et al. "Diagnostic pathways for breast cancer in 10 International Cancer Benchmarking Partnership (ICBP) jurisdictions: an international comparative cohort study based on questionnaire and registry data." BMJ Open 12, no. 12 (December 2022): e059669. http://dx.doi.org/10.1136/bmjopen-2021-059669.
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ObjectivesA growing body of evidence suggests longer time between symptom onset and start of treatment affects breast cancer prognosis. To explore this association, the International Cancer Benchmarking Partnership Module 4 examined differences in breast cancer diagnostic pathways in 10 jurisdictions across Australia, Canada, Denmark, Norway, Sweden and the UK.SettingPrimary care in 10 jurisdictions.ParticipantData were collated from 3471 women aged >40 diagnosed for the first time with breast cancer and surveyed between 2013 and 2015. Data were supplemented by feedback from their primary care physicians (PCPs), cancer treatment specialists and available registry data.Primary and secondary outcome measuresPatient, primary care, diagnostic and treatment intervals.ResultsOverall, 56% of women reported symptoms to primary care, with 66% first noticing lumps or breast changes. PCPs reported 77% presented with symptoms, of whom 81% were urgently referred with suspicion of cancer (ranging from 62% to 92%; Norway and Victoria). Ranges for median patient, primary care and diagnostic intervals (days) for symptomatic patients were 3–29 (Denmark and Sweden), 0–20 (seven jurisdictions and Ontario) and 8–29 (Denmark and Wales). Ranges for median treatment and total intervals (days) for all patients were 15–39 (Norway, Victoria and Manitoba) and 4–78 days (Sweden, Victoria and Ontario). The 10% longest waits ranged between 101 and 209 days (Sweden and Ontario).ConclusionsLarge international differences in breast cancer diagnostic pathways exist, suggesting some jurisdictions develop more effective strategies to optimise pathways and reduce time intervals. Targeted awareness interventions could also facilitate more timely diagnosis of breast cancer.
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SUTHERLAND, Georgina, Jane YELLAND, Jan WIEBE, Jennifer KELLY, Penny MARLOWE, and Stephanie BROWN. "Role of general practitioners in primary maternity care in South Australia and Victoria." Australian and New Zealand Journal of Obstetrics and Gynaecology 49, no. 6 (December 2009): 637–41. http://dx.doi.org/10.1111/j.1479-828x.2009.01078.x.
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Reid, Robert J., and Edward H. Wagner. "The Veterans Health Administration Patient Aligned Care Teams: Lessons in Primary Care Transformation." Journal of General Internal Medicine 29, S2 (April 9, 2014): 552–54. http://dx.doi.org/10.1007/s11606-014-2827-8.
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Laing, Angus, Gordon Marnoch, Lorna McKee, Rita Joshi, and John Reid. "Administration to innovation: the evolving management challenge in primary care." Journal of Management in Medicine 11, no. 2 (April 1997): 71–87. http://dx.doi.org/10.1108/02689239710177701.
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Newman, D. "Maritime Pre-Hospital Emergency Care Primary Retrieval Team – Operational Considerations." Journal of The Royal Naval Medical Service 98, no. 1 (March 2012): 16–18. http://dx.doi.org/10.1136/jrnms-98-16.
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AbstractThis article examines the non clinical skills and training required for effective maritime pre-hospital emergency care provision within a Role Two Afloat facility, allowing for a Primary Retrieval Team to be deployed in support of boarding operations. The provision of pre-hospital emergency care and sending a retrieval team forward has been trialled in various forms. In 2010 and 2011 a R2A team was deployed aboard RFA FORT VICTORIA. This included a Primary Retrieval Team consisting of an Emergency Nurse Specialist, a Medical Assistant which can be enhanced when required by an Emergency Care or Anaesthetic Consultant. This differs from the land operations support provided by the airborne Medical Emergency Response Team (MERT) as the maritime environment requires a bespoke solution for casualty retrieval as the method of deployment and the type of casualties and their locations may be more varied, requiring greater flexibility of approach.
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Zalucki, Paula M. "PRACTITIONER APPLICATION: Reinventing Veterans Health Administration: Focus on Primary Care." Journal of Healthcare Management 50, no. 6 (November 2005): 409. http://dx.doi.org/10.1097/00115514-200511000-00010.
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Gutierrez, Jennifer C., Christian Terwiesch, Amy R. Pettit, and Steven C. Marcus. "Characterizing Primary Care Visit Activities at Veterans Health Administration Clinics1." Journal of Healthcare Management 60, no. 1 (January 2015): 30–42. http://dx.doi.org/10.1097/00115514-201501000-00007.
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Hollier, K., and A. Jennings. "Improving Cardiovascular Care in Rural Victoria: Primary Health Nurses a Vital Link in the Chain." Heart, Lung and Circulation 27 (2018): S384—S385. http://dx.doi.org/10.1016/j.hlc.2018.06.768.
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Reddy, Ashok, Karin M. Nelson, and Edwin S. Wong. "Primary Care Spending in the Veterans Health Administration in 2014 and 2018." JAMA Network Open 4, no. 7 (July 19, 2021): e2117533. http://dx.doi.org/10.1001/jamanetworkopen.2021.17533.
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Cucciare, Michael A., Nicole Ketroser, Paula Wilbourne, Amanda M. Midboe, Ruth Cronkite, Steven M. Berg-Smith, and John Chardos. "Teaching Motivational Interviewing to Primary Care Staff in the Veterans Health Administration." Journal of General Internal Medicine 27, no. 8 (February 28, 2012): 953–61. http://dx.doi.org/10.1007/s11606-012-2016-6.
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Saleem, Fatema, Aalaa Ahmed, Eman Sayed Faisal, Khatoon Abdulhadi, and Dr Afaf Mirza. "Knowledge and Practice of Immunization Among Primary Health Care Nurses in Bahrain." Journal of the Bahrain Medical Society 34, no. 4 (2022): 19–26. http://dx.doi.org/10.26715/jbms.34_4_3.
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Background & Objectives: Nurses play an important role in delivering and advocating for vaccines in the healthcare system. Our goal was to assess the nurses’ knowledge of vaccine administration, their immunization practice, knowledge of precautions and contraindications to vaccines, and practices towards them in primary health centers in Bahrain. Methods: We conducted an observational cross-sectional study using a self-administered questionnaire. All nurses practicing in the primary health centers in Bahrain were invited to participate in the study. The questionnaire contained several statements regarding general knowledge and practice of vaccines administration and contraindications. Written consent obtained from all participants prior to study. Results: Overall knowledge of vaccine administration, practice of immunization and practice towards precautions and contraindications to vaccines were satisfactory. Although, certain areas of gaps exist. The least satisfactory result was observed in the knowledge of vaccine precautions and contraindications. Conclusion: Our study showed good immunization practice in Bahrain. However, there is a need for improvement in the area of knowledge regarding precautions and contraindications of vaccines.
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Ong, Kevin, Andrew Carroll, Shannon Reid, and Adam Deacon. "Community Outcomes of Mentally Disordered Homicide Offenders in Victoria." Australian & New Zealand Journal of Psychiatry 43, no. 8 (January 1, 2009): 775–80. http://dx.doi.org/10.1080/00048670903001976.
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Objective: The aim of the present study was to describe characteristics and post-release outcomes of Victorian homicide offenders under the Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 (and/or its forerunner legislation) released from forensic inpatient psychiatric care since the development of specialist forensic services. Method: A legal database identified subjects meeting inclusion criteria: hospitalized in forensic psychiatric care due to finding of mental impairment or unfitness to stand trial for homicide in Victoria; released into the community; and released between 1 January 1991 and 30 April 2002. Using clinical records, demographics, index offence, progress in hospital, diagnosis, psychosocial and criminological data were obtained. Outcomes (offending or readmission into secure care) were obtained from the clinical records. Results: Of the 25 subjects, 19 (76%) were male. Primary diagnoses on admission to forensic hospital care were schizophrenia, n = 16 (64%); other psychotic disorder, n = 5 (20%); depression, n = 3 (12%); and personality disorder, n = 1 (4%). Mean time in custodial supervision was 11 years and 2 months, less for those whose offence occurred after the development of forensic rehabilitation services. In the first 3 years after release, there was a single episode of criminal recidivism, representing a recidivism rate of 1 in 25 (4%) over 3 years. Twelve subjects (48%) were readmitted at some point in the 3 year follow up. Conclusion: There was a very low rate of recidivism after discharge, but readmissions to hospital were common. Lengths of custodial care were reduced after the introduction of forensic rehabilitation facilities. Recidivism is low when there are well-designed and implemented forensic community treatment programmes, consistent with other data suggesting a reciprocal relationship between safe community care and a low threshold for readmission to hospital, lessening re-offending at times of crisis. Further research should be directed at timing of release decisions, based on reducing identified risk factors to acceptable levels.
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Ker, Alex, Gloria Fraser, Antonia Lyons, Cathy Stephenson, and Theresa Fleming. "Providing gender-affirming hormone therapy through primary care: service users." Journal of Primary Health Care 12, no. 1 (2020): 72. http://dx.doi.org/10.1071/hc19040.
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ABSTRACT INTRODUCTIONPrimary health care providers are playing an increasingly important role in providing gender-affirming health care for gender diverse people. This article explores the experiences of a primary care-based pilot clinic providing gender-affirming hormone therapy in Wellington, New Zealand. AIMTo evaluate service users’ and health professionals’ experiences of a pilot clinic at Mauri Ora (Victoria University of Wellington’s Student Health and Counselling Service) that provided gender-affirming hormones through primary care. METHODSIn-depth interviews were conducted with four (out of six) service users and four health professionals about their perspectives on the clinic. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTSThree themes were identified in service users’ interviews, who discussed receiving affirming care due to the clinic’s accessibility, relationship-centred care and timeliness. Three themes were identified in the health professionals’ interviews, who described how the clinic involves partnership, affirms users’ gender and agency, and is adaptable to other primary care settings. Both service users and health professionals discussed concerns about the lack of adequate funding for primary care services and the tensions between addressing mental health needs and accessing timely care. DISCUSSIONThe experiences of service users and health professionals confirm the value of providing gender-affirming hormone therapy in primary care. Models based in primary care are likely to increase accessibility, depathologise gender diversity and reduce wait times.
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Temkin-Greener, Helena, Jill Szydlowski, Orna Intrator, Tobie Olsan, Jurgis Karuza, Xueya Cai, Shan Gao, and Suzanne M. Gillespie. "Perceived Effectiveness of Home-Based Primary Care Teams in Veterans Health Administration." Gerontologist 60, no. 3 (January 18, 2019): 494–502. http://dx.doi.org/10.1093/geront/gny174.
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Abstract Background and Objectives Previous studies have shown that staff perception of team effectiveness is related to better health outcomes in various care settings. This study focused on the Veterans Health Administration’s Home-Based Primary Care (HBPC) program. We examined variations in HBPC interdisciplinary teamwork (IDT) and identified modifiable team and program characteristics that may influence staff perceptions of team effectiveness. Research Design We used a broadly validated survey instrument to measure perceived team effectiveness, workplace conditions/resources, group culture, and respondents’ characteristics. Surveys were initiated in January and completed in July, 2016. Methods Team membership rosters (n = 249) included 2,852 IDT members. The final analytical data set included 1,403 surveys (49%) from 221 (89%) teams. A generalized estimating equation model with logit link function, weighted by survey response rates, was used to examine factors associated with perceived team effectiveness. Results Respondents who served as primary care providers (PCPs) were 8% more likely (p = .0044) to view team’s performance as highly effective compared to other team members. Teams with nurse practitioners serving as team leader reported 6% higher likelihood of high-perceived team effectiveness (p = .0234). High team effectiveness was 13% more likely in sites where the predominant culture was characterized as group/developmental, and 7%–8% more likely in sites with lower environmental stress and better resources and staffing, respectively. Conclusions and Implications Team effectiveness is an important indirect measure of HBPC teams’ function. HBPC teams should examine their predominant culture, workplace stress, resources and staffing, and PCP leadership model as part of their quality improvement efforts.
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Simmons, David. "Characteristics and blood pressure management in patients with and without diabetes in primary care in rural Victoria." Diabetes Research and Clinical Practice 81, no. 1 (July 2008): 19–24. http://dx.doi.org/10.1016/j.diabres.2008.03.007.
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Campbell, Ryan. "PRACTITIONER APPLICATION: Characterizing Primary Care Visit Activities at Veterans Health Administration Clinics1." Journal of Healthcare Management 60, no. 1 (January 2015): 43. http://dx.doi.org/10.1097/00115514-201501000-00008.
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True, Gala, Greg L. Stewart, Michelle Lampman, Mary Pelak, and Samantha L. Solimeo. "Teamwork and Delegation in Medical Homes: Primary Care Staff Perspectives in the Veterans Health Administration." Journal of General Internal Medicine 29, S2 (April 9, 2014): 632–39. http://dx.doi.org/10.1007/s11606-013-2666-z.
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Lewis, Tyler, Cristian Merchan, Diana Altshuler, and John Papadopoulos. "Safety of the Peripheral Administration of Vasopressor Agents." Journal of Intensive Care Medicine 34, no. 1 (January 11, 2017): 26–33. http://dx.doi.org/10.1177/0885066616686035.
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Vasopressors are an integral component of the management of septic shock and are traditionally given via a central venous catheter (CVC) due to the risk of tissue injury and necrosis if extravasated. However, the need for a CVC for the management of septic shock has been questioned, and the risk of extravasation and incidence of severe injury when vasopressors are given via a peripheral venous line (PVL) remains poorly defined. We performed a retrospective chart review of 202 patients who received vasopressors through a PVL. The objective was to describe the vasopressors administered peripherally, PVL size and location, the incidence of extravasation events, and the management of extravasation events. The primary vasopressors used were norepinephrine and phenylephrine. The most common PVL sites used were the forearm and antecubital fossa. The incidence of extravasation was 4%. All of the events were managed conservatively; none required an antidote or surgical management. Vasopressors were restarted at another peripheral site in 88% of the events. The incidence of extravasation was similar to prior studies. The use of a PVL for administration of vasopressors can be considered in patients with a contraindication to a CVC.
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Jones, Audrey L., Stefan G. Kertesz, Leslie R. M. Hausmann, Maria K. Mor, Ying Suo, Warren B. P. Pettey, James H. Schaefer, Adi V. Gundlapalli, and Adam J. Gordon. "Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration." Journal of Substance Abuse Treatment 113 (June 2020): 107996. http://dx.doi.org/10.1016/j.jsat.2020.02.013.
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Boyarinov, G. A., O. D. Solovyova, E. I. Yakovleva, L. V. Boyarinova, and A. V. Deryugina. "Metabolic Correction of Primary Hemostasis in the Acute Phase of Traumatic Brain Injury." General Reanimatology 17, no. 1 (February 25, 2021): 57–68. http://dx.doi.org/10.15360/1813-9779-2021-1-57-68.
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The aim of the study was to investigate the effect of ethylmethylhydroxypyridine on the ultrastructural alterations in endothelial cells of liver sinusoidal capillaries (SC) and primary hemostasis in the acute phase of traumatic brain injury (TBI).Materials and methods. Ultrastructural endothelial cell changes were studied in 36 female outbred rats in the acute phase of TBI using electron microscopy, and the platelet count was determined using a blood analyzer. The experimental group (n=18) animals received intraperitoneal injections of ethylmethylhydroxypyridine at the dose of 8.0 mg/kg per day for 12 days, and the control group (n=18) rats were administered with normal saline solution at the same dose.Results. Administration of ethylmethylhydroxypyridine in the early post TBI period reduced microvilli damage in endothelial, hepatic and stellate cells in the Disse space, whereas in the control group a significant decrease of these cells counts was detected. In contrast to the control group, the experimental group animals did not demonstrate thrombocytopenia on the days 1, 3, and 7 after injury. There was a significant increase in the platelet count compared with the baseline values, which was highest on day 12 after injury.Conclusion. Intraperitoneal administration of ethylmethylhydroxypyridine in rats in early post TBI period inhibited the TBI-associated damaging effect of secondary factors on liver sinusoid endothelial cells and platelet consumption.
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Robinson, Kerin, Mary Ell, Josephine Raw, and Dianne Simpson. "Health Workforce Planning: An Analysis of Employer Demand Pertaining to the Victorian Medical Record Administration & Diagnostic Coding Workforces." Health Information Management 24, no. 2 (June 1994): 42–51. http://dx.doi.org/10.1177/183335839402400203.
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In 1990, LaTrobe University introduced the world's first Post-Graduate Diploma in Nosology, in response to unmet demand for diagnostic coders in Victoria. After the first graduates entered employment, a two-part study was undertaken. The composition, employment levels and projected institutional demand for the coding workforce (comprising medical record administrator coders, Nosologists and “unqualified” coders) were ascertained. In parallel, the current employment levels and projected demand for the institutional medical record administrator workforce also were investigated. The institutional variables of major health care role, annual inpatient discharges and operating sector were found to impact upon employment levels and demand for both workforces by current, prospective and non-employers. The study identified a minimal projected demand for nosologists, the reasons for which are postulated, and negligible projected demand for nonqualified coding personnel. The results highlight a health current and projected employer demand for both medical record administrators and medical record administrator coders.
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Wilkinson, Anna Lee, Daniela K. van Santen, Michael W. Traeger, Rachel Sacks-Davis, Jason Asselin, Nick Scott, Brendan L. Harney, et al. "Hepatitis C incidence among patients attending primary care health services that specialise in the care of people who inject drugs, Victoria, Australia, 2009 to 2020." International Journal of Drug Policy 103 (May 2022): 103655. http://dx.doi.org/10.1016/j.drugpo.2022.103655.
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Alfano, Catherine M., Kevin Oeffinger, Tara Sanft, and Brooke Tortorella. "Engaging TEAM Medicine in Patient Care: Redefining Cancer Survivorship From Diagnosis." American Society of Clinical Oncology Educational Book, no. 42 (April 2022): 1–11. http://dx.doi.org/10.1200/edbk_349391.
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New approaches to cancer survivorship care must address the rising number of survivors who need complex care; the need to personalize care to improve health equity; workforce shortages and clinician knowledge deficits about the long-term and late effects of cancer; the need to engage and coordinate oncology, primary care, and a large multidisciplinary team of subspecialists and programs to meet survivors’ needs; and the need to control costs and deliver better value. This review proposes eight core tenets of an evolved standard of care to meet these needs by starting at diagnosis and continuing throughout oncology and into follow-up to: (1) facilitate team medicine by connecting oncology, primary care, subspecialists and programs, researchers, and patients and caregivers; (2) educate patients and support them in self-management; (3) mitigate toxicities; (4) manage comorbidities; (5) promote healthy behaviors and wellness; (6) improve health equity; (7) provide clear personalized follow-up; and (8) provide ongoing opportunities for participation in research as the standard of care. Strategies to successfully implement this care are discussed from the perspectives of oncology, primary care, and health care administration.
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O’Shea, Amy M. J., Aaron Baum, Bjarni Haraldsson, Ariana Shahnazi, Matthew R. Augustine, Kailey Mulligan, and Peter J. Kaboli. "Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic." JAMA Network Open 5, no. 10 (October 17, 2022): e2236524. http://dx.doi.org/10.1001/jamanetworkopen.2022.36524.
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ImportanceAlthough telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access.ObjectiveTo identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality.Design, Setting, and ParticipantsThis cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021).ExposuresFederal Communications Commission–reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran’s home address using US Census Bureau shapefiles.Main Outcomes and MeasuresAll visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient’s broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates.ResultsIn primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients’ quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46; P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84; P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09).Conclusions and RelevanceThis cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.
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Schiess, Nicoline, Halah Ibrahim, Sami Shaban, Maria Nichole Perez, and Satish Chandrasekhar Nair. "Career Choice and Primary Care in the United Arab Emirates." Journal of Graduate Medical Education 7, no. 4 (December 1, 2015): 663–66. http://dx.doi.org/10.4300/jgme-d-14-00780.1.
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ABSTRACT Background The low number of medical trainees entering primary care is contributing to the lack of access to primary care services in many countries. Despite the need for primary care physicians in the Middle East, there is limited information regarding trainees' career choices, a critical determinant in the supply of primary care physicians. Objective We analyzed the career choices of medical students in the United Arab Emirates (UAE), with a larger goal of reforming postgraduate training in the region and enhancing the focus on primary care. Methods We conducted a cross-sectional survey of applicants to a large established internal medicine residency program in the UAE. We calculated data for demographics, subspecialty choice, and factors affecting subspecialty choice, and we also reported descriptive statistics. Results Our response rate was 86% (183 of 212). Only 25% of applicants (n = 46) were interested in general internal medicine. The majority of respondents (n = 126, 69%) indicated a desire to pursue subspecialty training, and the remainder chose careers in research or administration. A majority of respondents (73%) were women, unmarried, and childless. Educational debt or lifestyle were not indicated as important factors in career choice. Conclusions Low interest in primary care was similar to that in many Western countries, despite a much higher percentage of female applicants and a reduced emphasis on lifestyle or income factors in career decisions. Reasons for the reduced interest in primary care deserve further exploration, as do tests of interventions to increase interest, such as improving the primary care clerkship experience.
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Hurlbert, R. John. "Methylprednisolone for acute spinal cord injury: an inappropriate standard of care." Journal of Neurosurgery: Spine 93, no. 1 (July 2000): 1–7. http://dx.doi.org/10.3171/spi.2000.93.1.0001.
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Object. Since publication in 1990, results from the National Acute Spinal Cord Injury Study II (NASCIS II) trial have changed the way patients suffering an acute spinal cord injury (SCI) are treated. More recently, recommendations from NASCIS III are being adopted by institutions around the world. The purpose of this paper is to reevaluate carefully the results and conclusions of these studies to determine the role they should play in influencing decisions about care of the acutely spinal cord—injured patient. Methods. Published results from NASCIS II and III were reviewed in the context of the original study design, including primary outcomes compared with post-hoc comparisons. Data were retroconverted from tabular form back to raw form to allow direct inspection of changes in treatment groups. These findings were further analyzed with respect to justification of practice standards. Although well-designed and well-executed, both NASCIS II and III failed to demonstrate improvement in primary outcome measures as a result of the administration of methylprednisolone. Post-hoc comparisons, although interesting, did not provide compelling data to establish a new standard of care in the treatment of patients with acute SCI. Conclusions. The use of methylprednisolone administration in the treatment of acute SCI is not proven as a standard of care, nor can it be considered a recommended treatment. Evidence of the drug's efficacy and impact is weak and may only represent random events. In the strictest sense, 24-hour administration of methylprednisolone must still be considered experimental for use in clinical SCI. Forty-eight-hour therapy is not recommended. These conclusions are important to consider in the design of future trials and in the medicolegal arena.
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Eastwood, Kathryn, Dhanya Nambiar, Rosamond Dwyer, Judy A. Lowthian, Peter Cameron, and Karen Smith. "Ambulance dispatch of older patients following primary and secondary telephone triage in metropolitan Melbourne, Australia: a retrospective cohort study." BMJ Open 10, no. 11 (November 2020): e042351. http://dx.doi.org/10.1136/bmjopen-2020-042351.
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BackgroundMost calls to ambulance result in emergency ambulance dispatch (direct dispatch) following primary telephone triage. Ambulance Victoria uses clinician-led secondary telephone triage for patients identified as low-acuity during primary triage to refer them to alternative care pathways; however, some are returned for ambulance dispatch (secondary dispatch). Older adult patients are frequent users of ambulance services; however, little is known about the appropriateness of subsequent secondary dispatches.ObjectivesTo examine the appropriateness of secondary dispatch through a comparison of the characteristics and ambulance outcomes of older patients dispatched an emergency ambulance via direct or secondary dispatch.DesignA retrospective cohort study of ambulance patient data between September 2009 and June 2012 was conducted.SettingThe secondary telephone triage service operated in metropolitan Melbourne, Victoria, Australia during the study period.ParticipantsThere were 90 086 patients included aged 65 years and over who had an emergency ambulance dispatch via direct or secondary dispatch with one of the five most common secondary dispatch paramedic diagnoses.Main outcome measuresDescriptive analyses compared characteristics, treatment and transportation rates between direct and secondary dispatch patients.ResultsThe dispatch groups were similar in demographics, vital signs and hospital transportation rates. However, secondary dispatch patients were half as likely to be treated by paramedics (OR 0.51; CI 0.48 to 0.55; p<0.001). Increasing age was associated with decreasing treatment (p<0.005) and increasing transportation rates (p<0.005).ConclusionSecondary triage could identify patients who would ultimately be transported to an emergency department. However, the lower paramedic treatment rates suggest many secondary dispatch patients may have been suitable for referral to alternative low-acuity transport or referral options.
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Cornell, Portia Y., Christopher W. Halladay, Anna-Rae Montano, Caitlin Celardo, Gina Chmelka, Jennifer W. Silva, and James L. Rudolph. "Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans." JAMA Network Open 6, no. 1 (January 4, 2023): e2249731. http://dx.doi.org/10.1001/jamanetworkopen.2022.49731.
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ImportancePalliative care improves quality of life for patients and families but may be underused.ObjectiveTo assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization.Design, Setting, and ParticipantsThis cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022.ExposuresThe PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention.Main Outcomes and MeasuresThe primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay.ResultsThe analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics—a 2-fold difference relative to the mean.Conclusions and RelevanceThis cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.
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SHEAFF, ROD. "Medicine and Management in English Primary Care: A Shifting Balance of Power?" Journal of Social Policy 38, no. 4 (October 2009): 627–47. http://dx.doi.org/10.1017/s0047279409990183.
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AbstractThe English NHS has been repeatedly restructured since 1991. Drawing on multiple case studies in English primary health care from 1998 to 2005 and on (other) published studies, this article uses Therborn's theory of power to make a framework analysis of how these reforms redistributed power between medicine and management in NHS primary care. Legal changes ended the GP monopoly of primary medical care provision and, with greater managerial discretion in NHS spending, allowed more diverse organisational forms of primary care provision to appear, although general practice remained predominant. Changes in managerial and professional ideologies relaxed the restrictions on managerial decisions about general practice. Re-negotiations between the medical profession and the state mostly tended to increase managerial power. Evidence-based medicine has tended to weaken the impersonal sources of medical power. On balance, these events have tended to increase managerial power over medical practice. They also suggest adjustments to Therborn's conceptualisation of power.
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Khano, Sonia, Lena Sanci, Susan Woolfenden, Yvonne Zurynski, Kim Dalziel, Siaw-Teng Liaw, Douglas Boyle, et al. "Strengthening Care for Children (SC4C): protocol for a stepped wedge cluster randomised controlled trial of an integrated general practitioner-paediatrician model of primary care." BMJ Open 12, no. 9 (September 2022): e063449. http://dx.doi.org/10.1136/bmjopen-2022-063449.
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IntroductionAustralia’s current healthcare system for children is neither sustainable nor equitable. As children (0–4 years) comprise the largest proportion of all primary care-type emergency department presentations, general practitioners (GPs) report feeling undervalued as an integral member of a child’s care, and lacking in opportunities for support and training in paediatric conditions. This Strengthening Care for Children (SC4C) randomised trial aims to evaluate a novel, integrated GP-paediatrician model of care, that, if effective, will improve GP quality of care, reduce burden to hospital services and ensure children receive the right care, at the right time, closer to home.Methods and analysisSC4C is a stepped wedge cluster randomised controlled trial (RCT) of 22 general practice clinics in Victoria and New South Wales, Australia. General practice clinics will provide control period data before being exposed to the 12-month intervention which will be rolled out sequentially each month (one clinic per state) until all 22 clinics receive the intervention. The intervention comprises weekly GP-paediatrician co-consultation sessions; monthly case discussions; and phone and email paediatrician support, focusing on common paediatric conditions. The primary outcome of the trial is to assess the impact of the intervention as measured by the proportion of children’s (0–<18 years) GP appointments that result in a hospital referral, compared with the control period. Secondary outcomes include GP quality of care; GP experience and confidence in providing paediatric care; family trust in and preference for GP care; and the sustainability of the intervention. An implementation evaluation will assess the model to inform acceptability, adaptability, scalability and sustainability, while a health economic evaluation will measure the cost-effectiveness of the intervention.Ethics and disseminationHuman research ethics committee (HREC) approval was granted by The Royal Children’s Hospital Ethics Committee in August 2020 (Project ID: 65955) and site-specific HRECs. The investigators (including Primary Health Network partners) will communicate trial results to stakeholders and participating GPs and general practice clinics via presentations and publications.Trial registration numberAustralia New Zealand Clinical Trials Registry 12620001299998.
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Hernan, Andrea L., Kate Kloot, Sally J. Giles, Hannah Beks, Kevin McNamara, Marley J. Binder, and Vincent Versace. "Investigating the feasibility of a patient feedback tool to improve safety in Australian primary care: a study protocol." BMJ Open 9, no. 5 (May 2019): e027327. http://dx.doi.org/10.1136/bmjopen-2018-027327.
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IntroductionPatients are a valuable source of information about ways to prevent harm in healthcare, and can provide feedback about the factors that contribute to safety incidents. The Primary Care Patient Measure of Safety (PC PMOS) is a novel and validated tool that captures patient feedback on safety and can be used by primary care practice teams to identify and prevent safety incidents. The aim of this study is to assess the feasibility of PC PMOS as a tool for data-driven safety improvement and monitoring in Australian primary care.Methods and analysisFeasibility will be assessed using a mixed-methods approach to understand the enablers, barriers, acceptability, practicability, intervention fidelity and scalability of C PMOS as a tool for safety improvement across six primary care practices in the south-west region of Victoria. Patients over the age of 18 years attending their primary care practice will be invited to complete the PC PMOS when presenting for an appointment. Staff members at each practice will form a safety improvement team. Staff will then use the patient feedback to develop and implement specific safety interventions over a 6-month period. Data collection methods during the intervention period includes audio recordings of staff meetings, overt observations at training and education workshops, reflexive researcher insights, document collection and review. Data collection postintervention includes patient completion of the PC PMOS and semistructured interviews with staff. Triangulation and thematic analysis techniques will be employed to analyse the qualitative and content data. Analysis methods will use current evidence and models of healthcare culture, safety improvement and patient involvement in safety to inform the findings.Ethics and disseminationEthics approval was granted by Deakin University Human Ethics Advisory Group, Faculty of Health (HEAG-H 175_2017). Study results will be disseminated through local and international conferences and peer-reviewed publications.
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Sá, Luísa, Andreia Sofia Costa Teixeira, Fernando Tavares, Cristina Costa-Santos, Luciana Couto, Altamiro Costa-Pereira, Alberto Pinto Hespanhol, Paulo Santos, and Carlos Martins. "Diagnostic and laboratory test ordering in Northern Portuguese Primary Health Care: a cross-sectional study." BMJ Open 7, no. 11 (November 2017): e018509. http://dx.doi.org/10.1136/bmjopen-2017-018509.
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ObjectivesTo characterise the test ordering pattern in Northern Portugal and to investigate the influence of context-related factors, analysing the test ordered at the level of geographical groups of family physicians and at the level of different healthcare organisations.DesignCross-sectional study.SettingNorthern Primary Health Care, Portugal.ParticipantsRecords about diagnostic and laboratory tests ordered from 2035 family physicians working at the Northern Regional Health Administration, who served approximately 3.5 million Portuguese patients, in 2014.OutcomesTo determine the 20 most ordered diagnostic and laboratory tests in the Northern Regional Health Administration; to identify the presence and extent of variations in the 20 most ordered diagnostic and laboratory tests between the Groups of Primary Care Centres and between health units; and to study factors that may explain these variations.ResultsThe 20 most ordered diagnostic and laboratory tests almost entirely comprise laboratory tests and account for 70.9% of the total tests requested. We can trace a major pattern of test ordering for haemogram, glucose, lipid profile, creatinine and urinalysis. There was a significant difference (P<0.001) in test orders for all tests between Groups of Primary Care Centres and for all tests, except glycated haemoglobin (P=0.06), between health units. Generally, the Personalised Healthcare Units ordered more than Family Health Units.ConclusionsThe results from this study show that the most commonly ordered tests in Portugal are laboratory tests, that there is a tendency for overtesting and that there is a large variability in diagnostic and laboratory test ordering in different geographical and organisational Portuguese primary care practices, suggesting that there may be considerable potential for the rationalisation of test ordering. The existence of Family Health Units seems to be a strong determinant in decreasing test ordering by Portuguese family physicians. Approaches to ensuring more rational testing are needed.
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Curtis, Kate, Margaret Fry, Sarah Kourouche, Belinda Kennedy, Julie Considine, Hatem Alkhouri, Mary Lam, et al. "Implementation evaluation of an evidence-based emergency nursing framework (HIRAID): study protocol for a step-wedge randomised control trial." BMJ Open 13, no. 1 (January 2023): e067022. http://dx.doi.org/10.1136/bmjopen-2022-067022.
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IntroductionPoor patient assessment results in undetected clinical deterioration. Yet, there is no standardised assessment framework for >29 000 Australian emergency nurses. To reduce clinical variation and increase safety and quality of initial emergency nursing care, the evidence-based emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) was developed and piloted. This paper presents the rationale and protocol for a multicentre clinical trial of HIRAID.Methods and analysisUsing an effectiveness-implementation hybrid design, the study incorporates a stepped-wedge cluster randomised controlled trial of HIRAID at 31 emergency departments (EDs) in New South Wales, Victoria and Queensland. The primary outcomes are incidence of inpatient deterioration related to ED care, time to analgesia, patient satisfaction and medical satisfaction with nursing clinical handover (effectiveness). Strategies that optimise HIRAID uptake (implementation) and implementation fidelity will be determined to assess if HIRAID was implemented as intended at all sites.Ethics and disseminationEthics has been approved for NSW sites through Greater Western Human Research Ethics Committee (2020/ETH02164), and for Victoria and Queensland sites through Royal Brisbane & Woman’s Hospital Human Research Ethics Committee (2021/QRBW/80026). The final phase of the study will integrate the findings in a toolkit for national rollout. A dissemination, communications (variety of platforms) and upscaling strategy will be designed and actioned with the organisations that influence state and national level health policy and emergency nurse education, including the Australian Commission for Quality and Safety in Health Care. Scaling up of findings could be achieved by embedding HIRAID into national transition to nursing programmes, ‘business as usual’ ED training schedules and university curricula.Trial registration numberACTRN12621001456842.
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Vela-Vallespín, Carmen, Paula Manchon‐Walsh, Luisa Aliste, Josep M. Borras, and Mercè Marzo-Castillejo. "Prehospital care for ovarian cancer in Catalonia: could we do better in primary care? Retrospective cohort study." BMJ Open 12, no. 7 (July 2022): e060499. http://dx.doi.org/10.1136/bmjopen-2021-060499.
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ObjectiveTo assess the impact of prehospital factors (diagnostic pathways, first presentation to healthcare services, intervals, participation in primary care) on 1-year and 5-year survival in people with epithelial ovarian cancer (EOC).DesignRetrospective quasi-population-based cohort study.SettingCatalan Integrated Public Healthcare System.ParticipantsPeople with EOC who underwent surgery with a curative intent in public Catalan hospitals between 1 January 2013 and 31 December 2014.Outcome measuresData from primary and secondary care clinical histories and care processes in the 18 months leading up to confirmation (signs and symptoms at presentation, diagnosis pathways, referrals, diagnosis interval) of the EOC diagnosis (stage, histology type, treatment). Diagnostic process intervals were based on the Aarhus statement. 1-year and 5-year survival analysis was undertaken.ResultsOf the 513 patients included in the cohort, 67.2% initially consulted their family physician, while 36.4% were diagnosed through emergency services. In the Cox models, survival was influenced by advanced stage at 1 year (HR 3.84, 95% CI 1.23 to 12.02) and 5 years (HR 5.36, 95% CI 3.07 to 9.36), as was the type of treatment received, although this association was attenuated over follow-up. Age became significant at 5 years of follow-up. After adjusting for age, adjusted morbidity groups, stage at diagnosis and treatment, 5-year survival was better in patients presenting with gynaecological bleeding (HR 0.35, 95% CI 0.16 to 0.79). Survival was not associated with a starting point involving primary care (HR 1.39, 95% CI 0.93 to 2.09), diagnostic pathways involving referral to elective gynaecological care from non-general practitioners (HR 0.80, 95% CI 0.51 to 1.26), or self-presentation to emergency services (HR 0.82, 95% CI 0.52 to 1.31).ConclusionsSurvival in EOC is not associated with diagnostic pathways or prehospital healthcare, but it is influenced by stage at diagnosis, administration of primary cytoreduction plus chemotherapy and patient age.
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Belknap, DC, CF Seifert, and M. Petermann. "Administration of medications through enteral feeding catheters." American Journal of Critical Care 6, no. 5 (September 1, 1997): 382–92. http://dx.doi.org/10.4037/ajcc1997.6.5.382.
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BACKGROUND: Enteral feeding catheters are commonly used to administer both nutritional feedings and oral forms of medications. Obstruction of the catheters is a major concern. OBJECTIVES: To study characteristics of obstruction of enteral feeding catheters in ICU patients and current knowledge and practices of ICU nurses of administering medications through such catheters. METHODS: A postcard invitation to participate in this descriptive survey was mailed to a random sample of 12,069 members of the American Association of Critical-Care Nurses. The 52-item investigator-designed questionnaire was mailed to the 1700 critical care nurses who agreed to participate; 1167 (68.6%) returned completed survey questionnaires. RESULTS: Nurses estimated that 33.8% of their patients received 8.9 doses of medication per day through the enteral feeding catheter. The rate of obstruction of the tube by medications was 15.6%. Crushed medications contributed to obstruction, although liquid forms of the medications often were available. Nurses' primary source of knowledge about administering medications through enteral feeding catheters was clinical practice (56.9%) and consultation with peers (21.7%); only 19% had had inservice training on the topic. Written agency guidelines varied considerably, and 74% of nurses used two or more techniques that were contrary to recommendations. Factors significantly associated with lower rates of obstruction of enteral feeding catheters included (1) assistance from the pharmacy service to ensure liquid forms of medications, (2) nurses' attendance at a relevant seminar or inservice training program, and (3) not routinely crushing and administering enteric-coated or sustained-release medications through the enteral feeding catheter. CONCLUSIONS: Collaboration between nursing and pharmacy services to ensure delivery of liquid medications and avoid use of crushed medications may reduce the high rate of catheter obstruction due to medications. Research-based guidelines and a more formal dissemination of information to nurses are needed.
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Brenner, Thorsten, Felix CF Schmitt, Serdar Demirel, Eduardo Salgado, Juan Antonio Celi de la Torre, Martin Göring, Thomas Bruckner, et al. "The role of unfractionated heparin for the antiaggregatory effect of aspirin in patients undergoing carotid endarterectomy: Results of an observational clinical study." Vascular 25, no. 1 (July 9, 2016): 19–27. http://dx.doi.org/10.1177/1708538116638961.
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The aims of the present study were to examine the influence of a low-dose unfractionated heparin regime on platelet aggregation and to additionally assess the prevalence of primary aspirin resistance in patients undergoing carotid endarterectomy. Therefore, 50 patients undergoing carotid endarterectomy were enrolled. A bolus of 3000 IU unfractionated heparin was administered 2 min before carotid cross-clamping additionally to standard antiaggregatory therapy. Haemostaseological point of care testing was performed twice, prior to surgery and 10 min after unfractionated heparin administration by the use of aggregometric and viscoelastic point of care testing. Following unfractionated heparin administration, the activated partial thromboplastin time increased significantly and clotting time in viscoelastic INTEM test was shown to be significantly prolonged. In contrast, the antiaggregatory effect of aspirin was not diminished in aggregometric ASPI test. A low-dose unfractionated heparin regime during carotid endarterectomy was therefore considered to be safe, without diminishing the antiplatelet effect of aspirin. Moreover, aggregometric point of care testing was identified to be a suitable tool for the identification of patients with primary aspirin resistance ( n = 3).
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Davidson, Sandra K., Helena Romaniuk, Patty Chondros, Christopher Dowrick, Jane Pirkis, Helen Herrman, Susan Fletcher, and Jane Gunn. "Antidepressant treatment for primary care patients with depressive symptoms: Data from the diamond longitudinal cohort study." Australian & New Zealand Journal of Psychiatry 54, no. 4 (January 20, 2020): 367–81. http://dx.doi.org/10.1177/0004867419898761.
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Background: In light of emerging evidence questioning the safety of antidepressants, it is timely to investigate the appropriateness of antidepressant prescribing. This study estimated the prevalence of possible over- and under-treatment with antidepressants among primary care attendees and investigated the factors associated with potentially inappropriate antidepressant use. Methods: In all, 789 adult primary care patients with depressive symptoms were recruited from 30 general practices in Victoria, Australia, in 2005 and followed up every 3 months in 2006 and annually from 2007 to 2011. For this study, we first assessed appropriateness of antidepressant use in 2007 at the 2-year follow-up to enable history of depression to be taken into account, providing 574 (73%) patients with five yearly assessments, resulting in a total of 2870 assessments. We estimated the prevalence of use of antidepressants according to the adapted National Institute for Health and Care Excellence guidelines and used regression analysis to identify factors associated with possible over- and under-treatment. Results: In 41% (243/586) of assessments where antidepressants were indicated according to adapted National Institute for Health and Care Excellence guidelines, patients reported not taking them. Conversely in a third (557/1711) of assessments where guideline criteria were unlikely to be met, participants reported antidepressant use. Being female and chronic physical illness were associated with antidepressant use where guideline criteria were not met, but no factors were associated with not taking antidepressants where guideline criteria were met. Conclusions: Much antidepressant treatment in general practice is for people with minimal or mild symptoms, while people with moderate or severe depressive symptoms may miss out. There is considerable scope for improving depression care through better allocation of antidepressant treatment.
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Byrne, John M., Susan Hall, Sam Baz, Todd Kessler, Maher Roman, Mark Patuszynski, Kruti Thakkar, and T. Michael Kashner. "Quality and Safety Training in Primary Care: Making an Impact." Journal of Graduate Medical Education 4, no. 4 (December 1, 2012): 510–15. http://dx.doi.org/10.4300/jgme-d-11-00322.1.
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Abstract Purpose Preparing residents for future practice, knowledge, and skills in quality improvement and safety (QI/S) is a requisite element of graduate medical education. Despite many challenges, residency programs must consider new curricular innovations to meet the requirements. We report the effectiveness of a primary care QI/S curriculum and the role of the chief resident in quality and patient safety in facilitating it. Method Through the Veterans Administration Graduate Medical Education Enhancement Program, we added a position for a chief resident in quality and patient safety, and 4 full-time equivalent internal medicine residents, to develop the Primary Care Interprofessional Patient-Centered Quality Care Training Curriculum. The curriculum includes a first-or second-year, 1-month block rotation that serves as a foundational experience in QI/S and interprofessional care. The responsibilities of the chief resident in quality and patient safety included organizing and teaching the QI/S curriculum and mentoring resident projects. Evaluation included prerotation and postrotation surveys of self-assessed QI/S knowledge, abilities, skills, beliefs, and commitment (KASBC); an end-of-the-year KASBC; prerotation and postrotation knowledge test; and postrotation and faculty surveys. Results Comparisons of prerotation and postrotation KASBC indicated significant self-assessed improvements in 4 of 5 KASBC domains: knowledge (P < .001), ability (P < .001), skills (P < .001), and belief (P < .03), which were sustained on the end-of-the-year survey. The knowledge test demonstrated increased QI/S knowledge (P = .002). Results of the postrotation survey indicate strong satisfaction with the curriculum, with 76% (25 of 33) and 70% (23 of 33) of the residents rating the quality and safety curricula as always or usually educational. Most faculty members acknowledged that the chief resident in quality and patient safety enhanced both faculty and resident QI/S interest and participation in projects. Conclusions Our primary care QI/S curriculum was associated with improved and persistent resident self-perceived knowledge, abilities, and skills and increased knowledge-based scores of QI/S. The chief resident in quality and patient safety played an important role in overseeing the curriculum, teaching, and providing leadership.
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Jonas, Wayne B., and Elena Rosenbaum. "The Case for Whole-Person Integrative Care." Medicina 57, no. 7 (June 30, 2021): 677. http://dx.doi.org/10.3390/medicina57070677.
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Rationale: There is a need for medicine to deliver more whole-person care. This is a narrative review of several models of whole-person care and studies that illustrate the business case for whole-person models in primary care. Objectives: To provide an overview of what whole-person care models exist and explore evidence to support these models. Study Selection: Representative whole-person care models widely used in the United States are summarized and evaluated. Selected studies focused on outpatient primary care with examples from programs that integrate the delivery of conventional medical care, complementary and alternative medicine, and self-care within the context of social and cultural environments. Methods: Pubmed search conducted December 2020–February 2021. Two iterative searches using terms for “Whole Health Veterans Administration”, “integrative medicine”, “integrative health”, “complementary and alternative medicine”, and, as they related to the outcomes, of “health outcomes”, “cost-effectiveness”, “cost reduction”, “patient satisfaction”, and “physician satisfaction”. Additional studies were identified from an initial search and the authors’ experience of over 50 years. We looked for studies of whole-person care used in general primary care, those not using a single modality and only from United States practices. Results: A total of 125 (out of 1746) studies were found and met our inclusion criteria. We found that whole-person models of primary care exist, are quite heterogeneous in their approaches, and routinely report substantial benefits for improving the patient experience, clinical outcomes and in reducing costs. Conclusions: Evidence for the benefit of whole-person care models exist but definitions are quite heterogenous and unfocused. There is a need for more standardization of whole-person models and more research using whole systems approaches rather than reductionistic attempts using isolated components.
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Gill, Harman Singh, Elsa Lindgren, Alexander D. Steele, Gouri Chakraborti, Dylan A. Calhoun, Pankaj Bharati, Sathvik Srikanth, Sholeen T. Nett, and Matthew S. Braga. "Errors of Commission in Cardiac Arrest Care in the Intensive Care Unit." Journal of Intensive Care Medicine 36, no. 7 (May 27, 2021): 749–57. http://dx.doi.org/10.1177/08850666211018101.
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Introduction: Cardiopulmonary arrests (CPAs) are common in the intensive care unit (ICU). However, effects of protocol deviations on CPA outcomes in the ICU are relatively unknown. Objectives: To establish the frequency of errors of commission (EOCs) during CPAs in the ICU and their relationship with CPA outcomes. Methods: Retrospective analysis of data entered into institutional registry with inclusion criteria of age >18 years and non-traumatic cardiac arrest in the ICU. EOCs consist of administration of drugs or procedures performed during a CPA that are not recommended by ACLS guidelines. Primary outcome: relationship of EOCs with likelihood of return of spontaneous circulation (ROSC). Secondary outcomes: relationship of specific EOCs to ROSC and relationship of EOCs and CPA length on ROSC. Results: Among 120 CPAs studied, there was a cumulative ROSC rate of 66%. Cumulatively, EOCs were associated with a decreased likelihood of ROSC (OR: 0.534, 95% CI: 0.387-0.644). Specifically, administration of sodium bicarbonate (OR: 0.233, 95% CI: 0.084-0.644) and calcium chloride (OR: 0.278, 95% CI: 0.098-0.790) were the EOCs that significantly reduced likelihood of attaining ROSC. Each 5-minute increment in CPA duration and/or increase in number of EOCs corresponded to fewer patients sustaining ROSC. Conclusions: EOCs during CPAs in the ICU were common. Among all EOCs studied, sodium bicarbonate and calcium chloride seemed to have the greatest association with decreased likelihood of attaining ROSC. Number of EOCs and CPA duration both seemed to have an inversely proportional relationship with the likelihood of attaining and sustaining ROSC. EOCs represent potentially modifiable human factors during a CPA through resources such as life safety nurses.
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Avramovic, Sanja, Farrokh Alemi, Rania Kanchi, Priscilla M. Lopez, Richard B. Hayes, Lorna E. Thorpe, and Mark D. Schwartz. "US veterans administration diabetes risk (VADR) national cohort: cohort profile." BMJ Open 10, no. 12 (December 2020): e039489. http://dx.doi.org/10.1136/bmjopen-2020-039489.
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PurposeThe veterans administration diabetes risk (VADR) cohort facilitates studies on temporal and geographic patterns of pre-diabetes and diabetes, as well as targeted studies of their predictors. The cohort provides an infrastructure for examination of novel individual and community-level risk factors for diabetes and their consequences among veterans. This cohort also establishes a baseline against which to assess the impact of national or regional strategies to prevent diabetes in veterans.ParticipantsThe VADR cohort includes all 6 082 018 veterans in the USA enrolled in the veteran administration (VA) for primary care who were diabetes-free as of 1 January 2008 and who had at least two diabetes-free visits to a VA primary care service at least 30 days apart within any 5-year period since 1 January 2003, or veterans subsequently enrolled and were diabetes-free at cohort entry through 31 December 2016. Cohort subjects were followed from the date of cohort entry until censure defined as date of incident diabetes, loss to follow-up of 2 years, death or until 31 December 2018.Findings to dateThe incidence rate of type 2 diabetes in this cohort of over 6 million veterans followed for a median of 5.5 years (over 35 million person-years (PY)) was 26 per 1000 PY. During the study period, 8.5% of the cohort were lost to follow-up and 17.7% died. Many demographic, comorbidity and other clinical variables were more prevalent among patients with incident diabetes.Future plansThis cohort will be used to study community-level risk factors for diabetes, such as attributes of the food environment and neighbourhood socioeconomic status via geospatial linkage to residence address information.
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Martindale, Anne-Marie, Rebecca Elvey, Susan J. Howard, Sheila McCorkindale, Smeeta Sinha, and Tom Blakeman. "Understanding the implementation of ‘sick day guidance’ to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation." BMJ Open 7, no. 11 (November 2017): e017241. http://dx.doi.org/10.1136/bmjopen-2017-017241.
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ObjectivesThe study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings.DesignQualitative semistructured interviews were conducted and comparative analysis informed by normalisation process theory was undertaken to understand sense-making, implementation and appraisal of the cards and associated guidance.SettingA single primary care health setting in the North of England.Participants29 participants took part in the qualitative evaluation: seven general practitioners, five practice nurses, five community pharmacists, four practice pharmacists, two administrators, one healthcare assistant and five patients.InterventionThe sick day guidance intervention was rolled out (2015–2016) in general practices (n=48) and community pharmacies (n=60). The materials consisted of a ‘medicine sick day guidance’ card, provided to patients who were taking the listed drugs. The card provided advice about medicines management during episodes of acute illness. An information leaflet was provided to healthcare practitioners and administrators suggesting how to use and give the cards.ResultsImplementation of sick day guidance cards to prevent AKI entailed a new set of working practises across primary care. A tension existed between ensuring reach in administration of the cards to at risk populations while being confident to ensure patient understanding of their purpose and use. Communicating the concept of temporary cessation of medicines was a particular challenge and limited their administration to patient populations at higher risk of AKI, particularly those with less capacity to self-manage.ConclusionsSick day guidance cards that focus solely on medicines management may be of limited patient benefit without adequate resourcing or if delivered as a standalone intervention. Development and evaluation of primary care interventions is urgently warranted to tackle the harm associated with AKI.
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Schectman, Gordon, and Richard Stark. "Orchestrating Large Organizational Change in Primary Care: The Veterans’ Health Administration Experience Implementing a Patient-Centered Medical Home." Journal of General Internal Medicine 29, S2 (April 9, 2014): 550–51. http://dx.doi.org/10.1007/s11606-014-2828-7.
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Dualan, Jun Jun A. "33 Effectiveness of Caregiver-oriented Transitional Care Program (CTCP) in Promoting Preparedness of Caregivers for Home Care of Burn Patients." Journal of Burn Care & Research 41, Supplement_1 (March 2020): S23—S24. http://dx.doi.org/10.1093/jbcr/iraa024.037.
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Abstract Introduction Unpreparedness of caregivers of burn patients can result to several complications at post-discharge period (Zwicker, 2010; AHRQ, 2012). Some burn centers in resource-scarce countries had documented several burn morbidity and mortality that occurred post hospital discharge. Psychological conditions, contractures, infection and even death are just some of the complications. One of the current trends in burns involves sending patients home with a burn dressing and following them up as outpatients for wound inspection. This could significantly reduce cost of hospitalization with shortened hospital stay and allows burn units to accommodate the overflow of acute and complex cases for admission. Although there are advantages in early discharge, this approach requires a change in the health teaching method and contents since hospital-to-home transition is expedited. Considering this dilemma, the investigator developed the CTCP to address the gap in transitional care of burns. This study aimed to compare the preparedness of caregivers before and after CTCP; and compare caregivers’ handwashing competency, wound dressing competency and medication administration hassle before and after CTCP. Methods One-group pre-and-posttest quasi-experimental design was used to study thirty adult caregivers of burn patients that were recruited via convenience sampling in a burn center between November 2017 to March 2018. CTCP was conducted in three sessions with the aid of videos and written instructional materials. Caregivers were evaluated in terms of preparedness (primary outcome) and handwashing competency, wound dressing competency and medication administration hassle (secondary outcomes). All measurement instruments were content valid and reliable. Results At alpha 0.05, data analysis revealed statistically significant results supporting the use of CTCP. Preparedness (p< 0.001), handwashing competency (p< 0.001), wound dressing competency (p< 0.001) and medication administration hassle (p< 0.001) improved after receiving the structured teaching intervention. Conclusions The study supported the relevance of the interventions to prepare caregivers for home care of burn patients to help prevent potential complications after hospital discharge. This is therefore recommended to be adapted by burn units that recognize primary caregivers as extended team members. Applicability of Research to Practice Since there is a limited evidence in nursing discharge education programs specific to burns, the results generated from this study can help practitioners effectively prepare caregivers for home care of burn patients as educational intervention is supported with strategies that increase learning retention.
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Hogge, J., D. Krasner, H. Nguyen, LB Harkless, and DG Armstrong. "The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds." Journal of the American Podiatric Medical Association 90, no. 2 (February 1, 2000): 57–65. http://dx.doi.org/10.7547/87507315-90-2-57.
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This article discusses the advantages and disadvantages of primary wound healing as compared with primary amputation in individuals with chronic diabetic foot wounds. The authors review the potential benefits of vascular surgical procedures and advanced dressings, including two of the most promising modalities in modern wound care: growth factors and bioengineered skin. In this era of cost-conscious health-care administration, it is incumbent on the practitioner to consider not only the basic science of wound care, but also the economic aspect of treatment rendered. These various interventions, dressings, growth factor delivery systems, and new modalities could significantly reduce healing time, thereby reducing the risk of infection, hospitalization, and amputation while improving quality of life. If so, they may be truly cost-effective.
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Hegarty, Kelsey, Jodie Valpied, Angela Taft, Stephanie Janne Brown, Lisa Gold, Jane Gunn, and Lorna O'Doherty. "Two-year follow up of a cluster randomised controlled trial for women experiencing intimate partner violence: effect of screening and family doctor-delivered counselling on quality of life, mental and physical health and abuse exposure." BMJ Open 10, no. 12 (December 2020): e034295. http://dx.doi.org/10.1136/bmjopen-2019-034295.
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ObjectivesThis was a 2-year follow-up study of a primary care-based counselling intervention (weave) for women experiencing intimate partner violence (IPV). We aimed to assess whether differences in depression found at 12 months (lower depression for intervention than control participants) would be sustained at 24 months and differences in quality in life, general mental and physical health and IPV would emerge.DesignCluster randomised controlled trial. Researchers blinded to allocation. Unit of randomisation: family doctors.SettingFifty-two primary care clinics, Victoria, Australia.ParticipantsBaseline: 272 English-speaking, female patients (intervention n=137, doctors=35; control n=135, doctors=37), who screened positive for fear of partner in past 12 months. Twenty-four-month response rates: intervention 59% (81/137), control 63% (85/135).InterventionsIntervention doctors received training to deliver brief, woman-centred counselling. Intervention patients were invited to receive this counselling (uptake rate: 49%). Control doctors received standard IPV information; delivered usual care.Primary and secondary outcome measuresTwenty-four months primary outcomes: WHO Quality of Life-Bref dimensions, Short-Form Health Survey (SF-12) mental health. Secondary outcomes: SF-12 physical health and caseness for depression and anxiety (Hospital Anxiety Depression Scale), post-traumatic stress disorder (Check List-Civilian), IPV (Composite Abuse Scale), physical symptoms (≥6 in last month). Data collected through postal survey. Mixed-effects regressions adjusted for location (rural/urban) and clustering.ResultsNo differences detected between groups on quality of life (physical: 1.5, 95% CI −2.9 to 5.9; psychological: −0.2, 95% CI −4.8 to 4.4,; social: −1.4, 95% CI −8.2 to 5.4; environmental: −0.8, 95% CI −4.0 to 2.5), mental health status (−1.6, 95% CI −5.3 to 2.1) or secondary outcomes. Both groups improved on primary outcomes, IPV, anxiety.ConclusionsIntervention was no more effective than usual care in improving 2-year quality of life, mental and physical health and IPV, despite differences in depression at 12 months. Future refinement and testing of type, duration and intensity of primary care IPV interventions is needed.Trial registration numberACTRN12608000032358.