Primary care patient and practitioner views of weight and weight-related discussion: a mixed-methods study.
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ABSTRACT:
SUBMITTER: McHale CT
PROVIDER: S-EPMC7064140 | biostudies-literature | 2020 Mar
REPOSITORIES: biostudies-literature
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Primary care patient and practitioner views of weight and weight-related discussion: a mixed-methods study.
McHale Calum T CT Laidlaw Anita H AH Cecil Joanne E JE
BMJ open 20200309 3
<h4>Objective</h4>To understand the beliefs that primary care practitioners (PCPs) and patients with overweight and obesity have about obesity and primary care weight management in Scotland.<h4>Setting</h4>Seven National Health Service (NHS) Scotland primary care centres.<h4>Participants</h4>A total of 305 patients and 14 PCPs (12 general practitioners; two practice nurses) participated.<h4>Design and methodology</h4>A cross-sectional mixed-methods study. PCPs and patients completed questionnair ...[more]
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Project description:BackgroundMichigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs).ObjectiveAssess PCPs' perspectives about the impact of HMP on their patients and practices.DesignIn 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs.SettingInterviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail.ParticipantsInterviewees were physician (n =?16) and non-physician practitioners (n =?3). All Michigan PCPs caring for ??12 HMP enrollees were surveyed (response rate 55.5%, N =?2104).MeasurementsPCPs' experiences with HMP patients and recent changes in their practices.ResultsInterviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened.LimitationsPCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ? 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias.ConclusionsPCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.
| S-EPMC6082204 | biostudies-literature
Project description:BackgroundWith the increasing adoption of electronic health record (EHR) systems, documentation-related burdens have been increasing for health care providers. Recent estimates indicate that primary care providers spend about one-half of their workdays interacting with the EHR, of which about half is focused on clerical tasks. To reduce documentation burdens associated with the EHR, health care systems and physician practices are increasingly implementing medical scribes to assist providers with real-time documentation. Scribes are typically unlicensed paraprofessionals who assist health care providers by documenting notes electronically under the direction of a licensed practitioner or physician in real time. Despite the promise of scribes, few studies have investigated their effect on clinical encounters, particularly with regard to patient-provider communication.ObjectiveThe purpose of this quasi-experimental pilot study was to understand how scribes affect patient-physician communication in primary care clinical encounters.MethodsWe employed a convergent mixed methods design and included a sample of three physician-scribe pairs and 34 patients. Patients' clinical encounters were randomly assigned to a scribe or nonscribe group. We conducted patient surveys focused on perceptions of patient-provider communication and satisfaction with encounters, video recorded clinical encounters, and conducted physician interviews about their experiences with scribes.ResultsOverall, the survey results revealed that patients across both arms reported very high satisfaction of communication with their physician, their physician's use of the EHR, and their care, with very little variability. Video recording analysis supported patient survey data by demonstrating high measures of communication among physicians in both scribed and nonscribed encounters. Furthermore, video recordings revealed that the presence of scribes had very little effect on the clinical encounter.ConclusionsFrom the patient's perspective, scribes are an acceptable addition to clinical encounters. Although they do not have much impact on patients' perceptions of satisfaction and their impact on the clinical encounter itself was minimal, their potential to reduce documentation-related burden on physicians is valuable. Physicians noted important issues related to scribes, including important considerations for implementing scribe programs, the role of scribes in patient interactions, how physicians work with scribes, characteristics of good scribes, and the role of scribes in physician workflow.
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Project description:New models of primary care include patient-reported outcome measures (PROMs) to promote patient-centered care. PROMs provide information on patient functional status and well-being, can be used to enhance care quality, and are proposed for use in assessing performance. Our objective was to identify a short list of candidate PROMs for use in primary care practice and to serve as a basis for performance measures (PMs). We used qualitative and quantitative methods to identify relevant patient-reported outcome (PRO) domains for use in performance measurement (PRO-PM) and their associated PROMs. We collected data from key informant groups: patients (n = 13; one-on-one and group interviews; concept saturation analysis), clinical thought leaders (n = 9; group discussions; thematic analysis), primary care practices representatives (n = 37; six focus groups; thematic analysis), and primary care payer representatives (n = 10; 12-question survey; frequencies of responses). We merged the key informant group information with findings from environmental literature scans. We conducted a targeted evidence review of measurement properties for candidate PROMs. We used a scoping review and key informant groups to identify PROM evaluation criteria, which were linked to the National Quality Forum measure evaluation criteria. We developed a de novo schema to score candidate PROMs against our criteria. We identified four PRO domains and 10 candidate PROMs: 3 for depressive symptoms, 2 for physical function, 3 for self-efficacy, 2 for ability to participate. Five PROMs met ≥ 70% of the evidence criteria for three PRO domains: PHQ-9 or PROMIS Depression (depression), PF-10 or PROMIS-PF (physical functioning), and PROMIS Self-Efficacy for Managing Treatments and Medications (self-efficacy). The PROMIS Ability to Participate in Social Roles and Activities met 68% of our criteria and might be considered for inclusion. Existing evidence and key informant data identified 5 candidate PROMs to use in primary care. These instruments can be used to develop PRO-PMs.
| S-EPMC7459066 | biostudies-literature
Project description:BACKGROUND:Cellulitis is a common painful infection of the skin and underlying tissues that recurs in approximately one-third of cases. The only proven strategy to reduce the risk of recurrence is long-term, low-dose antibiotics. Given current concerns about antibiotic resistance and the pressure to reduce antibiotic prescribing, other prevention strategies are needed. OBJECTIVES:To explore patients' views about cellulitis and different ways of preventing recurrent episodes. METHODS:Adults aged ≥ 18 years with a history of first-episode or recurrent cellulitis were invited through primary care, hospitals and advertising to complete a survey, take part in an interview or both. RESULTS:Thirty interviews were conducted between August 2016 and July 2017. Two hundred and forty surveys were completed (response rate 17%). Triangulation of quantitative and qualitative data showed that people who have had cellulitis have wide-ranging beliefs about what can cause cellulitis and are often unaware of risk of recurrence or potential strategies to prevent recurrence. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were more popular potential strategies than the use of compression stockings or long-term antibiotics. Participants expressed caution about long-term oral antibiotics, particularly those who had experienced only one episode of cellulitis. CONCLUSIONS:People who have had cellulitis are keen to know about possible ways to prevent further episodes. Enhanced foot hygiene, applying emollients daily, exercise and losing weight were generally viewed to be more acceptable, feasible strategies than compression or antibiotics, but further research is needed to explore uptake and effectiveness in practice.
| S-EPMC6487809 | biostudies-other
Project description:BackgroundThe UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting.Methods and findingsWe undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales' National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions. Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods.ConclusionsThis study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.
| S-EPMC5240916 | biostudies-literature
Project description:BackgroundChildren are scheduled to receive 18-20 immunizations before their 18th birthday in England and Wales; this approximates to 13 million vaccines administered per annum. Each immunization represents a potential opportunity for immunization-related error and effective immunization is imperative to maintain the public health benefit from immunization. Using data from a national reporting system, this study aimed to characterize pediatric immunization-related safety incident reports from primary care in England and Wales between 2002 and 2013.MethodsA cross-sectional mixed methods study was undertaken. This comprised reading the free-text of incident reports and applying codes to describe incident type, potential contributory factors, harm severity, and incident outcomes. A subsequent thematic analysis was undertaken to interpret the most commonly occurring codes, such as those describing the incident, events leading up to it and reported contributory factors, within the contexts they were described.ResultsWe identified 1745 reports and most (n=1077, 61.7%) described harm outcomes including three deaths, 67 reports of moderate harm and 1007 reports of low harm. Failure of timely vaccination was the potential cause of three child deaths from meningitis and pneumonia, and described in a further 113 reports. Vaccine administration incidents included the wrong number of doses (n=476, 27.3%), wrong timing (n=294, 16.8%), and wrong vaccine (n=249, 14.3%). Documentation failures were frequently implicated. Socially and medically vulnerable children were commonly described.ConclusionThis is the largest examination of reported contributory factors for immunization-related patient safety incidents in children. Our findings suggest investments in IT infrastructure to support data linkage and identification of risk predictors, development of consultation models that promote the role of parents in mitigating safety incidents, and improvement efforts to adapt and adopt best practices from elsewhere, are needed to mitigate future immunization-related patient safety incidents. These priorities are particularly pressing for vulnerable patient groups.
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Project description:BackgroundTo describe the ethical issues and experiences of scientists conducting mixed methods health services research and to advance empirical and conceptual discussion on ethical integrity in mixed methods health research.MethodsThe study was conducted with 64 scholars, faculty and consultants from the NIH-funded Mixed Methods Research Training Program (MMRTP) for the Health Sciences. This was a cross-sectional study. Survey results were analyzed using descriptive statistics to characterize responses and open coding to summarize strategies about eight ethical mixed methods research issues. Respondents completed an online survey to elicit experiences related to eight ethical issues (informed consent, confidentiality, data management, burden, safety, equitable recruitment, communication, and dissemination) and strategies for addressing them.ResultsOnly about one-third of respondents thought their research ethics training helped them plan, conduct, or report mixed methods research. The most frequently occurring ethical issues were participant burden, dissemination and equitable recruitment (> 70% endorsement). Despite occurring frequently, < 50% of respondents rated each ethical issue as challenging. The most challenging ethical issues were related to managing participant burden, communication, and dissemination. Strategies reported to address ethical issues were largely not specific or unique to mixed methods with the exception of strategies to mitigate participant burden and, to a lesser degree, to facilitate equitable recruitment and promote dissemination of project results.ConclusionsMixed methods health researchers reported encountering ethical issues often yet varying levels of difficulty and effectiveness in the strategies used to mitigate ethical issues. This study highlights some of the unique challenges faced by mixed methods researchers to plan for and appropriately respond to arising ethical issues such as managing participant burden and confidentiality across data sources and utilizing effective communication and dissemination strategies particularly when working with a multidisciplinary research team. As one of the first empirical studies to examine mixed methods research ethics, our findings highlight the need for greater attention to ethics in health services mixed methods research and training.
| S-EPMC8204431 | biostudies-literature
Project description:BACKGROUND:Primary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care. METHODS:This case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively. RESULTS:Data from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3?years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70-4.36), multimorbid (OR 1.37; 95%-CI 1.24-1.51; p?<?0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15-1.42; p?<?0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72-3.42; p?<?0.001) and anthropometric data (OR 1.33; 95%-CI 1.09-1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04-1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30-0.41; p?<?0.001) were prescribed or changed less frequently in NP consultations. CONCLUSIONS:Quantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.
| S-EPMC7425147 | biostudies-literature
Project description:BackgroundMajor depressive disorder (MDD) is highly prevalent and often managed by general practitioners (GPs). GPs mostly prescribe medication and show low referral rates to psychotherapy. Many patients remain untreated. Blended psychotherapy (bPT) combines internet-based interventions with face-to-face psychotherapy and could increase treatment access and availability. Effectively implementing bPT in routine care requires an understanding of professional users' perspectives and behavior.ObjectiveThis study aims to identify barriers and facilitators perceived by GPs in referring patients to bPT. Explanations for variations in referral rates were examined.MethodsSemistructured interviews were conducted with 12 of 110 GPs participating in a German randomized controlled trial (RCT) to investigate barriers to and facilitators for referrals to bPT for MDD (10 web-based modules, app-based assessments, and 6 face-to-face sessions). The interview guide was based on the theoretical domains framework. The interviews were audio recorded and transcribed verbatim, and the qualitative content was analyzed by 2 independent coders (intercoder agreement, k=0.71). A follow-up survey with 12 interviewed GPs enabled the validation of emergent themes. The differences in the barriers and facilitators identified between groups with different characteristics (eg, GPs with high or low referral rates) were described. Correlations between referrals and characteristics, self-rated competences, and experiences managing depression of the RCT-GPs (n=76) were conducted.ResultsGPs referred few patients to bPT, although varied in their referral rates, and interviewees referred more than twice as many patients as RCT-GPs (interview-GPs: mean 6.34, SD 9.42; RCT-GPs: mean 2.65, SD 3.92). A negative correlation was found between GPs' referrals and their self-rated pharmacotherapeutic competence, r(73)=-0.31, P<.001. The qualitative findings revealed a total of 19 barriers (B) and 29 facilitators (F), at the levels of GP (B=4 and F=11), patient (B=11 and F=9), GP practice (B=1 and F=3), and sociopolitical circumstances (B=3 and F=6). Key barriers stated by all interviewed GPs included "little knowledge about internet-based interventions" and "patients' lack of familiarity with technology/internet/media" (number of statements, each k=22). Key facilitators were "perceived patient suitability, e.g. well-educated, young" (k=22) and "no conflict with GP's role" (k=16). The follow-up survey showed a very high agreement rate of at least 75% for 71% (34/48) of the identified themes. Descriptive findings indicated differences between GPs with low and high referral rates in terms of which and how many barriers (low: mean 9.75, SD 1.83; high: mean 10.50, SD 2.38) and facilitators (low: mean 18.25, SD 4.13; high: mean 21.00; SD 3.92) they mentioned.ConclusionsThis study provides insights into factors influencing GPs' referrals to bPT as gatekeepers to depression care. Barriers and facilitators should be considered when designing implementation strategies to enhance referral rates. The findings should be interpreted with care because of the small and self-selected sample and low response rates.
| S-EPMC7463410 | biostudies-literature
Project description:Background:To better meet long-term care (LTC) residents' (patients in LTC) needs, nurse practitioners (NPs) were proposed as part of a quality improvement initiative. No research has been conducted in LTC in Québec Canada, where NP roles are new. We collected provider interviews, field notes and resident outcomes to identify how NPs in LTC influence care quality and inform the wider implementation of these roles in Québec. This paper reports on resident outcomes and field notes. Methods:Research Design: This mixed methods quality improvement study included a prospective cohort study in six LTC facilities in Québec. Participants: Data were collected from September 2015-August 2016. The cohort consisted of all residents (n?=?538) followed by the nurse practitioners. Nurse practitioner interventions (n?=?3798) related to medications, polypharmacy, falls, restraint use, transfers to acute care and pressure ulcers were monitored. Analysis: Bivariate analyses and survival analysis of occurrence of events over time were conducted. Content analysis was used for the qualitative data. Results:Nurse practitioners (n?=?6) worked half-time in LTC with an average caseload ranging from 42 to 80 residents. Sites developed either a shared care or a consultative model. The average age of residents was 82, and two thirds were women. The most common diagnosis on admission was dementia (62%, n?=?331). The number of interventions/resident (range: 2.2-16.3) depended on the care model. The average number of medications/resident decreased by 12% overall or 10% for each 30-day period over 12?months. The incidence of polypharmacy, falls, restraint use, and transfers to acute care decreased, and very few pressure ulcers were identified. Conclusions:The implementation of NPs in LTC in Québec can improve care quality for residents. Results show that the average number of medications per day per resident, the incidence of polypharmacy, falls, restraint use, and transfers to acute care all decreased during the study, suggesting that a wider implementation of NP roles in LTC is a useful strategy to improve resident care. Although additional studies are needed, the implementation of a consultative model should be favoured as our project provides preliminary evidence of the contributions of these new roles in LTC in Québec.
| S-EPMC6990528 | biostudies-literature