Perspectives on Tiered Older Driver Assessment in Primary Care Settings.
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ABSTRACT:
SUBMITTER: Betz ME
PROVIDER: S-EPMC5994886 | biostudies-other | 2016 Apr
REPOSITORIES: biostudies-other
Publications
Perspectives on Tiered Older Driver Assessment in Primary Care Settings.
Betz Marian E ME Jones Jacqueline J Genco Emma E Carr David B DB DiGuiseppi Carolyn C Haukoos Jason S JS Lowenstein Steven R SR Schwartz Robert R
The Gerontologist 20140502 2
<h4>Purpose of the study</h4>Widespread screening of older drivers, with in-depth evaluation only of those who screen positive ("tiered assessment"), might efficiently balance driver safety and mobility. To inform program development, we sought to examine the perspectives of older drivers and clinicians on the concept of tiered assessment in primary care settings.<h4>Design and methods</h4>Iterative focus groups and interviews with 33 community-dwelling current drivers aged ≥65 years and 8 prima ...[more]
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Project description:BackgroundPrimary care physicians play a leading role in counselling older drivers, but discussions often do not occur until safety concerns arise. Prior work suggests that routine questioning about driving might facilitate these difficult conversations.ObjectiveTo explore system-level factors affecting driving discussions in primary care settings, in order to inform the design and implementation of a programme supporting routine conversations.MethodsThis qualitative descriptive study used iterative interviews with providers (physicians, nurses, medical assistants, social workers, and administrative staff) working at two clinics (one geriatric, one general internal medicine) at a tertiary-care teaching hospital. General inductive techniques in transcript analysis were used to identify stakeholder-perceived system-level barriers and facilitators to routine conversations with older drivers.ResultsFrom 15 interviews, four themes emerged: (1) complexity of defined provider roles within primary care setting (which can both support team work and hamper efficiency); (2) inadequate resources to support providers (including clinical prompts, local guides, and access to social workers and driving specialists); (3) gaps in education of providers and patients about discussing driving; and (4) suggested models to enhance provider conversations with older drivers (including following successful examples and using defined pathways integrated into the electronic medical record). A fifth theme was that participants characterised their experiences in terms of current and ideal states.ConclusionsPhysicians have been tasked with assessing older driver safety and guiding older patients through the process of 'driving retirement.' Attention to system-level factors such as provider roles, resources, and training can support them in this process.
| S-EPMC4512937 | biostudies-literature
Project description:Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.
| S-EPMC6555171 | biostudies-literature
Project description:BACKGROUND:It is well known that older adults are high users of the health care system. Older adults with chronic conditions receive care from multiple providers, across multiple settings, and this care is often unorganized and confusing. In 2005, Ontario established a model of inter-professional primary care (family health teams) with the aim of providing enhanced interdisciplinary primary care to patients. Primary care requires an in-depth understanding of the operations of primary care teams and their relationships with other community services. The aim of this study was to develop a deeper understanding of the current operations of two family health teams in Ontario, including their current processes for referrals, information sharing, and engagement of patients in decision-making. METHODS:Focus group and individual semi-structured interviews with health care providers were conducted. Purposeful sampling was used to ensure information was obtained from different professional perspectives. Interviews were audio-recorded and transcribed verbatim. Using NVivo 10, data were analyzed using line by line thematic analysis techniques. A cluster technique was then applied to group similar codes into themes. RESULTS:Three focus group interviews (involving 4-6 health care providers/focus group) and six individual interviews were conducted with health care providers from two primary care teams and surrounding community care organizations. Six key themes were identified: 1) challenges engaging older adults in decisions about their care; 2) who is responsible for coordinating the care? 3) fragmented information sharing between health care providers; 4) lack of standardized referral processes and follow-up; 5) identifying services in the community for older adults; and 6) caring for older adults in rural communities. CONCLUSIONS:The results of this study provide an in-depth understanding of the current context in which the primary care teams are currently operating. Improved primary care will require stronger processes of coordination, greater knowledge of and connections with other community services, and enhanced patient engagement processes. This information provides a helpful basis for implementing interventions in primary care.
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Project description:Primary care occupies a strategic position in the evaluation and treatment of depression in late life, yet many older patients do not initiate or adhere to treatments available in primary care.To explore how primary care providers describe the process of discussing depression care with older adults.?Semi-structured interviews conducted with 15 providers involved with intervention studies of depression management for older adults. We used the constant comparative method to identify themes related to negotiating the treatment of depression with older adults.Providers felt that older patients often attribute depression to non-medical causes. They talked about the challenges and described the need to 'convince' them of the medical model of depression.How primary care physicians surmise patients' views of depression may influence the discussion of depression in practice. As medication is most often provided for depression treatment, some may feel compelled to convince their patients of biomedical explanations while others may avoid treating depression altogether.
| S-EPMC3183148 | biostudies-literature
Project description:IntroductionInitiating tobacco use in adolescence increases the risk of nicotine dependence and continued use into adulthood. Primary care visits provide opportunities for the assessment and treatment of tobacco use; however, little is known about prevalence and correlates of assessing smoking status and current use among adolescents in these settings.Aims and methodsUsing electronic health record data from the OCHIN network, we identified adolescents with greater than or equal to one primary care visit to a study clinic (n = 366 clinics from 15 US states) during January 1, 2016 to December 31, 2017. We estimated odds ratios of smoking assessment and current smoking status by patient covariates.ResultsOf 140 887 patients, 87.4% were assessed for smoking. Being Latino or Black (adjusted odds ratio = 1.22, 95% confidence interval: 1.13-1.32; adjusted odds ratio = 1.17, 95% confidence interval: 1.07-1.29, respectively, vs. non-Hispanic White), publicly insured, having more visits, and having an asthma diagnosis or other respiratory symptoms were associated with higher odds of assessment. Odds were lower if the patient was male and uninsured. Of those assessed, 1.6% identified as current smokers. Being older, having more visits, an asthma diagnosis, other respiratory symptoms, and lower household income was associated with higher odds of being a current smoker. Latinos and Blacks had lower odds than non-Hispanic Whites.ConclusionsAlthough some commonly reported tobacco-related disparities were not present, smoking assessment and current smoking status differed significantly by most patient demographics. Implementation of adolescent tobacco assessment protocols and the development of interventions to target subpopulations of adolescents with higher rates of smoking could mitigate disparate rates of assessment and smoking, respectively.ImplicationsClinical guidelines recommend screening adolescents for tobacco use in primary care settings. We found that most adolescents seen in US safety-net primary care clinics were assessed for smoking. We also found that smoking assessment and current smoking status differed significantly by most patient demographics. Implementing tobacco assessment protocols specific to adolescents could mitigate disparate rates of assessment and ensure accurate documentation of all forms of tobacco use, given the evolution of alternative tobacco products and poly use among adolescents. Interventions to target subpopulations of adolescents with higher smoking rates are needed to prevent the negative health effects of continued smoking.
| S-EPMC7593351 | biostudies-literature
Project description:AimsThe aim of this study was firstly to reveal the determinants of GP prescribing behaviour for older adults in primary care and secondly to elicit GPs' views on the potential role for broad intervention strategies involving pharmacists and/or information technology systems in general practice.MethodsSemi-structured qualitative interviews were carried out with a purposive sample of GPs. Three multidisciplinary researchers independently coded the interview data using a framework approach. Emerging themes were mapped to the Theoretical Domains Framework (TDF), a tool used to apply behaviour change theories.ResultsSixteen GPs participated in the study. The following domains in the TDF were identified as being important determinants of GP prescribing behaviour: 'Knowledge', 'Skills', 'Reinforcement', 'Memory Attention and Decision Process', 'Environmental Context and Resources', 'Social Influences', 'Social/Professional Role and Identity'. Participants reported that the challenges associated with prescribing for an increasingly older population will require them to become more knowledgeable in pharmacology and drug interactions and they called for extra training in these topics. GPs viewed strategies such as academic detailing sessions delivered by pharmacists or information technology systems as having a positive role to play in optimizing prescribing.ConclusionThis study highlights the complexities of behavioural determinants of prescribing for older people in primary care and the need for additional supports to optimize prescribing for this growing cohort of patients. Interventions that incorporate, but are not limited to interprofessional collaboration with pharmacists and information technology systems, were identified by GPs as being potentially useful for improving prescribing behaviour, and therefore require further exploration.
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Project description:BackgroundIncorporation of patient religious and spiritual beliefs in medical care has been shown to improve the efficacy of medical interventions and health outcomes. While previous study has highlighted differences in patient desire for spiritual assessment based on patient religiosity, little is known about patient desire for spiritual assessment based on community type, particularly in urban compared to rural communities. We hypothesized that, given demographic trends which show a higher degree of religiosity in rural areas, patients in rural communities will be more likely to desire spiritual assessment.MethodsIn this cross-sectional study of 141 adult primary care patients in rural and urban Colorado at non-religiously affiliated clinics, we surveyed patient demographic information, measures of religiosity, patient desire for spiritual assessment, and frequency of spiritual assessment in practice. Univariate logistic regression analyses were used to compare the two populations.ResultsIn both Denver County (urban) and Lincoln County (rural) over 90% of patients identified as religious, spiritual, or a combination of the two. Thirty eight percent (38.3%) of patients in Denver County and 49.1% of patients in Lincoln desired spiritual assessment. Over 97% of patients in both areas reported rarely or never being asked about their R/S within the past year. For patients who have had five or more clinic visits in the past year, more than 91% in both areas stated they have never or rarely been asked about their beliefs.ConclusionsWhile the majority of patients in this study identify as religious or spiritual and many patients desire spiritual assessment, the majority of patients have never or rarely been asked about their spirituality within the past year. This demonstrates a significant gap between patient preference and provider practice of spiritual assessment in the primary care setting, which was similar in both rural and urban settings. This highlights the need for interdisciplinary focus on spiritual assessment and incorporation of patient R/S beliefs in medical care to provide holistic patient care and improve health outcomes.
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Project description:BackgroundTo improve care for patients with chronic diseases, a recent policy initiative in Thailand focused on strengthening primary care based on the concept of Chronic Care Model (CCM). This study aimed to assess the perception of patients about the health care services after the implementation.MethodsWe conducted a cross-sectional survey of 4071 patients with hypertension and/or diabetes registered with 27 primary care units and 11 hospital non-communicable diseases (NCDs) clinics in 11 provinces. The patients were interviewed using a validated questionnaire of the Patient Assessment of Chronic Illness Care. Upgraded primary care units (PCUs) were ordinary PCUs with the multi-professional team including a physician. Trained upgraded PCUs were upgraded PCUs with the training input. Structural equation modeling was used to create subscale scores for CCM and 5 A model characteristics. Mixed effect logistic models were employed to examine the association of subscales (high vs low score) of patient perception of the care quality with type of PCUs.ResultsCompared to hospital NCD clinics, ordinary PCUs were the best in the odds of receiving high score for every CCM subscale (ORs: 1.46-1.85; p < 0.05), whereas the trained upgraded PCUs were better in terms of follow-up (ORs:1.37; p < 0.05), and the upgraded PCU did not differ in all domains. According to the 5 A model subscales, patient assessment also revealed better performance of ordinary PCUs in all domains compared to hospital NCD clinics whereas upgraded PCUs and trained upgraded PCUs did so in some domains. Seeing the same doctor on repeated visits (ORs: 1.82-2.17; p < 0.05) or having phone contacts with the providers (ORs:1.53-1.99; p < 0.05) were found beneficial using CCM subscales and the 5A model subscales. However, patient assessment by both subscales did not demonstrate a statistically significant association across health insurance status.ConclusionsThe policy implementation might not satisfy the patients' perception on quality of chronic care according to the CCM and the 5A model subscale. However, the arrangement of chronic care with patients seeing the same doctors or patients having telephone contact with healthcare providers may satisfy the patients' perceived needs.
| S-EPMC7953793 | biostudies-literature
Project description:Dementia screening is currently recommended only for symptomatic patients.To evaluate memory complaints, a mental status test, and several cognitive tests as dementia screens in primary care.Cross-sectional clinical epidemiologic study.Three hundred thirty-nine comprehensively assessed, primary care patients aged > or = 65 years.Memory complaints were abstracted from chart review. Scores on Mini-Mental State Examination (MMSE) and domain-specific cognitive testing were compared to a dementia diagnosis based on Clinical Dementia Rating score > or = 1, and areas under the receiver operating characteristic curves (AUC) were calculated. Classification and regression tree analyses were performed on memory complaints and tests with the highest AUCs.Of 33 patients with dementia, only 5 had documented memory complaints. In 25 patients with documented memory complaints, no cognitive tests further improved identification of the 5 with dementia. In 28 patients with dementia but without memory complaints, an MMSE score < 20 identified 8 cases; among those with MMSE scores 20-21, a visual memory test identified a further 11 cases. Further cognitive testing could not detect 9 dementia cases without memory complaints and with MMSE scores > or = 22.In older primary care patients with memory complaints, cognitive screening does not help identify those who require further examination for dementia. Most patients with dementia do not report memory complaints. In these asymptomatic individuals, general mental status testing, supplemented by a memory test when the mental status score is equivocal, will identify lower-scoring patients who need dementia assessment. However, high-scoring asymptomatic dementia cases will remain undetected.
| S-EPMC2219718 | biostudies-other
Project description:RationaleLung cancer screening has a mortality benefit to high-risk smokers, but implementation remains suboptimal. Providers represent the key entry point to screening, and an understanding of provider perspectives on lung cancer screening is necessary to improve referral and overall implementation.ObjectivesThe objective of this study was to understand knowledge, beliefs, attitudes, barriers, and facilitators to screening in a diverse group of referring pulmonologists and primary care providers.MethodsWe conducted an electronic survey of primary care and pulmonary providers within a tertiary care medical center across different practice sites. The survey covered the following domains: 1) beliefs and assessment of evidence, 2) knowledge of lung cancer screening and guidelines, 3) current screening practices, 4) barriers and facilitators, and 5) demographic and practice characteristics.ResultsThe 196 participants included 80% primary care clinicians and 19% pulmonologists (1% others). Forty-one percent practiced at university-based or affiliated clinics, 47% at county hospital-based clinics, and 12% at other or unidentified sites. The majority endorsed lung cancer screening effectiveness (74%); however, performance on knowledge-based assessments of screening eligibility, documentation, and nodule management was suboptimal. Key barriers included inadequate time (36%), inadequate staffing (36%), and patients having too many other illnesses to address screening (38%). Decision aids, which are used at the point of referral, were commonly identified both as important lung cancer screening clinical facilitators (51%) and as provider knowledge facilitators (59%). There were several differences by provider specialty, including primary care providers more frequently reporting time constraints and their patients having too many other illnesses to address screening as significant barriers to lung cancer screening.ConclusionsProviders endorsed the benefits of lung cancer screening, but there are limitations in provider knowledge of key screening components. The most frequently reported barriers to screening represent a lack of clinical time or resources to address lung cancer screening in clinical practice. Facilitators for nodule management as well as point-of-care referral materials may be helpful in reducing knowledge gaps and the clinical burden of referral. These are all modifiable factors, which could be addressed to increase screening referral. Differences in attitudes and barriers by specialty should also be considered to optimize screening implementation.
| S-EPMC5822418 | biostudies-literature