Regular physical activity reduces falls, hip fractures, and all-cause mortality, but physical activity levels are low in older age groups.
To evaluate two exercise programmes promoting physical ...activity among older people.
Pragmatic three-arm, parallel-design cluster randomised controlled trial involving 1256 people aged ≥65 years (of 20 507 invited) recruited from 43 general practices in London, Nottingham, and Derby.
Practices were randomised to the class-based Falls Management Exercise programme (FaME), the home-based Otago Exercise Program (OEP), or usual care. The primary outcome was the proportion reaching the recommended physical activity target 12 months post-intervention. Secondary outcomes included falls, quality of life, balance confidence, and costs.
In total, 49% of FaME participants reached the physical activity target compared with 38% for usual care (adjusted odds ratio 1.78, 95% confidence interval CI =1.11 to 2.87, P = 0.02). Differences between FaME and usual care persisted 24 months after intervention. There was no significant difference comparing those in the OEP (43% reaching target at 12 months) and usual-care arms. Participants in the FaME arm added around 15 minutes of moderate-to-vigorous physical activity per day to their baseline level; this group also had a significantly lower rate of falls (incident rate ratio 0.74, 95% CI = 0.55 to 0.99, P = 0.042). Balance confidence was significantly improved in both intervention arms. The mean cost per extra person achieving the physical activity target was £1740. Attrition and rates of adverse reactions were similar.
The FaME programme increases self-reported physical activity for at least 12 months post-intervention and reduces falls in people aged ≥65 years, but uptake is low. There was no statistically significant difference in reaching the target, or in falls, between the OEP and usual-care arms.
Correspondence to: T Greenhalgh trish.greenhalgh@phc.ox.ac.uk What you need to know Most patients with covid-19 can be managed remotely with advice on symptomatic management and self isolation ...Although such consultations can be done by telephone in many cases, video provides additional visual cues and therapeutic presence Breathlessness is a concerning symptom, though there is currently no validated tool for assessing it remotely Safety-netting advice is crucial because some patients deteriorate in week 2, most commonly with pneumonia A 37 year-old healthcare assistant develops a cough. ...video can provide additional visual information, diagnostic clues, and therapeutic presence.345 Hence, video may be appropriate for sicker patients, those with comorbidities, those whose social circumstances have a bearing on the illness, and those who are very anxious. Have your current “stay at home” covid-19 guidance on hand.78 Establishing a technical connection for a video consultation Research shows that if the technical connection is high quality, clinicians and patients tend to communicate by video in much the same way as in an in-person consultation.3 When you are ready to connect, follow your local procedure (in some cases, for example, the link will be via a fixed URL and in others, a new URL will be generated for each appointment). Ask open ended questions and listen to whether the patient can complete their sentences: “How is your breathing today?” Align with the NHS 111 symptom checker, which asks three questions (developed through user testing but not evaluated in formal research): “Are you so breathless that you are unable to speak more than a few words?” “Are you breathing harder or faster than usual when doing nothing at all?” “Are you so ill that you've stopped doing all of your usual daily activities?” Focus on change.
This paper applies a critical analysis of the impact of neo-liberal driven management reform to examine changes in Australian primary health care (PHC) services over five years. The implementation of ...comprehensive approaches to primary health care (PHC) in seven services: five state-managed and two non-government organisations (NGOs) was tracked from 2009 to 2014. Two questions are addressed: 1) How did the ability of Australian PHC services to implement comprehensive PHC change over the period 2009–2014? 2) To what extent is the ability of the PHC services to implement comprehensive PHC shaped by neo-liberal health sector reform processes? The study reports on detailed tracking and observations of the changes and in-depth interviews with 63 health service managers and practitioners, and regional and central health executives. The documented changes were: in the state-managed services (although not the NGOs) less comprehensive service coverage and more focus on clinical services and integration with hospitals and much less development activity including community development, advocacy, intersectoral collaboration and attention to the social determinants. These changes were found to be associated with practices typical of neo-liberal health sector reform: considerable uncertainty, more directive managerial control, budget reductions and competitive tendering and an emphasis on outputs rather than health outcomes. We conclude that a focus on clinical service provision, while highly compatible with neo-liberal reforms, will not on its own produce the shifts in population disease patterns that would be required to reduce demand for health services and promote health. Comprehensive PHC is much better suited to that task.
•Theories on neo-liberalism explain changes to comprehensive primary health care.•Neo-liberal practices have reduced the comprehensiveness of primary health care.•Increasing health care costs increases pressure to reduce health promotion actions.•Community management encourages comprehensive primary health care.•Primary health care includes disease prevention and health promotion for all.
In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes ...through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.
To create an index that measures the extent of PCMH implementation, describe variation in implementation, and examine the association between the implementation index and key outcomes.
We conducted an observational study using data on more than 5.6 million veterans who received care at 913 VHA hospital-based and community-based primary care clinics and 5404 primary care staff from (1) VHA clinical and administrative databases, (2) a national patient survey administered to a weighted random sample of veterans who received outpatient care from June 1 to December 31, 2012, and (3) a survey of all VHA primary care staff in June 2012. Composite scores were constructed for 8 core domains of PACT: access, continuity, care coordination, comprehensiveness, self-management support, patient-centered care and communication, shared decision making, and team-based care.
Patient satisfaction, rates of hospitalization and emergency department use, quality of care, and staff burnout.
Fifty-three items were included in the PACT Implementation Progress Index (Pi2). Compared with the 87 clinics in the lowest decile of the Pi2, the 77 sites in the top decile exhibited significantly higher patient satisfaction (9.33 vs 7.53; P < .001), higher performance on 41 of 48 measures of clinical quality, lower staff burnout (Maslach Burnout Inventory emotional exhaustion subscale, 2.29 vs 2.80; P = .02), lower hospitalization rates for ambulatory care-sensitive conditions (4.42 vs 3.68 quarterly admissions for veterans 65 years or older per 1000 patients; P < .001), and lower emergency department use (188 vs 245 visits per 1000 patients; P < .001).
The extent of PCMH implementation, as measured by the Pi2, was highly associated with important outcomes for both patients and providers. This measure will be used to track the effectiveness of implementing PACT over time and to elucidate the correlates of desired health outcomes.
Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by ...provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level.
Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting.
Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits.
A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care.
In 2015, the US Preventive Services Task Force updated their hypertension recommendations to advise that adults with elevated office blood pressure (BP) undergo out-of-office BP measurement to ...exclude white coat hypertension before diagnosis. Our goal was to determine the most important barriers to primary care providers' ordering ambulatory and home BP monitoring in the United States. We enrolled 63 primary care providers into nominal group panels in which participants iteratively listed and ranked barriers to ambulatory and home BP monitoring. Top-ranked barriers to ambulatory BP monitoring were challenges in accessing testing, costs of testing, concerns about the willingness or ability of patients to successfully complete tests, and concerns about the accuracy and benefits of testing. Top-ranked barriers to home BP monitoring were concerns about compliance with the correct test protocol, accuracy of tests results, out-of-pocket costs of home BP devices, and time needed to instruct patients on home BP monitoring protocol. Efforts to increase the use of ambulatory and home BP monitoring by primary care providers in the United States should prioritize increasing the financial and personnel resources available for testing and addressing provider concerns about patients' ability to conduct high-quality tests.
To conduct a systematic review of randomized controlled trials (RCTs) of the safety and effectiveness of primary care provided by advanced practice nurses (APNs) and evaluate the potential of their ...deployment to help alleviate primary care shortages.
PubMed, Medline and the Cumulative Index to Nursing and Allied Health Literature.
RCTs and their follow-up reports that compared outcomes of care provided to adults by APNs and physicians in equivalent primary care provider roles were selected for inclusion.
Ten articles (seven RCTs, plus two economic evaluations and one 2-year follow-up study of included RCTs) met inclusion criteria. Data were extracted regarding study design, setting and outcomes across four common categories.
The seven RCTs include data for 10 911 patients who presented for ongoing primary care (four RCTs) or same-day consultations for acute conditions (three RCTs) in the primary care setting. Study follow-up ranged from 1 day to 2 years. APN groups demonstrated equal or better outcomes than physician groups for physiologic measures, patient satisfaction and cost. APNs generally had longer consultations compared with physicians; however, two studies reported that APN patients required fewer consultations over time.
There were few differences in primary care provided by APNs and physicians; for some measures APN care was superior. While studies are needed to assess longer term outcomes, these data suggest that the APN workforce is well-positioned to provide safe and effective primary care.
Ghana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment ...effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana.
Using a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims.
Out-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation.
The study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.
Primary care panel sizes are an important component of primary care practices. Determining the appropriate panel size has implications for patient access, physician workload, and care ...comprehensiveness and will have an impact on quality of care. An often quoted standard panel size is 2500. However, this number seems to arise in the literature anecdotally, without a basis in research. Subsequently, multiple studies observed that a panel size of 2500 is not feasible because of time constraints and results in incomplete preventive care and health care screening services. In this article we review the origins of a panel size of 2500, review the subsequent work examining this number and effectively debunking it as a feasible panel size, and discuss the importance of primary care physicians setting an appropriate panel size.
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