Using unannounced standardised patients as a quality improvement tool to improve primary care

Abstract presented at the 2nd International Conference on General Practice & Primary Care, 18-19 September 2017, Zurich, Switzerlan

The influence of power dynamics and trust on multidisciplinary collaboration: a qualitative case study of type 2 diabetes mellitus

<p>Abstract</p> <p>Background</p> <p>Ongoing care for chronic conditions such as diabetes is best provided by a range of health professionals working together. There are challenges in achieving this where collaboration crosses organisational and sector boundaries. The aim of this article is to explore the influence of power dynamics and trust on collaboration between health professionals involved in the management of diabetes and their impact on patient experiences.</p> <p>Methods</p> <p>A qualitative case study conducted in a rural city in Australia. Forty five health service providers from nineteen organisations (including fee-for-service practices and block funded public sector services) and eight patients from two services were purposively recruited. Data was collected through semi-structured interviews that were audio-taped and transcribed. A thematic analysis approach was used using a two-level coding scheme and cross-case comparisons.</p> <p>Results</p> <p>Three themes emerged in relation to power dynamics between health professionals: their use of power to protect their autonomy, power dynamics between private and public sector providers, and reducing their dependency on other health professionals to maintain their power. Despite the intention of government policies to support more shared decision-making, there is little evidence that this is happening. The major trust themes related to role perceptions, demonstrated competence, and the importance of good communication for the development of trust over time. The interaction between trust and role perceptions went beyond understanding each other's roles and professional identity. The level of trust related to the acceptance of each other's roles. The delivery of primary and community-based health services that crosses organisational boundaries adds a layer of complexity to interprofessional relationships. The roles of and role boundaries between and within professional groups and services are changing. The uncertainty and vulnerability associated with these changes has affected the level of trust and mistrust.</p> <p>Conclusions</p> <p>Collaboration across organisational boundaries remains challenging. Power dynamics and trust affect the strategic choices made by each health professional about whether to collaborate, with whom, and to what level. These decisions directly influenced patient experiences. Unlike the difficulties in shifting the balance of power in interprofessional relationships, trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair.</p

Healthcare improvement as planned system change or complex responsive processes? A longitudinal case study in general practice

Background: Interest in how to implement evidence-based practices into routine health care has never been greater. Primary care faces challenges in managing the increasing burden of chronic disease in an ageing population. Reliable prescriptions for translating knowledge into practice, however, remain elusive, despite intense research and publication activity. This study seeks to explore this dilemma in general practice by challenging the current way of thinking about healthcare improvement and asking what can be learned by looking at change through a complexity lens. Methods. This paper reports the local level of an embedded case study of organisational change for better chronic illness care over more than a decade. We used interviews, document review and direct observation to explore how improved chronic illness care developed in one practice. This formed a critical case to compare, using pattern matching logic, to the common prescription for local implementation of best evidence and a rival explanation drawn from complexity sciences interpreted through modern sociology and psychology. Results: The practice changed continuously over more than a decade to deliver better chronic illness care in line with research findings and policy initiatives - re-designing care processes, developing community linkages, supporting patient self-management, using guidelines and clinical information systems, and integrating nurses into the practice team. None of these improvements was designed and implemented according to an explicit plan in response to a documented gap in chronic disease care. The process that led to high quality chronic illness care exhibited clear complexity elements of co-evolution, non-linearity, self-organisation, emergence and edge of chaos dynamics in a network of agents and relationships where a stable yet evolving way of organizing emerged from local level communicative interaction, power relating and values based choices. Conclusions: The current discourse of implementation science as planned system change did not match organisational reality in this critical case of improvement in general practice. Complexity concepts translated in human terms as complex responsive processes of relating fit the pattern of change more accurately. They do not provide just another fashionable blueprint for change but inform how researchers, policymakers and providers participate in improving healthcare. 2013 Booth et al.; licensee BioMed Central Ltd

Strategic approaches to the development of Australia\u27s future primary care workforce

Shortages in, and maldistribution of, the primary health care workforce will continue to limit access to health care. The current health reform proposals and policies recognise workforce development as a priority, but only partially address the barriers to improvement. In particular, there will need to be more systematic development of interdisciplinary education within primary health care services, and funding to support this

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

Background: To evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW). Methods: A systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings. We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine). Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies. Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High = 8 points of contact/hours; Moderate \u3e3 and \u3c8; Low = ¿3 points of contact hours) and setting (primary health, community or other). Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported. Results: 52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.Conclusion: Group and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs. 2012 Taggart et al.; licensee BioMed Central Ltd

Access to preventive care by immigrant populations

Many immigrant populations lack access to primary health care. A recently published study on cholesterol screening among immigrant populations in the US found disparities in cholesterol screening in those originating from Mexico, largely due to limited access to healthcare. This inverse care affects immigrants in many destination countries despite their greater health need

An Australian general practice based strategy to improve chronic disease prevention, and its impact on patient reported outcomes: Evaluation of the preventive evidence into practice cluster randomised controlled trial

© 2017 The Author(s). Background: Implementing evidence-based chronic disease prevention with a practice-wide population is challenging in primary care. Methods: PEP Intervention practices received education, clinical audit and feedback and practice facilitation. Patients (40 69 years) without chronic disease from trial and control practices were invited to participate in baseline and 12 month follow up questionnaires. Patient-recalled receipt of GP services and referral, and the proportion of patients at risk were compared over time and between intervention and control groups. Mean difference in BMI, diet and physical activity between baseline and follow up were calculated and compared using a paired t-test. Change in the proportion of patients meeting the definition for physical activity diet and weight risk was calculated using McNemar's test and multilevel analysis was used to determine the effect of the intervention on follow-up scores. Results: Five hundred eighty nine patients completed both questionnaires. No significant changes were found in the proportion of patients reporting a BP, cholesterol, glucose or weight check in either group. Less than one in six at-risk patients reported receiving lifestyle advice or referral at baseline with little change at follow up. More intervention patients reported attempts to improve their diet and reduce weight. Mean score improved for diet in the intervention group (p = 0.04) but self-reported BMI and PA risk did not significantly change in either group. There was no significant change in the proportion of patients who reported being at-risk for diet, PA or weight, and no changes in PA, diet and BMI in multilevel linear regression adjusted for patient age, sex, practice size and state. There was good fidelity to the intervention but practices varied in their capacity to address changes. Conclusions: The lack of measurable effect within this trial may be attributable to the complexities around behaviour change and/or system change. This trial highlights some of the challenges in providing suitable chronic disease preventive interventions which are both scalable to whole practice populations and meet the needs of diverse practice structures. Trial registration: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12612000578808 (29/5/2012). This trial registration is retrospective as our first patient returned their consent on the 21/5/2012. Patient recruitment was ongoing until 31/10/2012

Empirical constraints on extrusion mechanisms from the upper margin of an exhumed high-grade orogenic core, Sutlej valley, NW India

The Early–Middle Miocene exhumation of the crystalline core of the Himalaya is a relatively well-understood process compared to the preceding phase of burial and prograde metamorphism in the Eocene–Oligocene. Highly deformed rocks of the Greater Himalayan Sequence (GHS) dominate the crystalline core, and feature a strong metamorphic and structural overprint related to the younger exhumation. The Tethyan Sedimentary Series was tectonically separated from the underlying GHS during the Miocene by the South Tibetan Detachment, and records a protracted and complex history of Cenozoic deformation. Unfortunately these typically low-grade or unmetamorphosed rocks generally yield little quantitative pressure–temperature�time information to accompany this deformation history. In parts of the western Himalaya, however, the basal unit of the Tethyan Sedimentary Series (the Haimanta Group) includes pelites metamorphosed to amphibolite facies. This presents a unique opportunity to explore the tectono-thermal evolution of crystalline rocks which record the early history of the orogen. Pressure–temperature�time–deformation (P–T�t–d) paths modelled for two Haimanta Group pelitic rocks reveal three distinct stages of metamorphism: (1) prograde Barrovian metamorphism to 610–620 °C at c. 7–8 kbars, with garnet growing over an early tectonic fabric (S1); (2) initial decompression during heating to 640–660 °C at c. 6–7 kbars, with development of a pervasive crenulation cleavage (S2) and staurolite and kyanite porphyroblast growth; (3) further exhumation during cooling, with minor retrograde metamorphism and modification of the pervasive S2 fabric. Monazite growth ages constrain the timing of initial garnet growth (> 34 Ma), the start of D2 and maximum burial (c. 30 Ma), and the termination of garnet growth (c. 28 Ma). Muscovite Ar/Ar ages indicate cooling through c. 300 °C at c. 13 Ma, from which we derive an initial exhumation rate of c. 1.3 mm year? 1 for the Haimanta Group. The underlying GHS was exhumed at a rate of 2.2 to 3 mm year? 1 during this time. The difference in exhumation rate between these two units is considered to reflect Early Miocene displacement on the intervening South Tibetan Detachment. Slower exhumation (c. 0.6 mm year? 1) of both units after c. 13 Ma followed the cessation of major displacement on this structure, after which time the Haimanta Group and the GHS were exhumed as one relatively coherent tectonic block