Informing implementation of quality improvement in Australian primary care

Background: Quality Improvement (QI) initiatives in primary care are effective at improving uptake of evidence based guidelines, but are difficult to implement and sustain. In Australia meso-level health organisations such as Primary health care Organisations (PHCO) offer new opportunities to implement area-wide QI programs. This study sought to identify enablers and barriers to implementation of an existing Australian QI program and to identify strategic directions that PHCOs can use in the ongoing development of QI in this environment. Methods: Semi-structured telephone interviews were conducted with 15 purposively selected program staff and participants from the Australian Primary Care Collaborative (APCC) QI program. Interviewees included seven people involved in design, administration and implementation of the APCC program and eight primary care providers (seven General Practitioners (GPs) and one practice nurse) who had participated in the program from 2004 to 2014. Interviewees were asked to describe their experience of the program and reflect on what enabled or impeded its implementation. Interviews were recorded, transcribed and iteratively analysed, with early analysis informing subsequent interviews. Identified themes and their implications were reviewed by a GP expert reference group. Results: Implementation enablers and barriers were grouped into five thematic areas: (1) leadership, particularly the identification and utilisation of change champions; (2) organisational culture that supports quality improvement; (3) funding incentives that support a culture of quality and innovation; (4) access to and use of accurate data; and 5) design and utilisation of clinical systems that enable and support these issues. In all of these areas, the active involvement of an overarching external support organisation was considered a key ingredient to successful implementation. Conclusion: There are substantial opportunities for PHCOs to play a pivotal role in QI implementation in Australia and internationally. In developing QI programs and policies, such organisations ought to invest their efforts in: (1) identifying and mentoring local leaders; (2) fostering QI culture via development of local peer networks; (3) developing and advocating for alternative funding models to support and incentivise these activities; (4) investing in data and audit tool infrastructure; and (5) facilitation of systems implementation within primary care practices

Clinical value of chest pain presentation and prodromes on the assessment of cardiovascular disease: a cohort study

The study was funded by a grant from the Worshipful Company of Curriers Millenium Bursary Fund

Managing risk in cancer presentation, detection and referral: a qualitative study of primary care staff views

Objectives In the UK, there have been a number of national initiatives to promote earlier detection and prompt referral of patients presenting to primary care with signs and symptoms of cancer. The aim of the study was to explore the experiences of a range of primary care staff in promoting earlier presentation, detection and referral of patients with symptoms suggestive of cancer. Setting Six primary care practices in northwest England. Participants: 39 primary care staff from a variety of disciplines took part in five group and four individual interviews. Results The global theme to emerge from the interviews was ‘managing risk’, which had three underpinning organising themes: ‘complexity’, relating to uncertainty of cancer diagnoses, service fragmentation and plethora of guidelines; ‘continuity’, relating to relationships between practice staff and their patients and between primary and secondary care; ‘conflict’ relating to policy drivers and staff role boundaries. A key concern of staff was that policymakers and those implementing cancer initiatives did not fully understand how risk was managed within primary care. Conclusions Primary care staff expressed a range of views and opinions on the benefits of cancer initiatives. National initiatives did not appear to wholly resolve issues in managing risk for all practitioners. Staff were concerned about the number of guidelines and priorities they were expected to implement. These issues need to be considered by policymakers when developing and implementing new initiatives

Primary care consultations and costs among HIV-positive individulas in UK primary care 1995-2005: a cohort study

Objectives: To investigate the role of primary care in the management of HIV and estimate primary care-associated costs at a time of rising prevalence. Methods: Retrospective cohort study between 1995 and 2005, using data from general practices contributing data to the UK General Practice Research Database. Patterns of consultation and morbidity and associated consultation costs were analysed among all practice-registered patients for whom HIV-positive status was recorded in the general practice record. Results: 348 practices yielded 5504 person-years (py) of follow-up for known HIV-positive patients, who consult in general practice frequently (4.2 consultations/py by men, 5.2 consultations/py by women, in 2005) for a range of conditions. Consultation rates declined in the late 1990s from 5.0 and 7.3 consultations/py in 1995 in men and women, respectively, converging to rates similar to the wider population. Costs of consultation (general practitioner and nurse, combined) reflect these changes, at £100.27 for male patients and £117.08 for female patients in 2005. Approximately one in six medications prescribed in primary care for HIV-positive individuals has the potential for major interaction with antiretroviral medications. Conclusion: HIV-positive individuals known in general practice now consult on a similar scale to the wider population. Further research should be undertaken to explore how primary care can best contribute to improving the health outcomes of this group with chronic illness. Their substantial use of primary care suggests there may be potential to develop effective integrated care pathways

Improving access to high-quality primary care for socioeconomically disadvantaged older people in rural areas: a mixed method study protocol

Introduction: The UK has an ageing population, especially in rural areas, where deprivation is high among older people. Previous research has identified this group as at high risk of poor access to healthcare. The aim of this study is to generate a theory of how socioeconomically disadvantaged older people from rural areas access primary care, to develop an intervention based on this theory and test it in a feasibility trial. Methods and analysis: On the basis of the MRC Framework for Developing and Evaluating Complex Interventions, three methods will be used to generate the theory. First, a realist review will elucidate the patient pathway based on existing literature. Second, an analysis of the English Longitudinal Study of Ageing will be completed using structural equation modelling. Third, 15 semistructured interviews will be undertaken with patients and four focus groups with health professionals. A triangulation protocol will be used to allow each of these methods to inform and be informed by each other, and to integrate data into one overall realist theory. Based on this theory, an intervention will be developed in discussion with stakeholders to ensure that the intervention is feasible and practical. The intervention will be tested within a feasibility trial, the design of which will depend on the intervention. Lessons from the feasibility trial will be used to refine the intervention and gather the information needed for a definitive trial. Ethics and dissemination: Ethics approval from the regional ethics committee has been granted for the focus groups with health professionals and interviews with patients. Ethics approval will be sought for the feasibility trial after the intervention has been designed. Findings will be disseminated to the key stakeholders involved in intervention development, to researchers, clinicians and health planners through peer-reviewed journal articles and conference publications, and locally through a dissemination event

Shared geriatric mental health care in a rural community

Introduction: A pilot project in shared mental health care was initiated to explore opportunities to increase the capacity of the rural primary care system as a resource for older people with mental health needs. This was done within a framework for the delivery of best practices in geriatric mental health outreach. Methods: Shared-care strategies combining education and clinical consultation between mentor psychiatrists and family physicians were implemented and then evaluated after one year to identify key factors in the success of approaches to shared mental health care for older people in a rural setting. Results: Results provided new insights into shared care between primary care and specialty geriatric mental health services, rural geriatric mental health service delivery, developmental phases in service learning approaches, and building knowledge networks to promote continuing best practices. Conclusion: The results from the project's process evaluation have been integrated into the development of a permanent shared geriatric mental health care service for the rural setting. Preparation for an outcome evaluation that will focus on the impact on patient care has also been initiated

Characterizing infection in anti-neutrophil cytoplasmic antibody-associated vasculitis:results from a longitudinal, matched-cohort data linkage study

Objectives: Infection exerts a major burden in ANCA-associated vasculitis (AAV), however, its precise extent and nature remains unclear. In this national study we aimed to longitudinally quantify, characterize and contextualize infection risk in AAV. Methods: We conducted a multicentre matched cohort study of AAV. Complementary data on infections were retrieved via data linkage with the population-based Scottish microbiological laboratory, hospitalization and primary care prescribing registries. Results: A total of 379 AAV patients and 1859 controls were followed up for a median of 3.5 years (interquartile range 1.9-5.7). During follow-up, the proportions of AAV patients with at least one laboratory-confirmed infection, severe infection and primary care antibiotic prescription were 55.4%, 35.6% and 74.6%, respectively. The risk of infection was higher in AAV than in matched controls {laboratory-confirmed infections: incidence rate ratio [IRR] 7.3 [95% confidence interval (CI) 5.6, 9.6]; severe infections: IRR 4.4 [95% CI 3.3, 5.7]; antibiotic prescriptions: IRR 2.2 [95% CI 1.9, 2.6]}. Temporal trend analysis showed that AAV patients remained at a higher risk of infections throughout the follow-up period, especially year 1. Although the Escherichia genus was the most commonly identified pathogen (16.6% of AAV, 5.5% of controls; P &lt; 0.0001), AAV patients had the highest risk for Herpes [IRR 12.5 (95% CI 3.7, 42.6)] and Candida [IRR 11.4 (95% CI 2.4, 55.4)]. Conclusion: AAV patients have up to seven times higher risk of infection than the general population and the overall risk remains significant after 8 years of follow-up. The testing of enhanced short- to medium-term prophylactic antibiotic regimes should be considered.</p

Use of electronic medical records and biomarkers to manage risk and resource efficiencies

Peer reviewedPublisher PD