THE MULTIPLE LOCATION TIME WEIGHTED INDEX: USING PATIENT ACTIVITY SPACES TO CALCULATE PRIMARY CARE SERVICE AREAS

Geographic health planning analyses, such as service area calculations, are hampered by a lack of patient-specific geographic data. Using the limited patient address information in patient management systems, planners analyze patient origin based on home address. But activity space research done sparingly in public health and extensively in non-health related arenas uses multiple addresses per person when analyzing accessibility. Also, health care access research has shown that there are many non-geographic factors that influence choice of provider. Most planning methods, however, overlook non-geographic factors influencing choice of provider, and the limited data mean the analyses can only be related to home address. This research attempted to determine to what extent geography plays a part in patient choice of provider and to determine if activity space data can be used to calculate service areas for primary care providers. During Spring 2008, a convenience sample of 384 patients of a locally-funded Community Health Center in Houston, Texas, completed a survey that asked about what factors are important when he or she selects a health care provider. A subset of this group (336) also completed an activity space log that captured location and time data on the places where the patient regularly goes. Survey results indicate that for this patient population, geography plays a role in their choice of health care provider, but it is not the most important reason for choosing a provider. Other factors for choosing a health care provider such as the provider offering “free or low cost visits”, meeting “all of the patient’s health care needs”, and seeing “the patient quickly” were all ranked higher than geographic reasons. Analysis of the patient activity locations shows that activity spaces can be used to create service areas for a single primary care provider. Weighted activity-space-based service areas have the potential to include more patients in the service area since more than one location per patient is used. Further analysis of the logs shows that a reduced set of locations by time and type could be used for this methodology, facilitating ongoing data collection for activity-space-based planning efforts.

The multiple location time weighted index: Using patient activity spaces to calculate primary care service areas

Geographic health planning analyses, such as service area calculations, are hampered by a lack of patient-specific geographic data. Using the limited patient address information in patient management systems, planners analyze patient origin based on home address. But activity space research done sparingly in public health and extensively in non-health related arenas uses multiple addresses per person when analyzing accessibility. Also, health care access research has shown that there are many non-geographic factors that influence choice of provider. Most planning methods, however, overlook non-geographic factors influencing choice of provider, and the limited data mean the analyses can only be related to home address. This research attempted to determine to what extent geography plays a part in patient choice of provider and to determine if activity space data can be used to calculate service areas for primary care providers. ^ During Spring 2008, a convenience sample of 384 patients of a locally-funded Community Health Center in Houston, Texas, completed a survey that asked about what factors are important when he or she selects a health care provider. A subset of this group (336) also completed an activity space log that captured location and time data on the places where the patient regularly goes. ^ Survey results indicate that for this patient population, geography plays a role in their choice of health care provider, but it is not the most important reason for choosing a provider. Other factors for choosing a health care provider such as the provider offering "free or low cost visits", meeting "all of the patient's health care needs", and seeing "the patient quickly" were all ranked higher than geographic reasons. ^ Analysis of the patient activity locations shows that activity spaces can be used to create service areas for a single primary care provider. Weighted activity-space-based service areas have the potential to include more patients in the service area since more than one location per patient is used. Further analysis of the logs shows that a reduced set of locations by time and type could be used for this methodology, facilitating ongoing data collection for activity-space-based planning efforts. ^

Primary Care Service Areas in South Carolina

This project was developed in collaboration with the South Carolina Department of Health and Environmental Control Primary Care Office in order to identify primary care market areas and resources within South Carolina. Primary Care Service Areas are designed to identify small geographic areas that are relatively self-contained markets for primary care. Included is a map and listing for Primary Care Service Areas in the state.

Primary care physician supply and other key determinants of health care utilisation: The case of Switzerland

Background The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland. Methods The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data. Results Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care. Conclusion The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds of the served populations.

From geriatric service to primary care: a retrospective pharmaceutical analysis of the medical prescription

Introduction The population of elderly persons is increasing andnegative outcomes due to polymedication are frequent. Discrepanciesin information about medication are frequent when older persons aretransitioning from hospital to home, increasing the risk of hospitalreadmission. The aims of this study were a) to determine discrepanciesin medical regimen indicated in two official discharge documents(DS = discharge summary, DP=discharge prescription); b) to characterizethe pharmacotherapy prescribed in older patients dischargedfrom a geriatric service.Materials & Methods Elderly patients (N=230) discharged from thegeriatric service (CHUV, Lausanne) over a 6-month period (January toJune 2009) were selected. Community pharmacists compared DS andDP to identify discrepancies including (a) drugs' name; (b) schedule ofadministration, dosage, frequency, prn prescription, treatment durationand galenic formulation. Beers' criteria were applied to identifypotentially inappropriate drugs and a descriptive analysis of drug costs,prescription profiles and generics were also performed.Results On average, patients were 82 ± 7 years old and stayed23.0 ± 11.6 days in the geriatric service. The delay between the datesof patient's discharge with the DP and the sending of the DS to hisgeneral physician averaged 14.0 ± 7.5 days (range 1-55). The DPhad an average of 10.0 ± 3.3 drugs (range 2-19). 77% of patients hadat least one discrepancy. A drug was missing on the DS in 57.8% ofpatients and 19.6% had a missing prn prescription. Among the 2312drugs prescribed, 3% belonged to Beers' list. They were prescribed to61 patients (26.5%), with 6 patients cumulating two Beers' potentiallyinappropriate drugs in their treatment. Analgesics (85% of thepatients), anticoagulants (80%), mineral supplements (77%), laxatives(52%) and antihypertensives (46%) were the drug classes most frequentlyprescribed. Mean costs of treatment as per DP was160.4 ± 179.4 Euros. Generic prescription represented more than 5%of the costs for 3 therapeutic classes (cholesterol-lowering agents(64%), antihypertensives (50%) and antidepressants (47%)).Discussion & Conclusion The high discrepancy rate between medicationlisted in the DP and the DS highlights a need for safetyimprovement. Potential benefits are expected from reinforced pharmacist-physician collaboration in transition from hospital to primarycare. In addition, even though Beers' criteria are questionable, thedrugs prescribed in this already fragile population, and the potentialopportunities of economical optimizations, are advocating thedevelopment and the scientific evaluation of a structured advancedcollaborative pharmacy practice service. This foresees improvedeffectiveness, safety and efficiency in the medication management ofelderly persons.

Stigmatization of alcohol and other drug users by primary care providers in Southeast Brazil

This study reports on the views of Primary Health Care (PHC) providers in Southeast Brazil on the use of alcohol and other drugs which reflect stigma, moralization, or negative judgment. Six hundred nine PHC professionals from the Brazilian states of Sao Paulo and Minas Gerais took part in the study. The majority (86.5%) of these professionals were female. Attitudes toward the use of alcohol and other drugs were evaluated in comparison to Hansen`s disease, obesity, depression, schizophrenia. HIV/AIDS, and tobacco use. The use of tobacco, marijuana/cocaine, and alcohol were the most negatively judged behaviors (p < 0.05). Nursing assistants and community health care workers demonstrated the severest judgment of alcohol use. In addition, marijuana/cocaine addicts and alcoholics suffered the highest rate of rejection by professionals. The hypothesis that the use of alcohol and other drugs is a behavior stigmatized by health professionals being confirmed, it is important to develop strategies for changing provider attitudes in order to provide a higher quality of service to these patients. This study is important as a first study among PHC professionals about social stigma of alcohol and other drugs users. (C) 2009 Elsevier Ltd. All rights reserved.

Validity and reliability of a health care service evaluation instrument for tuberculosis

OBJECTIVE To evaluate the validity and reliability of an instrument that evaluates the structure of primary health care units for the treatment of tuberculosis.METHODS This cross-sectional study used simple random sampling and evaluated 1,037 health care professionals from five Brazilian municipalities (Natal, state of Rio Grande do Norte; Cabedelo, state of Paraíba; Foz do Iguaçu, state of Parana; Sao José do Rio Preto, state of Sao Paulo, and Uberaba, state of Minas Gerais) in 2011. Structural indicators were identified and validated, considering different methods of organization of the health care system in the municipalities of different population sizes. Each structure represented the organization of health care services and contained the resources available for the execution of health care services: physical resources (equipment, consumables, and facilities); human resources (number and qualification); and resources for maintenance of the existing infrastructure and technology (deemed as the organization of health care services). The statistical analyses used in the validation process included reliability analysis, exploratory factor analysis, and confirmatory factor analysis.RESULTS The validation process indicated the retention of five factors, with 85.9% of the total variance explained, internal consistency between 0.6460 and 0.7802, and quality of fit of the confirmatory factor analysis of 0.995 using the goodness-of-fit index. The retained factors comprised five structural indicators: professionals involved in the care of tuberculosis patients, training, access to recording instruments, availability of supplies, and coordination of health care services with other levels of care. Availability of supplies had the best performance and the lowest coefficient of variation among the services evaluated. The indicators of assessment of human resources and coordination with other levels of care had satisfactory performance, but the latter showed the highest coefficient of variation. The performance of the indicators “training” and “access to recording instruments” was inferior to that of other indicators.CONCLUSIONS The instrument showed feasibility of application and potential to assess the structure of primary health care units for the treatment of tuberculosis.

Les urgences: une opportunité d'accès a des interventions préventives en partenariat avec les médecins de premier recours [Preventive medicine in emergency centres: an opportunity of partnership for emergency physicians and primary care physicians].

Whereas preventive interventions for primary care physicians are now well established, the preventive interventions in emergency departments have been only partially and recently evaluated. Emergency departments probably represent however an opportunity for preventive medicine. Indeed, the population, sometimes vulnerable, consulting emergency departments, frequently presents risks factors and risks behaviours. Moreover, the concept of &quot;teachable moment&quot; and the studies recently performed seem to confirm this hypothesis. This article review the currently preventive interventions recommended in emergency departments and discuss the rationale to implement preventive medicine in emergency departments and the limits of this process.

Guidelines for the management of depression and anxiety disorders in primary care.

High risk groups for depression and anxiety disorders include those with co-occuring alcohol or other drug misuse.This resource was contributed by The National Documentation Centre on Drug Use.

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study.

OBJECTIVE: To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs). DESIGN: Controlled longitudinal study. SETTING: English National Health Service between 1998/99 and 2010/11. PARTICIPANTS: Populations registered with each of 6975 family practices in England. MAIN OUTCOME MEASURES: Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs. RESULTS: Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. CONCLUSIONS: The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

Preanalytical mistakes in samples from primary care patients.

BACKGROUND Preanalytical mistakes (PAMs) in samples usually led to rejection upon arrival to the clinical laboratory. However, PAMs might not always be detected and result in clinical problems. Thus, PAMs should be minimized. We detected PAMs in samples from Primary Health Care Centres (PHCC) served by our central laboratory. Thus, the goal of this study was to describe the number and types of PAMs, and to suggest some strategies for improvement. METHODS The presence of PAMs, as sample rejection criteria, in samples submitted from PHCC to our laboratory during October and November 2007 was retrospectively analysed. RESULTS Overall, 3885 PAMs (7.4%) were detected from 52,669 samples for blood analyses. This included missed samples (n=1763; 45.4% of all PAMs, 3.3% of all samples), haemolysed samples (n=1408; 36.2% and 2.7%, respectively), coagulated samples (n=391; 10% and 0.7%, respectively), incorrect sample volume (n=110; 2.8% and 0.2%, respectively), and others (n=213; 5.5% and 0.4%, respectively). For urine samples (n=18,852), 1567 of the samples were missing (8.3%). CONCLUSIONS We found the proportion of PAMs in blood and urine samples to be 3-fold higher than that reported in the literature. Therefore, strategies for improvement directed towards the staff involved, as well as an exhaustive audit of preanalytical process are needed. To attain this goal, we first implemented a continued education programme, financed by our Regional Health Service and focused in Primary Care Nurses.