Understanding how health systems facilitate primary care redesign

Abstract Background Learning health systems have been gaining traction over the past decade. The purpose of this study was to understand the spread of learning health systems in primary care, including where they have been implemented, how they are operating, and potential challenges and solutions. Methods We completed a scoping review by systematically searching OVID Medline®, Embase®, IEEE Xplore®, and reviewing specific journals from 2007 to 2020. We also completed a Google search to identify gray literature. Results We reviewed 1924 articles through our database search and 51 articles from other sources, from which we identified 21 unique learning health systems based on 62 data sources. Only one of these learning health systems was implemented exclusively in a primary care setting, where all others were integrated health systems or networks that also included other care settings. Eighteen of the 21 were in the United States. Examples of how these learning health systems were being used included real-time clinical surveillance, quality improvement initiatives, pragmatic trials at the point of care, and decision support. Many challenges and potential solutions were identified regarding data, sustainability, promoting a learning culture, prioritization processes, involvement of community, and balancing quality improvement versus research. Conclusions We identified 21 learning health systems, which all appear at an early stage of development, and only one was primary care only. We summarized and provided examples of integrated health systems and data networks that can be considered early models in the growing global movement to advance learning health systems in primary care.

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The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

BMC Health Services Research ◽

10.1186/s12913-021-06140-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dimuthu Rathnayake ◽

Mike Clarke

Keyword(s):

Primary Care ◽

Health Systems ◽

Elective Surgery ◽

Waiting Times ◽

Surgical Care ◽

High Income ◽

Surgical Patients ◽

Timely Access ◽

Referral Systems

Abstract Background Long waiting times for elective surgery are common to many publicly funded health systems. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. Primary care practitioners play a major role in determining which patients are referred to surgeon and might represent an opportunity to improve this situation. With conventional methods of referrals, surgery clinics are often overcrowded with non-surgical referrals and surgical patients experience longer waiting times as a consequence. Improving the quality of referral communications should lead to more timely access and better cost-effectiveness for elective surgical care. This review summarises the research evidence for effective interventions within the scope of primary-care referral methods in the surgical care pathway that might shorten waiting time for elective surgeries. Methods We searched PubMed, EMBASE, SCOPUS, Web of Science and Cochrane Library databases in December-2019 to January-2020, for articles published after 2013. Eligibility criteria included major elective surgery lists of adult patients, excluding cancer related surgeries. Both randomised and non-randomised controlled studies were eligible. The quality of evidence was assessed using ROBINS-I, AMSTAR 2 and CASP, as appropriate to the study method used. The review presentation was limited to a narrative synthesis because of heterogeneity. The PROSPERO registration number is CRD42019158455. Results The electronic search yielded 7543 records. Finally, nine articles were considered as eligible after deduplication and full article screening. The eligible research varied widely in design, scope, reported outcomes and overall quality, with one randomised trial, two quasi-experimental studies, two longitudinal follow up studies, three systematic reviews and one observational study. All the six original articles were based on referral methods in high-income countries. The included research showed that patient triage and prioritisation at the referral stage improved timely access and increased the number of consultations of surgical patients in clinics. Conclusions The available studies included a variety of interventions and were of medium to high quality researches. Managing patient referrals with proper triaging and prioritisation using structured referral formats is likely to be effective in health systems to shorten the waiting times for elective surgeries, specifically in high-income countries.

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Prevalence and treatment of opioid use disorders among primary care patients in six health systems

Drug and Alcohol Dependence ◽

10.1016/j.drugalcdep.2019.107732 ◽

2020 ◽

Vol 207 ◽

pp. 107732 ◽

Cited By ~ 3

Author(s):

Gwen Lapham ◽

Denise M. Boudreau ◽

Eric A. Johnson ◽

Jennifer F. Bobb ◽

Abigail G. Matthews ◽

...

Keyword(s):

Primary Care ◽

Health Systems ◽

Opioid Use ◽

Primary Care Patients ◽

Opioid Use Disorders

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Barbara Starfi eld and colleagues on The contribution of primary care to health systems and health (2005)

Family Medicine ◽

10.1201/9781315365305-24 ◽

2016 ◽

pp. 203-252

Keyword(s):

Primary Care ◽

Health Systems

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Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocab189 ◽

2021 ◽

Author(s):

Brian E Dixon ◽

Kimberly M Judon ◽

Ashley L Schwartzkopf ◽

Vivian M Guerrero ◽

Nicholas S Koufacos ◽

...

Keyword(s):

Primary Care ◽

Usual Care ◽

Acute Care ◽

Health Systems ◽

Veterans Affairs ◽

Care Team ◽

Primary Care Team ◽

Medical Centers ◽

Event Notification

Abstract Objective To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults. Materials and methods We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups. Results Compared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057). Discussion ENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems. Conclusion Given the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes. Trial Registration ClinicalTrials.gov NCT02689076. “Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization.” Registered February 23, 2016.

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Primary care redesign: A simulation study at a pediatric clinic

2014 IEEE International Conference on Automation Science and Engineering (CASE) ◽

10.1109/coase.2014.6899379 ◽

2014 ◽

Cited By ~ 1

Author(s):

Xiang Zhong ◽

Molly Williams ◽

Jingshan Li ◽

Sally A. Kraft ◽

Jeffrey S. Sleeth

Keyword(s):

Primary Care ◽

Simulation Study ◽

Primary Care Redesign ◽

Pediatric Clinic

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Identifying important health system factors that influence primary care practitioners’ referrals for cancer suspicion: a European cross-sectional survey

BMJ Open ◽

10.1136/bmjopen-2018-022904 ◽

2018 ◽

Vol 8 (9) ◽

pp. e022904 ◽

Cited By ~ 5

Author(s):

Michael Harris ◽

Peter Vedsted ◽

Magdalena Esteva ◽

Peter Murchie ◽

Isabelle Aubin-Auger ◽

...

Keyword(s):

Primary Care ◽

Decision Making ◽

Factor Analysis ◽

Health System ◽

Health Systems ◽

European Countries ◽

Cancer Symptoms ◽

Referral Decision ◽

System Factors ◽

Primary Care Practitioners

ObjectivesCancer survival and stage of disease at diagnosis and treatment vary widely across Europe. These differences may be partly due to variations in access to investigations and specialists. However, evidence to explain how different national health systems influence primary care practitioners’ (PCPs’) referral decisions is lacking.This study analyses health system factors potentially influencing PCPs’ referral decision-making when consulting with patients who may have cancer, and how these vary between European countries.DesignBased on a content-validity consensus, a list of 45 items relating to a PCP’s decisions to refer patients with potential cancer symptoms for further investigation was reduced to 20 items. An online questionnaire with the 20 items was answered by PCPs on a five-point Likert scale, indicating how much each item affected their own decision-making in patients that could have cancer. An exploratory factor analysis identified the factors underlying PCPs’ referral decision-making.SettingA primary care study; 25 participating centres in 20 European countries.Participants1830 PCPs completed the survey. The median response rate for participating centres was 20.7%.Outcome measuresThe factors derived from items related to PCPs’ referral decision-making. Mean factor scores were produced for each country, allowing comparisons.ResultsFactor analysis identified five underlying factors: PCPs’ ability to refer; degree of direct patient access to secondary care; PCPs’ perceptions of being under pressure; expectations of PCPs’ role; and extent to which PCPs believe that quality comes before cost in their health systems. These accounted for 47.4% of the observed variance between individual responses.ConclusionsFive healthcare system factors influencing PCPs’ referral decision-making in 20 European countries were identified. The factors varied considerably between European countries. Knowledge of these factors could assist development of health service policies to produce better cancer outcomes, and inform future research to compare national cancer diagnostic pathways and outcomes.

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Fragmentation of Care Among Black Women With Breast Cancer and Comorbidities: The Role of Health Systems

JCO Oncology Practice ◽

10.1200/op.20.01089 ◽

2021 ◽

Vol 17 (5) ◽

pp. e637-e644 ◽

Cited By ~ 1

Author(s):

Michelle Doose ◽

Janeth I. Sanchez ◽

Joel C. Cantor ◽

Jesse J. Plascak ◽

Michael B. Steinberg ◽

...

Keyword(s):

Breast Cancer ◽

Primary Care ◽

Black Women ◽

Health System ◽

Health Systems ◽

Care Coordination ◽

Surgical Care ◽

Primary Care Visit ◽

Practice Setting ◽

Care Fragmentation

PURPOSE: Black women are disproportionately burdened by comorbidities and breast cancer. The complexities of coordinating care for multiple health conditions can lead to adverse consequences. Care coordination may be exacerbated when care is received outside the same health system, defined as care fragmentation. We examine types of practice setting for primary and breast cancer care to assess care fragmentation. MATERIALS AND METHODS: We analyzed data from a prospective cohort of Black women diagnosed with breast cancer in New Jersey who also had a prior diagnosis of diabetes and/or hypertension (N = 228). Following breast cancer diagnosis, we examined types of practice setting for first primary care visit and primary breast surgery, through medical chart abstraction, and identified whether care was used within or outside the same health system. We used multivariable logistic regression to explore sociodemographic and clinical factors associated with care fragmentation. RESULTS: Diverse primary care settings were used: medical groups (32.0%), health systems (29.4%), solo practices (23.7%), Federally Qualified Health Centers (8.3%), and independent hospitals (6.1%). Surgical care predominately occurred in health systems (79.8%), with most hospitals being Commission on Cancer–accredited. Care fragmentation was experienced by 78.5% of Black women, and individual-level factors (age, health insurance, cancer stage, and comorbidity count) were not associated with care fragmentation ( P > .05). CONCLUSION: The majority of Black breast cancer survivors with comorbidities received primary care and surgical care in different health systems, illustrating care fragmentation. Strategies for care coordination and health care delivery across health systems and practice settings are needed for health equity.

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IMPLEMENTING THE 4MS IN PRIMARY CARE: BUILDING AN AGE-FRIENDLY HEALTH SYSTEM

Innovation in Aging ◽

10.1093/geroni/igz038.2828 ◽

2019 ◽

Vol 3 (Supplement_1) ◽

pp. S769-S769

Author(s):

Ellen Flaherty ◽

Terry Fulmer

Keyword(s):

Primary Care ◽

Health System ◽

Health Systems ◽

Clinical Training ◽

Care Management ◽

Transitional Care ◽

Transfer Model ◽

Term Care ◽

Care Systems ◽

Care Improvement

Abstract The Age Friendly Health Systems initiative is a culture change movement funded by the John A. Hartford Foundation in collaboration with the Institute for Health Care Improvement. Transforming clinical training environments into integrated geriatrics and primary care systems to become Age-Friendly Health Systems must incorporate the principles of value-based care and alternative-payment models. This symposium will discuss how the implementation of the Geriatric Interprofessional Team Transformation in Primary Care (GITT-PC) model and the Reducing Avoidable Facility Transfer Model (RAFT) in primary care will improve patient outcomes focused on the 4M’s of the Age Friendly Health System. The success of the GITT-PC model focuses on 4 Medicare reimbursable services including the Annual Wellness Visit, Transitional Care Management, Chronic Care Management and Advance Care Planning. The RAFT model focuses on What Matters Most to residents of long term care facilities and reduces ED visits and hospital transfers through elicitation of goals of care and 24 hour virtual support from an interprofessional geriatric team.

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Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Ethiopia

BMJ Global Health ◽

10.1136/bmjgh-2018-001108 ◽

2018 ◽

Vol 3 (Suppl 5) ◽

pp. e001108 ◽

Cited By ~ 6

Author(s):

Yibeltal Mekonnen ◽

Charlotte Hanlon ◽

Solomon Emyu ◽

Ruth Vania Cornick ◽

Lara Fairall ◽

...

Keyword(s):

Primary Care ◽

Health Systems ◽

Addis Ababa ◽

Scale Up ◽

Health Systems Strengthening ◽

Sub Saharan Africa ◽

Practical Approach ◽

Supervisory Support ◽

Ministry Of Health ◽

Systems Research

The Federal Ministry of Health, Ethiopia, recognised the potential of the Practical Approach to Care Kit (PACK) programme to promote integrated, comprehensive and evidence-informed primary care as a means to achieving universal health coverage. Localisation of the PACK guide to become the ‘Ethiopian Primary Health Care Clinical Guidelines’ (PHCG) was spearheaded by a core team of Ethiopian policy and technical experts, mentored by the Knowledge Translation Unit, University of Cape Town. A research collaboration, ASSET (heAlth Systems StrEngThening in sub-Saharan Africa), has brought together policy-makers from the Ministry of Health and health systems researchers from Ethiopia (Addis Ababa University) and overseas partners for the PACK localisation process, and will develop, implement and evaluate health systems strengthening interventions needed for a successful scale-up of the Ethiopian PHCG. Localisation of PACK for Ethiopia included expanding the guide to include a wider range of infectious diseases and an expanded age range (from 5 to 15 years). Early feedback from front-line primary healthcare (PHC) workers is positive: the guide gives them greater confidence and is easy to understand and use. A training cascade has been initiated, with a view to implementing in 400 PHC facilities in phase 1, followed by scale-up to all 3724 health centres in Ethiopia during 2019. Monitoring and evaluation of the Ministry of Health implementation at scale will be complemented by indepth evaluation by ASSET in demonstration districts. Anticipated challenges include availability of essential medications and laboratory investigations and the need for additional training and supervisory support to deliver care for non-communicable diseases and mental health. The strong leadership from the Ministry of Health of Ethiopia combined with a productive collaboration with health systems research partners can help to ensure that Ethiopian PHCG achieves standardisation of clinical practice at the primary care level and quality healthcare for all.

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