scholarly journals Management of chronic headache with referral from primary care to direct access to MRI compared with Neurology services: an observational prospective study in London

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e036097
Author(s):  
Tiago Rua ◽  
Asif Mazumder ◽  
Yvonne Akande ◽  
Charikleia Margariti ◽  
Juliana Ochulor ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Satisfaction ◽  
Access To Care ◽  
Secondary Care ◽  
Chronic Headache ◽  
Brain Mri ◽  
Secondary Outcome ◽  
Cost Difference ◽  
Brain Scan ◽  
Mean Cost

ObjectivesTo evaluate the cost, accessibility and patient satisfaction implications of two clinical pathways used in the management of chronic headache.InterventionManagement of chronic headache following referral from Primary Care that differed in the first appointment, either a Neurology appointment or an MRI brain scan.Design and settingA pragmatic, non-randomised, prospective, single-centre study at a Central Hospital in London.ParticipantsAdult patients with chronic headache referred from primary to secondary care.Primary and secondary outcome measuresParticipants’ use of healthcare services and costs were estimated using primary and secondary care databases and questionnaires quarterly up to 12 months postrecruitment. Cost analyses were compared using generalised linear models. Secondary outcomes assessed: access to care, patient satisfaction, headache burden and self-perceived quality of life using headache-specific (Migraine Disability Assessment Scale and Headache Impact Test) and a generic questionnaire (5-level EQ-5D).ResultsMean (SD) cost up to 6 months postrecruitment per participant was £578 (£420) for the Neurology group (n=128) and £245 (£172) for the MRI group (n=95), leading to an estimated mean cost difference of £333 (95% CI £253 to £413, p<0.001). The mean cost difference at 12 months increased to £518 (95% CI £401 to £637, p<0.001). When adjusted for baseline and follow-up imbalances between groups, this remained statistically significant. The utilisation of brain MRI improved access to care compared with the Neurology group (p<0.001). Participants in the Neurology group reported higher levels of satisfaction associated with the pathway and led to greater change in care management.ConclusionDirect referral to brain MRI from Primary Care led to cost-savings and quicker access to care but lower satisfaction levels when compared with referral to Neurology services. Further research into the use of brain MRI for a subset of patient population more likely to be reassured by a negative brain scan should be considered.Trial registration numberNCT02753933.

Pharmacoeconomic, Medication Access, and Patient-Satisfaction Analysis of a Pharmacist-Managed VTE Clinic Compared to Primary Care Physician Outpatient Therapy

2020 ◽  
pp. 089719002096621
Author(s):  
Chandler Wayne Howell ◽  
Todd A. Walroth ◽  
Daren M. Beam ◽  
Christopher A. Geik ◽  
Molly M. Howell ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Satisfaction ◽  
Primary Care Physician ◽  
Medical Condition ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Care Physician ◽  
Secondary Outcome ◽  
P Value ◽  
Patient Satisfaction Score

Venous thromboembolism (VTE) is a common medical condition often treated with direct oral anticoagulants (DOACs). Current literature supports outpatient treatment of select, low-risk VTE patients by a pharmacist with DOACs; however, no studies exist to demonstrate if a pharmacist-managed VTE clinic provides financial benefit compared to physician-managed outpatient care. To compare the financial implications and patient satisfaction of pharmacist-managed VTE care versus outpatient VTE care by a primary care physician. A single-center retrospective chart review was conducted on all patients seen at a pharmacist-managed VTE clinic for safety and reimbursement outcomes between August 1, 2018 and July 31, 2019. These data points were used to assess the primary endpoint of net gain per patient visit and secondary outcomes, including patient satisfaction score. The primary outcome median (IQR) for net gain per visit was $16.57 (16.57, 16.57) for the pharmacist-managed group and $64.37 (47.04, 64.37) in the physician-managed group with a 95% CI of 39.13-47.80. The median cost to the organization per visit was $4.96 (4.96, 4.96) for the pharmacist-managed group and $39.41 (23.65, 39.41) for the physician managed group with a 95% CI of 26.57-34.45. Statistical difference was also found for a secondary outcome of percentage of days covered for the pharmacist-managed group compared to the physician managed group, median (IQR) 100% (76,100) vs 92.2% (67.2, 98.9) respectfully, with a p-value of 0.043. The pharmacist-managed VTE clinic, although financially sustainable, provides significantly less net revenue per patient than physician managed clinics, demonstrating the need for increased payer recognition for pharmacists.

scholarly journals Referrals to secondary care in an outpatient primary care walk-in clinic for refugees in Germany: results from a secondary data analysis based on electronic medical records

BMJ Open ◽  
2020 ◽  
Vol 10 (10) ◽  
pp. e035625
Author(s):  
Ingmar Schäfer ◽  
Jan Hendrik Oltrogge ◽  
Susanne Pruskil ◽  
Claudia Mews ◽  
Dana Schlichting ◽  
...  
Keyword(s):  
Primary Care ◽  
Secondary Care ◽  
Cox Regression ◽  
Country Of Origin ◽  
Secondary Data ◽  
Routine Data ◽  
Health Problems ◽  
Secondary Outcome ◽  
Data Set ◽  
Healthcare Needs

ObjectivesThe aims of our study were to describe the disease spectrum of refugees, to analyse to what extent their healthcare needs could be met in an outpatient primary care walk-in clinic and which cases required additional services from secondary care (ie, outpatient specialists or hospitals).DesignRetrospective longitudinal observational study.SettingThe study was based on routine data from a walk-in clinic in the largest central first reception centre in Hamburg, Germany between 4 November 2015 and 21 July 2016.Participants1467 asylum seekers with 4006 episodes of care (ie, distinctive health problems) resulting in 5545 consultations. The patients were 60% men and had a mean age of 23.2 years. About 90% of the patients were from Central Asia or from the Middle East and North Africa.Primary and secondary outcome measuresThe endpoint of our analyses was referral to secondary care. Time to event was defined as days under treatment until the first referral. Predictor variables were the patients’ diagnoses grouped in 46 categories. The data set was analysed by Cox regression allowing for multiple failure times per patient. This analysis was adjusted for age, sex and country of origin.ResultsReferrals to secondary care occurred in 15.5% of the episodes. The diagnosis groups with the highest referral rates were ‘eye’ (HR 4.9; 95% CI 3.12 to 7.8; p≤0.001), ‘teeth/gum symptom/complaint or disease’ (3.51; 2.52 to 4.9; p≤0.001) and ‘urological system/female or male genital’ (2.50; 1.66 to 3.77; p≤0.001). Age, sex and country of origin had no significant effect on time until referral.ConclusionsIn most cases, the walk-in clinic physicians could provide first-line medical care for the health problems of patients not integrated in the German healthcare system. Additional resources were needed particularly not only for visual impairment and dental problems but also for psychological disorders, antenatal care and certain infections and injuries.

scholarly journals Psychosomatic therapy for patients frequently attending primary care with medically unexplained symptoms, the CORPUS trial: study protocol for a randomised controlled trial

Trials ◽  
2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Margreet S. H. Wortman ◽  
Johannes C. van der Wouden ◽  
Janneke P. C. Grutters ◽  
Bart Visser ◽  
Willem J. J. Assendelft ◽  
...  
Keyword(s):  
Primary Care ◽  
Economic Evaluation ◽  
Usual Care ◽  
Secondary Care ◽  
Outcome Measure ◽  
Medically Unexplained Symptoms ◽  
Secondary Outcome ◽  
Patient Specific ◽  
Medically Unexplained ◽  
Unexplained Symptoms

Abstract Background Medically unexplained symptoms (MUS) are highly prevalent and pose a burden both on patients and on health care. In a pilot study psychosomatic therapy delivered by specialised therapists for patients with MUS showed promising results with regard to patient’s acceptability, feasibility and effects on symptoms. The aim of this study is to establish whether psychosomatic therapy by specialised psychosomatic exercise therapists is cost- effective in decreasing symptoms and improving functioning in patients who frequently consult their general practitioner (GP) with MUS. Methods A randomised effectiveness trial with an economic evaluation in primary care with 158 patients aged 18 years and older who are frequently consulting their GP with MUS. Patients will be assigned to psychosomatic therapy in addition to usual care or usual care only. Psychosomatic therapy is a multi-component and tailored intervention, aiming to empower patients by applying psycho-education, relaxation techniques, mindfulness, cognitive approaches and/or graded activity. Patients assigned to the psychosomatic therapy receive 6 to 12 sessions of psychosomatic therapy, of 30–45 min each, delivered by a specialised exercise or physical therapist. Primary outcome measure is patient-specific functioning and disability, measured with the Patient-Specific Functional Scale (PSFS). Secondary outcome measures are symptom severity, consultation frequency and referrals to secondary care, patient satisfaction, quality of life and costs. Assessments will be carried out at baseline, and after 4 and 12 months. An economic evaluation alongside the trial will be conducted from a societal perspective, with quality-adjusted life years (QALYs) as outcome measure. Furthermore, a mixed-methods process evaluation will be conducted. Discussion We expect that psychosomatic therapy in primary care for patients who frequently attend the GP for MUS will improve symptoms and daily functioning and disability, while reducing consultation frequency and referrals to secondary care. We expect that the psychosomatic therapy provides value for money for patients with MUS. Trial registration Netherlands Trial Register, ID: NL7157 (NTR7356). Registered 13 July 2018.

scholarly journals Is there scope to improve the selection of patients with alcohol-related liver disease for referral to secondary care? A retrospective analysis of primary care referrals to a UK liver centre, incorporating simple blood tests

BMJ Open ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. e047786
Author(s):  
Freya Alison Rhodes ◽  
Sara Cococcia ◽  
Preya Patel ◽  
Jasmina Panovska-Griffiths ◽  
Sudeep Tanwar ◽  
...  
Keyword(s):  
Primary Care ◽  
Liver Disease ◽  
Fatty Liver ◽  
Retrospective Analysis ◽  
Secondary Care ◽  
Fatty Liver Disease ◽  
Secondary Outcome ◽  
Advanced Fibrosis ◽  
Blood Tests ◽  
Related Liver Disease

ObjectivesTwenty per cent of people with alcohol use disorders develop advanced fibrosis and warrant referral to secondary care. Improving outcomes in alcohol-related liver disease (ArLD) relies on its earlier detection in primary care with non-invasive tests (NIT). We aimed to determine the proportion of alcohol-related referrals who were diagnosed with advanced fibrosis in secondary care, the prevalence of both alcohol and fatty liver disease (‘BAFLD’) and the potential impact of NIT on referral stratification.Design/settingRetrospective analysis of all general practitioner-referrals with suspected ArLD/non-alcoholic fatty liver disease (NAFLD) to a UK hepatology-centre between January 2015 and January 2018.ParticipantsOf 2944 new referrals, 762 (mean age 55.5±13.53 years) met inclusion criteria: 531 NAFLD and 231 ArLD, of which 147 (64%) could be reclassified as ‘BAFLD’.Primary outcome measureProportion of referrals with suspected ArLD/NAFLD with advanced fibrosis as assessed by tertiary centre hepatologists using combinations of FibroScan, imaging, examination and blood tests and liver histology, where indicated.Secondary outcome measuresIncluded impact of body mass index/alcohol consumption on the odds of a diagnosis of advanced fibrosis, and performance of NIT in predicting advanced fibrosis in planned post-hoc analysis of referrals.ResultsAmong ArLD referrals 147/229 (64.2%) had no evidence of advanced fibrosis and were judged ‘unnecessary’. Advanced fibrosis was observed in men drinking ≥50 units per week (U/w) (OR 2.74, 95% CI 1.51 to 5, p=0.001) and ≥35 U/w in women (OR 5.11, 95% CI 1.31 to 20.03, p=0.019). Drinking >14 U/w doubled the likelihood of advanced fibrosis in overweight/obesity (OR 2.11; 95% CI 1.44 to 3.09; p<0.001). Use of fibrosis 4 score could halve unnecessary referrals (OR 0.50; 95% CI 0.32 to 0.79, p=0.003) with false-negative rate of 22%, but was rarely used.ConclusionsThe majority of referrals with suspected ArLD were deemed unnecessary. NIT could improve identification of liver damage in ArLD, BAFLD and NAFLD in primary care. Anecdotal thresholds for harmful drinking (35 U/w in women and 50 U/w in men) were validated. The impact of alcohol on NAFLD highlights the importance of multi-causality in chronic liver disease.

scholarly journals Observational study of the implementation of telephone advice nursing in Sweden: did callers follow recommendations and did the rate of healthcare visits change?

BMJ Open ◽  
2021 ◽  
Vol 11 (8) ◽  
pp. e051233
Author(s):  
Amanda Sundberg ◽  
Anna Carin Wahlberg ◽  
Niklas Zethraeus ◽  
Korinna Karampampa
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Subgroup Analysis ◽  
Secondary Care ◽  
Primary Outcome ◽  
Secondary Outcome ◽  
Nursing Service ◽  
Time Period ◽  
Telephone Advice ◽  
Wait And See

ObjectivesTelephone advice nursing is introduced in many countries with one key aim being a reduction of avoidable healthcare visits. The aim of this study was to explore whether callers to a telephone advice nursing service followed the telenurses’ recommendations, and whether there was a change in the level and trend of the rate of healthcare visits after the introduction of telephone advice nursing.DesignObservational study.SettingPrimary and secondary care in Jönköping Region, Sweden.ParticipantsTelephone advice nursing calls, 6:00–23:00, 2014–2015 (n=185 994) and outpatient healthcare visits 2012–2015 (n=6 877 266).Primary outcomeProportion of callers who visited healthcare within the time period advised by the telenurse.Secondary outcomeChange in level or trend of the overall rate of healthcare visits per 1000 persons and 4-week period after the introduction of telephone advice nursing, with subgroup analysis for primary and secondary care.Results77% of callers who were recommended either to visit healthcare within 24 hours or to ‘wait and see’ followed the recommendations. There was no significant change in level (−5.15; 95% CI −15.80 to 5.50; p=0.349) or trend (−0.24; 95% CI −0.86 to 0.38; p=0.448) of the overall rate of visits per 1000 persons and 4-week period after the introduction of telephone advice nursing. For the rate of primary care visits, an increase in level (8.01; 95% CI 6.36 to 9.66; p<0.001) and trend (1.28; 95% CI 1.17 to 1.39; p<0.001) were observed. For the rate of secondary care visits, a decrease in level (−8.77, 95% CI −14.41 to −3.13; p=0.004) and trend (−1.03, 95% CI −1.35 to −0.71; p<0.001) were observed.ConclusionsThe introduction of telephone advice nursing may have contributed to a shift in the rate of healthcare visits from secondary to primary care.

Effect and acceptability of AKI education using peer review audit in primary care

2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X696977
Author(s):  
Mufaza Asrar ◽  
Joanna McKinnell ◽  
Nitin Kolhe ◽  
Lynn Woods ◽  
Sally Bassett ◽  
...  
Keyword(s):  
Primary Care ◽  
Peer Review ◽  
Secondary Care ◽  
Group Discussion ◽  
Risk Groups ◽  
Risk Identification ◽  
Care Staff ◽  
Small Group Teaching ◽  
Post Intervention ◽  
Early Management

BackgroundThis was part of the Southern Derby shire CCG AKI awareness and improved management in primary and secondary care. The programme involved educating the primary care staff (GPs nurses) about AKI, identifying and early management in at risk groups. The secondary care aspect involved protocol development for AKI risk/identification to reduce morbidity.AimAs two-thirds of AKI originates in the community we aimed to increase awareness and knowledge levels of AKI in primary care via a CCG wide education programme. This included nephrology a peer review audit of cases with an evaluation of the programme’s acceptability and impact.MethodOver a 12month period, peer review audit sessions were delivered to GPs and the primary care MDT. These sessions consisted of a short presentation by a consultant nephrologist followed by discussion of cases. Qualitative feedback was collected from all participants. Web-based, CCG-wide questionnaires incorporating factual and clinical questions were used to assess baseline and post-intervention knowledge level.Results93% of participants (94 responses) found the peer review audit sessions useful, particularly the presence of nephrologist. 45% of participants were anxious about group discussion of cases, although 36% thought they were the most useful component of the sessions. Formal presentations were ranked as the most popular format of receiving education. 996 individuals completed the questionnaires. At baseline 61% were GPs, 27% practice nurses and 8% Advanced Practitioners, with similar proportions at 1yr. Exposure to AKI teaching, self-reported awareness and confidence levels were higher in the second questionnaire and there was a significant improvement in test scores.ConclusionPrimary care education can improve knowledge and awareness of AKI. Small group teaching with involvement of a nephrologist was popular. These results suggest that there is a need to tailor education styles to individual preferences, and peer review audit may not be universally acceptable in primary care.

scholarly journals 22. Patient Satisfaction Remains Unchanged Following Implementation of an Antibiotic Stewardship Intervention in Primary Care

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S11-S12
Author(s):  
Zachary Hostetler ◽  
Keith W Hamilton ◽  
Leigh Cressman ◽  
McWelling H Todman ◽  
Ebbing Lautenbach ◽  
...  
Keyword(s):  
Primary Care ◽  
Patient Satisfaction ◽  
Odds Ratio ◽  
Logistic Regression Model ◽  
Adjusted Odds Ratio ◽  
Primary Care Providers ◽  
Mixed Effects ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Targeted Intervention

Abstract Background Inappropriate prescription of antibiotics for respiratory tract infections (RTIs) in ambulatory care settings is common, increasing the risk of adverse health outcomes. Behavioral and educational interventions targeting primary care providers (PCPs) have shown promise in reducing inappropriate antibiotic prescribing for RTIs. While one perceived barrier to such interventions is the concern that these adversely impact patient satisfaction, few data exist in this area. Here, we examine whether a recent PCP-targeted intervention that significantly reduced antibiotic prescribing for RTIs was associated with a change in patient satisfaction. Methods The PCP-targeted intervention involved monthly education sessions and peer benchmarking reports delivered to 31 clinics within an academic health system, and was previously shown to reduce antibiotic prescribing. Here, we performed a retrospective, secondary analysis of Press Ganey (PG) surveys associated with the outpatient encounters in the pre- and post-intervention periods. We evaluated the impact on patient perceptions of PCPs based on provider exposure to the intervention using a mixed effects logistic regression model. Results There were 17,416 out of 197,744 encounters (8.8%) with associated PG surveys for the study time period (July 2016 to September 2018). In the multivariate model, patient satisfaction with PCPs was most strongly associated with patient-level characteristics (age, race, health status, education status) and survey-level characteristics (survey response time, patient’s usual provider) (Figure 1). Satisfaction with PCPs did not change following delivery of the provider-based intervention even after adjusting for patient- and survey-level characteristics [adjusted odds ratio (95% CI): 1.005 (0.928, 1.087)]. However, a small increase in satisfaction associated with receiving antibiotics during the entire study period was seen [adjusted odds ratio (95% CI): 1.146 (1.06, 1.244)]. Figure 1: Association of a provider-targeted intervention as well as patient, provider, and practice characteristics with patient satisfaction in a multivariable mixed effects logistic regression model Conclusion Patient perceptions of PCPs remain unchanged following the delivery of a behavioral and educational intervention to primary care providers that resulted in observable decreases in antibiotic prescribing practices for RTIs. Disclosures All Authors: No reported disclosures

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