The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: a retrospective cohort study using health insurance claims data

Background Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA. Methods We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariable Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD. Results Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 9.6 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one’s own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one’s home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA. Conclusions The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.

Effect of Family Practice Contract Services on the Perceived Quality of Primary Care among Patients with Multimorbidity: A Cross-Sectional Study in Guangdong, China

Family practice contract services, an important primary-care reform policy for improving primary healthcare quality in China, incorporate patients with multiple chronic conditions into the priority coverage groups and focus on their management. This study aims to explore the family practice contract services’ effectiveness in improving the quality of primary care experienced by this population. A cross-sectional study using a three-stage sampling was conducted from January to March 2019 in Guangdong, China. A multivariable linear regression, including interaction terms, was applied to examine the associations between the contract services and primary care quality among people with different chronic conditions. The process quality of primary care was measured in six dimensions using the validated assessment survey of primary care (ASPC) scale. People with contract services scored higher in terms of quality of primary care than those without contract services. Contract services moderated the association between chronic condition status and primary care quality. Significantly positive interactions were observed in the patient-centred care dimension and negative interactions were reflected in the accessibility dimension. Our findings suggest that family practice contract services play a crucial role in improving patient-perceived primary care quality and provide emerging evidence that patients with multimorbidity tend to benefit more from the services, especially in patient-centred care.

Patient, carer and healthcare professional experiences of complex care quality in multidisciplinary primary healthcare centres: qualitative study with face-to-face, in-depth interviews and focus groups in five French multidisciplinary primary healthcare centres

ObjectivesTo explore care experiences in multidisciplinary primary healthcare centres from the patients, carers and healthcare professionals perspectives.DesignThis qualitative study used face-to-face, in-depth interviews and focus groups. Patients with multimorbidity monitored by a General Practitioner (GP) and another professional from the health centre were recruited through purposive sampling and included with their carer. They were interviewed together while professionals were interviewed separately. Verbatims were coded with subsequent blind analysis, using an inductive approach, to find aspects and features. The constant comparative method highlighted data consistencies and variations.ParticipantsTwenty-six patients, 23 family carers and 57 healthcare professionals.SettingFive multidisciplinary primary healthcare centres, in France, between March 2017 and December 2018.ResultsThis unique study grouped perspectives into nine core quality of primary care aspects: having accessible, available, and varied care; feeling welcome and enjoying comfortable, well-equipped, and clean premises; having quality medicotechnical care (medical knowledge and technical skills); having a reliable GP; receiving appropriate care from healthcare professionals other than the GP; maintaining an efficient relationship with healthcare professionals; benefiting from organised and coordinated care; being an informed, supported and involved patient; having an informed, supported and involved carer. New areas of interest include the multidisciplinary nature of the centres, appreciation of other professionals within the centre, medicotechnical dimensions of care and the carer’s role in maintaining patient autonomy.ConclusionsThis is the first study to interview patients and carers alongside healthcare professionals. This enhanced knowledge improves understanding of these aspects and can guide implementation of evaluation tools that truly reflect patient and carer needs and enable an efficient experience in terms of quality. To address deficiencies in existing questionnaires, the new perspectives found will be added to former aspects to create a comprehensive quality of primary care evaluation tool.Trial registration numberNCT02934711, Results.

Quality of Primary Care for the Adult Population With Autism Spectrum Disorder: Protocol for a Scoping Review

Background A strong primary care system is vital to overall health. Research on the primary care of people with autism spectrum disorder (ASD) has mostly focused on children. A synthesis of the existing literature related to the quality of primary care for the adult population with ASD would elucidate what is known about the topic as well as inform future research and clinical practice. Objective The purpose of our scoping review is to describe what is known about the quality of primary care for adults with ASD and identify knowledge gaps. Methods Prior to beginning the literature search, we reviewed literature related to defining both primary care and primary care quality to establish the context and concept of the research question. The search strategy was designed and executed by a research librarian. The MEDLINE, CINAHL, EMBASE, PsycINFO, and ProQuest Dissertations and Theses databases were searched for relevant literature. Grey literature will include relevant reports from government websites and associations with a focus on ASD. Two members of the research team will independently screen the academic and grey literature. Quantitative, qualitative, or mixed methods study designs involving the quality of primary care services or patient-centered care for adults with ASD are eligible for inclusion in our scoping review. Studies that make it past the full-text review will undergo data extraction and quality appraisal by 2 independent reviewers. The data extraction results will be presented in a tabular format to clearly present what is known about the quality of primary care for adults with ASD; this table will be accompanied by a narrative synthesis. Literature selected for extraction will be coded for themes, which will form the basis of a thematic synthesis. The scoping review will follow the guidance proposed by the Joanna Briggs Institute. Results The search of electronic databases was conducted in October 2020, and it returned 2820 results. This research is still in progress. The results from our scoping review are expected to be available by fall 2021. Conclusions The results from our scoping review will be useful for guiding future research on the quality of primary care for adults with ASD. International Registered Report Identifier (IRRID) PRR1-10.2196/28196

Evidence-based indicators for the measurement of quality of primary care using health insurance claims data in Switzerland: update of the SQUIPRICA working group

Background The level of quality of care of ambulatory services in Switzerland is almost completely unknown. Since health insurance claims are the only nationwide applicable and available data source for this purpose, a set of 24 quality indicators (QI) for the measurement of quality of primary care has been previously developed and implemented. The present paper reports on an evidence-based update and extension of the initial QI set. Methods Established pragmatic 6-step process based on informal consensus and potential QI extracted from international medical practice guidelines and pre-existing QI for primary care. Experts rated potential QI based on strength of evidence, relevance for Swiss public health, and controllability in the Swiss primary care context. Feasibility of a preliminary set of potential new QI was tested using claims data of persons with basic mandatory health insurance at one of the largest Swiss health insurers. This test built the basis for expert consensus on the final set of new QI. Additionally, two diabetes indicators included in the previous QI set were re-evaluated. Results Of 23 potential new indicators, 19 of them were selected for feasibility testing. The expert group consented a final set of 9 additional QI covering the domains general aspects/efficiency (2 QI), diagnostic measures (1 QI), geriatric care (2 QI), osteoarthritis (1 QI), and drug safety (3 QI). Two pre-existing diabetes indicators were updated. Conclusions Additional QI relating to overuse and intersectoral care aspects extend the options of measuring quality of primary care in Switzerland based on claims data and complement the initial QI set.

The Quality of Primary Care Performance in Private Sector Facilities in Nairobi, Kenya: A Cross-Sectional Descriptive Survey

BackgroundIntegrated health services with an emphasis on primary care are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality primary care are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is little information on these key elements and such information is needed to improve service delivery. This study aimed to evaluate the quality of primary care performance in a group of private sector clinics in Nairobi, Kenya.Methods A cross-sectional descriptive study adapted the Primary Care Assessment Tool for the Kenyan context and surveyed 412 systematically sampled primary care users, from 13 PC clinics. Data was analysed to measure 11 domains of primary care performance and two aggregated primary care scores using the Statistical Package for Social Sciences.Results Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying poor overall performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact (access), coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate primary care as acceptable to good.Conclusion These primary care clinics in Nairobi had a poor overall performance. There was a report of acceptable-to-good performance in first-contact utilisation, the information systems, family centredness and cultural competence. However, patients rated first-contact access, ongoing care, coordination of care, comprehensiveness of services, community orientation and availability of a complete primary health care team, as poor. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, improving access after-hours and marketing the use of the clinics to the practice population.

Patient-centered care, advance care planning, and treatment preferences among home medical care patients in Japan: The ZEVIOUS study

BackgroundIt remains unclear how both the quality of patient-centered care and the patient’s illness affect advance care planning (ACP) in primary care settings. Identifying the facilitators and barriers to ACP in primary care settings has become a growing scientific and clinical challenge.ObjectiveTo examine the association between the quality of primary care and ACP preparedness among patients. Additionally, to investigate whether ACP preparedness and the patient’s illness are associated with the expression of future treatment preferences.DesignMulticenter cross-sectional study.ParticipantsAdult Japanese patients receiving home medical care.Main MeasuresA survey was run to assess consideration of ACP by patients and expression of future treatment preferences. The quality of primary care, which reflects patient centeredness, was assessed with the Japanese version of the Primary Care Assessment Tool– Short Form. Information on the clinical conditions that required home medical care was collected from physicians.Key ResultsOf 194 patients using 29 home medical services, 62 patients (32%) showed signs of ACP preparedness, and 153 patients (78%) expressed their treatment preferences. In a multivariable-adjusted generalized estimating equation, primary care quality was associated with ACP preparedness (per 10-point increase, adjusted OR: 1.96, 95% CI: 1.51–2.56). However, we found insufficient evidence to support that ACP preparedness was associated with a lower incidence of non-expression of treatment preferences (adjusted OR: 1.02, 95% CI 0.49–2.12). In contrast, having cancer was associated with a lower incidence of non-expression of treatment preferences (adjusted OR: 0.12, 95% CI: 0.01–0.995).ConclusionsAt a minimum, patient centeredness in home medical care facilitates must ensure the initiation of ACP preparedness. To understand the association between ACP preparedness and expression of treatment preferences, further efforts are warranted to clarify the quality and content of ACP preparedness simultaneously with the patient’s illness.

The influence of primary care quality on nursing home admissions in a multimorbid population with and without dementia in Germany: A retrospective cohort study using health insurance claims data

Background Multimorbidity poses a challenge for high quality primary care provision for nursing care-dependent people with (PWD) and without (PWOD) dementia. Evidence on the association of primary care quality of multimorbid PWD and PWOD with the event of a nursing home admission (NHA) is missing. This study aimed to investigate the contribution of individual quality of primary care for chronic diseases in multimorbid care-dependent PWD and PWOD on the duration of ongoing residence at home before the occurrence of NHA. Methods We conducted a retrospective cohort study among elderly care-dependent PWD and PWOD in Germany for six combinations of chronic diseases using statutory health insurance claims data (2007–2016). Primary care quality was measured by 21 process and outcome indicators for hypertension, diabetes, depression, chronic obstructive pulmonary disease and heart failure. The primary outcome was time to NHA after initial onset of care-dependency. Multivariate Cox proportional hazard models were used to compare the time-to-event between PWD and PWOD. Results Among 5876 PWD and 12,837 PWOD 5130 NHA occurred. With the highest proportion of NHA for PWD with hypertension and depression and for PWOD with hypertension, diabetes and depression. Average duration until NHA ranged from 6.5 to 8.9 quarters for PWD and from 8.1 to 13.5 quarters for PWOD. Adjusted analyses show consistent associations of the quality of diabetes care with the duration of remaining in one's own home regardless of the presence of dementia. Process indicators assessing guideline-fidelity are associated with remaining in one's home longer, while indicators assessing complications, such as emergency inpatient treatment (HR = 2.67, 95% CI 1.99–3.60 PWD; HR = 2.81, 95% CI 2.28–3.47 PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 PWD; HR = 2.81, 95% CI 1.94–4.08 PWOD) in PWD and PWOD with hypertension and diabetes, increase the risk of NHA. Conclusions The quality of primary care provided to care-dependent multimorbid PWD and POWD, influences the time individuals spend living in their own homes after onset of care-dependency before a NHA. Health care professionals should consider possibilities and barriers of guideline-based, coordinated care for multimorbid care-dependent people. Further research on quality indicator sets that acknowledge the complexity of care for multimorbid elderly populations is needed.