Gatekeeping must go beyond the linear referral model

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...

The Critical and Evolving Roles for Psychiatry in Health Reform

The American Academy of Pediatrics (AAP) policy statement entitled “The New Morbidity Revisited: A Renewed Commitment to the Psychosocial Aspects of Pediatric Care”1 from the Committee on Psychosocial Aspects of Child and Family Health is found in this month's issue of Pediatrics . Few experienced pediatric practitioners would disagree with this description of our life's work. Most embrace this “renewed commitment” to relevant and comprehensive care for our children and families. It is not hard to look past the examination room and appreciate the struggles, tensions, and morbidities that this complex world presents our patients as they grow and develop. But what about the complex world of our practices? We are well-intended, but are we well-trained, and are we able to follow through on our “commitment”? “ Mental health needs of children and adolescents are increasing while access to behavioral health, mental health, and substance abuse service is decreasing .”2 The rate of psychosocial problems identified by primary care physicians in the children they care for has increased from 7% to 18% in the past 20 years. Information accumulated by the Pediatric Research in Office Settings (PROS) group3 confirmed what practicing pediatricians already know: the children we see for earaches bring with them symptoms of their behavioral health. These children may have attentional difficulties, conduct issues, or significant problems of mood. They may suffer acute adjustment difficulties or evidence posttraumatic stress from physical, emotional, or sexual abuse, and may experience family poverty, family divorce, or a host of other intrinsic or situational problems that impact on their health and the ability of their family and caregivers to provide for their health. We are seeing more problems and, lacking referral sources, often have to provide more care. Skills needed to address the new morbidities are part of our …

Exploring the Generalist-Subspecialist Interface in Internal Medicine

To examine the relationship between the number of hours physicians work and patients' assessment of the physician. Cross-sectional study with physician and patient surveys. Primary care practices in Massachusetts. A random sample of 6810 Massachusetts state employees in 15 different health plans. Eleven summary scales measuring 7 essential elements of primary care. Information was derived from the Primary Care Assessment Survey, a validated patient-completed questionnaire. Physicians were classified into 3 groups according to their reported hours of work: "overtime" (> 65 h/wk), "full time" (40-65 h/wk), and "part time" (< 40 h/wk). There was no statistically significant difference between the 3 groups of physicians in 10 of the 11 measures of primary care performance. Physicians who worked more than 65 hours per week were found to score significantly higher in the visit-based continuity of care category than physicians working fewer hours. Physicians working more than 65 hours per week were also found to be significantly less satisfied with the amount of time they had for family and personal life than the other 2 groups. Part-time physicians perform as well as full-time physicians in most aspects of primary care, including all interpersonal aspects of care, as reported by patients. Patients of physicians working more than 65 hours per week experienced higher levels of visit-based continuity of care than patients of physicians working fewer hours, but this appears to carry a cost to those physicians in the area of personal and professional satisfaction. Subsequent research should examine the relationship between physician workload and technical aspects of care.

Palliative Care Teaching in the Yale Internal Medicine Curriculum: How Are We Doing? (S710)

The problems presented by ophthalmic patients during a post-discharge telephone-reassurance programme

A family physician's open-ended commitment to the patient, not limited by the type of health problem or by a defined endpoint opens the door to the patients' world. Family physicians are uniquely privileged to provide all the key aspects of primary care-first contact care, comprehensive care, coordination and personalisation of care. The family physician as the trained primary care clinician is the interface between the illness experience of patients in primary care and the healthcare system in which patients undergo treatment. Based on our experience of working with communities, we submit that commitment to the person of the patient needs long-term relationship with communities. The breadth of knowledge and patient-doctor relationship in the compendium of a family physician skill set is a challenging and rewarding experience. This learned skill is attainable for all healthcare professionals.

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population. Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population. Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

Australia has the resources to provide reasonable primary medical and health care to all of its population. It is a particularly worthwhile expense, with positive social and biophysical outcomes (Jarman et al., 1999; Starfield, 1998). In many aspects of health care, primary care provides most of the benefit and almost all of the value. Why, then, don?t we provide this basic service to all Australians?

Chiropractic—primary care, neuromusculoskeletal care, or musculoskeletal care? Results of a survey of chiropractic college presidents, chiropractic organization leaders, and Connecticut-licensed doctors of chiropractic

&lt;p dir="ltr"&gt;&lt;b&gt;Background&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;As the population ages, the number of adults living with multimorbidity- defined as having two or more chronic conditions-is increasing. The current healthcare system often focuses on treating one disease at a time, can fail to meet these individuals ' needs with risk of on the one hand unmet care needs and on the other risk of more visits to more healthcare providers and medications than benefits the individual. To better serve older individuals with multimorbidity, the healthcare system, particularly primary care, needs to adapt and evolve. This involves adopting a more person-centred and holistic approach to care, considering the individual' wants and needs, all health conditions, and overall well-being, rather than treating each disease separately. By doing so, the healthcare system can provide coordinated, person-centred care that effectively meets the complex needs of these individuals.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Aim&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;The aim of this thesis was to develop and pilot a complex intervention to improve wellbeing and quality of life in individuals with multiple health conditions and common mental health problems in Swedish primary care.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Methods&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;This thesis involves four studies involving quantitative, qualitative and mixed methods methodologies. Study 1 is a systematic literature review and qualitative synthesis of collaborative care interventions for individuals with multimorbidity and common mental health problems in primary care and community settings and a map of intervention components. Study 2 is a total population-based cohort study investigating the association between having multimorbidity with an increasing number of chronic diseases and potentially inappropriate prescribing of benzodiazepines in the total adult population in Stockholm, Sweden in two cohorts, one before and one during COVID-19. Study 3 is a qualitative study exploring GP's experiences of managing individuals with multimorbidity and common mental health problems in primary care in Stockholm, Sweden using reflexive thematic analysis. From the findings of study 1 and 3 the intervention Health and Life in Balance was developed for improving patient capacity for older people with multimorbidity. The intervention includes the collaborative care components of relational continuity, a shared care plan, and teamwork identified in study 1. Moreover, it uses a person-centred approach to care, minimally disruptive medicine, to assess patient capacity and workload in individuals with multimorbidity. This approach was identified in the literature sharing similarities with the findings from study 3. Study 4 is a pragmatic convergent mixed methods non- randomised pilot study. The study aimed to assess the acceptance, feasibility and further need of development of Health and Life in Balance.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Results&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;In study 1, 12 Randomised controlled studies were included. Eleven studies with medium to high quality showed positive results in reducing depressive symptoms in individuals with multimorbidity involving depression and one chronic disease. The last study had medium to low quality and investigated the effect on anxiety and depressive symptoms. There was a lack of medium to high quality studies addressing collaborative care for individuals with multimorbidity and anxiety, and for individuals with more than two health conditions. The qualitative synthesis identified a map of shared content in the 11 studies of collaborative care models with medium to high quality. In study 2, an association between an increasing number of chronic conditions and potentially inappropriate prescribing of benzodiazepines was identified in both cohorts, before and during COVID-19. The logistic regression model was adjusted for age and socioeconomic status and stratified for sex. The association remained although decreased when adjusting for each of the clinical confounders: number of healthcare visits, polypharmacy, and having a psychiatric diagnosis. In study 3 two themes were generated: Unmet patient needs and fragmented care send patients and physicians off balance and Dancing with the patient individually and together with others leads to confident and satisfied patients and physicians. General practitioners found it hard to address common mental health problems in individuals with multimorbidity, limited by disease-specific guidelines and fragmentation. They highlighted that aspects of person-centred care, involving relational continuity, flexibility and teamwork, would help them better address these individuals. In study 4, Health and Life in Balance was acceptable and feasible regarding to have relational continuity to a district nurse addressing non-disease-specific issues for individuals in need of it. However, the intervention needs further development. The intervention needs to be targeted for individuals with the greatest care needs including aspects of frailty, deprived psychosocial situation and many healthcare providers. Further, it needs to be further developed to provide person-centred care in a busy primary care setting, including raising priority for individuals with multimorbidity involving non- disease-specific needs, addressing how to provide and implement a person- centred care, and addressing how to provide teamwork and cooperation with others.&lt;/p&gt;&lt;p dir="ltr"&gt;&lt;b&gt;Conclusions&lt;/b&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;This thesis identifies individuals with multiple health conditions to be at risk of potentially inappropriate prescribing of benzodiazepines and poorly addressed non-disease-specific issues in today's fragmented healthcare system and shows person-centred care as a potential solution to address these issues. Furthermore, it describes the development and piloting of Health and Life in Balance, a person-centred intervention aiming to address these risks. The findings from the pilot study identified the intervention to be acceptable and feasible when at-need individuals had relational continuity to a district nurse who could address non-disease-specific needs. Yet, the intervention needs further development to identify and target individuals with the greatest care needs, make these individuals a priority in primary care, and to ensure teamwork and delivery and implementation of person-centred care. The results from this thesis and included studies can inform policy makers and other stakeholders of the need of prioritising a shift from fragmented care to person- centred and holistic care for vulnerable individuals and a need of further intervention development to address these individuals' needs. Furthermore, the findings can be used in further intervention development. However, in future intervention development it is important to involve individuals with multimorbidity and other stakeholders in both the research group and in different phases of the intervention development.&lt;/p&gt;&lt;h3&gt;List of scientific papers&lt;/h3&gt;&lt;p dir="ltr"&gt;I. Specific content of collaborative care: a systematic review of collaborative care interventions for patients with multimorbidity involving depression and/or anxiety in primary care. &lt;b&gt;C Kappelin&lt;/b&gt;, A Carlsson, C Wachtler Fam Pract 2021 Sep 21;39(4):725-734. &lt;a href="https://doi.org/10.1093/fampra/cmab079" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1093/fampra/cmab079&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;II. The association between number of chronic diseases and potentially inappropriate benzodiazepine prescribing: A total population-based cohort study in Region Stockholm, Sweden. &lt;b&gt;Caroline Kappelin&lt;/b&gt;, Caroline Wachtler, Gunnar Ljunggren, Axel Carlsson. [Submitted]&lt;/p&gt;&lt;p dir="ltr"&gt;III. Dancing with the patient: a qualitative study of general practitioners' experiences of managing patients with multimorbidity and common mental health problems. &lt;b&gt;Kappelin C,&lt;/b&gt; Sandlund C, Westman J, Wachtler C. BMC Prim Care. 2023 Apr 20;24:104. &lt;a href="https://doi.org/10.1186/s12875-023-02056-y" rel="noreferrer" target="_blank"&gt;https://doi.org/10.1186/s12875-023-02056-y&lt;/a&gt;&lt;/p&gt;&lt;p dir="ltr"&gt;IV. Health and Life in Balance an intervention to improve patient capacity for older people with multimorbidity: A pragmatic mixed methods non-randomised pilot study. &lt;b&gt;Caroline Kappelin&lt;/b&gt;, Klas Ytterbrink Nordenskiöld, Elisabeth Bos Sparén, Annica Lagerin, Caroline Wachtler. [Submitted]&lt;/p&gt;

Providing cancer care: individual or team sport?

The rapid deployment of virtual primary care visits served as a first-line response to COVID-19 and can now be examined for insights, particularly as virtual care is playing an ongoing role in patient care and consultations. Input from primary care providers directly responsible for virtual care delivery is needed to inform policies and strategies for quality care and interactions. The overarching goal of this research study was to examine the use of virtual care as a mechanism for primary healthcare delivery. A phenomenological approach investigated the shift in primary care service delivery as experienced by primary care providers and initiated during the COVID-19 pandemic. Focus groups were conducted with primary care providers (n = 21) recruited through email, advertisements, and professional organizations, exploring how virtual care was delivered, the benefits and challenges, workflow considerations, and recommendations for future use. Integrating virtual care was performed with a great deal of autonomy as well as responsibility, and overwhelmingly depended on the telephone. Technology, communication, and workflow flexibility are three key operational aspects of virtual care and its delivery. Providers highlighted cross-cutting themes related to the dynamics of virtual care including balancing risk for quality care, physician work/life balance, efficiency, and patient benefits. Primary care providers felt that virtual care options allowed increased flexibility to attend to the needs of patients and manage their practice workload, and a few scenarios were shared for when virtual care might be best suited. However, they also recognized the need to balance in-person and virtual visits, which may require guidelines that support navigating various levels of care. Overall, virtual care was considered a good addition to the whole 'care package' but continued development and refinement is an expectation for optimizing and sustaining future use.

Background: PHC position has become increasingly important since it serves as the community's initial and continuing point of contact, acts as a gatekeeper to higher levels of care, and provides coordinated and all-encompassing treatment. The purpose of this study was to evaluate patients' level of satisfaction with the caliber of care they receive at PHC. Method: We carefully searched Google Scholar, EMBASE, and PubMed for original research publications, we took into account articles that were released between 2013 and 2021. We included studies focusing on patients' perceptions and expressions of satisfaction, and contained information on these topics, as well as aspects of primary care that patients consider important. Result: Although the included studies reported a high overall level of satisfaction, we discovered that there is a need for quality improvement in the following areas: access to specialized services such as dental clinics, availability of doctors in all specializations, and provision of appropriate diagnostic methods. It was shown that patients' satisfaction was highly correlated with sociodemographic traits like age and gender as well as services like PHC employees and area pharmacies. It is important to consider further that patients place a great importance on the moral character and interpersonal skills of PHC staff. Conclusion: Specifically at PHC, patient satisfaction in primary care were mostly established by their interactions with the physician.