Primary Care for Elderly People Why Do Doctors Find It So Hard
TL;DR: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education, and the voices of these physicians and the model resulting from the analysis can inform change.
Abstract: Purpose: Many primary care physicians find caring for elderly patients difficult. The goal of this study was to develop a detailed understanding of why physicians find primary care with elderly patients difficult. Design and Methods: We conducted in-depth interviews with 20 primary care physicians. Using an iterative approach based on grounded theory techniques, a multidisciplinary team analyzed the content of the interviews and developed a conceptual model of the difficulty. Results: Three major domains of difficulty emerged: (i) medical complexity and chronicity, (ii) personal and interpersonal challenges, and (iii) administrative burden. The greatest challenge occurred when difficulty in more than one area was present. Contextual conditions, such as the practice environment and the physician’s training and personal values, shaped the experience of providing care and how difficult it seemed. Implications: Much of the difficulty participants experienced could be facilitated by changes in the health care delivery system and in medical education. The voices of these physicians and the model resulting from our analysis can inform such change.
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20 May 2020
TL;DR: The MRS can risk stratify PACE participants and predict a host of important and relevant outcomes pertaining to medication-related morbidity, including the number of Pace participants with an ADE, total medical expenditures, ED visits, hospitalizations, and hospital length of stay.
Abstract: Preventable adverse drug events (ADEs) represent a significant public health challenge for the older adult population, since they are associated with higher medical expenditures and more hospitalizations and emergency department (ED) visits. This study examines whether a novel medication risk prediction tool, the MedWise Risk Score™ (MRS), is associated with ADEs and other pertinent outcomes in participants of the Programs of All-Inclusive Care for the Elderly (PACE). Unlike other risk predictors, this tool produces actionable information that pharmacists can easily use to reduce ADE risk. This was a retrospective cross-sectional study that analyzed administrative medical claims data of 1965 PACE participants in 2018. To detect ADEs, we identified all claims that had ADE-related International Classification of Diseases and Health Related Problems, 10th revision (ICD-10) codes. Using logistic and linear regression models, we examined the association between the MRS and a variety of outcomes, including the number of PACE participants with an ADE, total medical expenditures, ED visits, hospitalizations, and hospital length of stay. We found significant associations for every outcome. Specifically, every point increase in the MRS corresponded to an 8.6% increase in the odds of having one or more ADEs per year (OR = 1.086, 95% CI: 1.060, 1.113), $1037 USD in additional annual medical spending (adjusted R2 of 0.739; p < 0.001), 3.2 additional ED visits per 100 participants per year (adjusted R2 of 0.568; p < 0.001), and 2.1 additional hospitalizations per 100 participants per year (adjusted R2 of 0.804; p < 0.001). Therefore, the MRS can risk stratify PACE participants and predict a host of important and relevant outcomes pertaining to medication-related morbidity.
21 citations
TL;DR: NP and PA scope-of-practice regulations impact their practice in NHs, not always as intended.
Abstract: Objective
To examine nurse practitioner (NP) and physician assistant (PA) practice in nursing homes (NHs) during 2000–2010.
Data Sources
Data were derived from the Online Survey Certification and Reporting system and Medicare Part B claims (20 percent sample).
Methods
NP/PA state average employment, visit per bed year (VPBY), and providers per NH were examined. State fixed-effect models examined the association between state regulations and NP/PA use.
Principal Findings
NHs using any NPs/PAs increased from 20.4 to 35.0 percent during 2000–2010. Average NP/PA VPBY increased from 1.0/0.3 to 3.0/0.6 during 2000–2010. Average number of NPs/PAs per NH increased from 0.2/0.09 to 0.5/0.14 during 2000–2010. The impact of state scope-of-practice regulations was mixed.
Conclusions
NP and PA scope-of-practice regulations impact their practice in NHs, not always as intended.
21 citations
TL;DR: A dementia education intervention for primary care which fosters person-centred attitudes can involve all members of a primary care team and is likely to translate into improved practice.
Abstract: Background: Early diagnosis of dementia within primary care is important to allow access to support. However, dementia remains under-detected in general practice. Aim: This work aimed to develop and evaluate an educational intervention for primary care promoting person-centred responses to people experiencing cognitive decline. Method: A prototype educational intervention was pilot tested and refined; the final version of the educational intervention was then evaluated in four volunteer practices. A questionnaire was administered pre- and post-training to 94 practice staff to assess knowledge and attitudes to dementia. The responses of general practitioners (who make diagnostic, referral and treatment decisions) were compared with those from other staff who do not have such roles. Findings: Post-training, there were statistically significant improvements in understanding of person-centred care for people with dementia; attitudes to early diagnosis; awareness of noncognitive dementia symptoms; and awareness of the role that non-clinical staff may have in recognising dementia.
Conclusions: A dementia education intervention for primary care which fosters person-centred attitudes can involve all members of a primary care team. Further research is needed to ascertain if improvements in knowledge and attitudes translate into improved practice.
20 citations
Cites background from "Primary Care for Elderly People Why..."
...Management of cognitively impaired individuals within primary care presents interacting medical, interpersonal and administrative challenges (Adams et al., 2002)....
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TL;DR: It is emphasised that people with more complex multimorbidity would benefi t from having a generalist physician coordinating their care, and that in most countries geriatrics and general or family practice were key generalist medical disciplines.
20 citations
TL;DR: Patients did not perceive that FDs could offer fully comprehensive PC services, and these perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.
Abstract: Background: Primary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability. Aim: To assess patients’ perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine. Setting: Private sector PC clinics in Nairobi. Methods: A descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants. Results: Of the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%). Conclusion: Patients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.
17 citations
References
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TL;DR: The Nature of Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications as mentioned in this paper, and Qualitative Interviewing: Qualitative Analysis and Interpretation Enhancing the quality and credibility of qualitative analysis and interpretation.
Abstract: PART ONE: CONCEPTUAL ISSUES IN THE USE OF QUALITATIVE METHODS The Nature of Qualitative Inquiry Strategic Themes in Qualitative Methods Variety in Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications PART TWO: QUALITATIVE DESIGNS AND DATA COLLECTION Designing Qualitative Studies Fieldwork Strategies and Observation Methods Qualitative Interviewing PART THREE: ANALYSIS, INTERPRETATION, AND REPORTING Qualitative Analysis and Interpretation Enhancing the Quality and Credibility of Qualitative Analysis
31,305 citations
TL;DR: In this article, the authors discuss the uses of literature and open coding techniques for enhancing theoretical sensitivity of theoretical studies, and give guidelines for judging a grounded theory study.
Abstract: Introduction Getting Started Theoretical Sensitivity The Uses of Literature Open Coding Techniques for Enhancing Theoretical Sensitivity Axial Coding Selective Coding Process The Conditional Matrix Theoretical Sampling Memos and Diagrams Writing Theses and Monographs, and Giving Talks about Your Research Criteria for Judging a Grounded Theory Study
28,999 citations
Journal Article•
TL;DR: The Nature of Qualitative Inquiry Theoretical Orientations Particularly Appropriate Qualitative Applications as mentioned in this paper, and Qualitative Interviewing: Qualitative Analysis and Interpretation Enhancing the quality and credibility of qualitative analysis and interpretation.
22,714 citations
21,313 citations
TL;DR: The challenge is to organize these components into an integrated system of chronic illness care, which can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care.
Abstract: Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
2,805 citations
"Primary Care for Elderly People Why..." refers background in this paper
...In the area of practice organization, a number of interventions to facilitate primary care of chronically ill elders have been proposed and a few have been studied (Boult, Boult, Morishita, Smith, & Kane, 1998; Leveille et al., 1998; Schraeder, Shelton, & Sager, 2001; Netting & Williams, 2000; Wagner et al., 1996)....
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