[Pressing problems in primary care]

[Usefulness of the budget and the balanced scorecard in managing Primary Care Centres. Impact on staff motivation]

OBJECTIVE

To analyse the utility perceived by managers of centers of primary care about management tools (budget and balanced scorecard), together their impact on human resources motivation.

DESIGN

Qualitative study (case study) based on grounded theory performed between January and June 2014.

LOCATION

Units of Clinical Management of Primary Health (UGCAP) in Metropolitan Health Area of Seville, Spain.

PARTICIPANTS

UGCAP managers and Health Area (CEO) managers.

METHOD

Data were collected through 8 semi-structured interviews using non-probabilistic intentional sampling with representation and sufficiency criteria of discourse. Interviews were recorded, literally transcripted and analysis through in-vivo codes.

RESULTS

Both tools are fully implemented but differently used in primary care centers. Budget is perceived as a coercive management tool, which has been imposed for cost saving; however, it is scarcely adequate for day-by-day management. While balanced scorecard is a more flexible tool that allows identifying financial and welfare problems, budgeting limits heavily reduce the possibility of implementing adequate solutions. The policy of incentives is not adequate either, leading on de-motivation.

CONCLUSIONS

This study shows that budgeting restrictions have led to a significant reduction in autonomy of Spanish Primary Care centers. Management decision making is much centralised, also focused on cost saving over quality of healthcare. As a result, two needs emerge for the future: increasing centers' autonomy and improving staff commitment through training and professional development programs.

Measuring the quality of motivational interviewing in primary health care encounters: The development and validation of the motivational interviewing assessment scale (MIAS)

BACKGROUND

Motivational interviewing (MI) is a collaborative, goal-oriented method to help patients change behaviour. Tools that are often used to measure MI are the motivational interviewing skills code' (MISC), the 'motivational interviewing treatment integrity' (MITI) and the 'behaviour change counselling index' (BECCI). The first two instruments have not been designed to be used in primary healthcare (PHC) settings. The BECCI actually is time-consuming. The motivational interviewing assessment scale (MIAS, 'EVEM' in Spanish) was developed to measure MI in PHC encounters as an alternative to the previous instruments.

OBJECTIVES

To validate MIAS as an instrument to assess the quality of MI in PHC settings.

METHODS

(a)

DEVELOPMENT

Sixteen experts in MI participated in the design, face and consensus validity, using a Delphi-type methodology. (b)

VALIDATION

SETTING

27 PHC centres located in Spain.

SUBJECTS

four experts in MI tested its psychometric properties with 332 video recordings coming from the Dislip-EM study (consultations provided by 37 practitioners).

MEASUREMENTS

dimensionality, internal consistency, reliability (intra-class correlation coefficient-ICC), sensitivity to change and convergent validity with the BECCI scale.

RESULTS

A 14-item scale was obtained after the validation process. Factor analysis: two factors explained 76.6% of the total variance. Internal consistency, α = 0.99. Reliability: intra-rater ICC = 0.96; inter-rater ICC = 0.97. Sensitivity to change: means before and after training were 23.63 versus 38.57 (P < 0.001). Spearman's coefficient between the MIAS and the BECCI scale was 0.98 (P < 0.001).

CONCLUSION

The MIAS is a consistent and reliable instrument to assess the use of MI in PHC settings. [Box: see text].

[Frequent attendance: the primary care professional's perceptions on the influence of social factors and health care system organisation]

FREQUENT ATTENDANCE: The primary care professional's perceptions on the influence of social factors and health care system organisation.

OBJECTIVE

To find out the primary care (PC) professional's perceptions on the social factors and healthcare system organisation that influence frequent attendance.

METHOD

A qualitative study using semi-structured interviews in Primary Care Centres of six Health Areas in the Community of Madrid. Eighteen interviews were conducted, three per area (two physicians and one nurse). Structural sampling was carried out with regards to the variables that could influence the discourse: health area, occupation, sex and number of years worked. The transcriptions were analysed by two investigators and an agreement of interpretation was reached.

RESULTS

Among the social factors, health professionals perceived as determining factors: the influence of the media and the medicalization of society, lack of health education and self-care abilities of the population and contextual factors of the patient (social, work and family). Among the health care organisation factors that could influence frequent attendance were, system saturation, appointment on demand, fear of potential lawsuits by the patient, chronic patients protocols, administrative consultations, professional behaviour, and poor coordination with specialised care.

CONCLUSIONS

According to PC professionals, there are multiple environmental factors, both social and healthcare system organisational factors that encourage frequent attendance. Within the scope of health care system, organisational actions (such as teamwork and coordination with specialists) would help to manage demand.

[The development of primary care related to regional governmental policies]

OBJECTIVES

To developed an evaluation of primary care (PC) from the analysis of the new differences in PC among the autonomous communities nowadays.

DESIGN

Cross ecological study.

SETTING

Spain.

PARTICIPANTS

The 17 autonomous communities.

MEASUREMENTS

Indicators of service supplies, diagnostic and therapeutic resolution habilities, access to hospital diagnostic, relationship and access doctor-patient, effectiveness and efficiency, public budget in PC and patient noticed quality.

RESULTS

In all the indicators, leftist regional Governments have obtained a better punctuation than conservative ones. The main differences are in relation to the percentage of overcrowded doctor quotas (more than 1500 inhabitants per family doctor, with a 27.4% of difference); in limited access to diagnostic proves from PC services (25.3%); in PC services supplies (17.1%) in infirmary staff per habitant (10.9%), in pharmacological waste increase (10.9%); in the PC expending per capita (10.3%) and in the percentage of people who think that PC has improved. By means of quarter weighting, the differences of punctuation obtained by the regions are from a maximum of 46 (Aragón) to a minimum of 26 (Canary Islands), with an average of 39.94%.

CONCLUSIONS

Six years after finishing the health transferences, there are important differences in the development of the PC, and the conservative autonomous communities have the deepest deficient one.

La salud mental en los médicos de familia: efectos de la satisfacción y el estrés en el trabajo

OBJECTIVES

To asses "burnout" and psychiatric morbidity among family physicians and its relationship with stress and satisfaction at work.

METHODS

The 346 family doctors and 84 pediatricians in the Primary Health Care district of Majorca were invited to fill-out a questionnaire. Psychiatric morbidity was evaluated using the 28-item General Health Questionnaire. The three components of "burnout" (emotional exhaustion, depersonalization and low personal accomplishment) were assessed with the Maslach Burnout inventory. Satisfaction and stress at work were assessed with the Font Roja and Tabarca scales, respectively.

FINDINGS

266 family doctors and pediatricians answered the questionnaire (61.86%). Estimated prevalence of psychiatric morbidity was 25.7%. No significant differences were found between those with GHQ results and demographic and job variables. Fifty three per cent had high emotional exhaustion, 47.1% high depersonalization and low personal accomplishment were found in 33.3% of the doctors. Non significant differences were identified in the distribution of burnout dimensions and demographic and job characteristics. Satisfaction at work seems to protect doctors from mental distress and burnout. Job stress is related to higher emotional exhaustion and depersonalization but not with psychiatric morbidity.

CONCLUSIONS

Family practitioner's mental health is likely to be protected in those who are more satisfied at work and threatened in those doctors with high job stress. These facts have to be assumed not so much as an individual problem but rather as a general problem of all health organizations.

[Computer-aided prescribing: from utopia to reality]

OBJECTIVE

To determine whether the introduction of computer-aided prescribing helped reduce the administrative burden at primary care centers.

DESIGN

Descriptive, cross-sectional design.

SETTING

Torreblanca Health Center in the province of Seville, southern Spain. From 29 October 2003 to the present a pilot project involving nine pharmacies in the basic health zone served by this health center has been running to evaluate computer-aided prescribing (the Receta XXI project) with real patients.

PARTICIPANTS

All patients on the center's list of patients who came to the center for an administrative consultation to renew prescriptions for medications or supplies for long-term treatment.

MEASURES

Total number of administrative visits per patient for patients who came to the center to renew prescriptions for long-term treatment, as recorded by the Diraya system (Historia Clinica Digital del Ciudadano, or Citizen's Digital Medical Record) during the period from February to July 2004. Total number of the same type of administrative visits recorded by the previous system (TASS) during the period from February to July 2003.

MAIN RESULTS

The mean number of administrative visits per month during the period from February to July 2003 was 160, compared to a mean number of 64 visits during the period from February to July 2004. The reduction in the number of visits for prescription renewal was 60%.

CONCLUSIONS

Introducing a system for computer-aided prescribing significantly reduced the number of administrative visits for prescription renewal for long-term treatment. This could help reduce the administrative burden considerably in primary care if the system were used in all centers.

[Hospitalizations preventable by timely and effective primary health care]

OBJECTIVE

To know the specific health problems referred as ambulatory care sensitive conditions (ACSC) and to identify the primordial interventions of primary health care (PHC) in reducing hospitalisations due to ACSC.

DESIGN

Descriptive study of hospital discharges generated in Catalonia during 1998-1999, and a Delphi study to reach information about PHC primordial interventions.

MEASURES

Diagnostic codes of ACSC selected as markers of PHC effectiveness were used. We analysed hospital discharge distribution by age groups and overall, and hospitalisation rates with its 95% confidence intervals. Descriptive analysis of consensus reached by experts using self-administrated questionnaires was done.

RESULTS

The 8.42% of total discharges were due to ACSC. The majority of these (86.9%) fell in 4 of the 13 diagnostic categories included in the ACSC list. A great variety of pathologies with different frequencies were identified. Primary prevention and early diagnoses and treatment were considered as primordial interventions. Chronic health problems needed multimodal interventions.

CONCLUSIONS

Diagnostic codes included in each diagnostic category were congruent with the diseases identified. Interventions that could prevent hospitalisations due to ACSC are contemplated as role of PHC. Indicator validity to assess PHC effectiveness is maintained by both results.

[Research and the recent evolution of primary health care]

Primary care in Spain has undergone a burgeoning phase in the 80's, followed by a decade of stagnation in the 90's, with little creativity, a routinisation of tasks, and the set up of service port-folios and program-contracts. On the other hand, the recent changes in the orientation of the research promoted by the health administration, in favor of basic research, at the expense of health services research and clinical epidemiology, are in contrast with the importance of primary care as a natural setting for the management of many causal agents and risk factors for health. Despite such limitations, the culture of research has become present in many primary care centres and pharmacies, and primary care research is increasingly present in scientific journals. Nevertheless, it is necessary, also for the case of primary care, to manage research, in differentiated and specific ways, favoring priorization, evaluation and responsibility through flexible organisational formulas and information systems. This should include contracting procedures allowing for at least part-time research, as well as professional career models acknowledging research and teaching activities. Scientific and professional associations in primary care face the challenge of maintaning research projects, of increasing their presence among professionals, of formulating opinions regarding the problems of their sector, as well as of reinforcing their organizational and communication capabilities.