Integrated people-centred primary health care in Greece: unravelling Ariadne's thread

Measures during the COVID-19 pandemic in public primary health care in Greece: is there still a missing link to universal health coverage?

BACKGROUND

The PRICOV-19 study aimed to assess the organization of primary health care (PHC) during the COVID-19 pandemic in 37 European countries and Israel; and its impact on different dimensions of quality of care. In this paper, we described measures taken by public PHC centers in Greece. Additionally, we explored potential differences between rural and non-rural settings.

METHODS

The study population consisted of the 287 public PHC centers in Greece. A random sample of 100 PHC centers stratified by Health Region was created. The online questionnaire consisted of 53 items, covering six sections: general information on the PHC center, patient flow, infection prevention, information processing, communication to patients, collaboration, and collegiality.

RESULTS

Seventy-eight PHC centers (78%) - 50 rural and 28 non-rural - responded to the survey. Certain measures were reported by few PHC centers. Specifically, the use of online messages about complaints that can be solved without a visit to the PHC center (21% rural; and 31% non-rural PHC centers), the use of video consultations with patients (12% rural; and 7% non-rural PHC centers), and the use of electronic medical records (EMRs) to systematically identify the list of patients with chronic conditions (5% rural; and 10% non-rural PHC centers) were scarcely reported. Very few PHC centers reported measures to support identifying and reaching out to vulnerable population, including patients that may have experienced domestic violence (8% rural; and 7% non-rural PHC centers), or financial problems (26% rural; and 7% non-rural PHC centers). Providing administrative documents to patients through postal mail (12% rural; and 21% non-rural PHC centers), or regular e-mail (11% rural; and 36% non-rural PHC centers), or through a secured server (8% rural; and 18% non-rural PHC centers) was rarely reported. Finally, providing information in multiple languages through a PHC website (12% rural PHC centers only), or an answering machine (6% rural PHC centers only), or leaflets (3% rural PHC centers only; and for leaflets specifically on COVID-19: 6% rural; and 8% non-rural PHC centers) were lacking in most PHC centers.

CONCLUSION

Our study captured measures implemented by few PHC centers suggesting potential priority areas of future improvement.

A Groundbreaking Insight Into Primary Care Physiotherapists' Remuneration

Introduction Physiotherapy in Greece, as part of primary health care (PHC), faces sound imbalances: reduced quality, productivity, and efficiency, along with rather inflexible remuneration schemes. This study is aimed at reporting the attitude and perceptions of Greek PHC physiotherapists toward their current remuneration and also at identifying any other preferable remuneration schemes. Methods A stratified proportional sampling study was undertaken, using an anonymous, electronic survey. The participants were 250 self-employed physiotherapists running their business in Central and Eastern Macedonia and Thrace, being also contracted with the National Organisation for Healthcare Provision (EOPYY). The sample size stands for 34% of the population with a circa 5% margin of error. Results Nearly 9/10 physiotherapists (84%) underline that remuneration falls short of their productivity, leading to reduced job satisfaction. Moreover, their remuneration does not motivate them to provide services of higher quality (46%), while 58% of them stated that they are forced to claim informal fees. There is no clear desire regarding the remuneration scheme, but nearly ¼ of physiotherapists revealed their preference for the cost-per-case philosophy combined with co-payments. Conclusion The majority of physiotherapists believe that their current remuneration does not reflect their productivity nor the quality of their services and, therefore, informal payments arise. The preference of physiotherapists lies between cost-per-case fees and patient co-payments, which, however, favors supplier-induced demand and access inequalities, respectively. Hence, policymakers should revise the current remuneration scheme and overcome its deficiencies without creating new ones.

Palliative Care in the Community: The Greek Version of the Supportive and Palliative Care Indicators Tool (SPICT™)

INTRODUCTION/OBJECTIVES

Systematic identification of persons with palliative care needs constitutes a major challenge for promoting palliative care in all levels of the health system, including primary care. The aim of this study was to translate, cross-culturally adapt, and content validate Supportive and Palliative Care Indicators Tool (SPICT) for use in the Greek primary care context. Secondary objectives were to probe the use of SPICT-GR in exemplary case vignettes, to discuss the clarity and comprehensibility of its content as well as the appropriateness, acceptability, and feasibility of the tool within the Greek primary care.

METHODS

The Greek translation and cross-cultural adaptation of SPICT™ followed World Health Organization recommendations for translation and adaptation of instruments. For this purpose a working group was set up consisting of 2 senior researchers, a primary care professional with postgraduate training in Palliative Medicine and a general practitioner (GP) with special interest in primary palliative care. Three focus groups comprised of health professionals (n = 23) working in primary care settings participated in the pilot testing phase. Participants also completed a questionnaire including rating their perceptions on tool's utility and feasibility as well as on the clarity and relevance of its items. Thematic analysis was used for focus groups discussions on how the tool was perceived and interpreted by health professionals in a Greek healthcare context and descriptive statistics for the quantitative analysis of the questionnaire data.

RESULTS

The majority assessed the tool as useful (65%), considered its implementation in primary care as feasible (91%) and rated its items as "relevant" or "very relevant" and "clear" or "very clear." Three themes emerged from focus groups discussions: Guiding clinical practice and facilitating collaboration; promoting comprehensive care and awareness for palliative care; applicability in and suitability for primary care.

CONCLUSIONS

SPICT-GR™ was identified as a practical and applicable tool for primary care, a source of guidance for the comprehensive identification of patients' palliative care needs, promoting awareness on palliative care and facilitating a shared language among health care professionals.

People-centred primary health care: a scoping review

BACKGROUND

Integrated people-centred health services (IPCHS) are vital for ensuring comprehensive care towards achieving universal health coverage (UHC). The World Health Organisation (WHO) envisions IPCHS in delivery and access to health services. This scoping review aimed to synthesize available evidence on people-centred primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published literature on people-centred PHC. We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar) using search terms related to people-centred and integrated PHC/primary care services. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to select studies. We analyzed data and generated themes using Gale's framework thematic analysis method. Themes were explained under five components of the WHO IPCHS framework.

RESULTS

A total of fifty-two studies were included in the review; most were from high-income countries (HICs), primarily focusing on patient-centred primary care. Themes under each component of the framework included: engaging and empowering people and communities (engagement of community, empowerment and empathy); strengthening governance and accountability (organizational leadership, and mutual accountability); reorienting the model of care (residential care, care for multimorbidity, participatory care); coordinating services within and across sectors (partnership with stakeholders and sectors, and coordination of care); creating an enabling environment and funding support (flexible management for change; and enabling environment).

CONCLUSIONS

Several people-centred PHC and primary care approaches are implemented in HICs but have little priority in low-income countries. Potential strategies for people-centred PHC could be engaging end users in delivering integrated care, ensuring accountability, and implementing a residential model of care in coordination with communities. Flexible management options could create an enabling environment for strengthening health systems to deliver people-centred PHC services.

The digitized chronic disease management model: scalable strategies for implementing standardized healthcare and big data analytics in Shanghai

Background

Chronic disease management (CDM) falls under production relations, and digital technology belongs to the realm of productivity. Production relations must adapt to the development of productivity. Simultaneously, the prevalence and burden of chronic diseases are becoming increasingly severe, leveraging digital technology to innovate chronic disease management model is essential.

Methods

The model was built to cover experts in a number of fields, including administrative officials, public health experts, information technology staff, clinical experts, general practitioners, nurses, metrologists. Integration of multiple big data platforms such as General Practitioner Contract Platform, Integrated Community Multimorbidity Management System and Municipal and District-Level Health Information Comprehensive Platform. This study fully analyzes the organizational structure, participants, service objects, facilities and equipment, digital technology, operation process, etc., required for new model in the era of big data.

Results

Based on information technology, we build Integrated Community Multimorbidity Care Model (ICMCM). This model is based on big data, is driven by "technology + mechanism," and uses digital technology as a tool to achieve the integration of services, technology integration, and data integration, thereby providing patients with comprehensive people-centered services. In order to promote the implementation of the ICMCM, Shanghai has established an integrated chronic disease management information system, clarified the role of each module and institution, and achieved horizontal and vertical integration of data and services. Moreover, we adopt standardized service processes and accurate blood pressure and blood glucose measurement equipment to provide services for patients and upload data in real time. On the basis of Integrated Community Multimorbidity Care Model, a platform and index system have been established, and the platform's multidimensional cross-evaluation and indicators are used for management and visual display.

Conclusions

The Integrated Community Multimorbidity Care Model guides chronic disease management in other countries and regions. We have utilized models to achieve a combination of services and management that provide a grip on chronic disease management.

Healthcare Professionals' Perspectives on the Implementation of the Integrated Care Models for Chronic Patients

Objective This study aimed to assess the understanding, adoption, and barriers to implementing integrated care for chronic diseases among healthcare professionals in Greece. By gathering insights from healthcare professionals directly involved in the care of patients with chronic conditions, this study sought to identify areas for improvement and inform future policy and strategic initiatives to enhance the quality of care and patient outcomes in Greece. Specific objectives included assessing healthcare professionals' knowledge and understanding of integrated care concepts, principles, and components in chronic disease management and exploring healthcare professionals' experiences in providing or participating in integrated care activities for patients with chronic diseases. Methods This study employed a census-based survey design to assess healthcare professionals' understanding, adoption, and barriers to the implementation of integrated care for chronic diseases in the Greek healthcare system. The sampling technique has been used to ensure the representation of different healthcare professions and regions in Greece. The survey questionnaire was structured based on the internationally recognized Chronic Care Model Elements Survey, specifically tailored to capture insights on integrated care for chronic illnesses in Greece. Healthcare professionals from diverse settings, including primary healthcare centers, public and private hospitals, specialty clinics, rehabilitation centers, home-based care services, and private sector practitioners, were targeted to gather comprehensive perspectives. Both urban and rural areas were included to ensure a representative sample, enabling an understanding of integrated care implementation in Greece. Results A total of 246 responses from healthcare professionals in Greece were collected and analyzed. An applicability index was constructed to evaluate the suitability of the integrated care system in Greece, utilizing variables collected during the survey. The reliability of the index was assessed using Cronbach's Alpha coefficient, which demonstrated a high value of 0.940, indicating strong internal consistency and correlation among the questions related to integrated care. However, the data collected for Greece exhibited a departure from a normal distribution using the Shapiro-Wilk test, suggesting the presence of barriers to the implementation of integrated care within the Greek healthcare system. Conclusions The study revealed several obstacles to integrated care implementation, encompassing organizational and individual factors, such as financial constraints, cultural differences, and regulatory challenges. Tackling these barriers will require a collective approach and close collaboration among multiple stakeholders to create an enabling context for adopting integrated care. Possible strategies involve resource allocation, fostering communication and cooperation among healthcare providers, and revising regulatory frameworks to facilitate integrated care practices. In order to achieve the national objectives of improving public health, the survey increases the focus on evidence-based public health.

School Health Services and Health Education Curricula in Greece: Scoping Review and Policy Plan

The new generation's health and wellbeing is of paramount importance: it constitutes United Nations' priority, complies with Children's Rights and responds to the Sustainable Development Goals of the United Nations. In this perspective, school health and health education, as facets of the public health domain targeted at young people, deserve further attention after the unprecedented COVID-19 pandemic crisis in order to revise policies. The key objectives of this article are (a) to review the evidence generated over a span of two decades (2003-2023), identifying the main policy gaps by taking Greece as a case study, and (b) to provide a concrete and integrated policy plan. Following the qualitative research paradigm, a scoping review is used to identify policy gaps in school health services (SHS) and school health education curricula (SHEC). Data are extracted from four databases: Scopus, PubMed, Web of Science and Google Scholar, while the findings are categorized into the following themes following specific inclusion and exclusion criteria: school health services, school health education curricula, school nursing, all with reference to Greece. A corpus of 162 out 282 documents in English and Greek initially accumulated, is finally used. The 162 documents consisted of seven doctoral theses, four legislative texts, 27 conference proceedings, 117 publications in journals and seven syllabuses. Out of the 162 documents, only 17 correspond to the set of research questions. The findings suggest that school health services are not school-based but a function of the primary health care system, whereas health education retains a constantly changing position in school curricula, and several deficiencies in schoolteachers' training, coordination and leadership impede the implementation. Regarding the second objective of this article, a set of policy measures is provided in terms of a problem-solving perspective, towards the reform and integration of school health with health education.

University Student Health Services, Local Experience, and Emerging Needs: Bridging the Past With the Future

University students' health and well-being is critical, especially in the aftermath of the coronavirus disease 2019 pandemic; however, a comprehensive and integrated approach in academic institutions remains neglected. In this context, the local experience from a pilot university-based Student Health Center at an urban campus in Greece is presented. Select health promotion and disease prevention screening and monitoring initiatives are summarized from the viewpoint of a Strengths, Weaknesses, Opportunities, and Threats analysis, with emerging health needs and policy implications. Long-term sustainability is feasible, only if synergies and close collaboration with other university units and local health authorities are developed. A post-pandemic call to action for intervention programs that integrate physical and mental health care, as well as raise awareness among university stakeholders and health policy makers, is issued. [Journal of Psychosocial Nursing and Mental Health Services, 61(3), 27-31.].

COVID-19 Emotional and Mental Impact on Cancer Patients Receiving Radiotherapy: An Interpretation of Potential Explaining Descriptors

Background: Significant changes in the accessibility and viability of health services have been observed during the COVID-19 period, particularly in vulnerable groups such as cancer patients. In this study, we described the impact of radical practice and perceived changes on cancer patients’ mental well-being and investigated potential outcome descriptors. Methods: Generalized anxiety disorder assessment (GAD-7), patient health (PHQ-9), and World Health Organization-five well-being index (WHO-5) questionnaires were used to assess anxiety, depression, and mental well-being. Information on participants, disease baseline information, and COVID-19-related questions were collected, and related explanatory variables were included for statistical analysis. Results: The mean score values for anxiety, depression, and mental well-being were 4.7 ± 5.53, 4.9 ± 6.42, and 72.2 ± 18.53, respectively. GAD-7 and PHQ-9 scores were statistically associated (p < 0.001), while high values of GAD-7 and PHQ-9 questionnaires were related to low values of WHO-5 (p < 0.001).Using the GAD-7 scale, 16.2% of participants were classified as having mild anxiety (GAD-7 score: 5−9).Mild to more severe anxiety was significantly associated with a history of mental health conditions (p = 0.01, OR = 3.74, 95% CI [1.372−10.21]), and stage category (stage III/IV vs. I/II, p = 0.01, OR = 3.83, 95% CI [1.38−10.64]. From the participants, 36.2% were considered to have depression (PHQ-9 score ≥ 5). Depression was related with older patients (p = 0.05, OR = 1.63, 95% CI [1.16−2.3]), those with previous mental health conditions (p = 0.03, OR = 14.24, 95% CI [2.47−81.84]), those concerned about the COVID-19 impact on their cancer treatment (p = 0.027, OR = 0.19, 95% CI [0.045−0.82]) or those who felt that COVID-19 pandemic has affected mental health (p = 0.013, OR = 3.56, 95% CI [1.30−9.72]). Additionally, most participants (86.7%) had a good well-being score (WHO-5 score ≥ 50). Mental well-being seemed more reduced among stage I−III patients than stage IV patients (p = 0.014, OR = 0.12, 95% CI [0.023−0.65]). Conclusion: There is a necessity for comprehensive cancer care improvement. These patients’ main concern related to cancer therapy, yet the group of patients who were mentally affected by the pandemic should be identified and supported.

Pertussis Prevalence in Adult Population in Greece: A Seroprevalence Nationwide Study

The reported cases of pertussis vary considerably globally. In the present nationwide study, we aimed to record the Bordetella pertussis prevalence in Greece by measuring serum IgG specific antibody levels to pertussis toxin (anti-PT IgG). General practitioners and laboratories participated in this study from 12 regions of Greece. A geographically stratified sampling plan based on regional units (NUTS level 2) was applied in order to produce a representative sample, taking into consideration age group (30−39, 40−49, 50−59, 60−69, 70−79 and 80+) and sex. In total, 1169 subjects participated in the study. The percentage of participants with anti-PT IgG antibodies higher than 50 IU/mL was 3.7%. The levels of anti-PT IgG antibodies of total sample ranged between 1.46 IU/mL to 126.60 IU/mL, with mean 17.74 IU/mL and standard deviation 14.03 U/mL (p-value < 0.001). The total seroprevalence of Greek regions for pertussis disease varied significantly among prefectures. The region with the highest seroprevalence was Peloponnese 21.3%, followed by the region of Central Greece 15.3%. The proportion of adults who have pertussis specific antibodies <50 IU/mL has been >90%, suggesting that a large number of adults may be vulnerable to infection of pertussis despite well-established vaccination programs in Greece. Despite the fact that vaccination reduced the number of reported pertussis cases in the last decades in Greece, our seroprevalence study may indicate that the herd immunity level among Greek adults is suboptimal.

Implementation of the Community Assets Supporting Transitions (CAST) transitional care intervention for older adults with multimorbidity and depressive symptoms: A qualitative descriptive study

Background

Older adults with multimorbidity experience frequent care transitions, particularly from hospital to home, which are often poorly coordinated and fragmented. We conducted a pragmatic randomized controlled trial to test the implementation and effectiveness of Community Assets Supporting Transitions (CAST), an evidence-informed nurse-led intervention to support older adults with multimorbidity and depressive symptoms with the aim of improving health outcomes and enhancing transitions from hospital to home. This trial was conducted in three sites, representing suburban/rural and urban communities, within two health regions in Ontario, Canada.

Purpose

This paper reports on facilitators and barriers to implementing CAST.

Methods

Data collection and analysis were guided by the Consolidated Framework for Implementation Research framework. Data were collected through study documents and individual and group interviews conducted with Care Transition Coordinators and members from local Community Advisory Boards. Study documents included minutes of meetings with research team members, study partners, Community Advisory Boards, and Care Transition Coordinators. Data were analyzed using content analysis.

Findings

Intervention implementation was facilitated by: (a) engaging the community to gain buy-in and adapt CAST to the local community contest; (b) planning, training, and research meetings; (c) facilitating engagement, building relationships, and collaborating with local partners; (d) ensuring availability of support and resources for Care Transition Coordinators; and (e) tailoring of the intervention to individual client (i.e., older adult) needs and preferences. Implementation barriers included: (a) difficulties recruiting and retaining intervention staff; (b) difficulties engaging older adults in the intervention; (c) balancing tailoring the intervention with delivering the core intervention components; and (c) Care Transition Coordinators’ challenges in engaging providers within clients’ circles of care.

Conclusion

This research enhances our understanding of the importance of considering intervention characteristics, the context within which the intervention is being implemented, and the processes required for implementing transitional care intervention for complex older adults.

Vaccination coverage of patients with type 2 diabetes mellitus: Challenging issues from an outpatient secondary care setting in Greece

Background

Increased morbidity/mortality due to vaccine preventable diseases (VPD) is encountered in type 2 diabetes (T2D) people. Aim of this study was to assess their vaccination coverage and describe trends possibly affecting compliance.

Methods

Information on vaccination coverage was retrieved from either documents or interview provided by patients, and/or their vaccination record card at a specialized outpatient diabetes center. The selection of the patients was arbitrary.

Results

An increasing vaccination rate for influenza was observed from 2018 to 2020 among 372 participants. The vaccination coverage for S.pneumoniae was 67.2% (PCV13), 20.4% (PPSV23), 26.3% for herpes zoster in individuals ≥60 years, 1.9% for tetanus-diphtheria-pertussis and 1.1% for hepatitis B. A 10.2% of participants were found to be unvaccinated. Vaccination uptake for influenza and PCV13 was related to age, ≥3 comorbidities and long-term follow-up. T2D individuals consecutively vaccinated for influenza were 3.78 times more likely to be also vaccinated with PCV13.

Conclusions

Vaccination rates of patients with T2D show an increasing trend, especially for influenza and S. pneumoniae, although the one for S. pneumoniae was low. Older people seem more prone to vaccination, the one for herpes zoster was low with infected patients remaining unvaccinated while significantly low coverage was observed for other VPDs. The findings are important to improve effectiveness of preventative services.

Introducing New Paths towards Public Primary Healthcare Services in Greece: Efforts for Scaling-Up Mental Healthcare Services Addressed to Older Adults

The exponential growth in the aging population challenges the Primary Care Providers (PCPs) who provide health care services to older adults who are considered highly vulnerable and are in need of specialized healthcare services. The development of new policies and the adoption of appropriate health strategies by PCPs may improve the early detection and prevention of mental disorders in older adults. This reduces both queuing and costs in outpatient clinics while preventing stigma for patients and families. To this end, specialized training for PCPs at the Local Primary Health Care Unit (LPHCU) was provided in order to conduct efficient assessments of older adults (65 and above years old, without previously diagnosed depression or dementia, and willing to participate). The assessment is based on the Mini Mental State Examination (MMSE) and Geriatric Depression Scale (GDS). Older adults identified with MMSE <20 and GDS >5 were referred to the psychiatric outpatient clinic. The aim of this study is to discuss evidence-informed policymaking in Greece with a focus on advancing mental health practices and scaling up quality primary healthcare services for older adults.

Factors Impacting Primary Care Engagement in a New Approach to Integrating Care in Ontario, Canada

Introduction:

In 2019, Ontario’s Ministry of Health (the Ministry) introduced Ontario Health Teams (OHTs) to provide population-based integrated healthcare. Primary care was foundational to this approach. We sought to identify factors that impacted primary care engagement during OHT formation from different perspectives.

Methods:

Interviews with 111 participants (administrators n = 80; primary care providers n = 17; patient family advisors = 14) from 11 OHTs were conducted following a semi-structured guide. Interviews were transcribed, coded, and thematically analyzed.

Results:

Participants felt that primary care engagement was an ongoing, continuous cycle. Four themes were identified: 1) ‘A low rules environment’: limited direction from the Ministry (system-level), 2) ‘They’re at different starting points’: impact of local context (initiative-level); 3) ‘We want primary care to be actively involved’: engagement efforts made by OHTs (initiative-level); 4) ‘Waiting to hear a little bit more’: primary care concerns about the OHT approach (sector-level). Thirteen factors impacting primary care engagement were identified across the four themes.

Discussion and Conclusion:

The 13 factors influencing primary care engagement were interconnected and operated at health system, integrated care initiative, and sector levels. Future research should focus on integrated care initiatives as they mature, to address potential gaps in the involvement of primary care physicians.

Reported COVID-19 Vaccination Coverage and Associated Factors among Members of Athens Medical Association: Results from a Cross-Sectional Study

There are limited data on the prevalence and determinants of COVID-19 vaccination coverage among physicians. A cross-sectional, questionnaire-based, online study was conducted among the members of the Athens Medical Association (I.S.A.) over the period 25 February to 13 March 2021. All members of I.S.A. were invited to participate in the anonymous online survey. A structured, anonymous questionnaire was used. Overall, 1993 physicians participated in the survey. The reported vaccination coverage was 85.3%. The main reasons of no vaccination were pending vaccination appointment followed by safety concerns. Participants being informed about the COVID-19 vaccines by social media resulted in lower COVID-19 vaccination coverage than health workers being informed by other sources. Logistic regression analysis demonstrated that no fear over COVID-19 vaccination-related side effects, history of influenza vaccination for flu season 2020–2021, and the perception that the information on COVID-19 vaccination from the national public health authorities is reliable, were independent factors of reported COVID-19 vaccination coverage. Our results demonstrate a considerable improvement of the COVID-19 vaccination uptake among Greek physicians. The finding that participants reported high reliability of the information related to COVID-19 vaccination provided by the Greek public health authorities is an opportunity which should be broadly exploited by policymakers in order to combat vaccination hesitancy, and further improve COVID-19 vaccination uptake and coverage among physicians/HCWs, and the general population.

COVID-19 pandemic and reasons to prioritize the needs of the health care system to ensure its sustainability: A scoping review from January to October 2020 (Review)

The worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led the World Health Organization to characterize the pandemic as a public health emergency of international concern. National health care systems in countries during the initial surge of the pandemic were unable to handle the sanitarian crisis that had emerged. Thus, the prevention and control of future global health emergencies must be a priority. The present scoping review aimed to retrieve articles that summarize the current experience on issues related to historical knowledge, and epidemiology, clinical features and overall burden of SARS-CoV-2 on health care services. In summary, a comprehensive overview of the information that has been learnt during this period is presented in the current review. Furthermore, taking into account the global experience, the need for planning cohesive and functional health services before similar pandemic events occur in the future is highlighted. The next public health issue should be prevented rather than treated. In spite of the vaccination benefits, a number of sporadic cases of SARS-CoV-2infections will persist. Information collected remains relevant for appraising how similar threats can be faced in the future. Overall, collaborative health care plans need to be rethought to increase preparedness.

Patient Safety Culture Assessment in Primary Care Settings in Greece

Introduction: A positive safety culture is considered a pillar of safety in health organizations and the first crucial step for quality health services. In this context, the aim of this study was to set a reference evaluation for the patient safety culture in the primary health sector in Greece, based on health professionals’ perceptions. Methods: We used a cross-sectional survey with a 62% response rate (n = 459), conducted in primary care settings in Greece (February to May 2020). We utilized the “Medical Office Survey on Patient Safety Culture” survey tool from the Agency for Healthcare Research and Quality (AHRQ). The study participants were health professionals who interacted with patients from 12 primary care settings in Greece. Results: The most highly ranked domains were: “Teamwork” (82%), “Patient Care Tracking/Follow-up” (80% of positive scores), and “Organizational Learning” (80%); meanwhile, the lowest-ranked ones were: “Leadership Support for Patient Safety” (62%) and “Work Pressure and Pace” (46%). The other domains, such as “Overall Perceptions of Patient Safety and Quality” (77%), “Staff Training“ (70%), “Communication about Error” (70%), “Office Processes and Standardization” (67%), and “Communication Openness” (64%), ranked somewhere in between. Conclusions: A positive safety culture was identified in primary care settings in Greece, although weak areas concerning the safety culture should be addressed in order to improve patient safety.

The effectiveness of primary health care reforms in Greece towards achieving universal health coverage: a scoping review

INTRODUCTION

Between 2010 and 2018, Greece implemented an Economic Adjustment Programme and underwent a series of extensive reforms, including in the health sector. We conducted a scoping review to examine whether the Primary Health Care reforms during that period assisted the country in moving towards Universal Health Coverage.

METHODS

We performed a review of the literature on the following databases: Scopus, PubMed, Epistemonikos, Web of Science, and Google Scholar, including published research articles and grey literature. Findings were synthesised thematically, using the World Health Organization Universal Health Coverage dimensions: population coverage, service coverage, and financial protection.

RESULTS

Forty-four documents were included in this review. Out of these, thirty-eight were research-based (thirty-three qualitative, two quantitative, and three mixed design studies), two grey literature, and four legislative bills. The evidence suggests that despite the systemic interventions addressing longstanding distortions, population coverage, service coverage and financial protection have not significantly improved.

CONCLUSIONS

This review suggests that Primary Health Care reforms in Greece have not managed to substantially improve Universal Health Coverage, although some positive steps towards that direction have taken place with the establishment of community-based multidisciplinary health teams. Before further interventions are implemented, an evidence-based monitoring and evaluation mechanism is necessary in order to clearly evaluate their effectiveness and progress.

Primary care and the COVID-19 pandemic: Schrödinger's cat

We read with interest the article by Tomoset al. [1] reporting on the low death rates during the coronavirus disease 2019 (COVID-19) pandemic crisis in Greece. The authors underlined the importance of primary care in the management of suspected and mild cases and the reduction of inappropriate hospital referrals [1]. With good intentions, the authors offered their own view by stating that the key issue for the reported “Greek success story” is that the primary healthcare system is based on specialist doctors and not general practitioners [1]. They also suggested an algorithm that will help physicians to stratify the risk of infection, highlighting the importance of telemedicine [1]. We also support the usefulness of this conceptual framework. For large population groups that mainly benefit from rural primary care, limited access to private services can be an additional benefit.

The #COVID19 pandemic crisis requires the collaboration of all healthcare providers. Every contribution is welcome to gain time during the phase of “system state” superposition.https://bit.ly/3m4SBxY

The 2017 Primary Health Care (PHC) reform in Greece: Improving access despite economic and professional constraints?

Between 2010 and 2018 Greece was subject to a bailout programme by international creditors and three successive Economic Adjustment Programmes (EAP). These involved large-scale austerity measures and drastic reductions in public sector spending including healthcare. Within this context and in line with the international best practice guidelines for primary care, in August 2017 the left-wing SYRIZA government passed a law for the reform of the Primary Health Care (PHC) sector. The reform introduced the establishment of Local Health Units and the embedded notion of the 'family doctor' as the first pillar of healthcare provision. These reforms aimed to strengthen primary care and to improve access to publicly provided primary care services. Despite the promising claims, the reform was a subject of criticism and failed to engage key stakeholder groups and to be delivered within the original timeline. The aim of this paper is to present the chronicle of the reform, its current status at a national level and its implementation challenges. To address current implementation hindrances, the reform of the Greek PHC sector is expected to undergo systemic changes, including factoring in the scheme's funding needs after 2021, with the successive government reconsidering its future form.

Stress and perceived health among primary care visitors in two corners of Europe: Scandinavia and Greece

BACKGROUND

The global financial crisis emerging in 2008 struck Greece especially hard, whereas Scandinavian countries were less affected. This has created a unique opportunity to study the long-term effect of community stress on populations. Increasing frequencies of mental health issues and poorer perceived health among the Greek population have been reported. The physiological marker of long-term stress, cortisol in hair, is applied in this study together with measures of perceived health and stress, depression and anxiety. Our aim was to study self-reported and physiological stress, perceived health, including mental health, in the general population of Greece compared to Scandinavia, in order to assess long-term effects of the economic crisis on these parameters.

METHODS

A cross-sectional comparative study of adult (18-65 years) Primary Health Care visitors from semi-rural areas in Greece (n = 84) and Scandinavia (n = 140). Data collection was performed in 2012, and encompassed a questionnaire with a variety of health and stress indicators as well as hair samples for analyzes of cortisol levels.

RESULTS

The Greek sample reported significantly poorer overall health (p < 0.0001) than the Scandinavians and a significantly higher perceived stress (p < 0.0001). The Greeks were also less hopeful of the future (p < 0.0001), and to a larger extent fulfilled the HAD criteria for depression (p < 0.0001) and anxiety (p = 0.002). The strongest predictors explaining ill health in logistic regressions were being Greek (p = 0.001) and feeling hopeless about the future p = 0.001, OR = 6.00 (CI 2.10-14.88). Strong predictors in logistic regressions for high perceived stress were anxiety: high (p < 0.0001) and medium (p = 0.0001), as well as medium depression (p = 0.02).

CONCLUSIONS

Greek adult Primary Health Care visitors perceived their health more negatively than the Scandinavians, including a higher presence of depression, anxiety, and a lower hope for the future. The Greeks also reported higher perceived stress, but this was not reflected in higher cortisol levels. The findings presented here, identify possible adverse long-term effects of the economic crisis in the examined Greek population that are not seen in the Scandinavian cohort. These differences may also be interpreted against the background of socio-cultural differences in the northern and south-eastern corners of Europe.

Cognitive Impairment and Dementia in Primary Care: Current Knowledge and Future Directions Based on Findings From a Large Cross-Sectional Study in Crete, Greece

Introduction: Dementia severely affects the quality of life of patients and their caregivers; however, it is often not adequately addressed in the context of a primary care consultation, especially in patients with multi-morbidity. Study Population and Methods: A cross-sectional study was conducted between March-2013 and December-2014 among 3,140 consecutive patients aged >60 years visiting 14 primary health care practices in Crete, Greece. The Mini-Mental-State-Examination [MMSE] was used to measure cognitive status using the conventional 24-point cut-off. Participants who scored low on MMSE were matched with a group of elders scoring >24 points, according to age and education; both groups underwent comprehensive neuropsychiatric and neuropsychological assessment. For the diagnosis of dementia and Mild-Cognitive-Impairment (MCI), the Diagnostic and Statistical Manual-of-Mental-Disorders (DSM-IV) criteria and the International-Working-Group (IWG) criteria were used. Chronic conditions were categorized according to ICD-10 categories. Logistic regression was used to provide associations between chronic illnesses and cognitive impairment according to MMSE scores. Generalized Linear Model Lasso Regularization was used for feature selection in MMSE items. A two-layer artificial neural network model was used to classify participants as impaired (dementia/MCI) vs. non-impaired. Results: In the total sample of 3,140 participants (42.1% men; mean age 73.7 SD = 7.8 years), low MMSE scores were identified in 645 (20.5%) participants. Among participants with low MMSE scores 344 (54.1%) underwent comprehensive neuropsychiatric evaluation and 185 (53.8%) were diagnosed with Mild-Cognitive-Impairment (MCI) and 118 (34.3%) with dementia. Mental and behavioral disorders (F00-F99) and diseases of the nervous system (G00-G99) increased the odds of low MMSE scores in both genders. Generalized linear model lasso regularization indicated that 7/30 MMSE questions contributed the most to the classification of patients as impaired (dementia/MCI) vs. non-impaired with a combined accuracy of 82.0%. These MMSE items were questions 5, 13, 19, 20, 22, 23, and 26 of the Greek version of MMSE assessing orientation in time, repetition, calculation, registration, and visuo-constructive ability. Conclusions: Our study identified certain chronic illness-complexes that were associated with low MMSE scores within the context of primary care consultation. Also, our analysis indicated that seven MMSE items provide strong evidence for the presence of dementia or MCI.

Challenges in Implementing Integrated Care in Central and Eastern Europe - Experience of Poland

During their transition, Central and Eastern European countries’ health and social care systems have undergone significant changes, and are currently dealing with serious problems of disintegration, coordination, and a lack of control over the market environment, especially for meeting patients’ needs. The increased health and social needs related to the ageing society and epidemiological patterns in these countries also require increased funding, reformation of rationing, sectors to be integrated (the managed care approach), and the development of an analytical information base for surveillance of new health and social care solutions.

COVID-19 pandemic: challenges and opportunities for the Greek health care system

After coming out of the state debt crisis, Greece is facing yet another crisis – that of the COVID-19 pandemic. The key challenges facing the organizational structure and function of the Greek public health system in order to meet the populations’ health needs are discussed. Social distancing, through imposed national lockdown very early in the pandemic, has been a key emergency public health measure that has saved lives. However, the system needs to enhance its capacity, through strengthening primary health and social support care, to be able to meet existing unmet health needs, the impact of the pandemic on mental health, as well as to tackle future new waves of outbreak. The related changes in health service provisions in response to the COVID-19 pandemic call for developing new models and novel approaches for delivering effective mental health services.