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Jug J, Peček I, Bukvić S, Petrovčić M, Bosnić F, Rukavina A, Stojanović Špehar S. Continuity of care in patients with type 2 diabetes in Croatian primary care setting during COVID-19 pandemic: A retrospective observational study. Prim Care Diabetes 2022; 16:768-774. [PMID: 36220766 PMCID: PMC9515337 DOI: 10.1016/j.pcd.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 04/12/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022]
Abstract
AIM To examine the differences in the continuity of health care for type 2 diabetic patients before and during COVID pandemic in family medicine depending on whether the physician who provided care finished vocational training in family medicine or not. METHODS This retrospective longitudinal research lasted from 2018 to 2020 in eight family medicine practices on 648 patients with type 2 diabetes diagnosed before 2018, and without Sars-Cov2 infection in previous medical history in Zagreb, Croatia. Follow-up parameters (HbA1c, LDL, eGFR, blood pressure, BMI, eye fundus and neurological findings, number of check-ups and vaccination against the flu) were noted before (2018, 2019), and in the COVID period (2020) in the care of family medicine specialists (FMPs) and without it (FMPws). RESULTS No differences were found between the gender and age of patients. A decrease was seen in existing laboratory findings (64-47%, P < 0.001), eye fundus check-ups (39-37%, P = NS), neurologist check-ups (28-25%, P = NS) and FMP check-ups (382-321, P < 0.001) during the COVID period with significant differences between FMPs and FMPws. Significant changes were seen in LDL cholesterol (2.7-2.4 mmol/L, P < 0.001) and eGFR (83-80 ml/min/1.73 m2, P = 0.002), but BMI, blood pressure and HbA1c (>7% had 42% of patients) values did not differ during the COVID period. CONCLUSION According to the observed parameters, the continuity of care for diabetic patients in Zagreb has worsened during the COVID pandemic but remained significantly better in care of FMPs than in FMPws, without differences in achieving target values of follow-up parameters.
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Riordan F, McHugh SM, O'Donovan C, Mtshede MN, Kearney PM. The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:1836-1848. [PMID: 32016700 PMCID: PMC7280455 DOI: 10.1007/s11606-020-05676-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
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Affiliation(s)
- F Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - S M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | | | - Mavis N Mtshede
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - P M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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Abstract
BACKGROUND Around the world, health reforms are increasingly fostering collaboration and integration among primary care physicians with the aim of facilitating knowledge sharing and evidence-informed decision-making. Although extant research on this topic is abundant, the evidence and results regarding social and organizational factors affecting the formation of knowledge-sharing networks in this setting are inconclusive. PURPOSE The aim of this article is to explore multiple theoretical mechanisms explaining the formation of knowledge-sharing networks among primary care physicians across relevant clinical areas. METHODOLOGY/APPROACH The data are collected from two local health authorities in the Italian National Health Service that are responsible for delivering primary care in two Italian regions. Exponential random graph models are used to test the hypotheses. FINDINGS Our findings indicate that knowledge-sharing networks are highly correlated across clinical areas. In addition, knowledge-sharing networks are highly reciprocal and clustered. We also observe that formal models adopted to foster collaboration have remarkably different effects on the formation of knowledge networks, depending upon the diverse knowledge management approaches adopted in the surveyed local health authorities. PRACTICE IMPLICATIONS Primary care organizations need to develop and implement knowledge management practices in order to help physicians in identifying knowledge domain experts as well as to support connections through formal groupings and incentives.
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de Fernelmont L, Laere SV, Devroey D. The Quality of EBM Sources Perceived By Belgian Family Physicians. Open Access Maced J Med Sci 2018; 6:1918-1923. [PMID: 30455774 PMCID: PMC6236040 DOI: 10.3889/oamjms.2018.382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 09/08/2018] [Accepted: 10/17/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Belgian family physicians use several local and international sources for evidence-based medicine (EBM). AIM This study aims to investigate the quality of these EBM sources according to the Belgian family physicians. METHODS A sample of Belgian family physicians completed a digital survey on the quality of EBM sources. RESULTS Respondents evaluated the quality of the information for the major part of the local and international EBM sources good to excellent. More than 50% of the respondents found in the major part of the sources an answer to the question. More than half of the respondents found the necessary information in less than 5 minutes in most of the sources. Younger participants self-evaluated their search skills better than older participants. CONCLUSION The quality of most frequently used EBM sources in Belgium is evaluated as good and client-friendly. More than half of the respondents found an answer to their questions in most of the sources and this within 5 minutes.
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Affiliation(s)
- Laurence de Fernelmont
- Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Sven Van Laere
- Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
| | - Dirk Devroey
- Vrije Universiteit Brussel, Department of Family Medicine and Chronic Care, Brussels, Belgium
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Goal importance, use of performance measures, and knowledge exchange: An empirical study on general practitioners' performance. Health Care Manage Rev 2018; 45:117-129. [PMID: 29905596 DOI: 10.1097/hmr.0000000000000206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In many health systems, general practitioners (GPs) exhibit high levels of isolation and, at the same time, low levels of organizational identification, which can hinder their individual performance. The extant health care literature suggests that the physicians' belief that organizational goals are important, the adoption of performance measurement systems, and knowledge-sharing practices affect their individual performance. Most research has investigated these constructs in isolation, however, rather than explored their collective impact on GPs' individual performance. PURPOSE The aim of this study was to explore how GPs' belief in goal importance, use of performance measures, and knowledge exchange affect their individual performance, here defined as their individual achievement of organizational goals. METHODOLOGY We developed five hypotheses regarding how GPs' belief in goal importance and use of performance measures may affect individual performance, as well as how knowledge exchange may moderate these relationships. We tested our theoretical conjectures using data collected in a community of GPs in the Italian National Health Service. A survey questionnaire was administered to gather information about the GPs' level of belief in goal importance, use of performance measures, and perception about knowledge exchange in their primary care units. We considered two measures of GPs' individual performance: efficiency and appropriateness of drug prescription. We tested our hypotheses using probit regressions. RESULTS Our findings show that perceived importance of organizational goals and use of performance measures have a positive effect on GPs' individual performance. Meanwhile, GPs' use of performance measures moderates the relationship between their belief in goal importance and individual performance. Finally, perceived knowledge exchange moderates the relationships between belief in goal importance/use of performance measures and individual performance. PRACTICE IMPLICATIONS Executives could improve GPs' individual performance through interventions that reinforce their belief that organizational goals are important, facilitate a more intensive use of performance measures, and encourage knowledge exchange practices.
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Barsanti S, Bonciani M. General practitioners: Between integration and co-location. The case of primary care centers in Tuscany, Italy. Health Serv Manage Res 2018; 32:2-15. [DOI: 10.1177/0951484818757154] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Healthcare systems have followed several strategies aimed at integrating primary care services and professionals. Medical homes in the USA and Canada, and primary care centres across Europe have collocated general practitioners and other health and social professionals in the same building in order to boost coordination among services and the continuity of care for patients. However, in the literature, the impact of co-location on primary care has led to controversial results. This article analyses the possible benefits of the co-location of services in primary care focusing on the Italian model of primary care centres (Case della Salute) in terms of general practitioners’ perception. We used the results of a web survey of general practitioners in Tuscany to compare the experiences and satisfaction of those general practitioners involved and not involved in a primary care centre, performed a MONAVA and ANOVA analysis. Our case study highlights the positive impact of co-location on the integration of professionals, especially with nurses and social workers, and on organizational integration, in terms of frequency of meeting to discuss about quality of care. Conversely, no significant differences were found in terms of either clinical or system integration. Furthermore, the collaboration with specialists is still weak. Considering the general practitioners’ perspective in terms of experience and satisfaction towards primary care, co-location strategies is a necessary step in order to facilitate the collaboration among professionals and to prevent unintended consequences in terms of an even possible isolation of primary care as an involuntary ‘disintegration of the integration’.
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Affiliation(s)
- Sara Barsanti
- Laboratorio Management e Sanità, Institute of Management of Scuola Superiore Sant’Anna of Pisa, Pisa, Italy
| | - Manila Bonciani
- Laboratorio Management e Sanità, Institute of Management of Scuola Superiore Sant’Anna of Pisa, Pisa, Italy
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Di Martino M, Lallo A, Kirchmayer U, Davoli M, Fusco D. Prevalence of antibiotic prescription in pediatric outpatients in Italy: the role of local health districts and primary care physicians in determining variation. A multilevel design for healthcare decision support. BMC Public Health 2017; 17:886. [PMID: 29149875 PMCID: PMC5693576 DOI: 10.1186/s12889-017-4905-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 11/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND According to scientific literature, antibacterials are prescribed for common pediatric conditions that do not benefit from antibiotic therapy. The link between antibiotic use and bacterial resistance is well known. Antibiotic overprescribing generates high social costs and severe consequences for children. Our objectives were to analyze antibiotic prescription patterns in pediatric outpatients residing in the Lazio region (Italy), to identify physicians' characteristics associated with increased propensity for prescription, to identify the priority axes for action to improve the rational use of antibiotics. METHODS We enrolled all children aged 13 years or less in 2014. Antibiotic prescription patterns were analyzed during a one-year follow-up period. The main outcome measures were the antibiotic prescription prevalence, and the geographic variation in antibiotic prescribing. Multilevel models were performed to analyze variation. Variation was expressed as Median Odds Ratios (MORs). If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large. RESULTS We enrolled 636,911 children. Most of them were aged 6-13 years (57.3%). In 2015, the antibiotic prescription prevalence was 46% in the 0-13, 58% in the 0-5, and 37% in the 6-13 age group. Overall, penicillins were the most prescribed antibiotics, their consumption increased from 43% to 52% during the 2007-2015 period. In 2015, the antibiotic prescription prevalence ranged from 30% to 62% across local health districts (LHDs) of the region. Moreover, a significant (p < 0.001) variation was observed between physicians working in the same LHD: MORs were equal to 1.52 (1.48-1.56) and 1.46 (1.44-1.48) in the 0-5 and 6-13 age groups, respectively. The probability of prescribing antibiotics was significantly (p < 0.001) lower for more-experienced physicians. CONCLUSIONS Pediatric antibiotic use in the Lazio region is much higher than in other European countries. The intra-regional drug prescribing variability underlines the lack of therapeutic protocols shared at regional level and raises equity issues in access to optimal care. Both LHD managers and individual physicians should be involved in training interventions to improve the targeted use of antibiotics and mitigate the effect of contextual variables, such as the spatial-related socioeconomic status of the patient/parent binomial.
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Affiliation(s)
- Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112 - 00147, Roma, Italy.
| | - Adele Lallo
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112 - 00147, Roma, Italy
| | - Ursula Kirchmayer
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112 - 00147, Roma, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112 - 00147, Roma, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Via Cristoforo Colombo, 112 - 00147, Roma, Italy
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Leone L, Pesce C. From Delivery to Adoption of Physical Activity Guidelines: Realist Synthesis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E1193. [PMID: 28991184 PMCID: PMC5664694 DOI: 10.3390/ijerph14101193] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Evidence-based guidelines published by health authorities for the promotion of health-enhancing physical activity (PA), continue to be implemented unsuccessfully and demonstrate a gap between evidence and policies. This review synthesizes evidence on factors influencing delivery, adoption and implementation of PA promotion guidelines within different policy sectors (e.g., health, transport, urban planning, sport, education). METHODS Published literature was initially searched using PubMed, EBSCO, Google Scholar and continued through an iterative snowball technique. The literature review spanned the period 2002-2017. The realist synthesis approach was adopted to review the content of 39 included studies. An initial programme theory with a four-step chain from evidence emersion to implementation of guidelines was tested. RESULTS The synthesis furthers our understanding of the link between PA guidelines delivery and the actions of professionals responsible for implementation within health services, school departments and municipalities. The main mechanisms identified for guidance implementation were scientific legitimation, enforcement, feasibility, familiarity with concepts and PA habits. Threats emerged to the successful implementation of PA guidelines at national/local jurisdictional levels. CONCLUSIONS The way PA guidelines are developed may influence their adoption by policy-makers and professionals. Useful lessons emerged that may inform synergies between policymaking and professional practices, promoting win-win multisectoral strategies.
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Affiliation(s)
- Liliana Leone
- CEVAS Center for Research and Evaluation, 00175 Rome, Italy.
| | - Caterina Pesce
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", 00135 Rome, Italy.
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When peers count: The effects on integrated type II diabetes care of communication within general practitioner-only subgroups in interprofessional primary care teams. Health Care Manage Rev 2017; 44:67-78. [PMID: 28306609 DOI: 10.1097/hmr.0000000000000158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Primary care teams (hereafter referred to as primary care units [PCUs]) composed of general practitioners (GPs), nurses, and specialist doctors have recently been established in the Italian context, with the main aim of improving integrated care for chronic diseases. PURPOSES The aim of the study was to assess whether the increased professional diversity of PCUs has resulted in an improvement in the integrated care of type II diabetes and to identify a potential mechanism mediating this effect. METHODOLOGY/APPROACH We analyzed 213 PCUs, comparing their performance in integrated type II diabetes care at two time points. Using social categorization theory and a fixed effects regression analysis, we tested a mediation model in which the frequency of communication among GPs in the PCUs, that is, within-subgroup communication, mediates the relationship between PCU professional diversity and team performance in diabetes care. FINDINGS We show that when the professional diversity of the PCUs increases, integrated care of type II diabetes improves and better meets the standards of optimal care. Within-GP subgroup communication works as a mediating mechanism that translates the PCU professional diversity into better team performance. The mediation effect, however, is curvilinear. Beyond certain levels, within-subgroup communication can hamper PCUs' capacity to work collaboratively in integrated type II diabetes care. PRACTICE IMPLICATIONS The article suggests that, when creating interprofessional primary care teams, managers might be able to steer teams toward a better performance by encouraging communication among peers of the same profession.
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Diop M, Fiset-Laniel J, Provost S, Tousignant P, Borgès Da Silva R, Ouimet MJ, Latimer E, Strumpf E. Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec's Family Medicine Groups, 2002-2010. Health Policy 2017; 121:378-388. [PMID: 28233598 DOI: 10.1016/j.healthpol.2017.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/23/2016] [Accepted: 02/01/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance. METHODS We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000-2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models. RESULTS Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=-2.83% [-4.08%, -1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=-0.24% [-2.24%; 1.75%]). CONCLUSIONS We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.
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Affiliation(s)
- Mamadou Diop
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Julie Fiset-Laniel
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Sylvie Provost
- Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Institut de recherche en santé publique de l'Université de Montréal, Pavillon 7101 avenue du Parc, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7 Canada
| | - Pierre Tousignant
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Roxane Borgès Da Silva
- Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Université de Montréal, Faculté des sciences infirmières, Marguerite-d'Youville C.P 6128, succursale Centre-ville, Montréal, QC H3C 3J7 Canada
| | - Marie-Jo Ouimet
- Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Eric Latimer
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Douglas Mental Health University Institute, Perry Pavilion Room E-3114, 6875 boulevard LaSalle, Montreal, QC H4H 1R3 Canada
| | - Erin Strumpf
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Institut de recherche en santé publique de l'Université de Montréal, Pavillon 7101 avenue du Parc, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7 Canada; McGill University, Department of Economics, 855 Sherbrooke St. West, Leacock 418, Montreal, QC H3A 2T7 Canada.
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Lippi Bruni M, Mammi I, Ugolini C. Does the extension of primary care practice opening hours reduce the use of emergency services? JOURNAL OF HEALTH ECONOMICS 2016; 50:144-155. [PMID: 27744236 DOI: 10.1016/j.jhealeco.2016.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 06/06/2023]
Abstract
Overcrowding in emergency departments generates potential inefficiencies. Using regional administrative data, we investigate the impact that an increase in the accessibility of primary care has on emergency visits in Italy. We consider two measures of avoidable emergency visits recorded at list level for each General Practitioner. We test whether extending practices' opening hours to up to 12 hours/day reduces the inappropriate utilization of emergency services. Since subscribing to the extension program is voluntary, we account for the potential endogeneity of participation in a count model for emergency admissions in two ways: first, we use a two-stage residual inclusion approach. Then we exploit panel methods on data covering a three-year period, thus accounting directly for individual heterogeneity. Our results show that increasing primary care accessibility acts as a restraint on the inappropriate use of emergency departments. The estimated effect is in the range of a 10-15% reduction in inappropriate admissions.
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Affiliation(s)
- Matteo Lippi Bruni
- Department of Economics, University of Bologna, Piazza Scaravilli 2, 40126 Bologna, Italy.
| | - Irene Mammi
- Department of Economics, University of Bologna, Piazza Scaravilli 2, 40126 Bologna, Italy
| | - Cristina Ugolini
- Department of Economics, University of Bologna, Piazza Scaravilli 2, 40126 Bologna, Italy
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Armeni P, Compagni A, Longo F. Multiprofessional Primary Care Units: What Affects the Clinical Performance of Italian General Practitioners? Med Care Res Rev 2016; 71:315-36. [PMID: 24993251 DOI: 10.1177/1077558714536618] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Multiprofessional primary care models promise to deliver better care and reduce waste. This study evaluates the impact of such a model, the primary care unit (PCU), on three outcomes. A multilevel analysis within a "pre- and post-PCU" study design and a cross-sectional analysis were conducted on 215 PCUs located in the Emilia-Romagna region in Italy. Seven dimensions captured a set of processes and services characterizing a well-functioning PCU, or its degree of vitality. The impact of each dimension on outcomes was evaluated. The analyses show that certain dimensions of PCU vitality (i.e., the possibility for general practitioners to meet and share patients) can lead to better outcomes. However, dimensions related to the interaction and the joint works of general practitioners with other professionals tend not to have a significant or positive impact. This suggests that more effort needs to be invested to realize all the potential benefits of the PCU's multiprofessional approach to care.
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Di Martino M, Ventura M, Cappai G, Lallo A, Davoli M, Agabiti N, Fusco D. Adherence to Long-Acting Bronchodilators After Discharge for COPD: How Much of the Geographic Variation is Attributable to the Hospital of Discharge and How Much to the Primary Care Providers? COPD 2016; 14:86-94. [PMID: 27419396 DOI: 10.1080/15412555.2016.1202225] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In moderate-severe chronic obstructive pulmonary disease (COPD), long-acting bronchodilators (LBs) are recommended to improve the quality of life. The aims of this study were to measure adherence to LBs after discharge for COPD, identify determinants of adherence, and compare amounts of variation attributable to hospitals of discharge and primary care providers, i.e. local health districts (LHDs) and general practitioners (GPs). This cohort study was based on the Lazio region population, Italy. Patients discharged in 2007-2011 for COPD were followed up for 2 years. Adherence was defined as a medication possession ratio >80%. Cross-classified models were performed to analyse variation. Variances were expressed as median odds ratios (MORs). An MOR of 1.00 stands for no variation, a large MOR indicates considerable variation. We enrolled 13,178 patients. About 29% of patients were adherent to LBs. Adherence was higher for patients discharged from pneumology wards and for patients with GPs working in group practice. A relevant variation between LHDs (MOR = 1.21, p = 0.001) and GPs (MOR = 1.28, p = 0.035) was detected. When introducing the hospital of discharge in the model, the MOR related to LHDs decreased to 1.05 (p = 0.345), MOR related to GPs dropped to 1.22 (p = 0.086), whereas MOR associated with hospitals of discharge was 1.38 (p < 0.001). Treatments with proven benefit for COPD were underused. Moreover, a relevant geographic variation was observed. This heterogeneity raises equity concerns in access to optimal care. The reduction of variability among LHDs and GPs after entering the hospital level proved that differences we observe in primary care partially 'reflect' the clinical approach of hospitals of discharge.
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Affiliation(s)
- Mirko Di Martino
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Martina Ventura
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Giovanna Cappai
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Adele Lallo
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Marina Davoli
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Nera Agabiti
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
| | - Danilo Fusco
- a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy
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Di Martino M, Alagna M, Cappai G, Mataloni F, Lallo A, Perucci CA, Davoli M, Fusco D. Adherence to evidence-based drug therapies after myocardial infarction: is geographic variation related to hospital of discharge or primary care providers? A cross-classified multilevel design. BMJ Open 2016; 6:e010926. [PMID: 27044584 PMCID: PMC4823440 DOI: 10.1136/bmjopen-2015-010926] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To measure the adherence to polytherapy after myocardial infarction (MI), to compare the proportions of variation attributable to hospitals of discharge and to primary care providers, and to identify determinants of adherence to medications. SETTING This is a population-based study. Data were obtained from the Information Systems of the Lazio Region, Italy (5 million inhabitants). PARTICIPANTS Patients hospitalised with incident MI in 2007-2010. OUTCOME MEASURE The outcome was chronic polytherapy after MI. Adherence was defined as a medication possession ratio ≥0.75 for at least three of the following drugs: antiplatelets, β-blockers, ACEI angiotensin receptor blockers, statins. DESIGN AND ANALYSIS A 2-year cohort study was performed. Cross-classified multilevel models were applied to analyse geographic variation and compare proportions of variability attributable to hospitals of discharge and primary care providers. The variance components were expressed as median ORs MORs. If the MOR is 1.00, there is no variation between clusters. If there is considerable between-cluster variation, the MOR will be large. RESULTS A total of 9606 patients were enrolled. About 63% were adherent to chronic polytherapy. Adherence was higher for patients discharged from cardiology wards (OR=1.56 vs other wards, p<0.001) and for patients with general practitioners working in group practice (OR=1.14 vs single-handed, p=0.042). A relevant variation in adherence was detected between local health districts (MOR=1.24, p<0.001). When introducing the hospital of discharge as a cross-classified level, the variation between local health districts decreased (MOR=1.13, p=0.020) and the variability attributable to hospitals of discharge was significantly higher (MOR=1.37, p<0.001). CONCLUSIONS Secondary prevention pharmacotherapy after MI is not consistent with clinical guidelines. The relevant geographic variation raises equity issues in access to optimal care. Adherence was influenced more by the hospital that discharged the patient than by the primary care providers. Cross-classified models proved to be a useful tool for defining priority areas for more targeted interventions.
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Affiliation(s)
- Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Michela Alagna
- Faculty of Education—Free University of Bolzano, Bolzano, Italy
| | - Giovanna Cappai
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | | | - Adele Lallo
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | | | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
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Calciolari S, Ilinca S. Unraveling care integration: Assessing its dimensions and antecedents in the Italian Health System. Health Policy 2015; 120:129-38. [PMID: 26725643 DOI: 10.1016/j.healthpol.2015.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 09/24/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
In recent decades, consensus has grown on the need to organize health systems around the concept of care integration to better confront the challenges associated with demographic trends and financial sustainability. However, care integration remains an imprecise umbrella term in both the academic and policy arenas. In addition, little substantive knowledge exists on the success factors for integration initiatives. We propose a composite measure of care integration and a conceptual framework suggesting its relationships with three types of antecedents: contextual, cultural, and organizational factors. Our framework was tested using data from the Italian National Health System (NHS). We administered an ad-hoc questionnaire to all Italian local health units (LHUs), with a 60.4% response rate, and used structural equation modeling to assess the relationships between the relevant latent constructs. The results validated our measure of care integration and supported the hypothesized relationships. In particular, integration was found to be fostered by results-oriented institutional settings, a professional culture conducive to inclusiveness and shared goals, and organizational arrangements promoting clear expectations among providers. Thus, integration improves care and mediates the effects of specific operating means on care enhancement.
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Affiliation(s)
- Stefano Calciolari
- Università della Svizzera Italiana, IdEP Institute, Lugano, Switzerland.
| | - Stefania Ilinca
- European Centre for Social Welfare Policy and Research, Vienna, Austria
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Avaldi VM, Lenzi J, Castaldini I, Urbinati S, Di Pasquale G, Morini M, Protonotari A, Maggioni AP, Fantini MP. Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy. PLoS One 2015; 10:e0127796. [PMID: 26010223 PMCID: PMC4444393 DOI: 10.1371/journal.pone.0127796] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/18/2015] [Indexed: 01/25/2023] Open
Abstract
Background Primary health care is essential for an appropriate management of heart failure (HF), a disease which is a major clinical and public health issue and a leading cause of hospitalization. The aim of this study was to evaluate the impact of different organizational factors on readmissions of patients with HF. Methods The study population included elderly resident in the Local Health Authority of Bologna (Northern Italy) and discharged with a diagnosis of HF from January to December 2010. Unplanned hospital readmissions were measured in four timeframes: 30 (short-term), 90 (medium-term), 180 (mid-long-term), and 365 days (long-term). Using multivariable multilevel Poisson regression analyses, we investigated the association between readmissions and organizational factors (discharge from a cardiology department, general practitioners’ monodisciplinary organizational arrangement, and implementation of a specific HF care pathway). Results The 1873 study patients had a median age of 83 years (interquartile range 77–87) and 55.5% were females; 52.0% were readmitted to the hospital for any reason after a year, while 20.1% were readmitted for HF. The presence of a HF care pathway was the only factor significantly associated with a lower risk of readmission for HF in the short-, medium-, mid-long- and long-term period (short-term: IRR [incidence rate ratio]=0.57, 95%CI [confidence interval]=0.35–0.92; medium-term: IRR=0.70, 95%CI=0.51–0.96; mid-long-term: IRR=0.79, 95%CI=0.64–0.98; long-term: IRR=0.82, 95%CI=0.67–0.99), and with a lower risk of all-cause readmission in the short-term period (IRR=0.73, 95%CI=0.57–0.94). Conclusion Our study shows that the HF care specific pathway implemented at the primary care level was associated with lower readmission rate for HF in each timeframe, and also with lower readmission rate for all causes in the short-term period. Our results suggest that the engagement of primary care professionals starting from the early post-discharge period may be relevant in the management of patients with HF.
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Affiliation(s)
- Vera Maria Avaldi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
| | - Ilaria Castaldini
- Department of Programming and Control, Bologna Local Healthcare Authority, Bologna, Italy
| | | | | | - Mara Morini
- Department of Primary Care, Bologna Local Healthcare Authority, Bologna, Italy
| | - Adalgisa Protonotari
- Department of Programming and Control, Bologna Local Healthcare Authority, Bologna, Italy
| | | | - Maria Pia Fantini
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum—University of Bologna, Bologna, Italy
- * E-mail:
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17
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Modesti A, Bartaloni R, Bellagamba F, Caglieri R, Cenori K, Ciampalini G, Costagli A, Galloni V, Del Papa C, Modesti L, Dell'Omo G, Pedrinelli R. Health care delivery in type 2 diabetes. A survey in an Italian primary care practice. Prim Care Diabetes 2015; 9:9-14. [PMID: 24908631 DOI: 10.1016/j.pcd.2014.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/22/2014] [Accepted: 04/23/2014] [Indexed: 10/25/2022]
Abstract
AIMS Evidence-based guidelines provide targets and performance measures for the treatment of type 2 diabetic patients but a wide gap separates guidelines-driven recommendations from their clinical application, a phenomenon hindering the transfer of proven benefits to affected populations. METHODS We analyzed the quality of diabetic care delivered by 8 general practitioners joint in a group practice attending 571 diabetic patients (5.6% of the total enlisted subjects) by assessing process (% of HbA1c, SBP and LDL-C determinations) and intermediate outcome (% of patients with HbA1c <7% vs >8%, systolic BP <130 mmHg vs >140 mmHg, LDL-cholesterol <100 mg/dL vs >130 mg/dL) indicators. RESULTS HbA1c was at target in 49% of patients and >8% in 22%; SBP and LDL-C determination was available in about two-thirds of patients, only a minority at target for SBP and LDL-C. Antihyperglycemic and antihypertensive treatment was prescribed in most patients but only a third was on statins. During the post-evaluation phase, percentages of patients with HbA1c >8%, SBP < 130 mmHg and LDL-C < 100 mg/dL and the drug prescription pattern did not change. CONCLUSIONS Several weaknesses affect primary care delivery to type 2 diabetic patients and efforts are needed to improve the management of this high-risk group.
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Affiliation(s)
- Andrea Modesti
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Roberto Bartaloni
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Franca Bellagamba
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Rossano Caglieri
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Katia Cenori
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Giorgio Ciampalini
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Attilio Costagli
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Vanni Galloni
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Cecilia Del Papa
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Leonardo Modesti
- "Modulo Pontedera" Progetto Regionale di Medicina d'Iniziativa, Pontedera, Italy
| | - Giulia Dell'Omo
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Italy
| | - Roberto Pedrinelli
- Dipartimento di Patologia Chirurgica, Medica, Molecolare e dell'Area Critica, Università di Pisa, Italy.
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Cooley ME, Blonquist TM, Catalano PJ, Lobach DF, Halpenny B, McCorkle R, Johns EB, Braun IM, Rabin MS, Mataoui FZ, Finn K, Berry DL, Abrahm JL. Feasibility of using algorithm-based clinical decision support for symptom assessment and management in lung cancer. J Pain Symptom Manage 2015; 49:13-26. [PMID: 24880002 PMCID: PMC4621015 DOI: 10.1016/j.jpainsymman.2014.05.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 04/25/2014] [Accepted: 05/06/2014] [Indexed: 12/22/2022]
Abstract
CONTEXT Distressing symptoms interfere with the quality of life in patients with lung cancer. Algorithm-based clinical decision support (CDS) to improve evidence-based management of isolated symptoms seems promising, but no reports yet address multiple symptoms. OBJECTIVES This study examined the feasibility of CDS for a Symptom Assessment and Management Intervention targeting common symptoms in patients with lung cancer (SAMI-L) in ambulatory oncology. The study objectives were to evaluate completion and delivery rates of the SAMI-L report and clinician adherence to the algorithm-based recommendations. METHODS Patients completed a web-based symptom assessment and SAMI-L created tailored recommendations for symptom management. Completion of assessments and delivery of reports were recorded. Medical record review assessed clinician adherence to recommendations. Feasibility was defined as 75% or higher report completion and delivery rates and 80% or higher clinician adherence to recommendations. Descriptive statistics and generalized estimating equations were used for data analyses. RESULTS Symptom assessment completion was 84% (95% CI=81-87%). Delivery of completed reports was 90% (95% CI=86-93%). Depression (36%), pain (30%), and fatigue (18%) occurred most frequently, followed by anxiety (11%) and dyspnea (6%). On average, overall recommendation adherence was 57% (95% CI=52-62%) and was not dependent on the number of recommendations (P=0.45). Adherence was higher for anxiety (66%; 95% CI=55-77%), depression (64%; 95% CI=56-71%), pain (62%; 95% CI=52-72%), and dyspnea (51%; 95% CI=38-64%) than for fatigue (38%; 95% CI=28-47%). CONCLUSION The CDS systems, such as SAMI-L, have the potential to fill a gap in promoting evidence-based care.
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Affiliation(s)
- Mary E Cooley
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA.
| | | | | | | | | | | | - Ellis B Johns
- Virginia Commonwealth University Shenandoah Valley, Front Royal, Virginia, USA
| | - Ilana M Braun
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | | | | | | | - Donna L Berry
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Janet L Abrahm
- Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Mascia D, Dandi R, Di Vincenzo F. Professional networks and EBM use: a study of inter-physician interaction across levels of care. Health Policy 2014; 118:24-36. [PMID: 25022323 DOI: 10.1016/j.healthpol.2014.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 05/19/2014] [Accepted: 06/05/2014] [Indexed: 11/16/2022]
Abstract
Physicians around the globe are increasingly encouraged to adopt guidelines, protocols and other scientific material when making clinical decisions. Extant research suggests that the clinicians' propensity to use evidence-based medicine (EBM) is strongly associated with the professional collaborative networks they establish and maintain with peers. In this paper we explore whether and how the connectedness of primary care physicians with colleagues working in hospital settings is related to their frequency of EBM use in clinical practice. We used survey data from 104 pediatricians working in five local health authorities in the Italian NHS. Social network and attributional data concerning single physicians, as well as their self-reported frequency of EBM use, were collected for three major pathologies in pediatric care: asthmatic, gastro-enteric and urinary pathologies. Ordered regression analysis was employed. Our findings documented a positive association between the number of physicians' relationships with hospital colleagues and the frequency of use EBM. Results also indicated that physicians' organizational affiliations influence the frequency of EBM use. Finally, contrary to our expectations, it was found that clinicians' affiliation to formal collaborative arrangements is at odds with the likelihood of reporting higher frequency of EBM use.
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Affiliation(s)
- Daniele Mascia
- Catholic University of the Sacred Heart, Department of Public Health, Largo F. Vito 1, 00168 Rome, Italy.
| | - Roberto Dandi
- LUISS Guido Carli University, Department of Business and Management, Viale Pola 12, 00198 Rome, Italy.
| | - Fausto Di Vincenzo
- G. d'Annunzio University, Department of Economic Studies, Viale Pindaro 42, 65100 Pescara, Italy.
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20
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Simulation curriculum can improve medical student assessment and management of acute coronary syndrome during a clinical practice exam. Am J Med Sci 2013; 347:452-6. [PMID: 24280987 DOI: 10.1097/maj.0b013e3182a562d7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND It has been noted that increased focus on learning acute care skills is needed in undergraduate medical curricula. This study investigated whether a simulation-based curriculum improved a senior medical student's ability to manage acute coronary syndrome as measured during a clinical performance examination (CPX). The authors hypothesized that simulation training would improve overall performance when compared with targeted didactics or historical controls. METHODS All 4th-year medical students (n = 291) over 2 years at the authors' institution were included in this study. In the 3rd year of medical school, the "control" group received no intervention, the "didactic" group received a targeted didactic curriculum, and the "simulation" group participated in small group simulation training and the didactic curriculum. For intergroup comparison on the CPX, the authors calculated the percentage of correct actions completed by the student. Data are presented as mean ± standard deviation with significance defined as P < 0.05. RESULTS There was a significant improvement in overall performance with simulation versus both didactics and control (P < 0.001). Performance on the physical examination component was significantly better in simulation versus both didactics and control, as was for diagnosis: simulation versus both didactics and control (P < 0.02 for all comparisons). CONCLUSIONS Simulation training had a modest impact on overall CPX performance in the management of a simulated acute coronary syndrome. Additional studies are needed to evaluate how to further improve curricula regarding unstable patients.
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21
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Mascia D, Cicchetti A, Damiani G. "Us and them": a social network analysis of physicians' professional networks and their attitudes towards EBM. BMC Health Serv Res 2013; 13:429. [PMID: 24148207 PMCID: PMC3815661 DOI: 10.1186/1472-6963-13-429] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 10/18/2013] [Indexed: 11/11/2022] Open
Abstract
Background Extant research suggests that there is a strong social component to Evidence-Based Medicine (EBM) adoption since professional networks amongst physicians are strongly associated with their attitudes towards EBM. Despite this evidence, it is still unknown whether individual attitudes to use scientific evidence in clinical decision-making influence the position that physicians hold in their professional network. This paper explores how physicians’ attitudes towards EBM is related to the network position they occupy within healthcare organizations. Methods Data pertain to a sample of Italian physicians, whose professional network relationships, demographics and work-profile characteristics were collected. A social network analysis was performed to capture the structural importance of physicians in the collaboration network by the means of a core-periphery analysis and the computation of network centrality indicators. Then, regression analysis was used to test the association between the network position of individual clinicians and their attitudes towards EBM. Results Findings documented that the overall network structure is made up of a dense cohesive core of physicians and of less connected clinicians who occupy the periphery. A negative association between the physicians’ attitudes towards EBM and the coreness they exhibited in the professional network was also found. Network centrality indicators confirmed these results documenting a negative association between physicians’ propensity to use EBM and their structural importance in the professional network. Conclusions Attitudes that physicians show towards EBM are related to the part (core or periphery) of the professional networks to which they belong as well as to their structural importance. By identifying virtuous attitudes and behaviors of professionals within their organizations, policymakers and executives may avoid marginalization and stimulate integration and continuity of care, both within and across the boundaries of healthcare providers.
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Affiliation(s)
- Daniele Mascia
- Catholic University of the Sacred Heart, Department of Public Health, Largo Francesco Vito 1, Rome 00168, Italy.
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Damiani G, Silvestrini G, Federico B, Cosentino M, Marvulli M, Tirabassi F, Ricciardi W. A systematic review on the effectiveness of group versus single-handed practice. Health Policy 2013; 113:180-7. [PMID: 23910731 DOI: 10.1016/j.healthpol.2013.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 06/25/2013] [Accepted: 07/04/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Since the 1970s, many countries have employed the use of the General practitioner group practice, but there is contrasting evidence about its effectiveness. A systematic review was performed to assess whether group practice has a more positive impact compared with the single-handed practice on different aspects of health care. METHODS A systematic review was conducted by querying electronic databases and reviewing articles published between 1990 and 2012. A quality assessment was performed. The effect of group practice was evaluated by collecting all items analysed by the articles into four main categories: (1) studies of quality (measured in terms of clinical processes) and productivity (measured in terms of throughput), named "Clinical process measures and throughput"; (2) studies exploring physician's opinion--"Doctor's perspective"; (3) studies looking into the use of innovation, information and communication technology (ICT) and quality assurance--"Innovation, ICT and quality assurance"; (4) studies focused on patient's opinion--"Patient's perspective". The results were synthesized according to three levels of scientific evidence. RESULTS A total of 26 studies were selected. The most studied category was Clinical process measures and throughput (58%). A positive impact of group medicine on "Clinical process measures and throughput", "Doctor's perspective", "Innovation, ICT and quality assurance" was found. There was contrasting evidence considering the "Patient's perspective". CONCLUSIONS Group practice might be a successful organizational requirement to improve the quality of clinical practice in Primary Health Care. Further comparative studies are needed to investigate the impact of organizational and professional determinants such as physician's economic incentives, mode of payment, size of the groups and multispecialty on the effectiveness of medical primary care.
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Affiliation(s)
- Gianfranco Damiani
- Department of Public Health, Catholic University of the Sacred Heart, Rome, Italy.
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Visca M, Donatini A, Gini R, Federico B, Damiani G, Francesconi P, Grilli L, Rampichini C, Lapini G, Zocchetti C, Di Stanislao F, Brambilla A, Moirano F, Bellentani D. Group versus single handed primary care: a performance evaluation of the care delivered to chronic patients by Italian GPs. Health Policy 2013; 113:188-98. [PMID: 23800605 DOI: 10.1016/j.healthpol.2013.05.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 05/20/2013] [Accepted: 05/25/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVES In family medicine contrasting evidence exists on the effectiveness of team practice compared with solo practice on chronic disease management. In Italy, several experiences of team practice have been introduced since the late 1990s but few studies detail their impact on the quality of care. The aim of this paper is to evaluate the impact of team practice in family medicine in six Italian regions using chronic disease management process indicators as a measure of outcome. METHODS Cross-sectional studies were performed to assess impact on quality of care for diabetes, congestive heart failure and ischaemic heart disease. The impact of team vs. solo practice was approximated through performance comparison of general practitioners (GPs) adhering to a team with respect to GPs working in a solo practice. Among the 2082 practitioners working in the 6 regions those assisting 300+ patients were selected. Quality of care towards 164,267 patients having at least one of three chronic conditions was estimated for the year 2008 using administrative databases. Quality indicators (% of patients receiving appropriate care) were selected (4 for diabetes, 4 for congestive heart failure, 3 for ischaemic heart disease) and a total score was computed for each patient. For each disease the response variable associated to each physician was the average score of the patients on his/her list. A multilevel model was estimated assessing the impact of team vs. solo practice. RESULTS No impact was found for diabetes and heart failure. For ischaemic heart disease a slightly significant impact was observed (0.040; 95% CI: 0.015, 0.065). CONCLUSIONS No significant difference was found between team practice and solo practice on chronic disease management in six Italian regions.
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Affiliation(s)
- Modesta Visca
- Agenas - Agenzia Nazionale per i Servizi Sanitari Regionali, Via Puglie, 23, 00187 Roma, Italy.
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Canadian Allergists' and Nonallergists' Perception of Epinephrine Use and Vaccination of Persons with Egg Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:289-94. [DOI: 10.1016/j.jaip.2013.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 02/20/2013] [Accepted: 03/14/2013] [Indexed: 11/18/2022]
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Rucci P, Piazza A, Menchetti M, Berardi D, Fioritti A, Mimmi S, Fantini MP. Integration between Primary Care and Mental Health Services in Italy: Determinants of Referral and Stepped Care. INTERNATIONAL JOURNAL OF FAMILY MEDICINE 2012; 2012:507464. [PMID: 22675628 PMCID: PMC3363367 DOI: 10.1155/2012/507464] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Revised: 03/16/2012] [Accepted: 03/19/2012] [Indexed: 06/01/2023]
Abstract
This study, carried out in the context of a collaborative care program for common mental disorders, is aimed at identifying the predictors of Primary Care Physician (PCP) referral to Community Mental Health Center (CMHC) and patterns of care. Patients with depression or anxiety disorders who had a first contact with CMHCs between January 1, 2007-December 31, 2009 were extracted from Bologna Local Health Authority database. A classification and regression tree procedure was used to determine which combination of demographic and diagnostic variables best distinguished patients referred by PCPs and to identify predictors of patterns of care (consultation, shared care, and treatment at the CMHC) for patients referred by PCPs. Of the 8570 patients, 57.4% were referred by PCPs. Those less likely to be referred by PCPs were living in the urban area, suffered from depressive disorder, and were young. As to the pattern of care, patients living in the urban area were more likely to receive shared care compared with those living in the nonurban area, while the reverse was true for consultation. Predictors of CMHC treatment were depression and young age. Prospective studies are needed to assess length, quantity, and quality of collaborative treatment for common mental disorder delivered at any step of care.
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Affiliation(s)
- Paola Rucci
- Dipartimento di Medicina e Sanità Pubblica, Alma Mater Studiorum Università di Bologna, Via San Giacomo 12, 40124 Bologna, Italy
| | - Antonella Piazza
- Dipartimento Salute Mentale e Dipendenze Patologiche, Azienda USL di Bologna, Viale Pepoli 5, 40123 Bologna, Italy
| | - Marco Menchetti
- Istituto di Psichiatria, Alma Mater Studiorum Università di Bologna, Viale Pepoli 5, 40123 Bologna, Italy
| | - Domenico Berardi
- Istituto di Psichiatria, Alma Mater Studiorum Università di Bologna, Viale Pepoli 5, 40123 Bologna, Italy
| | - Angelo Fioritti
- Dipartimento Salute Mentale e Dipendenze Patologiche, Azienda USL di Bologna, Viale Pepoli 5, 40123 Bologna, Italy
| | - Stefano Mimmi
- Dipartimento di Medicina e Sanità Pubblica, Alma Mater Studiorum Università di Bologna, Via San Giacomo 12, 40124 Bologna, Italy
| | - Maria Pia Fantini
- Dipartimento di Medicina e Sanità Pubblica, Alma Mater Studiorum Università di Bologna, Via San Giacomo 12, 40124 Bologna, Italy
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