An incentive program for general practitioners to encourage systematic and igh-quality care in chronic disease management was introduced in Australia in 1999. There is little empirical evidence and ambiguous theoretical guidance on which effects to expect. This paper evaluates the impact of the incentive program on quality of care in diabetes, as measured by the probability of ordering an HbA1c test. The empirical analysis is conducted with a unique data set and a bivariate probit model to control for the self-selection process of practices into the program. The study finds that the incentive program increased the probability of an HbA1c test being ordered by 20 percentage points and that participation in the program is facilitated by the support of Divisions of General Practice.
OBJECTIVES: We tested the effectiveness of a lay health worker intervention to increase breast and cervical cancer screening among low-income Hispanic women.
METHODS: Participants were women 50 years and older who were nonadherent to mammography (n = 464) or Papanicolaou (Pap) test (n = 243) screening guidelines. After the collection of baseline data, lay health workers implemented the Cultivando la Salud (CLS; Cultivating Health) intervention. Data collectors then interviewed the participants 6 months later.
RESULTS: At follow-up, screening completion was higher among women in the intervention group than in the control group for both mammography (40.8% vs 29.9%; P < .05) and Pap test (39.5% vs 23.6%; P < .05) screening. In an intent-to-treat analysis, these differences remained but were not significant. The intervention increased mammography self-efficacy, perceived susceptibility, perceived survivability, perceived benefits of mammography, subjective norms, and processes of change. The intervention also significantly increased Pap test self-efficacy, perceived benefits of having a Pap test, subjective norms, and perceived survivability of cancer. It did not change Pap test knowledge, perceived susceptibility, or perceptions about negative aspects of Pap test screening.
CONCLUSIONS: Our results add to the evidence concerning the effectiveness of lay health worker interventions for increasing Pap test screening and mammography. Future research should explore the effectiveness of CLS in other Hispanic groups, the mechanisms through which interpersonal communication influences decisions about screening, and how effective interventions such as CLS can best be adopted and implemented in community-based organizations or other settings.
BACKGROUND: Open-access scheduling (also known as advanced access or same-day access) is a popular tool for improving patient access to primary care appointments.
OBJECTIVE: To assess the effect of open-access scheduling and describe the barriers to implementing the open-access scheduling model in primary care.
DESIGN: Case series.
SETTING: Boston, Massachusetts, metropolitan area.
PARTICIPANTS: 6 primary care practices studied from October 2003 through June 2006.
INTERVENTION: Implementation of open-access scheduling.
MEASUREMENTS: Time to third available appointments, no-show rates, and patient and staff satisfaction with appointment availability.
RESULTS: 5 of 6 practices were able to implement open-access scheduling. Within 4 months of implementation, these 5 practices substantially reduced their mean wait for third available appointments from 21 to 8 days for 15-minute visits and from 39 to 14 days for 30-minute visits. However, none of the 5 practices attained the goal of same-day access, and waits for third available appointments increased during 2 years of follow-up. No consistent changes in patient or staff satisfaction or patient no-show rates were found. Barriers to implementation included decreases in appointment supply from provider leaves of absence and departures and increases in appointment demand when practices reopened to new patients after initial implementation of open-access scheduling.
LIMITATIONS: The study lacked control practices. The small number of practices and providers precluded formal statistical comparisons.
CONCLUSION: In 5 of 6 primary care practices, implementation of open-access scheduling improved appointment access in some practices. However, none was able to achieve same-day access and patient and staff satisfaction and patient no-show rates were unchanged. Broader evaluation of open-access scheduling in primary care is needed.
BACKGROUND: Failure to attend appointments compromises health service efficiency. Despite considerable interest in using novel technologies to improve attendance, evidence from rigorously conducted controlled studies is lacking.
AIM: To evaluate the effectiveness of texting appointment reminders to patients who persistently fail to attend appointments.
DESIGN: Randomised controlled study.
SETTING: Inner city general practice in Lothian, Scotland.
METHOD: We included 415 appointments made by patients (n = 173) who had failed to attend two or more routine appointments in the preceding year. Patients whose appointments were randomised to the intervention group received a text message reminder of the appointment. Patients whose appointments were in the control group received no reminder. Our primary outcome measure was non-attendance rates. We undertook an intention-to-treat analysis and multi-level analysis to take account of the lack of independence of the outcomes of repeated appointments for the same patient.
RESULTS: Of the 418 appointments originally included in the study, three were excluded due to clerical error; 189 were randomised to the intervention group and 226 to the control group. Twenty-two appointments (12%) were not attended in the intervention group compared with 39 (17%) in the control group. A chi-square analysis, considering the outcome of appointments as independent from one another, gave a non-significant difference of 5% (95% CI of difference -1.1 to 12.3%, p = 0.13). Multilevel analysis applied to the binary outcome data on non-attendance gave an odds ratio for non-attendance in the intervention group compared with the control group of 0.63 (95% CI 0.36 to 1.1, p = 0.11).
CONCLUSION: Although the intervention showed promise, we failed to demonstrate significant reduction in non-attendance rates, as a result of texting appointment reminders to patients who persistently fail to attend their general practice appointments.
The objective of the study was to assess the effect of an invitation letter on the level of participation in a setting of mainly opportunistic screening for cervical cancer and to do a cost analysis of this intervention. We designed a quasi-randomized trial in which a sample of women between the ages of 25 and 64 years and residing in the province of Limburg, Belgium, who had no Pap smear taken in the past 30 months according to LIKAR (Limburg Cancer Registry), were assigned to an intervention group or to a control group. A written invitation was sent to 43 523 women in the intervention group. Baseline participation in cervical screening was recorded in the year before the intervention to determine its effect. Differences in cumulative incidence between the intervention and the control group were used to report the effect. The net effect of a written invitation resulted in 3355 more women undergoing a Pap smear, which is an increase of 6.4% (95% confidence interval: 5.9-6.9). The cost per additional Pap smear taken amounted to euro29.8. Within an opportunistic cervical cancer screening setting, the effect of a registry-based invitational programme to nonattenders increases the participation further, and at no extra cost compared with an invitational programme to all screen-eligible women irrespective of their screening status.
BACKGROUND: Out reach facilitation is designed to promote uptake of evidence-based guidelines. There is evidence indicating that outreach facilitation can be effective in improving implementation of preventive care in GPs' offices. In this trial, we test a modified version of an outreach facilitation intervention. OBJECTIVE: To evaluate whether a comprehensive preventive intervention program using outreach facilitators improves preventive care delivery. DESIGN: Match-paired, cluster-randomized controlled trial. SETTING: Fee-for-service primary care practices in Eastern Ontario, Canada, at a time of physician shortage. Participants: Volunteer sample of 54 primary care practices. MAIN OUTCOME MEASURES: Mean difference between trial arms in practices' delivery of preventive manoeuvres, measured by preventive performance indices estimated from chart reviews and patient survey data. RESULTS: No difference was detected between the trial's arms for the primary outcome's overall prevention index [2.0%; 95% confidence interval (CI) -3.2 to 7.3; P=0.44]. A small significant difference between the arms was detected for the secondary outcome's overall prevention index (2.8%; 95% CI 0.7-4.8; P=0.01). CONCLUSION: In contrast to similar facilitation trials, this outreach facilitation program did not produce improvements in the delivery of preventive care. This lack of effect may be due to differences in the intervention and context, or the practice's limited capacity to change. Our intervention simultaneously facilitated a high number of manoeuvres, blinded facilitators and physicians to the targeted tests and had a relatively short intervention period and large number of practices assigned per facilitator. Changes in the primary care service model in Ontario at the time of the trial could have also washed out the intervention effect. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
AIMS: To assess changes over two years in the health status and management of a cohort of people with Type 2 diabetes from different ethnic groups within a primary care diabetes annual review programme in New Zealand.
METHODS: The study evaluated changes in clinical measures and proportions achieving guideline targets for 7782 people who had data recorded at baseline in 2002-2003 and at follow-up two years later within the diabetes programme.
RESULTS: A large proportion of Maori (47%) and Pacific (69%) patients had poor glycaemic control at baseline and only small improvements were made over the two years. Significant improvements were made in all the ethnic groups in blood pressure and lipid management at two-year follow-up. By the two-year follow-up, over 75% of Maori and Pacific patients received appropriate treatment with anti-hypertensive and lipid lowering medication and many of the ethnic disparities in risk factors for complications were reduced.
CONCLUSIONS: Participation in the annual review programme may have contributed to improvements in clinical management and reduced disparities in a cohort with Type 2 diabetes. However, the removal of restrictions on statin use in 2002, and introduction of diabetes management guidelines in 2003 may also have improved management standards.
INTRODUCTION: The Macarthur GP After-hours Service (MGPAS) was established to streamline the provision of after-hours medical care in an outer-urban community. This paper reports on a process evaluation of the MGPAS.
METHODS: A mixed methods approach involving surveys, stakeholder interviews and analysis of administrative data was used.
RESULTS AND DISCUSSION: This model of care was well accepted and regarded by general practitioners, Macarthur Health Service staff and the community. The MGPAS was found to be an acceptable and efficient model of after-hours medical care. Areas that required further review included the need for telephone triage, home visiting and improved communication and referral to the health service. The financial viability of the MGPAS depends on supplementary funding due to the constraints of the Medicare rebate, and limited opportunities to reduce costs or increase revenue. Further research, including an economic evaluation to identify opportunity costs of the service, is needed.
BACKGROUND: General practices in England have been encouraged to introduce Advanced Access, but there is no robust evidence that this is associated with improved access in ways that matter to patients.
AIM: To compare priorities and experiences of patients consulting in practices which do or do not operate Advanced Access.
DESIGN OF STUDY: Patient questionnaire survey.
SETTING: Forty-seven practices in 12 primary care trust areas of England.
METHOD: Questionnaire administered when patients consulted.
RESULTS: Of 12,825 eligible patients, 10,821 (84%) responded. Most (70%) were consulting about a problem they had had for at least 'a few weeks'. Patients obtained their current appointment sooner in Advanced Access practices, but were less likely to have been able to book in advance. They could usually see a doctor more quickly than those in control practices, but were no more satisfied overall with the appointment system. The top priority for patients was to be seen on a day of choice rather than to be seen quickly, but different patient groups had different priorities. Patients in Advanced Access practices were no more or less likely to obtain an appointment that matched their priorities than those in control practices. Patients in both types of practice experienced problems making contact by telephone.
CONCLUSION: Patients are seen more quickly in Advanced Access practices, but speed of access is less important to patients than choice of appointment; this may be because most consultations are about long-standing problems. Appointment systems need to be flexible to accommodate the different needs of different patient groups.
An incentive program for general practitioners to encourage systematic and igh-quality care in chronic disease management was introduced in Australia in 1999. There is little empirical evidence and ambiguous theoretical guidance on which effects to expect. This paper evaluates the impact of the incentive program on quality of care in diabetes, as measured by the probability of ordering an HbA1c test. The empirical analysis is conducted with a unique data set and a bivariate probit model to control for the self-selection process of practices into the program. The study finds that the incentive program increased the probability of an HbA1c test being ordered by 20 percentage points and that participation in the program is facilitated by the support of Divisions of General Practice.
