Medicine, Dentistry & Health Sciences Collected Works - Research Publications
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ItemThe Journal of Comorbidity affiliates with the Society for Academic Primary Care.(SAGE Publications, 2016)
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ItemThe Journal of Comorbidity affiliates with the North American Primary Care Research Group.(SAGE Publications, 2017)
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ItemOrganizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review(BIOMED CENTRAL LTD, 2016-10-10)UNLABELLED: Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs). SOURCES: Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files. STUDY SELECTION: One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations.
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ItemContextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries(OXFORD UNIV PRESS, 2018-06)BACKGROUND: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. OBJECTIVE: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. METHODS: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. RESULTS: Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. CONCLUSION: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.
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ItemUncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach(OXFORD UNIV PRESS, 2018-06)BACKGROUND: Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. OBJECTIVE: To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. METHODS: We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. RESULTS: CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. CONCLUSIONS: The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.
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ItemThe Journal of Comorbidity affiliates with the Scottish School of Primary Care.(SAGE Publications, 2017)
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ItemDimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions(OXFORD UNIV PRESS, 2018-06)BACKGROUND: Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. OBJECTIVE: The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. METHODS: Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach. RESULTS: Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. CONCLUSION: The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.
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ItemNo Preview AvailableLink-me: Protocol for a randomised controlled trial of a systematic approach to stepped mental health care in primary care(ELSEVIER SCIENCE INC, 2019-03)Primary care in Australia is undergoing significant reform, with a particular focus on cost-effective tailoring of mental health care to individual needs. Link-me is testing whether a patient-completed Decision Support Tool (DST), which predicts future severity of depression and anxiety symptoms and triages individuals into care accordingly, is clinically effective and cost-effective relative to usual care. The trial is set in general practices, with English-speaking patients invited to complete eligibility screening in their general practitioner's waiting room. Eligible and consenting patients will then complete the DST assessment and are randomised and stratified according to predicted symptom severity. Participants allocated to the intervention arm will receive feedback on DST responses, select treatment priorities, assess motivation to change, and receive a severity-matched treatment recommendation (information about and links to low intensity services for those with mild symptoms, or assistance from a specially trained health professional (care navigator) for those with severe symptoms). All patients allocated to the comparison arm will receive usual GP care plus attention control. Primary (psychological distress) and secondary (depression, anxiety, quality of life, days out of role) outcomes will be assessed at 6 and 12 months. Differences in outcome means between trial arms both across and within symptom severity group will be examined using intention-to-treat analyses. Within trial and modelled economic evaluations will be conducted to determine the value for money of credentials of Link-me. Findings will be reported to the Federal Government to inform how mental health services across Australia are funded and delivered in the future.
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ItemImplementing dementia risk reduction in primary care: a preliminary conceptual model based on a scoping review of practitioners' views(CAMBRIDGE UNIV PRESS, 2019)Primary care practitioners (PCPs) do not routinely promote dementia risk reduction. The purpose of this study was to map the published literature on the views of PCPs about dementia risk reduction, in order to identify implementation constructs and strategies crucial to the development of an implementation intervention to support dementia risk reduction in primary care. We undertook a scoping review of the PCPs' views about promoting brain health for reducing dementia risk. We searched MEDLINE, PsycINFO, CINAHL, and Embase for English-language articles published between 1995 and December 2017. We then applied the Consolidated Framework for Implementation Research (CFIR) and matched Expert Recommendations for Implementing Change to the scoping review findings in order to develop a preliminary implementation model. Eight articles reported views of PCPs about dementia prevention. Study findings were mapped to 5 of the 39 CFIR constructs: (i) knowledge and beliefs about dementia risk reduction, (ii) evidence strength and quality, (iii) relative priority, (iv) available resources, and (v) external policy and incentives. The findings suggest implementation strategies to consider in our preliminary model include (i) educational meetings, (ii) identifying and preparing champions, (iii) conducting local consensus discussions, (iv) altering incentive structures, and (v) capturing and sharing local knowledge. There have been few studies about the views of PCPs about dementia risk reduction. Implementation in the primary care setting is fundamental to early identification of risk and supporting preventive practices, but it needs to focus on more than just education for PCPs. We need more up-to-date and in-depth data on the views of PCPs about dementia risk reduction and context-specific analyses of implementation needs. Further research into effective primary care interventions to reduce dementia risk is expected to support implementation efforts.
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ItemWhat are the patient factors that impact on decisions to progress to total knee replacement? A qualitative study involving patients with knee osteoarthritis(BMJ PUBLISHING GROUP, 2019-09)OBJECTIVES: General practitioners (GPs) are often the first health professionals to assess patients with osteoarthritis (OA). Despite clinical guideline recommendations for non-surgical intervention as first-line therapies, the most frequent referral from a GP for a person with knee OA is to an orthopaedic surgeon. The aim of our study was to explore patient factors that impact on the decision to progress to total knee replacement (TKR), including the experience of patients in general practice, their perceptions of their condition, and their access and use of community-based allied health interventions. DESIGN: Qualitative investigation using semi-structured interviews. The Candidacy framework was selected as a lens to examine the factors driving healthcare access. Data were analysed using a thematic analysis approach. Codes identified in the data were mapped to the seven Candidacy domains. Themes corresponding to each domain were described. SETTING: A public hospital in Melbourne, Australia. PARTICIPANTS: 27 patients with knee OA who were on a waiting list to undergo TKR. RESULTS: Ten themes described factors influencing access and use of non-surgical interventions and decision-making for undergoing TKR: (1) History of knee problems, change in symptoms; (2) Physical and psychosocial functioning (Identification of Candidacy); (3) GP and social networks as information sources, access to care (Navigation); (4) Referral pathways (Permeability of services); (5) Communication of impact (Appearances at health services); (6) GP-Surgeon as the predominant referral pathway (Adjudications); (7) Physical activity as painful; (8) Beliefs about effectiveness of non-surgical interventions (Offers and resistance); (9) Familiarity with local system; and (10) Availability (Operating conditions and local production of Candidacy). CONCLUSIONS: Using the Candidacy framework to analyse patients' experiences when deciding to progress to TKR highlighted missed opportunities in general practice to orient patients to first try non-surgical interventions. Patients with knee OA also require improved support to navigate allied health services.