Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China.

BACKGROUND: Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation. METHODS: We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed. RESULTS: A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes. CONCLUSIONS: Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

NICE guidelines, clinical practice and antisocial personality disorder: the ethical implications of ontological uncertainty.

The British National Institute for Health and Clinical Excellence (NICE) has recently (28 January 2009) released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personality disorder (ASPD). Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This paper argues that in refraining from emphasising uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals "at risk" of raising antisocial children. Although this paper does not argue that NICE is "wrong" in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE.

Girls' fearfulness as a product of mothers' fearfulness and fathers' authoritarianism.

Data from 27 girls of 10 to 12 years were obtained on the Fear Survey Schedule for Children--Revised and from their parents on the Fear Survey Schedule for Adults-III and the California F Scale. Analyses indicated fathers' authoritarianism scores and mothers' fear scores have independent associations with children's fears and suggested greater behavioural overcontrol by fathers and the greater propensity of mothers to communicate threatening information.

Reliabilities of human judgements: measurements from photographic CT scan images.

Studies of brain lesions are generally dependent on human judgement for identification and possibly for measurement, but estimates of reliability are frequently neglected. The present study involves three investigation based on X-ray CT scans into reliabilities of human judgements: (1) the areas of brain lesions identified over two occasions by a single judge, (2) brain areas based on the projection of scans by a second judge over two occasions, and (3) brain areas computed from brain outlines by two independent judges. Errors decreased geometrically over procedures in the order listed, reflecting the decreasing complexity of judgement involved. Nevertheless, all three reliabilities proved satisfactory, showing that these procedures may be applied consistently over occasions and between raters. This was reassuring since computerization is currently practicable only in (2) and (3), where errors were least. Although not always performed, reliability checks are important, as indicated by the outlier, Case 10. Where there is a large discrepancy, seeking the reason(s), with a view to standardizing the criteria of judgement, is preferable to automatic averaging, both as a safeguard in individual cases and also to estimate error of measurement in group studies. To assist decision in any particular instance as to whether averaging is an acceptable solution, a statistical rule of thumb is proposed for testing the significance of the difference between two judgements.

Men are innocent until proven guilty: a comment on the examination of sex differences by Pierce and Kirkpatrick (1992).

Pierce and Kirkpatrick (1992, Behaviour Research and Therapy, 30, 415-418) addressed the finding that men reported lower levels of fear than women in response to specific fear items and concluded on the basis of their experiment that this was because the men were lying. Their conclusion is questioned on various grounds, including inappropriate statistical analyses, inadequate treatment of physiological data, failure to address the possibility of sample selection bias (signalled by the high drop-out rate) and the inadequacy of self-assessed fear measures based on a small number of single items. An alternative interpretation of their data is offered, based on the inverse correlation between initial response level and size of increment, demonstrable in their study in males but not in females. It is argued here that the increments may have been due to anticipatory arousal, a mediating factor that would also account for the facilitation of generalization between certain specific items. It is further suggested that, if this explanation is correct, the men were acting with more rather than less honesty, and it may on the other hand be the reports of the females that were affected by their sex-role stereotype. Another possible explanation of the findings is discussed. If men relatively high in masculinity had a greater tendency to drop out, the experimental sample at the second testing would be biased towards men relatively low in masculinity and reporting higher fear levels.

Prognostic indicators and the pattern of recovery of communication in aphasic stroke patients.

Communication abilities were assessed on a wide range of tests in 56 aphasic stroke patients, 33 classified as "moderate" and 23 as "severe". Thirty-six of the patients had received language treatment. The biographical variables of age, months post-onset and handedness were shown to be differentially correlated with improvements. In particular, there were some significant trends of decreasing improvement with increasing months post-onset on expressive verbal tasks in treated moderate aphasics and on comprehension tasks in treated severe aphasics. Untreated patients did not show the same clear pattern of trends; however, these patients were reassessed after a shorter period and covered a smaller range of months post-onset. The role of treatment deserves further clarification. The results also indicate that language recovery is relatively independent of age and of handedness.

Orienting responses to stimuli others fear.

Three experiments investigated the magnitudes and habituation rates of electrodermal orienting responses (ORs) to phobic or neutral words or phrases. The experimental 'phobic' material denoted objects or situations feared by members of a student population but of which the students selected as subjects reported no fear. In each experiment, two different groups of subjects were given 12 presentations of either a phobic or a neutral word or phrase. In the first experiment the results did not differentiate the groups. In the second experiment shocks were given to the subjects before the experiment and they were threatened with further shocks; the phobic stimuli then elicited larger responses (P less than 0.05) and took more trials to habituation (P less than 0.05). In the third experiment subjects heard pleasant music and were told they would hear it again. There were no significant differences in magnitudes of responses or trials to habituation. The range of potentially phobic stimuli capable of eliciting larger and more slowly habituating ORs is found to be greater than implied by Ohman. The concept of biological significance is thought to be still applicable but it is argued that its implications for the significance of particular events have to be learned. A state of arousal is necessary to elicit significantly larger responses and there is some evidence that the state must be appropriate rather than non-specific.