Effecting change in primary care management of respiratory conditions: a global scoping exercise and literature review of educational interventions to inform the IPCRG's E-Quality initiative.

This discussion paper describes a scoping exercise and literature review commissioned by the International Primary Care Respiratory Group (IPCRG) to inform their E-Quality programme which seeks to support small-scale educational projects to improve respiratory management in primary care. Our narrative review synthesises information from three sources: publications concerning the global context and health systems development; a literature search of Medline, CINAHL and Cochrane databases; and a series of eight interviews conducted with members of the IPCRG faculty. Educational interventions sit within complex healthcare, economic, and policy contexts. It is essential that any development project considers the local circumstances in terms of economic resources, political circumstances, organisation and administrative capacities, as well as the specific quality issue to be addressed. There is limited evidence (in terms of changed clinician behaviour and/or improved health outcomes) regarding the merits of different educational and quality improvement approaches. Features of educational interventions that were most likely to show some evidence of effectiveness included being carefully designed, multifaceted, engaged health professionals in their learning, provided ongoing support, were sensitive to local circumstances, and delivered in combination with other quality improvement strategies. To be effective, educational interventions must consider the complex healthcare systems within which they operate. The criteria for the IPCRG E-Quality awards thus require applicants not only to describe their proposed educational initiative but also to consider the practical and local barriers to successful implementation, and to propose a robust evaluation in terms of changed clinician behaviour or improved health outcomes.

Implementation of 'matrix support' (collaborative care) to reduce asthma and COPD referrals and improve primary care management in Brazil: a pilot observational study.

Asthma and chronic obstructive pulmonary disease (COPD) are leading causes of hospitalisation and death in the city of Sao Bernardo do Campo. The municipality had difficulties in sustaining a pulmonology specialist team. Local policy has strengthened the knowledge of the primary care teams to improve the management of these diseases. Our aim is to pilot the implementation of an educational intervention based on collaborative care focused on reducing respiratory-related referrals. We implemented 'matrix support': a Brazilian collaborative educational intervention promoting specialist training and support for primary care physicians in three health territories with the highest number of referrals. Clinicians and nurses from primary care attended an 8-h workshop. The backlog of respiratory referrals was prioritised, where Asthma and COPD represented 70% of referral reasons. Initially, pulmonologists held joint consultations with physicians and nurses; as confidence grew, these were replaced by round-table note-based case discussions. The primary outcome was the number of asthma and COPD referrals. Almost all primary healthcare professionals in the three areas (132 of 157-87%) were trained; 360 patients were discussed, including 220 joint consultations. The number of respiratory referrals dropped from 290 (the year before matrix support) to 134 (the year after) (P<0.05). Referrals for asthma/COPD decreased from 13.4 to 5.4 cases per month (P=0.09) and for other lung diseases from 10.8 to 5.3 cases per month (P<0.05). Knowledge scores showed a significant improvement (P<0.001). Matrix-support collaborative care was well-accepted by primary care professionals associated with improved knowledge and reduced respiratory referrals. The initiative attracted specialists to the region overcoming historical recruitment problems.

Increasing capacity for innovation in bureaucratic primary care organizations: a whole system participatory action research project.

PURPOSE: We wanted to identify what organizational features support innovation in Primary Care Groups (PCGs). METHODS: Our study used a whole system participatory action research model. Four research teams provided complementary insights. Four case study PCGs were analyzed. Two had an intervention to help local facilitators reflect on their work. Data included 70 key informant interviews, observations of clinical governance interventions and committee meetings, analysis of written materials, surveys and telephone interviews of London Primary Care Organizations, interviews with 20 nurses, and interviews with 6 finance directors. A broad range of stakeholders reviewed data at annual conferences and formed conclusions about trustworthy principles. Sequential research phases were refocused in the light of these conclusions and in response to the changing political context. RESULTS: Five features were associated with increased organizational capacity for innovation: (1) clear structures and a vision for corporate and clinical governance; (2) multiple opportunities for people to reflect and learn at all levels of the organization, and connections between these "learning spaces"; (3) both clinicians and managers in leadership roles that encourage participation; (4) the right timing for an initiative and its adaptation to the local context; and (5) external facilitation that provides opportunities for people to make sense of their experiences. Low morale was commonly attributed to 3 features: (1) overwhelming pace of reform, (2) inadequate staff experience and supportive infrastructure, and (3) financial deficits. CONCLUSIONS: These features together may support innovation in other primary care bureaucracies. The research methodology enabled people from different backgrounds to make sense of diverse research insights.

Building capacity to improve respiratory care: the education strategy of the International Primary Care Respiratory Group 2014-2020.

Significant attention has been given to the global burden of noncommunicable diseases including respiratory diseases and the potential of primary care to address this challenge. The International Primary Care Respiratory Group (IPCRG) has a potentially significant role to build capacity through research and education in a complex global network with varying degrees of capability. In this paper we outline a comprehensive strategy, which revisits the IPCRG's educational role, our aims, audiences and approach in this context. The paper was developed through a collaborative process involving experts in global health, primary care and respiratory education, leading to a consensus educational strategy statement. This is further informed by a review of recent trends in continuing medical education. Professional education and training of health-care workers is a core component of the global response to the challenge of managing respiratory conditions in primary care. This paper offers a revised strategy for building capacity and improving clinical practice in IPCRG member countries by revisiting and broadening our aims, exploring the key audiences, focus and approaches.