Strategies for improving access to primary care services for homeless immigrants in England: a Delphi study.

AIM: The aim of the study was to identify the most prioritized strategies in improving access to primary care services (PCS) for homeless immigrants. BACKGROUND: The issue of improving access to PCS for homeless immigrants is a complex and multifaceted one, and yet there is limited research on the strategies aimed at improving these services. Hence, the need for more studies that directly engage homeless immigrants and service providers in understanding their barriers to accessing PCS and their preferences for improving access to these services. METHODS: The study used a two round Delphi method to elicit the views of stakeholders. The Delphi process utilized a web-based questionnaire. The stakeholders included healthcare providers and voluntary sector providers. The first round had a total of 58 items belonging to 14 categories. The second round comprised a total of 25 items belonging to 12 categories which were preselected based on participants' ranking of their importance in the first round. Participants were required to rank the relative importance of all the items on a 5-point Likert scale. Data were analysed using the STATA-15 software package. FINDINGS: A total of 12 stakeholders participated in both rounds of the Delphi survey. The top three strategies encompassed fighting against discrimination and prejudice, improving and promoting mental health services, and empowering homeless immigrants. These evidence-based strategies hold the potential to support the implementation of healthcare interventions aimed at improving access to PCS and healthcare outcomes for homeless immigrants. However, it is crucial to conduct further research that includes homeless immigrants in the Delphi study to gain insights into the strategies that are most important to them in enhancing access to PCS, as they are the primary target users. Such research will contribute to the development of comprehensive and effective interventions tailored to the specific needs of homeless.

Understanding the mix of services for mental health care in urban DR Congo: a qualitative descriptive study.

BACKGROUND: Mental health workers (MHWs) are exposed to conflicts of competence daily when performing tasks related to the provision of mental health services. This may be linked to a lack of understanding of their tasks as caregivers and providers. Furthermore, in most low-income settings, it is unclear how the available services are organized and coordinated to provide mental health care. To understand the above, this study aimed to identify the current mix of services for mental health care in the urban Democratic Republic of the Congo (DRC). METHODS: A qualitative descriptive study was carried out in Lubumbashi from February to April 2021. We conducted 7 focus group discussions (FGDs) with 74 key informants (family members, primary care physicians, etc.) and 13 in-depth interviews (IDIs) with key informants (traditional healers, psychiatrists, etc.). We performed a qualitative content analysis, guided by an analytical framework, that led to the development of a comprehensive inventory of MHWs from the household level to specialized facilities, exploring their tasks in care delivery, identifying existing services, and defining their current organization. RESULTS: Analysis of transcripts from the FGDs and IDIs showed that traditional healers and family caregivers are the leading providers in Lubumbashi. The exploration of the tasks performed by MHWs revealed that lifestyle, traditional therapies, psychotherapy, and medication are the main types of care offered/advised to patients. Active informal caregivers do not currently provide care corresponding to their competencies. The rare mental health specialists available do not presently recognize the tasks of primary care providers and informal caregivers in care delivery, and their contribution is considered marginal. We identified five types of services: informal services, traditional therapy services, social services, primary care services, and psychiatric services. Analyses pointed out an inversion of the ideal mix of these services. CONCLUSIONS: Our findings show a suboptimal mix of services for mental health and point to a clear lack of collaboration between MHWs. There is an urgent need to clearly define the tasks of MHWs, build the capacity of nonspecialists, shift mental health-related tasks to them, and raise awareness about collaborative care approaches.

Cost analysis of the WHO-HEARTS program for hypertension control and CVD prevention in primary health facilities in Ethiopia.

Background: In 2020, Ethiopia launched the Ethiopia Hypertension Control Initiative (EHCI) program to improve hypertension care using the approach described in the WHO HEARTS technical package. Objective: To estimate the costs of implementing the HEARTS program for hypertension control and cardiovascular disease (CVD) prevention in the primary care setting in Ethiopia for adult primary care users in the catchment area of five examined facilities. Study design: This study entails a program cost analysis using cross-sectional primary and secondary data. Methods: Micro-costing facility surveys were used to assess activity costs related to training, counselling, screening, lab diagnosis, medications, monitoring, and start-up costs at five selected health facilities. Cost data were obtained from primary and secondary sources, and expert opinion. Annual costs from the health system perspective were estimated using the Excel-based HEARTS costing tool under two intervention scenarios - hypertension-only control and a CVD risk management program, which addresses diabetes and hypercholesterolemia in addition to hypertension. Results: The estimated cost per adult primary care user was USD 5.3 for hypertension control and USD 19.3 for integrated CVD risk management. The estimated medication cost per person treated for hypertension was USD 9.0, whereas treating diabetes and high cholesterol would cost USD 15.4 and USD 15.3 per person treated, respectively. Medications were the major cost driver, accounting for 37% of the total cost in the hypertension control program. In the CVD risk management scenario, the proportions of medication and lab diagnostics of total costs were 18% and 64%, respectively. Conclusions: The results from this study can inform planning and budgeting for HEARTS scale-up to prevent CVD across Ethiopia.

Primary care services in the English NHS: are they a thorn in the side of integrated care systems? A qualitative analysis.

BACKGROUND: As integrated care systems are embedded across England there are regions where the integration process has been evaluated and continues to evolve. Evaluation of these integrated systems contributes to our understanding of the challenges and facilitators to this ongoing process. This can support integrated care systems nationwide as they continue to develop. We describe how two integrated care partnerships in different localities, at differing stages of integration with contrasting approaches experienced challenges specifically when integrating with primary care services. The aim of this analysis was to focus on primary care services and how their existing structures impacted on the development of integrated care systems. METHODS: We carried out an exploratory approach to re-analysing our previously conducted 51 interviews as part of our prior evaluations of integrated health and care services which included primary care services. The interview data were thematically analysed, focussing on the role and engagement of primary care services with the integrated care systems in these two localities. RESULTS: Four key themes from the data are discussed: (i) Workforce engagement (engagement with integration), (ii) Organisational communication (information sharing), (iii) Financial issues, (iv) Managerial information systems (data sharing, IT systems and quality improvement data). We report on the challenges of ensuring the workforce feel engaged and informed. Communication is a factor in workforce relationships and trust which impacts on the success of integrated working. Financial issues highlight the conflict between budget decisions made by the integrated care systems when primary care services are set up as individual businesses. The incompatibility of information technology systems hinders integration of care systems with primary care. CONCLUSIONS: Integrated care systems are national policy. Their alignment with primary care services, long considered to be the cornerstone of the NHS, is more crucial than ever. The two localities we evaluated as integration developed both described different challenges and facilitators between primary care and integrated care systems. Differences between the two localities allow us to explore where progress has been made and why.

Diagnosis and Treatment of Helicobacter pylori Infection in Real Practice-New Role of Primary Care Services in Antibiotic Resistance Era.

Helicobacter pylori (H. pylori) is a key agent in several upper gastrointestinal diseases. Treatment of H. pylori infection is the main strategy for resolving the associated gastroduodenal damage in infected patients and for the prevention of gastric cancer development. Infection management is becoming complex due to the increase in antibiotic resistance, which already represents a global healthcare problem. Resistance to clarithromycin, levofloxacin or metronidazole have forced the adaptation of eradication regimens in this new reality to reach the eradication rate target recommended in most international guidelines (>90%). In this challenging scenario, molecular methods are revolutionizing the diagnosis of antibiotic-resistant infections and the detection of antibiotic resistance and opening a path towards personalized treatments, although their use is not yet widespread. Moreover, the infection management by physicians is still not adequate, which contributes to aggravating the problem. Both gastroenterologists and mainly primary care physicians (PCPs), who currently routinely manage this infection, perform suboptimal management of the diagnosis and treatment of H. pylori infection by not following the current consensus recommendations. In order to improve H. pylori infection management and to increase PCPs' compliance with guidelines, some strategies have been evaluated with satisfactory results, but it is still necessary to design and evaluate new different approaches.

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada.

INTRODUCTION: It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status. METHODS: Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions). RESULTS: 6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits. CONCLUSION: Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

Self-care and self-medication as central components of healthcare in Germany - on the way to evidence-based pharmacy.

In Germany, self-care is, above all interpreted as the prevention and treatment of minor injuries and illnesses by the patients themselves - that is, without a physician's prescription or medical advice. Maintaining one's health in the sense of a preventive approach through non-medicinal measures also plays an important role. Self-medication in this context is the treatment with approved over-the-counter-(OTC)-medications. In addition, other OTC-products such as dietary supplements as well as complementary and alternative medicines including homeopathic medications are frequently requested options by pharmacy customers. OTC-medications are central components of the German healthcare system, with expert advice from pharmacists in community pharmacies (CP) enabling safe and effective treatment. Additionally, screening for appropriate self-medication by pharmacists ensures that serious illnesses receive timely medical attention. In addition to prescribed medication, self-medication is an important part of the CP business in Germany. In contrast to prescription products, the price of OTC-products is not regulated. As a consequence, the price of OTC-products (including also pharmacy-only drugs) is influenced by competition among CPs and mail-order pharmacies, respectively. The sales of OTC-products for self-medication outside pharmacies, e.g. in drugstores and supermarkets, is restricted to a limited number of specific products. Evidence-based counseling in CPs, while generally advocated still remains a challenge. The evidence for the usage of OTC-products from clinical studies is not yet optimally integrated into everyday pharmacy practice. Information tools such as EVInews offering regular newsletters and a database have been developed to reduce the evidence-to-practice gap and to improve the overall counseling quality. Furthermore, the switching of drugs from prescription-only to pharmacy-only status also challenge CPs to provide adequate and updated guidance.

Effect on medication adherence of applying a specialty pharmacy care model to nonspecialty medications: A quasi-experimental cohort study.

PURPOSE: Medication nonadherence is a multifactorial healthcare problem that contributes to increased healthcare costs and morbidity. To improve medication adherence, specialty pharmacies offer services not typically provided by retail pharmacies such as benefits investigation, financial assistance, medication synchronization, and proactive refill reminders. This study assessed the impact of the specialty pharmacy care model on medication adherence for patients on nonspecialty medications. METHODS: This study was a quasi-experimental cohort comparison of patients who were transferred from a health-system retail pharmacy to a health-system specialty pharmacy between April 1, 2020, and June 30, 2021. The primary endpoint in this study was the difference in mean medication adherence proportion of days covered (PDC) between the post-transfer and pretransfer periods. Secondary outcomes included the proportion of patients with PDC of greater than 80%, medication adherence by drug group, shipment volumes, number of medications per shipment, and the mean copay per medication. RESULTS: In this study of 163 patients, use of a specialty pharmacy care model led to a significant increase of 7.0% in mean PDC, a significant increase in the percentage of patients with PDC of greater than 80%, a significant decrease in the number of shipments per 30 days per patient, a significant increase in the number of medications included per shipment, and a significant reduction in the mean copay per medication. CONCLUSION: The findings in this study suggest that the application of the specialty pharmacy care model to nonspecialty pharmacy patients may improve medication adherence, decrease the number of shipments per patient sent from the pharmacy, and reduce patient copays.

Realist analysis of whether emergency departments with primary care services generate 'provider-induced demand'.

BACKGROUND: It is not known whether emergency departments (EDs) with primary care services influence demand for non-urgent care ('provider-induced demand'). We proposed that distinct primary care services in EDs encourages primary care demand, whereas primary care integrated within EDs may be less likely to cause additional demand. We aimed to explore this and explain contexts (C), mechanisms (M) and outcomes (O) influencing demand. METHODS: We used realist evaluation methodology and observed ED service delivery. Twenty-four patients and 106 staff members (including Clinical Directors and General Practitioners) were interviewed at 13 EDs in England and Wales (240 hours of observations across 30 days). Field notes from observations and interviews were analysed by creating 'CMO' configurations to develop and refine theories relating to drivers of demand. RESULTS: EDs with distinct primary care services were perceived to attract demand for primary care because services were visible, known or enabled direct access to health care services. Other influencing factors included patients' experiences of accessing primary care, community care capacity, service design and population characteristics. CONCLUSIONS: Patient, local-system and wider-system factors can contribute to additional demand at EDs that include primary care services. Our findings can inform service providers and policymakers in developing strategies to limit the effect of potential influences on additional demand when demand exceeds capacity.

Comparing healthcare quality: A common framework for both ordinal and cardinal data with an application to primary care variation in England.

The paper proposes a framework for comparing the quality of healthcare providers and assessing the variation in quality between them, which is directly applicable to both ordinal and cardinal quality data on a comparable basis. The resultant measures are sensitive to the full distribution of quality scores for each provider, not just the mean or the proportion meeting some binary quality threshold, thereby making full use of the multicategory response data increasingly available from patient experience surveys. The measures can also be standardized for factors such as age, sex, ethnicity, health and deprivation using a distribution regression model. We illustrate by measuring the quality of primary care services in England in 2019 using three different sources of publicly available, general practice-level information: multicategory response patient experience data, ordinal inspection ratings and cardinal clinical achievement scores. We find considerable variation at both local and regional levels using all three data sources. However, the correlation between the comparative quality indices calculated using the alternative data sources is weak, suggesting that they capture different aspects of general practice quality.

Cost of primary care approaches for hypertension management and risk-based cardiovascular disease prevention in Bangladesh: a HEARTS costing tool application.

OBJECTIVE: To estimate the costs of scaling up the HEARTS pilot project for hypertension management and risk-based cardiovascular disease (CVD) prevention at the full population level in the four subdistricts (upazilas) in Bangladesh. SETTINGS: Two intervention scenarios in subdistrict health complexes: hypertension management only, and risk-based integrated hypertension, diabetes, and cholesterol management. DESIGN: Data obtained during July-August 2020 from subdistrict health complexes on the cost of medications, diagnostic materials, staff salaries and other programme components. METHODS: Programme costs were assessed using the HEARTS costing tool, an Excel-based instrument to collect, track and evaluate the incremental annual costs of implementing the HEARTS programme from the health system perspective. PRIMARY AND SECONDARY OUTCOME MEASURES: Programme cost, provider time. RESULTS: The total annual cost for the hypertension control programme was estimated at US$3.2 million, equivalent to US$2.8 per capita or US$8.9 per eligible patient. The largest cost share (US$1.35 million; 43%) was attributed to the cost of medications, followed by the cost of provider time to administer treatment (38%). The total annual cost of the risk-based integrated management programme was projected at US$14.4 million, entailing US$12.9 per capita or US$40.2 per eligible patient. The estimated annual costs per patient treated with medications for hypertension, diabetes and cholesterol were US$18, US$29 and US$37, respectively. CONCLUSION: Expanding the HEARTS hypertension management and CVD prevention programme to provide services to the entire eligible population in the catchment area may face constraints in physician capacity. A task-sharing model involving shifting of select tasks from doctors to nurses and local community health workers would be essential for the eventual scale-up of primary care services to prevent CVD in Bangladesh.

Why patients attend emergency department for primary care type problems: views of healthcare providers working in a remote community.

INTRODUCTION: Emergency department (ED) utilisation continues to increase, particularly for primary care presentations that do not require high level ED services. The reasons for this are complex, and research has focused on patient perspectives in choosing where to seek care rather than those of ED and general practitioner (GP) providers. This study aimed to address this gap by exploring the views of ED and GP providers regarding ED utilisation for primary care type health conditions in a small, remote Australian city with perhaps unique population demographics and service configuration. METHODS: Service providers from the ED and general practice clinics were invited to participate in focus groups and semi-structured interviews exploring their views on ED utilisation for primary-care-type health presentations. The data were analysed using thematic content analysis. RESULTS: In total, 24 healthcare providers (five GPs, seven ED practitioners, seven community nurse navigators, four Aboriginal and Torres Strait Islander Health Workers and one Indigenous Liaison Officer) participated in focus groups discussion and interviews. The analysis identified three themes: access and logistic barriers, rational decision-making and self-perceived urgency. While there was some overlap in the healthcare providers' perceptions, there were also strong differences between ED and GP groups. In particular, the ED group believed that GP services are less accessible for urgent appointments, whereas GPs believed that such arrangements were in place. Both groups agreed on the need for clear communication between the ED and general practice. CONCLUSION: ED and GP providers demonstrate similarities and differences in understanding patients' reasons for choosing which service to access. The differences may stem from ED providers' focus on offering a rapid resolution of acute presentations and GP providers' focus on offering comprehensive and continuing care. Effective communication between general practice and the ED services and clearer referral pathways may help in reducing ED utilisation for less urgent primary-care-type problems.

Patients' experiences of attending emergency departments where primary care services are located: qualitative findings from patient and clinician interviews from a realist evaluation.

BACKGROUND: Patient experience is an important outcome and indicator of healthcare quality, and patient reported experiences are key to improving quality of care. While patient experience in emergency departments (EDs) has been reported in research, there is limited evidence about patients' specific experiences with primary care services located in or alongside EDs. We aim to identify theories about patient experience and acceptability of being streamed to a primary care clinician in an ED. METHODS: Using theories from a rapid realist review as a basis, we interviewed 24 patients and 106 staff members to generate updated theories about patient experience and acceptability of streaming to primary care services in EDs. Feedback from 56 stakeholders, including clinicians, policymakers and patient and public members, as well as observations at 13 EDs, also contributed to the development of these theories, which we present as a programme theory. RESULTS: We found that patients had no expectations or preferences for which type of clinician they were seen by, and generally found being streamed to a primary care clinician in the ED acceptable. Clinicians and patients reported that patients generally found primary care streaming acceptable if they felt their complaint was dealt with suitably, in a timely manner, and when clinicians clearly communicated the need for investigations, and how these contributed to decision-making and treatment plans. CONCLUSIONS: From our findings, we have developed a programme theory to demonstrate that service providers can expect that patients will be generally satisfied with their experience of being streamed to, and seen by, primary care clinicians working in these services. Service providers should consider the potential advantages and disadvantages of implementing primary care services at their ED. If primary care services are implemented, clear communication is needed between staff and patients, and patient feedback should be sought.

Community case managers' challenges collaborating with primary care when managing complex patients in the community: A qualitative study in Singapore.

Community case managers (CCMs) play a crucial role in the continuity of care for complex patients in the community. However, they are often considered as non-members of the healthcare team and not actively engaged by the primary care team because of the unique landscape of social services in Singapore. Given that these two distinct professional groups had minimal collaboration previously, integrating CCMs as partners of patient care within the primary care team may pose many challenges. The objective of this qualitative study was to understand the challenges encountered by CCMs when collaborating with primary care services. This exploratory qualitative descriptive study used individual in-depth interviews. CCMs were selected using convenience and snowball sampling. The interviews were semi-structured, guided by a topic guide. Fourteen CCMs were interviewed within a period of 12 weeks (October-December 2018). Thematic analysis was used to analyse the transcripts. Two researchers coded each transcript independently, and a coding framework was agreed upon. Potential themes were then independently developed based on the coding framework. Fourteen individual in-depth interviews were conducted. Six themes emerged from the data, i.e., self-identity, patient factor, inter-professional factor, collaborative culture, confidentiality and organisational structure. Challenges that resonated with previous studies were self-identity, inter-professional factors and confidentiality, whereas other challenges such as patient factors, collaborative culture and organisational structure were unique to Singapore's healthcare landscape. Significant challenges were encountered by CCMs when collaborating with primary care services. Understanding these challenges is key to refining intervention in current models of comprehensive community care between medical and non-medical professionals.

Primary care services in the UHC: Cost identification study

Background@#In order to financially sustain the participation of the private sector in the UHC, there is a need to find reasonable balance of accountability in the costing of health services. The costing must be based on actual resources used from the perspective of the private health service provider. @*Objective@#The objective of this paper was to determine the cost of primary care services from the framework of the UHC reform in the private sector.@*Method@#This is a multi-method approach to cost-identification in establishing and providing primary care health service in the UHC. The approaches used by the authors included review of published literature, laws and policies from DOH and other regulatory agencies. From this review, they develop the minimum facility requirement for basic primary care facility and primary care facility with ancillary services. They used the actual expenditures of existing primary care clinics, 2021 quotations from equipment and supplies companies, published construction rates and consensus approach to establish the cost. Based on 2021 value of Philippine Peso, they estimated the cost of constructing and operating a primary care facility.@*Results@#The total estimated cost of building a primary health care facility based on the DOH licensing standard was estimated to be around PhP2,490,000. The cost of furniture and equipment as required in the DOH AO was PhP474,685. Thus, the total cost of the construction and equipment for a basic primary care facility setup is PhP2,964,685. We estimated the annual operating cost with the building estimated to depreciate in 20 years and the furniture and equipment in 5 years, the annualized cost for the building is PhP124,500 and for the furniture and equipment PhP94,937. The total annual salary of the staff based on government standards was PhP2,381,962. The maintenance, operating and overhead expenses (MOOE) which included water and electricity, repair and maintenance, waste disposal, supplies and other fees was PhP451,190. The total annual operating cost of a basic primary care facility is PhP3,052,590. This facility can provide basic services such as outpatient consultation and minor surgeries. Using the same approach for the basic facility, the total annual operating cost of a basic primary care facility with ancillary service is PhP11,023,670. This facility can provide outpatient consultation, minor surgeries and primary care services such as health education and preventive care plus the ancillary services like pharmacy, clinical laboratory and x-ray. For patients with diabetes, the total annual cost is PhP8,986. The significant cost driver is the clinical assessment and non-pharmacologic intervention. The researchers found the same cost pattern for the annual cost care of patients with hypertension but with a slightly higher annual total with PhP9,963. Their sensitivity analysis based on inflation, construction, equipment and operating expense may increase these cost estimates by 20% in the next 5 years. @*Conclusion@#Based on their findings, the current per capita support from PHIC Konsulta package is not adequate in the private sector both for wellness and care of patients with chronic condition. PHIC needs to consider adjusting per capita rates and consider case rate payment as it is currently doing for hospital care. Without this proposed adjustment, only those patients in the higher socioeconomic status will be capable of consulting the private sector. This scenario defeats the equity issue that is a primary concern in the UHC.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities.

Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services. CONTEXT: The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits. METHODS: We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance. FINDINGS: We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services. CONCLUSIONS: There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.

Near Vision but not Hearing Loss is Associated with Lacking a Usual Source of Health Care.

Objectives: Sensory loss may be a barrier to accessing healthcare services, and this study seeks to examine the association of sensory loss with whether older adults report having a usual source of health care. Methods: Our study included 7548 older adults who participated in the National Health and Aging Trends Study in 2015. Having a self-reported usual source of health care was our outcome, and hearing and vision loss were our primary independent variables. Results: In multivariate analysis accounting for demographics, socioeconomic, health status, and environmental covariates, near vision loss but not distance vision or hearing loss was associated with decreased odds of having a usual source of health care. Discussion: That older adults with near vision loss were less likely to report having a usual source of health care is concerning. Examining barriers to care is needed to identify sensory loss-relevant processes to optimize and intervene upon.

The impact of localised general practice training on Queensland's rural and remote general practice workforce.

BACKGROUND: The diverse rural medical education initiatives that have been developed in Australia to address the medical workforce maldistribution have been less successful in many smaller and remote communities. This study explored the factors that attract and retain GP registrars and supervisors and the impact that localised training (i.e., rural and remote workplace-based training and support) has on both GP registrars and supervisors, and the GP workforce in rural and remote underserved areas. METHODS: A purposive sample of 79 GP registrars, supervisors, practice managers, health services staff and community representatives living and working in areas of low GP workforce in rural and remote Australia were invited to participate in semi-structured interviews and one focus group divided over two phases. Thematic analysis was used to explore themes within the data. FINDINGS: Attractors and barriers to rural and remote practice were identified as the main themes. Attractors include family and community lifestyle factors, individual intrinsic motivators, and remote medicine experiences. In contrast, barriers include work related, location, or family factors. Further, localised GP training was reported to specifically influence GP registrars and supervisors through education, social and financial factors. CONCLUSION: The current study has provided a contemporary overview of the issues encountered in expanding GP training capacity in rural and remote communities to improve the alignment of training opportunities with community and workforce needs. Strategies including matching scope of practice to registrar interests have been implemented to promote the attractors and lessen the barriers associated with rural and remote practice.

Practice profile of Filipino family physicians nationwide: A web-based survey

Background@#The practice of Family Medicine is important in the provision of primary health care. Family physicians (FPs) provide health services both in the public and private settings@*Objective@#To describe the practice profiles and geographic aggregation of Filipino family physicians@*Methods@#This study was a web-based cross-sectional design involving family physicians who are registered in the Philippine Academy of Family Physicians membership database. The questionnaire was semi-structured with 3 consecutive sections: consent form, basic demographics, practice profile of family physicians.@*Results@#Overall, 95% (N=1357) of family physicians reported seeing patients in a health facility at least once a week. Thirty percent of physicians are from Luzon (N=426), 28% from the National Capital Region (N=395), 20% from the Visayas region (N=288) and 18% from Mindanao (N=261). There were more FPs who reported mixed-type clinical practice (51%) than those who were exclusively engaged in practice (49%). Involvement in the private sector was common among physicians who are in the clinics (59%), while employment in the public sector was commonly reported among those in mixed-type of practice (42%). Family physicians provide a wide range of clinical services including counselling, vaccinations, simple surgical excision, and palliative services. The average reported outpatient consultation fees of FPs was Php 321 (SD+120) per patient.@*Conclusion@#The practice profile of family physicians includes active clinical practice, employment in either the public or private sector, with a small fraction in solo clinic practice. The range of primary care services offered include management of chronic conditions, counselling, home visits, preventive care such as prenatal care, vaccinations and screening tests like pap smear