¿Cómo valorar la atención centrada en la persona según los profesionales? Un estudio Delphi / How to assess Person-Centered Care according to professionals? A Delphi study

Objetivos: Conocer la perspectiva de profesionales sobre aspectos y dimensiones que deberían formar parte indispensable de la Atención Centrada en la Persona (ACP).DiseñoTécnica Delphi.EmplazamientoAtención Primaria.ParticipantesSetenta y cuatro expertos médicos especialistas en medicina familiar y comunitaria (MF), tutores docentes, psicólogos y sociólogos distribuidos por todo el territorio nacional (enero-junio 2015).MétodosRespondieron a tres cuestionarios: primero sobre aspectos que debería tener en cuenta un MF para realizar ACP en todas sus dimensiones. En el segundo se preguntó sobre el grado de acuerdo con cada ítem y dimensión en que lo clasificaba. Las respuestas se priorizaron en un tercer cuestionario (escala Likert, rango de puntuación 1-10).ResultadosLa tasa de respuesta (TR) al primer cuestionario fue de 54,05%, obteniéndose 84 ítems, los más frecuentes Respeto y Atención Integral. El 2.° cuestionario con TR=48,6%, obtuvo 52 ítems con acuerdo superior al 75%. La TR del tercer cuestionario fue de 52,7%, obteniendo 21 ítems con puntuación >9. Los valores más altos correspondieron a aspectos esenciales de la ACP: respeto, atención integral, enfoque biopsicosocial, autonomía del paciente y participación en la toma de decisiones.ConclusionesSe identificaron nuevas dimensiones: Prevención y promoción de la salud, Gestión de Recursos y Competencia Clínica; añadidas a las previamente descritas: Perspectiva biopsicosocial, Médico como persona, Paciente como persona, Relación médico-paciente y Poder y Responsabilidad compartidas.El respeto, la atención integral, el enfoque biopsicosocial, la autonomía del paciente y su participación en la toma de decisiones, son los aspectos más valorados entre los seleccionados por los profesionales participantes.

Objectives: To know the perspective of professionals on aspects and dimensions that should be an indispensable part of Person-Centered Care (PCA).DesignDelphi Technique.LocationPrimary Care.Participants74 medical experts specializing in family and community medicine (FM), teaching tutors, psychologists and sociologists distributed throughout the national territory (January-June 2015).MethodsThey responded to three questionnaires: first, on aspects that a FP should take into account to carry out PCA in all its dimensions. In the second, they asked about the degree of agreement with each item and dimension in which it was classified. The responses were prioritized in a third questionnaire (Likert scale, score range 1-10).ResultsThe response rate (RR) to the 1st questionnaire was 54.05%, obtaining 84 items, the most frequent Respect and Comprehensive Attention. The 2nd questionnaire with RR = 48.6%, obtained 52 items with a degree of agreement greater than 75%. The RR of the 3rd questionnaire was 52.7%, obtaining 21 items with a score> 9. The highest values corresponded to essential aspects of PCA: respect, comprehensive care, biopsychosocial approach, patient autonomy, and participation in decision-making.

The Declining Presence of Family Physicians in Hospital-Based Care.

Despite training to provide care across the continuum of health delivery settings, the proportion of family physicians (FPs) reporting inpatient care has decreased by 26% between 2013 and 2017, leaving approximately 1 in 4 of FPs practicing hospital medicine in 2017. Policy makers, payers, and leaders in medical education should closely track the impact of these trends, given previous evidence associating better cost and utilization outcomes with broader scope of practice.

Prevalence and Factors Associated with Family Physicians Providing E-Visits.

PURPOSE: The use of telemedicine has grown in recent years. As a subset of telemedicine, e-visits typically involve the evaluation and management of a patient by a physician or other clinician through a Web-based or electronic communication system. The national prevalence of e-visits by primary care physicians is unclear as is what factors influence adoption. The purpose of this study was to examine the prevalence of family physicians providing e-visits and associated factors. METHODS: A national, cross-sectional practice demographic questionnaire for 7580 practicing family physicians was utilized. Bivariate statistics were calculated and logistic regression was conducted examining both physician level and practice level factors associated with offering e-visits. RESULTS: The overall prevalence of offering e-visits was 9.3% (n = 702). Compared with private practice physicians, other physicians were more likely to offer e-visits if their primary practice was an academic health center/faculty practice (odds ratio [OR], 1.73; 95% CI, 1.03 to 2.91), managed care/health maintenance organization (HMO) practice (OR, 9.79; 95% CI, 7.05 to 13.58), hospital-/health system-owned medical practice (not including managed care or HMO) (OR, 2.50; 95% CI, 1.83 to 3.41), workplace clinic (OR, 2.28; 95% CI, 1.43 to 3.63), or federal (military, Veterans Administration [VA]/Department of Defense) (OR, 4.49; 95% CI, 2.93 to 6.89). Physicians with no official ownership stake (OR, 0.44; 95% CI, 0.28 to 0.68) or other ownership arrangement (OR, 0.29; 95% CI, 0.12 to 0.71) had lower odds of offering e-visits compared with sole owners. CONCLUSION: Fewer than 10% of family physicians provided e-visits. Physicians in HMO and VA settings (ie, capitated vs noncapitated models) were more likely to provide e-visits, which suggests that reimbursement may be a major barrier.

Dispositivo estructurado de intervenciones psicosociales en atención primaria: serie de casos retrospectiva / Structured psychosocial interventions in primary care: retrospective case series

Antecedentes: Más allá del pago por cápita, desde 2009 el Plan de Salud del Hospital Italiano de Buenos Aires reconoció a los médicos de familia el pago por prestación de intervenciones psicosociales de cuarenta minutos de duración realizadas para promover el bienestar y la autonomía de sus pacientes. Objetivos: Describir los problemas que motivaron estas intervenciones y las redefiniciones diagnósticas que realizaron estos profesionales. Métodos: Fueron revisadas las fichas estructuradas de registro de 482 intervenciones psicosociales realizadas durante 2011 y codificadas mediante la Clasificación Internacional de la Atención Primaria (CIAP-2). Resultados: Los motivos de consulta más frecuentes fueron los sentimientos depresivos y/o de ansiedad (33,25 %), problemas familiares y/o vinculados a crisis vitales (16 %), dolor (9,56 %) y cansancio (2,91 %). Entre las redefiniciones diagnósticas predominaron las crisis vitales (15,45 %), los problemas de la relación conyugal o con hijos (14,61 %), y los trastornos depresivos y/o de ansiedad (27 %). Conclusiones: nuestro modelo de trabajo contribuyó a que en una gran proporción de pacientes que había consultado por dolor u otros síntomas generales, detectáramos, abordáramos y documentáramos el proceso de atención de problemas de la esfera psicosocial, que suele ser subregistrado con el abordaje biomédico clásico. (AU)

Background: Beyond capitation payment, since 2009 Hospital Italiano de Buenos Aires Health Maintenance Organization incorporated "structured primary care psychosocial interventions" as a fee for service practice. They last 40 minutes and are undertaken by family physicians with the aim of improving the wellbeing of their patients and helping them to strengtheningtheir autonomy. Objectives: To identify chief complaints and problems (re)definitions carried out by family physicians. Methodology: 482 medical records written during 2011 were reviewed and coded according to the International Classification of Primary Care (ICPC-2). Results: Most frequent chief complaints were depressive and/or anxious feelings (33.25 %), family problems and/or phasesof adult life problems (16 %), pain (9.56 %) and fatigue (2.91 %). Most common problem (re)definitions were life events(15.45 %), followed by marital or childrelated problems (14.61 %), and depressive and/or anxiety disorders (27 %). Conclusions: Our working model enabled us to identify, address and document psychosocial problems which are often underreported within the classical biomedical approach in a large proportion of patients whose chief complaint were painor other general symptoms. (AU)

Declining Endoscopic Care by Family Physicians in Both Rural and Urban Areas.

Using data from 2014 through 2016, we demonstrated a decline in the percentage of family physicians providing endoscopic services in both rural and urban areas. Our findings suggest that forces in the health care system may be influencing the reduction in scope, rather than specific geographic factors.

Family Medicine Residents' Attitudes About Training in Ethiopia and the United States.

BACKGROUND AND OBJECTIVES: In Ethiopia, family medicine began in 2013. The objective of this study was to compare family medicine residents' attitudes about training in Ethiopia with those at a program in the United States. METHODS: Family medicine residents at Addis Ababa University in Addis Ababa, Ethiopia and the University of Maryland in Baltimore, Maryland completed a 43-item Likert scale survey in 2017. The survey assessed residents' attitudes about residency education, patient care, independence as family physicians, finances, impact of residency on personal life, and women's issues. We calculated descriptive statistics on the demographics data and analyzed survey responses using a two-sample t-test. RESULTS: A total of 18 (75%) Ethiopian residents and 18 (60%) US residents completed the survey (n=36). The Ethiopian residents had a wider age distribution (25-50 years) than the US residents (25-34 years). More US residents were female (72%) compared to the Ethiopian cohort (50%), while more Ethiopian residents were married (72%) compared to the US cohort (47%). There were statistically significant differences in attitudes toward patient care (P=0.005) and finances (P<0.001), differences approaching significance in attitudes toward residency education, and no significant differences in independence as family physicians, the impact of residency on personal life, and women's issues in family medicine. CONCLUSIONS: Across two very different cultures, resident attitudes about independence as family physicians, the impact of residency on personal life and women's issues, were largely similar, while cross-national differences in attitudes were found relative to residency education, patient care, and finances.

Imaging use for low back pain by Ontario primary care clinicians: protocol for a mixed methods study - the Back ON study.

BACKGROUND: At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. METHODS: The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. DISCUSSION: This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.

Expectativas de los pacientes respecto de la consulta con un médico de familia: estudio de corte transversal / Patient expectations regarding consultation with a family doctor: cross-sectional study

Antecedentes. El modelo biopsicosocial propone que la atención de la salud se centre en las necesidades de las personas.Sin embargo, no siempre los profesionales de la salud conocen adecuadamente lo que esperan de los encuentros clínicos sus pacientes. Objetivo. Explorar las expectativas respecto de sus encuentros clínicos de los/as pacientes atendidos por médicos de familia en un Centro de Salud de Atención Primaria del Conurbano Bonaerense (Buenos Aires, Argentina). Métodos. Estudio observacional descriptivo de corte transversal llevado a cabo sobre una muestra consecutiva de pacientes que acudieron a las consultas médicas de un centro de salud. Se les pidió a los pacientes que de un listado de diez potenciales expectativas, valoraran y priorizaran las más importantes para esa consulta. Resultados. Fueron entrevistadas 146 personas (91 % mujeres) con una mediana de edad de 30 años.Las expectativas más mencionadas (94 % de las personas encuestadas) fueron que el médico demuestre interés y escuche a sus pacientes, y que les brinde explicaciones sobre sus problemas y dudas. Conclusiones. Hemos podido documentar que las expectativas de nuestros pacientes respecto de sus entrevistas clínicas están muy vinculadas a su componente actitudinal (predisposición a escuchar con interés sus problemas) y al de las habilidades comunicacionales del profesional de la salud (explicaciones). (AU)

Background. The biopsychosocial model proposes that health care focus on the needs of people. However, health profes-sionals do not always know what their patients expect from clinical meetings. Objective. To explore the expectations regarding their clinical meetings of the patients attended by family doctors in aPrimary Health Care Center of Buenos Aires, Argentina. Methods. Descriptive cross-sectional observational study carried out on a consecutive sample of patients who attendedthe medical consultations of a health center. Patients were asked to rate and prioritize the most important ones for thatconsultation from a list of ten potential expectations. Results. 146 people (91 % women) with a median age of 30 years were interviewed.The most mentioned expectations (94 % of the people surveyed) were for the doctor to show interest and listen to theirpatients, and to give them explanations about their problems and doubts. Conclusions. We have been able to document that our patients' expectations regarding their clinical interviews are closelylinked to their attitudinal component (predisposition to listen with interest to their problems) and to the communication skillsof the healthcare professional (explanations). (AU)

Alma Ata 40 años después: hitos de la atención primaria / Alma Ata 40th anniversary: Milestones of primary health care

No disponible

Top 20 POEMs of the Past 20 Years: A Survey of Practice-Changing Research for Family Physicians.

POEMs (patient-oriented evidence that matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change practice. For 20 years the authors of this article have reviewed more than 100 English language clinical journals monthly to identify POEMs in the medical literature relevant to primary care practice. This article identifies the POEMs in each of the last 20 years that were highest ranked for having recommended a major and persistent change in practice that year. They include POEMs that recommend a novel, effective intervention, a second group that recommends abandoning an ineffective practice, and a third group that recommends abandoning a potentially harmful practice. The top POEMs of the past 20 years illustrate the breadth of practice change in primary care and the need for family physicians to have a systematic approach to keeping up with the medical literature, such as that in POEMs, especially because many of these important articles did not appear in the primary care literature.