Adam Windak

The european primary care monitor: structure, process and outcome indicators

BackgroundScientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care.MethodsA systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems).ResultsThe developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care.ConclusionsA standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.

Perspectives of family medicine in Central and Eastern Europe.

INTRODUCTION In the last decade of the 20th century, the countries of Central and Eastern Europe (CEE) have experienced rapid changes in health policies. This process was largely supported by international grants. After this support has ended, it is important to keep up with the development, developing its own strategies and priorities. Aims and methods. The aim of the paper is to make a proposal for the future development of the discipline in CEE countries. The proposal is based on reports on an invitational conference that was organized for the key representatives of family medicine from CEE countries. For the purpose of this paper, additional information about the situation was gathered from literature reviews, country visits and personal interviews. RESULTS Information shows that although family medicine has been formally recognized and introduced in university curricula, there is a very big difference in its academic position. Postgraduate training has been established in all CEE countries, according to the European Directive. Quality measures such as the development and implementation of guidelines and the re-certification procedure have also been formally introduced, but its quality varies. The key areas of concern are atomization of practices, unsatisfactory payment systems, lack of academic infrastructure and unsatisfactory continuous professional development. On the other hand, examples of good practice exist and need to be promoted. CONCLUSION There is a need for continuous exchange of expertise within the countries. The paper will serve as a discussion paper for the next meeting of experts from CEE countries.

Family medicine in post-communist Europe needs a boost. Exploring the position of family medicine in healthcare systems of Central and Eastern Europe and Russia

BackgroundThe countries of Central and Eastern Europe have experienced a lot of changes at the end of the 20th century, including changes in the health care systems and especially in primary care. The aim of this paper is to systematically assess the position of family medicine in these countries, using the same methodology within all the countries.MethodsA key informants survey in 11 Central and Eastern European countries and Russia using a questionnaire developed on the basis of systematic literature review.ResultsFormally, family medicine is accepted as a specialty in all the countries, although the levels of its implementation vary across the countries and the differences are important. In most countries, solo practice is the most predominant organisational form of family medicine. Family medicine is just one of many medical specialties (e.g. paediatrics and gynaecology) in primary health care. Full introduction of family medicine was successful only in Estonia.ConclusionsSome of the unification of the systems may have been the result of the EU request for adequate training that has pushed the policies towards higher standards of training for family medicine. The initial enthusiasm of implementing family medicine has decreased because there was no initiative that would support this movement. Internal and external stimuli might be needed to continue transition process.

Provision of ambulatory health services in Poland: a case study from Krakow

This study provides a comprehensive picture of the organization and delivery of ambulatory health care services in Poland. A main finding of the study is that, following the introduction of health insurance in 1999, the newly introduced Sickness Funds have become the main players in the medical services market, introducing new bidding procedures and contracts for provision of medical services. Contracts, and negotiations which precede them, have introduced elements of market competition, which has affected the number and types of services provided by health care centers operating under a contract. The health financing reforms have led to an even playing field for public and non-public providers, marked by a proliferation of structurally smaller health units. The introduction of a market environment has changed the way in which providers are compensated, with a discernible shift away from salary-based systems to capitation and fee-for-service compensation. The analysis of the provider market for outpatient care underscores the importance of understanding the organization and supply of health services, particularly insofar as it relates to the design of appropriate financial and other incentives for providers of health services and of policy interventions necessary for achieving systemic changes.

Association between anthropometric obesity measures and coronary artery disease: a cross-sectional survey of 16 657 subjects from 444 Polish cities

Background: Excessive body weight is known to cluster with cardiovascular (CV) risk factors, but it is not clear which anthropometric obesity measure provides best independent predictive value of coronary artery disease (CAD). Methods and results: We explored associations between CAD and four different obesity measures (body mass index (BMI), waist circumference, waist/height and waist/height2) in a cohort of 16 657 subjects (40.4% men; 20.8% CAD patients), recruited by 700 primary care physicians in 444 Polish cities. 42.8% of subjects were classified as overweight, 31.7% as obese and 39.8% had abdominal obesity. In univariate analyses all obesity measures correlated with CAD (p>0.001), but waist/height2 was the strongest discriminator between CAD patients and controls. Age-adjusted and sex-adjusted analyses confirmed a graded increase in CAD risk across distributions of all four obesity measures—1 standard deviation (SD) increase in BMI, waist, waist/height and waist/height2 increased the odds of CAD by 1.23, 1.24, 1.26 and 1.27, respectively (all p<0.001). In models fully adjusted for CV risk factors, waist/height2 remained the strongest obesity correlate of CAD, being the only independent associate of CAD in men. In a fully adjusted BMI—waist circumference stratified model, sarcopenic obesity (waist > median, BMI < median) and simple obesity (waist and BMI > median) were the strongest independent associates of CAD in men (p = 0.008) and women (p>0.001), respectively. Conclusion: This cross-sectional study showed that waist/height2 may potentially offer a slightly higher predictive value of CAD than BMI or waist circumference and revealed an apparent sexual dimorphism in correlations between obesity measures and CAD.

The development of academic family medicine in central and eastern Europe since 1990

BackgroundSince the early 1990s former communist countries have been reforming their health care systems, emphasizing the key role of primary care and recognizing family medicine as a specialty and an academic discipline. This study assesses the level of academic development of the discipline characterised by education and research in central and eastern European (CEE) countries.MethodsA key informants study, using a questionnaire developed on the basis of a systematic literature review and panel discussions, conducted in 11 central and eastern European countries and Russia.ResultsFamily medicine in CEE countries is now formally recognized as a medical specialty and successfully introduced into medical training at undergraduate and postgraduate levels. Almost all universities have FM/GP departments, but only a few of them are led by general practitioners. The specialist training programmes in all countries except Russia fulfil the recommendations of the European Parliament. Structured support for research in FM/GP is not always available. However specific scientific organisations function in almost all countries except Russia. Scientific conferences are regularly organised in all the countries, but peer-reviewed journals are published in only half of them.ConclusionsFamily medicine has a relatively strong position in medical education in central and eastern Europe, but research in family practice is less developed. Although the position of the discipline at the universities is not very strong, most of the CEE countries can serve as an example of successful academic development for countries southern Europe, where family medicine is still not fully recognised.

PoLA/CFPiP/PCS Guidelines for the Management of Dyslipidaemias for Family Physicians 2016

Dyslipidaemias are the most common yet the least well-controlled risk factor for cardiovascular disease (CVD) in Poland [1]. The main modifiable risk factors for atherosclerosis and its complications including ischaemic heart disease (IHD), stroke and peripheral artery disease (PAD) are: smoking, type 2 diabetes, arterial hypertension, inappropriate diet and eating habits, inadequate physical activity as well as the resulting overweight and obesity [6]. As shown by epidemiological studies conducted in Poland, there is a nationwide growth in the above risk factors (with the exception of smoking in the majority of age groups), which is attributable to the increasing prevalence of poor eating habits and sedentary lifestyle [1]. The elimination of risk factors represents one of the greatest challenges to be faced in the domain of public health. In order to rise to up to the challenge, wide-ranging population prevention measures are needed. However, family physicians as well as other health professionals (cardiologists, internists) have a special responsibility towards high-risk patients. The group definitely comprises a considerable proportion of dyslipidaemia patients. Consequently, dyslipidaemia management should be an element of a broader strategy targeted at lowering total CV risk and, hence, reducing mortality, morbidity and disability associated with CVD.

The return of old family doctors in the new Europe

Old-fashioned healthcare systems are not well equipped to cope with the major public health challenges of the nineties. Since the beginning of the nineties, total health expenditure has increased considerably through out Eastern Europe. Economic changes coupled with the urgent need to transform healthcare systems to meet the demands of the medical community and to satisfy rising patient expectations compelled governments to draw up a plan of action. The Polish experience provides a good example of this development.

Twenty-four-Hour Profile of Central Blood Pressure and Central-to-Peripheral Systolic Pressure Amplification

BACKGROUND The significant difference in central and peripheral blood pressure (BP) values has only recently been widely recognized. Ambulatory BP monitoring has been shown to have advantages over office BP measurements because ambulatory monitoring can provide important information not available when only office BP is measured. The aim of this study was to assess the 24-hour central systolic pressure (CSP) profile, CSP short-term variability, and 24-hour systolic pressure amplification profile. METHODS The study group comprised 50 hypertensive subjects and 50 normotensive subjects. All participants underwent 24-hour peripheral and central pressure monitoring. RESULTS CSP was lower than peripheral pressure levels during the day (124.1 ± 15.7 mm Hg vs 133.9 ± 16.3 mm Hg; P < 0.001) and night hours (114.4 ± 14.5 mm Hg vs 121.5 ± 15.2 mm Hg; P < 0.001). The CSP nocturnal fall was lower than the peripheral pressure fall in normotensive subjects as well as in hypertensive subjects. Although 24-hour systolic pressure amplification was similar in subjects with and without hypertension (9.2 ± 3.1 mm Hg and 8.3 ± 2.4 mm Hg; P = NS), it was significantly lower during the night than during the day in both groups. The nocturnal fall in systolic pressure amplification was correlated with the day-night difference in heart rate (r = 0.70; P < 0.001). CONCLUSIONS Central pressure differs significantly from peripheral pressure during regular daily activity as well as during night hours. Moreover, it appears that systolic pressure amplification varies throughout the 24-hour period and that the main factor determining nocturnal fall in systolic pressure amplification is nocturnal drop in the heart rate. More studies are required to demonstrate advantage of this novel technique over traditional pressure monitoring in clinical practice.

Educational expectations of GP trainers. A EURACT needs analysis

Introduction: In this background paper, we discuss the educational needs of family medicine teachers and trainers in the light of a EURACT (European Academy of Teachers in General Practice) project aimed at the development of a European framework for the professional development of general practice (GP) educators. Background: There is evidence that the ideal GP educator would benefit from systematic training in teaching skills. Although international literature indicates that such skills training should be in supervision, feedback, assessment and educational management, it is not clear if these needs vary between trainers who teach general practice in different settings and environments. Needs assessment: Recently EURACT, in collaboration with partners from five EU countries and Turkey, set up a project aimed at the development of a comprehensive ‘training the trainers’ programme. The project included a baseline survey of perceived educational needs and wants among both novice and expert European GP educators. The survey demonstrated that the educational needs of GP educators did not vary much in the content areas in which training was required throughout Europe but did vary in the level and depth of knowledge needed; this depended on their experience and level of expertise as teachers. Implications: Based on the information gathered and experience gained from previous EURACT courses, a Leonardo da Vinci project has developed and launched a comprehensive programme with courses at three levels of participant expertise, to address the personal learning needs of GP educators.