Danica Rotar Pavlič

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.

Specialist training of Slovene family physicians

Family medicine in Europe started to develop in the 1960s with the introduction of obligatory specialist training. Slovenia is a country with a long tradition of family medicine specialist training, but up until 2002 this was neither elaborated on nor conducted by peers in general practice/family medicine. When the countrys socialist system started to transform due to political reforms, Slovenia began to modify its system in order to meet the criteria of the European Union. One of the changes was the introduction of a new healthcare system with an influential Medical Chamber responsible for postgraduate training in all specialities. A new model for vocational training in family medicine was established in 2002, following the recommendations of the European Union of General Practitioners (UEMO). According to the new programme, which lasts 4 years, trainees spend half of their training in a hospital setting and half in general practice, where they are supervised by a trainer in practice. This article describes the legal process of introducing new forms of specialist training in Slovenia, and its content. Conclusion: A comparison with UEMO countries shows that the new model is comparable to other countries.

Process quality indicators in family medicine: results of an international comparison

BackgroundThe aim of our study was to describe variability in process quality in family medicine among 31 European countries plus Australia, New Zealand, and Canada. The quality of family medicine was measured in terms of continuity, coordination, community orientation, and comprehensiveness of care.MethodsThe QUALICOPC study (Quality and Costs of Primary Care in Europe) was carried out among family physicians in 31 European countries (the EU 27 except for France, plus Macedonia, Iceland, Norway, Switzerland, and Turkey) and three non-European countries (Australia, Canada, and New Zealand). We used random sampling when national registers of practitioners were available. Regional registers or lists of facilities were used for some countries.A standardized questionnaire was distributed to the physicians, resulting in a sample of 6734 participants. Data collection took place between October 2011 and December 2013. Based on completed questionnaires, a three-dimensional framework was established to measure continuity, coordination, community orientation, and comprehensiveness of care. Multilevel linear regression analysis was performed to evaluate the variation of quality attributable to the family physician level and the country level.ResultsNone of the 34 countries in this study consistently scored the best or worst in all categories. Continuity of care was perceived by family physicians as the most important dimension of quality. Some components of comprehensiveness of care, including medical technical procedures, preventive care and health care promotion, varied substantially between countries. Coordination of care was identified as the weakest part of quality. We found that physician-level characteristics contributed to the majority of variation.ConclusionsA comparison of process quality indicators in family medicine revealed similarities and differences within and between countries. The researchers found that the major proportion of variation can be explained by physicians’ characteristics.

Association of Common Mental Disorders and Quality of Life with the Frequency of Attendance in Slovenian Family Medicine Practices: Longitudinal Study

Background Most research on frequent attendance has been cross-sectional and restricted to one year attendance rates. A few longitudinal studies suggest that frequent attendance is self-limiting. Frequent attenders are more likely to have social and psychiatric problems, medically unexplained physical symptoms, chronic somatic diseases (especially diabetes) and are prescribed more psychotropic medication and analgesics. Research Question To describe the attendance rates in a longitudinal study and to test if depression, panic syndrome, other anxiety syndrome, alcohol misuse and general quality of life are associated with frequent attendance in next two consecutive years. Methods 1118 consecutive family practice attendees, aged 18 to 75 years from randomly selected family medicine practices were recruited at baseline and followed up at 12 and 24 months. We identified frequent attenders in the top 10 centile within one year. Using a multivariate model, we ascertained if presence of common mental disorders and quality of life assessed at baseline in 2003 predict frequent attendance in 2004 and 2005. Results 40% of frequent attenders continue to be frequent attenders in the following year and 20% of the frequent attenders were so for the 24 month period. Lower physical scores on the SF-12 questionnaire were strongly associated with future frequent attendance at 12 and 24 months. There was a trend for people with greater than elementary school education to be less likely to become frequent attenders at both 12 and 24 months. For other variables these effects were less consistent. Presence of major depression, panic syndrome, other anxiety syndrome and alcohol misuse were not predictive of frequent attendance in the following two years. Conclusion Low physical quality of life is strongly predictive of higher frequent attendance and similar finding was observed for people with lower educational level but further confirmatory research is required to establish this association.

Health beliefs and practices among Slovenian Roma and their response to febrile illnesses: a qualitative study

Health beliefs and practices among Slovenian Roma and their response to febrile illnesses: a qualitative study Introduction: When the Roma fell ill in the past, they used herbal home remedies to treat diseases. If the remedy failed to cure the illness, they called the local healer. Today, most Roma visit physicians. This study investigates health beliefs and practices held by the Roma people in Slovenia and their response to febrile illnesses. Methods: Field interviews using a semi-structured questionnaire were conducted in the vicinity of Kočevje. Sociodemographic data were gathered and recorded manually, and the interviews were tape recorded. Qualitative analysis was performed by three researchers. Special attention was paid to data validation. Results: The majority of Roma are not acquainted with thermometers and therefore do not use them. About one-third of the interviewees knew what the normal body temperature should be. Only 15% of the Roma population take their body temperature when they are feeling unwell. One-half visit their physicians. More than half of the population take paracetamol or aspirin when they feel feverish. More often, they resort to tea and emphasize the healing effect of sweating. Conclusion: The Roma beliefs and practices regarding health and fever are instructive and show how impoverished a narrow biomedical approach can be. Failure to use technical devices, such as thermometers, and lack of familiarity with the numerical values defining the border between normal and elevated body temperature, nonetheless do not mean that the Roma take inappropriate measures in response to illness. Illnesses (including fever) can also be recognized without these tools and can be appropriately responded to by drinking teas, using compresses, and taking fever-reducing medications. Stališča in Ravnanje Romov v Sloveniji v Zvezi z Vročinskimi Stanji: Kvalitativna Študija Uvod: V preteklosti so Romi za zdravljenje uporabljali domače zeliščne pripravke. Kadar ta zdravila niso bila učinkovita, so poklicali lokalnega zdravilca. Danes večina Romov obišče zdravnika. V prispevku ugotavljamo, kakšno je prepričanje in ravnanje slovenskih Romov v zvezi z zdravjem in kako ukrepajo pri vročinskih stanjih. Metode: V okolici Kočevja smo na terenu izvedli intervjuje na osnovi polstrukturiranih vprašalnikov. Zbrane sociodemografske podatke smo ročno zapisovali, pogovore pa smo posneli. Kvalitativno analizo podatkov so izvedli trije raziskovalci. Posebno pozornost smo namenili validaciji podatkov. Rezultati: Večina Romov ne pozna termometra in ga zato tudi ne uporablja. Približno ena tretjina vprašanih je vedela, kakšna naj bi bila normalna telesna temperatura. Ob slabem počutju si le 15 odstotkov romskega prebivalstva meri telesno temperaturo. Polovica jih obišče zdravnika. Več kot polovica romskih prebivalcev vzame paracetamol ali aspirin, kadar ima vročino. Pogosteje se zatečejo k pitju čaja in poudarjajo zdravilne učinke potenja. Zaključek: Prepričanja in ravnanje Romov v zvezi z zdravjem in povišano telesno temperaturo so poučna in nam kažejo, kako osiromašen je lahko ozko usmerjeni biomedicinski pristop. Dejstvo, da Romi ne uporabljajo tehničnih pripomočkov, npr. termometra, in ne poznajo številčne vrednosti, ki loči med normalno in povišano telesno temperaturo, še ne pomeni, da ob bolezni ravnajo neustrezno. Bolezenska stanja, tudi povišano telesno temperaturo, lahko prepoznamo tudi brez teh orodij in se jim ustrezno postavimo po robu s pitjem čaja, z uporabo obkladkov in z jemanjem zdravil proti vročini.

Longstanding disease, disability or infirmity and depression in primary care

ZusammenfassungINHALT: Allgemein anerkannte Ergebnisse weisen darauf hin, dass Depression bei Personen mit chronischen Leiden häufiger auftritt als allgemein in der Bevölkerung. Depression wird als weltweite Ursache für Behinderung bis zum Jahr 2020 an zweiter Stelle nach Herz-Kreislauf-Erkrankungen rangieren. Ärzte sind aufgrund des Alterns der Bevölkerung gefordert, einen höheren Anteil an chronisch erkrankt Patienten zu behandeln. ZIEL: Beurteilung des Vorherrschens und Auftretens von Depression und der Wahrscheinlichkeit für neu ausbrechende Depression bei Patienten mit selbst berichteter langjähriger Erkrankung, Behinderung oder Gebrechlichkeit in der Teilnehmerprobe der medizinischen Grundversorgung. METHODE: Besucher einer Allgemeinmedizinpraxis im Alter von 18 bis 75 Jahren wurden einer nach dem anderen aufgenommen und über sechs Monate (erste Etappe) untersucht. Langjährige Erkrankung, Behinderung oder Gebrechlichkeit wurden festgestellt. ERGEBNISSE: Starke Depression herrscht bei 8.9% der Patienten in der Gruppe mit langjähriger Erkrankung vor, im Vergleich zu 3.1% in der Gruppe ohne langjährige Erkrankung. Starke Depression tritt nach sechs Monaten bei 2.7% in der Gruppe mit langjähriger Erkrankung und bei 0.9% in der Gruppe ohne langjährige Erkrankung auf. Bei Patienten mit langjähriger Erkrankung in der ersten Etappe war die Wahrscheinlichkeit für starke Depression nach sechs Monaten viermal so hoch wie bei Patienten, die über keine langjährige Erkrankung in der ersten Etappe berichteten. SCHLUSSFOLGERUNG: Die Zusammenhänge zwischen langjähriger Erkrankung und Depression sind im Rahmen der medizinischen Grundversorgung wichtig.SummaryCONTEXT: Current evidence suggests that depression is much more prevalent among those with chronic medical conditions compared to the general population. Depression will rank second to cardiovascular disease as a global cause of disability by 2020. With ageing of the population physicians are called upon to treat a higher percentage of patients with chronic medical illness. OBJECTIVE: To assess the prevalence and incidence of depression and likelihood for new-onset depression in patients with self-reported longstanding disease, disability or infirmity in the sample of primary care attendees. METHODE: Consecutive family medicine practice attendees aged 18 to 75 years were recruited and followed up after six months. Presence of longstanding disease, disability or infirmity was recorded. RESULTS: Prevalence of major depression was 8.9% in the group of patients reporting longstanding disease compared to 3.1% in the group without longstanding disease. Incidence of major depression after 6 months was 2.7% in the group with longstanding disease and 0.9% in the group without longstanding disease. For the patients with longstanding disease at the baseline it was almost 4 times more likely to have major depression after 6 months than for patients who did not report any longstanding disease at the baseline. CONCLUSION: The associations between longstanding disease and depression are important in primary care setting.

Standpoints of Roma women regarding reproductive health

BackgroundLittle is known about the reproductive health of Roma women in Slovenia. The aim of this study is to present the standpoints of Roma women regarding reproductive health, the degree to which primary healthcare services are available to Roma women and the reproductive health circumstances which lead most Roma women to decide to visit a gynaecologist.MethodsA qualitative research study was carried out. Forty-four adult Roma women from the Hudeje/Vejar settlement in the Dolenjska region, Slovenia, took part in the research. The collected material was processed by means of inductive (qualitative) content analysis. The coding procedure was supported by the QDA software Atlas.ti.ResultsEighteen categories and six themes were identified that enable with the relevant codes an understanding of the standpoints of Roma women regarding reproductive health. The research results showed that the cultural needs of Roma women should be taken into account in their comprehensive healthcare treatment. Roma women wish for equal treatment when health is in question, drawing attention to better communication and the problem of ethnic discrimination in medical facilities. Roma women also feel a need to be educated and to receive professional advice, such as appropriate lectures and/or workshops dealing with reproductive health that would ensure them a higher quality of life over time.ConclusionsThe research results call attention to the necessity of recognising both the need to educate Roma women as well as the need for different approaches to the provision of healthcare services in the field of reproductive health with such a sensitive group of female inhabitants. It will be necessary to familiarise them with preventive programmes and to implement such programmes, to inform them of possible diseases and to encourage them in a friendly and easy-to-understand manner to regularly visit their gynaecologist.

Quality of Life And Patient Satisfaction with Family Practice Care in a Roma Population With Chronic Conditions in Northeast Slovenia / Kakovost Življenja V Povezavi S Kroničnimi Boleznimi In Z Zadovoljstvom Z Oskrbo Zdravnika Družinske Medicine Med Romskim Prebivalstvom V Sv Sloveniji

Abstract Objectives. Health-related quality of life (HRQoL) measures a patient’s subjective experience of his or her health status. We aimed to show how the presence of chronic diseases and satisfaction with family physicians (FPs) were associated with the HRQoL of a Roma population. Methods. A cross-sectional study was carried out in May 2011 on a representative sample of 650 Roma living in Prekmurje, Slovenia. The EQ-5D questionnaire was used for measuring the HRQoL of the Roma. Demographical data, 12 groups of diseases diagnosed in the last 12 months and satisfaction with FPs were included in the questionnaire. Results. The response rate was 88.3% (574), of which 56.4% were female, and the average age of the participants had a mean value of 40.2±12.7 years. The presence of cardiovascular problems with risk factors for them or presence of musculoskeletal disorders were strongly associated with the presence of pain (Cramer’s V = 0.40 and 0.46 respectively).There was a strong association between the presence of mental disorders and anxiety and depression (Cramer´s V = 0.58). The average satisfaction with the family physician was 3.9 (mean±1.10) on a five-point Likert scale. There was no significant association between HRQoL and satisfaction with the family physician. Conclusions. Roma with chronic mental health problems had the lowest HRQoL in the Roma population. More attention should be paid to this subgroup of Roma in family medicine, and interventions should be provided. High satisfaction with their FPs is not associated with the observed quality of life variables IZVLEČEK Uvod. Z zdravjem povezana kakovost življenja (HRQoL) je odraz pacientove subjektivne ocene lastnega zdravstvenega stanja. V naši raziskavi smo skušali ugotoviti, kakšen je vpliv nekaterih kroničnih bolezni in zadovoljstva z izbranim zdravnikom na HRQoL med romskim prebivalstvom. Metode. Maja 2011 smo izvedli presečno raziskavo v reprezentativnem vzorcu 650 pomurskih Romov. HRQoL smo merili z vprašalnikom EQ-5D; vključili smo še demografske podatke, zadovoljstvo z izbranim družinskim zdravnikom in 12 bolezenskih stanj, ki so bila diagnosticirana v zadnjih 12 mesecih. Rezultati. Odzivnost je bila 88,3-odstotna (574), 56,4 % je bilo žensk in povprečna starost sodelujočih je bila 40,2 +/- 12,7 leta. Nizek HRQoL v skupini s srčno-žilnimi boleznimi z dejavniki tveganja zanje in kostnomišičnimi boleznimi je bil močno povezan s prisotnostjo bolečine (Cramer z V = 0,40 in 0,46). V skupini z duševnimi težavami pa je bila močna povezava nizkega HRQoL s prisotnimi znaki anksioznosti in depresije (Cramer z V = 0,58). Povprečno zadovoljstvo z zdravnikom družinske medicine je bilo 3,9 (mediana +/- 1,10) na pettočkovni Likertovi lestvici. Ni bilo statistične povezave med HRQoL in zadovoljstvom z zdravnikom družinske medicine. Zaključki. Romi s prisotnostjo duševnih težav imajo najnižji HRQoL v romskem prebivalstvu. Več pozornosti bi v družinski medicini morali posvetiti tej podskupini Romov. Zadovoljstvo z zdravnikom družinske medicine ni povezano z opazovanimi spremenljivkami kakovosti življenja

A cross-sectional study of socio-demographic factors associated with patient access to primary care in Slovenia

IntroductionPrimary care (PC) is the provision of universally accessible, integrated, person-centred, comprehensive health and community services. Professionals active in primary care teams include family physicians and general practitioners (FP/GPs). There is concern in Slovenia that the current economic crisis might change the nature of PC services. Access, one of the most basic requirements of general practice, is universal in Slovenia, which is one of the smallest European countries; under national law, compulsory health insurance is mandatory for its citizens. Our study examined access to PC in Slovenia during a time of economic crisis as experienced and perceived by patients between 2011 and 2012, and investigated socio-demographic factors affecting access to PC in Slovenia.MethodsData were collected as a part of a larger international study entitled Quality and Costs of Primary Care in Europe (QUALICOPC) that took place during a period of eight months in 2011 and 2012. 219 general practices were included; in each, the aim was to evaluate 10 patients. Dependent variables covered five aspects of access to PC: communicational, cultural, financial, geographical and organizational. 15 socio-demographic factors were investigated as independent variables. Descriptive statistics, factor analysis and multilevel analysis were applied.ResultsThere were 1,962 patients in the final sample, with a response rate of 89.6%. The factors with the most positive effect on access to PC were financial and cultural; the most negative effects were caused by organizational problems. Financial difficulties were not a significant socio-demographic factor. Greater frequency of visits improves patients’ perception of communicational and cultural access. Deteriorating health conditions are expected to lower perceived geographical access. Patients born outside Slovenia perceived better organizational access than patients born in Slovenia.ConclusionsUniversal medical insurance in Slovenia protects most patients from PC inaccessibility. However, problems perceived by patients may indicate the need for changes in the organization of PC.

Assessing refugee healthcare needs in Europe and implementing educational interventions in primary care: a focus on methods

The current political crisis, conflicts and riots in many Middle Eastern and African countries have led to massive migration waves towards Europe. European countries, receiving these migratory waves as first port of entry (POE) over the past few years, were confronted with several challenges as a result of the sheer volume of newly arriving refugees. This humanitarian refugee crisis represents the biggest displacement crisis of a generation. Although the refugee crisis created significant challenges for all national healthcare systems across Europe, limited attention has been given to the role of primary health care (PHC) to facilitate an integrated delivery of care by enhancing care provision to refugees upon arrival, on transit or even for longer periods. Evidence-based interventions, encompassing elements of patient-centredness, shared decision-making and compassionate care, could contribute to the assessment of refugee healthcare needs and to the development and the implementation of training programmes for rapid capacity-building for the needs of these vulnerable groups and in the context of integrated PHC care. This article reports on methods used for enhancing PHC for refugees through rapid capacity-building actions in the context of a structured European project under the auspices of the European Commission and funded under the 3rd Health Programme by the Consumers, Health, Agriculture and Food Executive Agency (CHAFEA). The methods include the assessment of the health needs of all the people reaching Europe during the study period, and the identification, development, and testing of educational tools. The developed tools were evaluated following implementation in selected European primary care settings.