Jouke van der Zee

The breadth of primary care: a systematic literature review of its core dimensions

BackgroundEven though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.MethodsA systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, Kings Fund Database, IDEAS Database, and EconLit.ResultsEighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.ConclusionsA primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.

Europe’s Strong Primary Care Systems Are Linked To Better Population Health But Also To Higher Health Spending

Strong primary care systems are often viewed as the bedrock of health care systems that provide high-quality care, but the evidence supporting this view is somewhat limited. We analyzed comparative primary care data collected in 2009-10 as part of a European Union-funded project, the Primary Health Care Activity Monitor for Europe. Our analysis showed that strong primary care was associated with better population health; lower rates of unnecessary hospitalizations; and relatively lower socioeconomic inequality, as measured by an indicator linking education levels to self-rated health. Overall health expenditures were higher in countries with stronger primary care structures, perhaps because maintaining strong primary care structures is costly and promotes developments such as decentralization of services delivery. Comprehensive primary care was also associated with slower growth in health care spending. More research is needed to explore these associations further, even as the evidence grows that strong primary care in Europe is conducive to reaching important health system goals.

The impact of clerkships on students’ specialty preferences: what do undergraduates learn for their profession?

Objective  Clinical experiences and gender have been shown to influence medical students’ specialty choices. It remains unclear, however, which aspects of experiences make students favour some specialties and reject others. This study aimed to clarify the effects of clerkships on specialty choice and to identify explanatory factors.

General practice in urban and rural Europe : The range of curative services

The variation in the range of services provided by general practitioners (GPs) is not only related to personal characteristics and features of the countrys health care system but also to the geographical circumstances of the practice location. In conurbations health services are more widely available than in the countryside, where GPs often are the only providers. With highly mobile populations and a plentiful supply of doctors, in cities the prevailing regulations for access and use of services are more difficult to maintain. It is also more difficult to control access and thus opportunities for inappropriate use are greater. Against this background an international study was conducted on variation in task profiles of GPs, especially focusing on differences between urban and rural practices. In 1993 standardised questionnaires in the national languages were sent to samples of GPs in 30 countries. Various aspects of service provision were measured as well as practice organisation, location of the practice and personal backgrounds of the GP. Completed questionnaires were received from 7,233 respondents, an overall response rate of 47%. Sources of variation have been analysed by using a two-level model. Rural practices provided more comprehensive services regardless of the health care system. Approximately half of the variation was explained by features of a countrys health care system. The GPs position at the point of access to health care was strongly associated with the gatekeeper function controlling access to secondary care. In western countries where the GPs were self employed they had greater involvement in technical procedures and chronic disease management. There was a considerable gap between the task profiles of GPs in eastern and western Europe. We found evidence of a reduced gatekeeper role in inner cities in those countries where GPs held this position. GPs with an estimated overrepresentation of socially deprived people and elderly in the practice population reported a wider range of services. Differences also appeared to be related to factors which are largely controlled by the individual doctor, such as level of training and education, availability of equipment and practice staff. The results have important implications for education, policy development and health care planning both in eastern and western Europe.

Disaster and subsequent healthcare utilization: a longitudinal study among victims, their family members, and control subjects.

Background:The impact of disasters on primary healthcare utilization is largely unknown. Moreover, it is often overlooked how disaster affects those closest to the primary victims, their family members. Objective:The objective of this study was to examine the long-term effects of a catastrophic fire on primary healthcare utilization. Research Design:We conducted a prospective, population-based cohort study covering 1 year pre- and 3 years postfire. Utilization data were extracted from primary care records. Subjects:Subjects consisted of 286 disaster victims, 802 family members of disaster victims, 3722 community control subjects, and 10,230 patients from a national reference population. Measures:As outcome measures, we studied 1) the annual number of contacts in primary care and 2) the annual number of contacts for problems related to mental health. Determinants are injury characteristics of victims and bereavement. All analyses control for age, gender, and insurance status. Results:Being an uninjured victim who witnessed the disaster increases the number of contacts by a factor of 1.55 during the first year postfire (95% confidence interval [CI], 1.35–1.78). Uninjured victims contact the family practitioner more often for mental health-related problems than adolescent community control subjects (incidence rate ratio [IRR], 4.54; 95% CI, 1.69–12.20). In adult family members, the loss of a child predicts overall utilization (IRR, 1.88; 95% CI, 1.35–2.63) and utilization for mental health (IRR, 8.69; 95% CI, 2.10–35.92) during the first year postfire. Conclusion:Attention should be paid to the primary care needs of bereaved individuals and those who have witnessed the disaster.

Political, cultural and economic foundations of primary care in Europe

This article explores various contributing factors to explain differences in the strength of the primary care (PC) structure and services delivery across Europe. Data on the strength of primary care in 31 European countries in 2009/10 were used. The results showed that the national political agenda, economy, prevailing values, and type of healthcare system are all important factors that influence the development of strong PC. Wealthier countries are associated with a weaker PC structure and lower PC accessibility, while Eastern European countries seemed to have used their growth in national income to strengthen the accessibility and continuity of PC. Countries governed by left-wing governments are associated with a stronger PC structure, accessibility and coordination of PC. Countries with a social-security based system are associated with a lower accessibility and continuity of PC; the opposite is true for transitional systems. Cultural values seemed to affect all aspects of PC. It can be concluded that strengthening PC means mobilising multiple leverage points, policy options, and political will in line with prevailing values in a country.

Urban–rural health differences: primary care data and self reported data render different results

AIM Assessing the usefulness of GP electronic medical records for assessing the health of rural populations by comparing these data with data from health interview surveys. DATA Data from electronic medical records routinely recorded in general practices in 2000-2002. Data on self-reported health problems were obtained through questionnaires in a subset of the same patient population. RESULTS According to GP-records, acute somatic and chronic diseases were more frequently presented in rural areas. At the same time self reported health problems point to a better health in rural areas. CONCLUSION GP electronic medical records may be used to monitor the health of rural populations. These data can be obtained relatively quickly and easily and against acceptable cost. However, they do not give the same outcomes as health interview surveys. Reasons for this discrepancy may be; differences in the accessibility of specialist services and help seeking behaviour between urban and rural populations.

Income development of General Practitioners in eight European countries from 1975 to 2005

BackgroundThis study aims to gain insight into the international development of GP incomes over time through a comparative approach. The study is an extension of an earlier work (1975–1990, conducted in five yearly intervals). The research questions to be addressed in this paper are: 1) How can the remuneration system of GPs in a country be characterized? 2) How has the annual GP income developed over time in selected European countries? 3) What are the differences in GP incomes when differences in workload are taken into account? And 4) to what extent do remuneration systems, supply of GPs and gate-keeping contribute to the income position of GPs?MethodsData were collected for Belgium, Denmark, Germany, Finland, France, the Netherlands, Sweden and the United Kingdom. Written sources, websites and country experts were consulted. The data for the years 1995 and 2000 were collected in 2004–2005. The data for 2005 were collected in 2006–2007.ResultsDuring the period 1975–1990, the income of GPs, corrected for inflation, declined in all the countries under review. During the period 1995–2005, the situation changed significantly: The income of UK GPs rose to the very top position. Besides this, the gap between the top end (UK) and bottom end (Belgium) widened considerably. Practice costs form about 50% of total revenues, regardless of the absolute level of revenues. Analysis based on income per patient leads to a different ranking of countries compared to the ranking based on annual income. In countries with a relatively large supply of GPs, income per hour is lower. The type of remuneration appeared to have no effect on the financial position of the GPs in the countries in this study. In countries with a gate-keeping system the average GP income was systematically higher compared to countries with a direct-access system.ConclusionThere are substantial differences in the income of GPs among the countries included in this study. The discrepancy between countries has increased over time. The income of British GPs showed a marked increase from 2000 to 2005, due to the introduction of a new contract between the NHS and GPs.

A cohort study of the long-term impact of a fire disaster on the physical and mental health of adolescents†

The literature on adult trauma survivors demonstrates that those exposed to traumatic stress have a poorer physical health status than nonexposed individuals. Studies on physical health effects in adolescent trauma survivors, in contrast, are scarce. In the current study, it was hypothesized that adolescents who have been involved in a mass burn incident (N = 124) will demonstrate more physical and mental health problems than an unaffected cohort from the same community (N = 1,487). Health data were extracted from electronic medical records, covering 1-year prefire and 4-years postfire. When compared to the prefire baseline, survivors showed significantly larger increases in mental, respiratory, and musculoskeletal problems than community controls during the first year after the fire, but not during the later years.

The potential of legislation on organ donation to increase the supply of donor organs

OBJECTIVES The aim of this paper is to assess the possibilities to adapt the 1998 Dutch Organ Donation Act, taking account of fundamental principles such as the right to physical integrity, equitable access to and equal availability of care, and the non-commerciality principle, with a view to increasing the organ supply. METHODS In 2008 the Dutch Taskforce on Organ Donation presented several proposals to amend the Act and to increase the supply of organs. This paper describes the proposals to amend the Act and evaluates them by assessing their intrinsic adherence to basic principles and the available evidence that these proposals will indeed increase the organ supply. RESULTS Several proposals could constitute an infringement of fundamental principles of the Act. Moreover, evidence for their impact on the organ supply is lacking. Changing the consent system is possible, as this would not incur legal objections. There are diverging views regarding the impact of consent systems on the organ supply. CONCLUSIONS The scope for changing the Act and its impact on organ procurement is at best limited. Relying on legislation alone will possibly not bring much relief, whereas additional policy measures may be more successful.