This thesis examines hospitalizations for ambulatory care sensitive conditions among persons with an intellectual disability living in Manitoba from 1999 to 2003. Hospitalizations for ambulatory care sensitive conditions are considered an indicator of access to, and the quality of, primary care. Intellectual disability can be defined as a disability originating before age 18 characterized by significant limitations both in intellectual functioning and in adaptive behaviour as expressed in conceptual, social, and practical adaptive skills. Between 1 and 3% of the population has an intellectual disability. This thesis addressed three objectives: 1) To identify ambulatory care sensitive conditions that are applicable to persons with an intellectual disability; 2) To compare hospitalization rates for ambulatory care sensitive conditions between persons with and without an intellectual disability in Manitoba; 3) To identify factors associated with hospitalizations for ambulatory care sensitive conditions among adults with an intellectual disability living in Manitoba. An online survey of primary care providers with experience working with persons with an intellectual disability found consensus on fifteen ambulatory care sensitive conditions applicable to persons with an intellectual disability. Large discrepancies in hospitalization rates for these conditions were found between persons with and without an intellectual disability. Controlling for age, year, sex, and region, persons with an intellectual disability were 6 times more likely to be hospitalized for an ambulatory care sensitive condition. Future research should investigate reasons for the large discrepancy in rates between persons with and without an intellectual disability. Among adults with an intellectual disability, living in a rural area (odds ratio 1.3; 95% CI=1.0, 1.8), living in an area with a high proportion of First Nations people (odds ratio 2.3; 95% CI=1.3, 4.1), and experiencing higher levels of comorbidity (odds ratio 25.2; 95% CI=11.9, 53.0) were all associated with a higher likelihood of being hospitalized for an ambulatory care sensitive condition. Dwelling in higher income areas had a protective effect (odds ratio 0.56; CI=0.37, 0.85). The results suggest that addressing the socioeconomic problems of poorer areas and specifically areas densely populated by First Nations people would likely have an impact on hospitalizations for ACS conditions for persons with an intellectual disability.

The purpose of the present study was to begin to develop an understanding of how primary care resident physicians work with patients with personality disorder-type characteristics and processes. Participants include fifteen primary care resident physicians from a community health clinic. Participants individually viewed two video vignettes of an actor-patient being interviewed by a physician. Participants were asked how they would respond to statements the actor-patient made during the course of watching the video and then answered general questions about reactions to the actor-patient and working with patients with personality disorders. Using a naturalistic qualitative analysis, data were analyzed for categories and themes. The results of the analyses are presented within a basic framework for understanding how primary care residents work with and approach the doctor-patient relationship, and treat patients with personality disorder characteristics and associated personality processes. Broad themes emerge from the data. Content of residents' responses suggests two response styles: attention to patient's presenting physical concern or identify and potentially address underlying psychological and emotional concerns. Residents characterize the establishment of a relationship with this patient population as either a distancing, paternalistic approach, or an engaging and collegial relationship. Levels of self-awareness of reactions to patients consist of either a willingness to address personal reactions or a tendency to not identify or discuss those reactions. Residents also demonstrate a dichotomous response to willingness to work with this patient population characterized by either hesitancy to do so, or a desire to engage and attempt to work with these patients. A framework for understanding the possible effects and motivating variables behind these styles is presented. The predominant effects of the residents' interactions styles are either a distancing/paternalistic relationship or an engaging/collegial relationship. Two themes appear to characterize residents' motivations: the resident was driven by self-needs or patient-needs. These results may be useful in developing an initial theory of this previously unexamined dynamic. Moreover, these results may be useful in helping physicians better develop relationships with patients, especially through improvement in recognizing and utilizing personal reaction to patients. Future inquiries directed towards understanding what physician variables contribute to these two basic interaction styles identified here may be useful.

published_or_final_version / Public Health / Master / Master of Public Health

A longitudinal study was carried out on a population of 4,922 patients served by a general practice surgery with three doctors. The purpose was to investigate the opportunity which domiciliary care of elderly and infirm patients offers to UK pharmacists working in primary care. The aims of the study were: - 1) To identify indicators that could be used to identify patients in the community who might benefit from domiciliary pharmaceutical care, and which do not leave patients excluded. 2) To identify specific issues that would lead to better pharmaceutical care 3) To deliver a package of pharmaceutical care to these most "at risk" patients in the population over approximately a year. 4) To evaluate the interventions made considering the viewpoints of all parties found to be stakeholders. 5) To measure the scale of the challenge of domiciliary managed pharmaceutical care in relation to the population in the study. 6) To provide indicators for the development of pharmaceutical care including cost/ benefit and potential training requirements. A simple qualitative study design was pursued, based upon semi-structured interviews and field notes. A cohort of patients (n=149) identified as candidates for domiciliary visiting, represented 3% of the surgery population. After de-selection of unsuitable candidates, visits were made to 100 patients. Three concepts for the organisation of information and three clusters of criteria were identified and developed which would identify 94 out of 100 patients visited. A large number of indicators for pharmaceutical care were identified and described qualitatively under 14 headings. Though typical, these were not claimed as a comprehensive set of issues which could have been encountered. It was generally perceived that more of the pharmacist's interventions produced positive effects than those that were neutral or actually did harm. Some of the interventions were accepted by the GPs as very important, and developing the extended role to include for instance a cardiovascular review clinic; "in house" medication reviews was discussed. Domiciliary visits were deemed useful though the GPs pointed out that making visits was time consuming and, by implication, expensive. Patients reported a high level of satisfaction with the visiting programme. Satisfaction was explored in an attempt to differentiate sociometric issues from professional ones. Rating satisfaction with a domiciliary pharmaceutical service required that specific issues were identified and dealt with which reflected the main concerns of patients about their medicines. Most of the patients' concerns appeared to be centred around multiple medication, widely perceived (in this cohort) to have potential to cause harm. The author recommends that PCGs consider allocating part of the prescribing budget to fund a domiciliary pharmaceutical care service to a small targeted population through community pharmacies. This could be a first step in offering new professional opportunities through community pharmacies and might revitalise some which are currently in decline.

New applications of genomic medicine stemming from the Human Genome Project are predicted to become routine components of primary care. Primary care physicians (PCPs) will increasingly become responsible for screening patients for inherited diseases, recommending genetic testing, and making referrals to genetic services. Clinical applications of genomic medicine will occur at a variable pace. Characteristics of an innovation such as genomic medicine are strong indicators of its potential for adoption. The purpose of this study is to assess whether (and to what extent) physicians' perceptions of genomic medicine as an innovation influence their likelihood of adopting this innovation into primary care. The study's sample consists of 400 primary care physicians in Texas and employs a survey design. Based on Rogers' Diffusion of Innovations Theory, the perceived characteristics of genomic medicine - Relative Advantage, Compatibility, Complexity, Trialability, and Observability - are the study's independent/predictor variables. Likelihood of PCPs Adopting Genomic Medicine is the dependent variable. The nature of the social system (private or group practice) is examined as a possible moderator variable. The study suggests that Texas PCPs who are likely to adopt genomic medicine strongly perceive its clinical uses (such as genetic testing for carrier status or susceptibility to common diseases, testing an embryo for genetic disorders before it is implanted, and supplementing a family history) to be highly advantageous. For half of the PCPs, genetic services such as genetic counseling and genetic testing are not compatible with current practice. Perceived complexity of the innovation is the strongest predictor of likelihood of PCPs adopting genomic medicine. Many PCPs find it difficult to stay updated on genomic medicine and locate genetic services. Although Texas PCPs feel genomic medicine can be gradually incorporated into primary care practice, most are not presently observing their colleagues adopting genomic medicine or assisting their patients to make decisions regarding genetic services. Future efforts to advance the use of genomic medicine in primary care will require more emphasis on genetics in medical school curriculum and continuing education programs. Links with specialists trained in genetic counseling and health education will be essential to translate relevant information to patients and families.

Thesis (B.A.)--Haverford College, Independent College Programs, 2008. / Includes bibliographical references.

Thesis (Ph. D.)--Illinois State University, 2003. / Title from title page screen, viewed Dec. 16, 2004. Dissertation Committee: Dissertation Committee: Edward R. Hines (chair), Kenneth H. Strand, Ross A. Hodel, Zeng Lin. Includes bibliographical references (leaves 79-83) and abstract. Also available in print.

Background: The epidemic of type 2 diabetes poses an enormous and growing burden on health care globally. While the prevalence of diabetes is increasing worldwide, the developing countries will bear the greatest burden of this disease. Diabetes is one of the most common causes of kidney failure and nephropathy is a strong predictor of cardiovascular complications and death in these patients. Microalbuminuria represents a latent and early pre-symptomatic phase of nephropathy which can be stopped from progressing to an advanced stage if detected and treated early. The cost effectiveness of this screening and intervention has been researched and proven in the developed world, however similar studies in developing countries are non-existent. Microalbuminuria is not currently tested for in the public primary care sector. Aim and objectives: The aim was to assess the feasibility of introducing a screening test for microalbuminuria and the associated costs and consequences at Elsies River Community Health Centre (CHC) in the Metropolitan District of Cape Town. The objectives of the study are to assess the feasibility of implementing the test in our context, to assess any additional cost to the health services, to assess any measurable benefits in the quality of care for the patients, to extrapolate the likely long term consequences in terms of health outcomes, use of resources and costs and to make a policy recommendation to the Department of Health. Method: A cost and consequence study that describes the introduction of microalbuminuria testing in a cohort of type 2 diabetic patients at Elsies River Community Health Centre, Metro District Health Services, Cape Town, South Africa. Point of care status analyser microalbuminuria screening was introduced to the CHC after training of the chronic care team, and their fidelity to the protocol measured. All patients who met the inclusion criteria were screened. Patients whose first results were abnormal had a repeat test after 3-6 months, if both results were abnormal patient was diagnosed microalbuminuria positive, however a patient with a second normal result required a third test. Interventions included addition of an Angiotesin Converting Enzyme inhibitor to their treatment, more intensive glycaemic, blood pressure or lipid control via medication or lifestyle changes and treatment adherence health education. Field notes were taken by the researcher during visits and a recorded focus group interview conducted with the health workers to explore their views on the feasibility of the screening and intervention. Cost was assessed by the estimation of the additional resources required and the likely long term health outcomes extrapolated from available data and literature. Results: 15.2% of the sample population was noted to be microalbuminuria positive and they all received interventions. Additional cost required to screen a cohort of 100 patients was R1,109.40 per annum, out of which 15 patients at risk of developing nephropathy were identified and the cost of treating these patients was R1,393.20 for the first year. Qualitative data revealed that the test and interventions are feasible with an additional cost of staff time, medication and other materials which have been included in the cost above. Conclusion: This study represents the first attempt to successfully introduce screening for microalbuminuria in our public primary health care context. The chronic care team showed reasonable fidelity to the protocol and demonstrated the feasibility of screening and treating patients. The balance of costs and long term benefits suggests that this represents excellent value for money in a South African primary care setting.

Medically vulnerable populations are constantly at risk of having poor health related outcomes, low satisfaction in the healthcare system and increased mortality. Studies have shown the increased prevalence rates of various medical comorbidities in patients with severe mental illness. These patients are obviously vulnerable because of their mental illness but they are also more likely to have severe cases of medical conditions commonly seen in the general population. Expenditures and utilization of resources is often inappropriate due to frequent visits for acute needs and low rates of preventative care and primary care appointments. My proposed model focuses on the implementation of the integrated care model which encourages collaboration between mental health professionals and primary care physicians through referral programs or integrated clinic settings. This model is initiated with education to both current clinicians as well as future clinicians through medical schools and residency programs. Once the education component has begun, the next steps are formal exploration, preparation, implementation and evaluation of the model in clinics. The aim is to improve health outcomes by increasing preventative care and using behavioral techniques to assist with adherence, increase satisfaction in the healthcare system and contain expenditures by utilizing primary care services instead of emergency services when appropriate.

PURPOSE: There are approximately 21.3 million refugees worldwide. Connection to primary care is essential for these patients because of the potential for long-term and complex care that they require. Primary care and continuity of care also leads to better health outcomes. This study examined what effect primary language had on primary care choice by Refugee Health Assessment Program (RHAP) patients seen at Boston Medical Center (BMC) and whether patients who chose non-BMC primary care eventually returned to BMC. METHODS: A retrospective cohort study was conducted examining RHAP patients’ primary language, and whether those patients continued care at BMC or sought care elsewhere. RESULTS: Significant results were seen among subjects who identified Chinese, Haitian Creole, Somali, Spanish and Vietnamese as their primary language. Spanish, Chinese, and Vietnamese speakers had greater odds of seeking care outside of BMC. Haitian Creole and Somali speakers had greater odds of seeking care at BMC compared to English speakers. 80% of subjects returned to BMC after seeking care elsewhere. CONCLUSIONS: Primary language does effect choice of primary care provider within the refugee population. Providers should use these results to encourage refugee patients less likely to seek care to connect with a primary care provider.