PRIMARY CARE AT A GLANCE – HOT TOPICS AND NEW INSIGHTS Edited by Oreste Capelli Primary Care at a Glance – Hot Topics and New Insights Edited by Oreste Capelli Published by InTech Janeza Trdine 9, 51000 Rijeka, Croatia Copyright © 2012 InTech All chapters are Open Access distributed under the Creative Commons Attribution 3.0 license, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. After this work has been published by InTech, authors have the right to republish it, in whole or part, in any publication of which they are the author, and to make other personal use of the work. Any republication, referencing or personal use of the work must explicitly identify the original source. As for readers, this license allows users to download, copy and build upon published chapters even for commercial purposes, as long as the author and publisher are properly credited, which ensures maximum dissemination and a wider impact of our publications. Notice Statements and opinions expressed in the chapters are these of the individual contributors and not necessarily those of the editors or publisher. No responsibility is accepted for the accuracy of information contained in the published chapters. The publisher assumes no responsibility for any damage or injury to persons or property arising out of the use of any materials, instructions, methods or ideas contained in the book. Publishing Process Manager Dragana Manestar Technical Editor Teodora Smiljanic Cover Designer InTech Design Team First published April, 2012 Printed in Croatia A free online edition of this book is available at www.intechopen.com Additional hard copies can be obtained from orders@intechopen.com Primary Care at a Glance – Hot Topics and New Insights, Edited by Oreste Capelli p. cm. ISBN 978-953-51-0539-8 Contents Preface IX Section 1 Accessibility to Primary Care 1 Chapter 1 At the Frontlines: Confronting Poverty in Primary Care Medicine 3 Namrata Kotwani, Ruqayyah Abdul-Karim and Marion Danis Chapter 2 Public Health in Primary Care 27 L. Cegolon, G. Mastrangelo and J. H. Lange Chapter 3 Primary Care and Non-Physician Clinicians 43 James F. Cawley, Roderick S. Hooker and Diana Crowley Section 2 Comprehensiveness of Primary Care 51 Chapter 4 Integrating Spirituality into Primary Care 53 Giancarlo Lucchetti, Alessandra L. Granero Lucchetti, Rodrigo M. Bassi, Alejandro Victor Daniel Vera and Mario F. P. Peres Chapter 5 Traditional Medicine and Complementary/Alternative Medicine in Primary Health Care: The Brazilian Experience 65 Caroline da Rosa Chapter 6 Exposure to Environmental Tobacco Smoke in Babies 83 Lourdes Rofes Ponce, Ricardo Almon, Elisa Puigdomènech, Manuel A Gomez-Marcos and Carlos Martín-Cantera Chapter 7 Skills in Minor Surgical Procedures for General Practitioners 101 Jose María Arribas Blanco and María Hernández Tejero VI Contents Chapter 8 Telehealth: General Aspects in Primary Care 137 Alaneir de Fátima dos Santos, Humberto José Alves, Cláudio de Souza, Simone Ferreira dos Santos, Rosália Morais Torres and Maria do Carmo Barros de Melo Chapter 9 Telemedicine in Primary Care 151 Jumana Antoun Section 3 Coordination and Integration in Primary Care 163 Chapter 10 Serum Ferritin and Iron Studies – Laboratory Reporting and Clinical Application in Primary Care 165 Catherine Ogilvie and Edward Fitzsimons Chapter 11 Cancer Diagnosis and Treatment: An Overview for the General Practitioner 175 Josephine Emole Chapter 12 Diagnosis of Chronic Obstructive Pulmonary Disease with Special Reference to Over- and Underdiagnosis Using Spirometry 187 Peter Montnemey and Sölve Elmståhl Chapter 13 Chronic Obstructive Pulmonary Disease in Primary Care – From Diagnosis to Therapy 205 Elisabetta Rovatti, Oreste Capelli, Maria Isabella Bonacini, Imma Cacciapuoti and Antonio Brambilla Chapter 14 The Management of Peripheral Arterial Disease (PAD) in Primary Care 233 Andrew P. Coveney Chapter 15 Shared Medical Appointments: Implementing Diabetes SMAs to Improve Care for High Risk Patients and Maximize Provider Expertise 257 Susan Kirsh, Renée Lawrence, Lauren Stevenson, Sharon Watts, Kimberley Schaub, David Aron, Kristina Pascuzzi, Gerald Strauss and Mary Ellen O’Day Chapter 16 The Role of Fracture Liaison Services in Re-Fracture Prevention 279 Kirtan Ganda and Markus J. Seibel Chapter 17 The Effects of Lifestyle Modification on Glycemic Levels and Medication Intake: The Rockford CHIP 323 Heike S. Englert, Hans A. Dieh, Roger L. Greenlaw and Steve Aldana Contents VII Section 4 Continuity of Care in Primary Care 337 Chapter 18 Adherence to Long-Term Therapy – A Model of Assessment into Primary Care 339 Alex Müller Chapter 19 Palliative Care in General Practice 353 Imma Cacciapuoti, Laura Signorotti, Maria Isabella Bonacini, Oreste Capelli, Maria Rolfini and Antonio Brambilla Section 5 Accountability in Primary Care 387 Chapter 20 Ethics and the Practice of Primary Care Psychiatry 389 Russell H. Searight Chapter 21 Clinical Audit in Primary Care: From Evidence to Practice 407 Oreste Capelli, Silvia Riccomi, Marina Scarpa, Nicola Magrini, Elisabetta Rovatti, Imma Cacciapuoti and Antonio Brambilla Chapter 22 Performance Measurement and Optimization of Resource Allocation in a Health Care System 437 Artie W. Ng and Peter P. Yuen Preface In 1978 the Conference of Alma Ata stated in Section VI: “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process”. Over 30 years later, this book does not address the world of Primary Care in a systematic way, however it certainly represents the multiracial and multicultural reality of this world. The book brings together contributions by over 50 authors from many countries, all around the world, from Europe to Africa, from Asia to Australia, from North to South America. Different cultures are presented together, from those with advanced technologies to those of intangible spirituality, but they are all connected by five professional attributes, that in the 1978 the Institute of Medicine (IOM) 1 stated as essentials of practicing good Primary Care: accessibility, comprehensiveness, coordination, continuity and accountability. 1. Accessibility (to Primary Care) means that the Primary Care team assists the patient, or potential patient, to overcome any temporal, spatial, economic and psychological barriers to health care access. The concept of accessibility to Primary Care includes its availability, or actual capacity to achieve it (attainability), and its acceptability. The availability refers to the temporal aspects of access - for example, covering the entire course of the day and the ability to respond to the request for assistance in a reasonable time. The capacity regards both access in physical sense that the possible economic barriers. Acceptability refers to the psychological and social factors associated with access. 1 Institute of Medicine (1978). A manpower policy for primary health care: report of a study X Preface 2. Comprehensiveness refers to the willingness and ability to offer a range of services that meet the vast majority of needs in the assisted population. It involves the delivery of preventive services, diagnosis, treatment and rehabilitation. All the Primary Care operators should be able to treat, according to their skills, the vast majority of the problems that arise in their reference population. 3. The Coordination, or integration of care, refers to both the ability to simultaneously treat multiple diseases, both to make available, and use them appropriately and efficiently, resources and information available in various areas of the health care. The coordination, however, concerns not only the integration of contributions from a number of health professionals, but also the ability to choose diagnostic and therapeutic pathways consistent with the habits, preferences, lifestyle and expectations of the patient, her/his family, his professional and social environment. The Primary Care coordinator helps patients to untangle themselves in the maze of specialists and medical services, coordinating the advice of a specialized but fragmented assistance, providing the listening and the advice of a typical long-term relationship marked by mutual trust. This is the main role of "advocacy", exerted by the Primary Care professionals as advocates or representatives of the interests of patients, to aid and support them to take an active part in the processes of clinical decision making, assisting them in defining and trading of the care pathways with other parts of the health system and, if necessary, protecting them from testing and treatments unnecessary or harmful, as the risks of overtreatment. 4. The Continuity of care, as continuity over time, is typical of care in Primary Care, unlike the hospital or specialist care: the first is characterized by being provided for long periods of life, while the latter are limited to acute episodes or for limited periods of time. 5. Finally, the IOM definition includes Accountability, as a further essential attribute of the Primary Care. Accountability is a term difficult to translate out of anglo-saxon world; in Italy (my country) it should be synonymous of “responsibility”, as it expresses the need to account for our choices and actions, in a transparent manner, to both patients and the public health service. Accountability can be understood primarily as a self-assessment and review of our work, in the form of internal audit or peer review, which may highlight the need for operator training or work changing. Secondly, it entails an obligation to provide prior information of patients about the risks and possible undesirable effects of the investigations and treatments offered, so they can take an active part in the selection of diagnostic and therapeutic procedures. Finally, there is an economic accountability towards the health system and the community, which implies the assumption of efficiency-oriented behaviours and the most cost- effective quality. [...]... Bhutan Sri Lanka Algeria Anguilla Guam Bulgaria Slovakia Uruguay Greece Egypt Spain Estonia United Arab Emirates Bermuda 19 6 Primary Care at a Glance – Hot Topics and New Insights Rank Country 106 Paraguay 107 Bosnia and 18.6 Herzegovina Mexico 18.2 123 Jordan 14.2 139 Bahamas, The 9.3 124 14 140 Greenland 9.2 Portugal Iran Turkey Trinidad and Tobago Poland Croatia Jamaica Maldives Costa Rica Japan... delivery that allow bundling of appropriate intervention and health promotion strategies with comprehensive medical care may be particularly beneficial for low-income patients who are infrequent users of ambulatory care Combining routine and preventive clinical care as a matter of standard practice ensures that patients will receive appropriate prophylactic care and education upon visiting a primary care. .. surgeries and many patients are referred to them by medical personnel This seamless integration of medical and social services allows the poor, elderly, and disabled patients to attain financial and mental security 16 Primary Care at a Glance – Hot Topics and New Insights Similarly, “Just for Us” is another joint program run by an academic medical center and community organizations which provides financially... lowincome and ethnic minority patients Ensure availability of translators Obtain feedback to measure quality of care Increase partnerships with agencies outside Direct patients to government assistance the healthcare system programs, local educational resources, and advocacy organizations Educate patients about mitigating SEDH Discuss the link between SES and disease Acknowledge and address financial concerns... at a Glance – Hot Topics and New Insights indicators have not recognized care coordination in the treatment of chronic conditions and time spent on health promotion activities (Larson et al., 2003) Moreover, performance measures usually assess quality of care for specific diseases but cannot satisfactorily evaluate care that mitigates multiple, concurrent illnesses prevalent among low SES adults Attaining... about adjustments in clinical practice that may significantly improve care for low-income individuals in the primary care setting (Table 2) While medical care alone cannot address the impact of low income, inadequate educational attainments, suboptimal living and work conditions, and material and other psychosocial deprivation on the health of patients, if physicians acknowledge the impact of these factors... is predicated on patient recall, convenience, and rapid availability of results (Warren et al., 2006) Outreach programs which generate quarterly reminders through 12 Primary Care at a Glance – Hot Topics and New Insights letters, voicemail, and e-mail have been successful in persuading some individuals to schedule health screenings and self-management evaluations for chronic conditions If feasible,... profession as an essential component of the healthcare workforce; enhance the cultural proficiency of the primary care workforce; incorporate community health workers into the primary care team to promote patient participation in health education, behavioral health education, prevention, and health insurance programs; increase the diversity of the healthcare and public health workforces since racial and ethnic... English-speaking patients were associated with lower quality rankings for primary care physicians (Hong et al., 2010) At the same time, US physicians with a patient population that was over 50% Latino cited several hurdles to the delivery of high quality care to their patients, ranging from the patient’s inability to pay to difficulties communicating because of language barriers (Vargas Bustamante & Chen,... levels that predispose to obesity, diabetes, cardiovascular disease, and altered immune modulation (Brunner & Marmot, 2006) Another analytic strategy takes a life course approach building on evidence that a person’s social circumstances at each point in time accumulate over a lifetime to contribute to an individual’s health status so that, repeated periods of nutritional deficiency and social factors . PRIMARY CARE AT A GLANCE – HOT TOPICS AND NEW INSIGHTS Edited by Oreste Capelli Primary Care at a Glance – Hot Topics and New Insights Edited by Oreste Capelli. in Primary Care Medicine 3 Namrata Kotwani, Ruqayyah Abdul-Karim and Marion Danis Chapter 2 Public Health in Primary Care 27 L. Cegolon, G. Mastrangelo and J. H. Lange Chapter 3 Primary Care. the primary care setting (Table 2). While medical care alone cannot address the impact of low income, inadequate educational attainments, suboptimal living and work conditions, and material and