RESEARCH IN PRIMARY CARE building capacity

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RESEARCH IN PRIMARY CAREbuilding capacity

• CHRIS VAN WEEL
• UMC Nijmegen, Netherlands

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WONCA KINGSTON CONFERENCE RESEARCH
improving health care globally a critical
review of the necessity of family medicine
research and recommendations to build research
capacity
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WONCA KINGSTON RECOMMENDATIONS

• Build Research Capacity
• PBRNs
• Mentoring Programs
• University Departm.
• National Institutes
• Provide Research Fora

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NORMAN ROCKWELLNORMAN ROCKWELL VISITS A FAMILY
DOCTOR(1947)
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RESEARCH

• To make health care
• Safe
• Timely
• Personal
• Without evidence no progress
• Without patients no evidence

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BARBARA STARFIELD
Starfield B. Is primary care essential? Lancet
1994 344 129-133.
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RESEARCH

• To make health care
• Safe
• Timely
• Personal
• Without evidence no progress
• Without patients no evidence
• Without primary care no full picture

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RESEARCH TO EXPLORE PRACTICE
Primary care morbidity Patients'
perspective Physicians performance Use health
care facilities
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COMMON MORBIDITY IN GENERAL PRACTICE

• CHRONIC
• - Obesity
• - Hypertension
• - Chronic nervous complaints
• - Deafness
• - COPD
• - Chr. Isch. Heart disease
• - Myocardial infarction
• - Varicose veins
• Hyperlipemia
• Psoriasis

ACUTE - Respiratory tract infection -
Functional complaints - Dermatitis - Urinary
tract infection - Myalgia neck, shoulder, arm -
Ear wax - Minor trauma - Low back pain -
Vaginitis
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WHERE FAMILY MEDICINE IS DIFFERENT

• Family practice
• Setting
• Health
• Normal
• Patient
• Diff. Diseases
• How gets this patient sick

• Hospital
• Setting
• Illness
• Abnormal
• Disease
• Diff. Patients
• How did this disease happen

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CHARACTERISTICS OF THE FAMILY PHYSICIAN
Features of the medical generalist

• Care for all, unselected health problems in all
  patient groups
• Early signs/symptoms
• Combining cure, care and prevention
• Emphasis on effective and efficient diagnostic
  and therapeutic interventions

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CHARACTERISTICS OF THE FAMILY PHYSICIAN
In combination with features of the personal
doctor

• Continuity of care
• Family medicine
• Patients expectations
• Empowering individual health and strength (health
  promotion)
• Addressing individual and cultural norms and
  values

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RESEARCH TO EXPLORE PRACTICE
Primary care morbidity Patients'
perspective Physicians performance Use health
care facilities
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CONTEXT OF MEDICINELAUREN FORD (1938)
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STRENGTH and VALUEPRIMARY CARE
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PERFORMANCE FPs - PHYSICIANS (hypertension)
Gerritsma en Smal, 1982
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PERFORMANCE FPs - PHYSICIANS (hypertension)
Gerritsma en Smal, 1982
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PERFORMANCE FPs - PHYSICIANS (hypertension)
Gerritsma en Smal, 1982
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PERFORMANCE FPs - PHYSICIANS (hypertension)
Gerritsma en Smal, 1982
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PERFORMANCE FPs - PHYSICIANS (hypertension)
Gerritsma en Smal, 1982
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EXAMPLETREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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EFFECTIVENESS FP TREATMENT DEPRESSION
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CLINICAL COMPLEXITY FM

• Variation Morbidity and Co-morbidity
• Individual values
• Family context
• Social and cultural context
• Care over time long term perspective
• Unconditional care

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RESEARCH USE SERVICE DATA

• The use of service data is the simple solution to
  the complex problem of primary care research that
  is invariably wrong
• Service data are perfectly capable to answer
  questions researchers do not ask

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PERVERSE INCENTIVES

• RE-EMBURSEMENT
• Income perspective
• Prescription
• Unselected home visits, consultations
• Treatment
• Competition

• INTERVENTION
• Patient interest
• Advice, explanation
• Selective home visits consultations
• Prevention
• Collaboration

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WHAT SORT OF DATA?

• Probably both
• Service data
• Constructs to manipulate insurance system .
• Quality of care
• Scientific data
• Yardsticks to fantom benefits for patients
• Clinical research

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BUILDING RESEARCH CAPACITY
Sentinel Practices Practitioners
Involvement Research Institutes Departments of
FM Practice-Based Research Networks
(PBRN) Mentoring Programs
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KINGSTON EXAMPLES OF PBRN SUCCESS

• The Netherlands
• Academic Status
• Guidelines
• Italy (CSeRMEG)
• PPP Study
• South Africa
• HIV/AIDS

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CONCLUSIONS I

• Research, teaching follow practice
• Domain of research teaching
• Clinical field
• Personal relation
• Structure community setting
• Research teaching capacity
• Practice-based networks
• Personal investment (mentorships)
• Practice must take lead

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NORMAN ROCKWELLNORMAN ROCKWELL VISITS A FAMILY
DOCTOR(1947)
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CONCLUSIONS II

• PBRNs Advocacy
• Better, safer, more time health care of people
• Scientific data
• Scientific Input
• Related to research institute or university
• Mentoring of FP - researchers
• Practice must take lead
• Use of data study findings to help practice
• Ownership of FPs/practice of study data