Relationship between patient-perceived quality of primary care and self-reported hospital utilisation in China: A cross-sectional study

BACKGROUND

Reducing avoidable hospital admissions is a global healthcare priority, with optimal primary care recognised as pivotal for achieving this objective. However, in developing systems like China, where primary care is evolving without compulsory gatekeeping, the relationship between patient-perceived primary care quality and hospital utilisation remains underexplored.

OBJECTIVES

This study aimed to explore the association between patient-perceived primary care quality and self-reported hospital utilisation in China.

METHODS

Data were collected from 16 primary care settings. Patient-perceived quality of primary care was measured using the Assessment Survey of Primary Care scale across six domains (first-contact care, continuity, comprehensiveness, accessibility, coordination, and patient-centredness). Hospital utilisation included patient self-reported outpatient visits, hospital admissions, and emergency department (ED) visits in the last six months. Logistic regression analyses were examined associations between self-reported hospital utilisation and perceived primary care quality adjusted for potential confounders.

RESULTS

Of 1,185 patients recruited, 398 (33.6%) reported hospital utilisation. Logistic regression analyses showed that higher total scores for patient-perceived quality of primary care were associated with decreased odds of hospital utilisation (adjusted odds ratio(AOR): 0.417, 95% confidence interval (CI): 0.308-0.565), outpatient visits (AOR: 0.394, 95% CI: 0.275-0.566) and hospital admissions (AOR: 0.496, 95% CI: 0.276-0.891). However, continuity of care was positively associated with ED visits (AOR: 2.252, 95% CI: 1.051-4.825).

CONCLUSION

Enhanced patient-perceived quality of primary care in China is associated with a reduction in self-reported overall hospital utilisation, including outpatient visits and hospital admissions. However, better continuity of care may be associated with increased ED visits. Further research is warranted for precise insights and validation of these findings.

Moving forward after the COVID-19 pandemic: Lessons learned in primary care from the multi-country PRICOV-19 study

BACKGROUND

The COVID-19 pandemic has accentuated the indispensable role of primary care. Objectives: Recognising this, the PRICOV-19 study investigated how 5,489 GP practices across 38 countries (Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kosovo*, Latvia, Lithuania, Luxembourg, Malta, Republic of Moldova, Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, and United Kingdom) adapted their care delivery during the pandemic.

METHODS

Based on a series of discussions on the results of the PRICOV-19 study group, eight recommendations to enhance primary care's preparedness for future crises were formulated and endorsed by EQuiP and WONCA Europe.

RESULTS

The recommendations underscore the importance of recognising and sustaining the substantial strides made in patient safety within GP practices during the pandemic in current daily practices; acknowledging and supporting the pivotal role of GP practices in addressing health inequalities during crises; adopting interprofessional care models to enhance practices' resilience and adaptability to change; supporting training practices; creating healthy working environments; investing in infrastructure that supports adequate and safe care; and increasing funding for research on patient safety and primary care quality to inform evidence-based health policies and fostering international knowledge exchange among healthcare professionals and policymakers.

CONCLUSION

Policymakers, primary care associations, and the broader healthcare system are urged to collaboratively take responsibility and increase support for GP practices to enhance their resilience, adaptability, and capacity to deliver safe and equitable healthcare during future crises.

Could nudges reduce health literacy disparities in CVD prevention? An experiment using alternative messages for CVD risk assessment screening

OBJECTIVE

To explore the effect of SMS nudge messages amongst people with varying health literacy on their intention to get a Heart Health Check.

METHODS

A 3 (Initial SMS: scarcity, regret, or control nudge) x 2 (Reminder SMS: social norm or control nudge) factorial design was used in a hypothetical online experiment. 705 participants eligible for Heart Health Checks were recruited. Outcomes included intention to attend a Heart Health Check and psychological responses.

RESULTS

In the control condition, people with lower health literacy had lower behavioural intentions compared to those with higher health literacy (p = .011). Scarcity and regret nudges closed this gap, resulting in similar intention levels for lower and higher health literacy. There was no interactive effect of the reminder nudge and health literacy (p = .724).

CONCLUSION

Scarcity and regret nudge messages closed the health literacy gap in behavioural intentions compared to a control message, while a reminder nudge had limited additional benefit. Health literacy should be considered in behavioural intervention evaluations to ensure health equity is addressed.

PRACTICE IMPLICATIONS

Results informed a national screening program using a universal precautions approach, where messages with higher engagement for lower health literacy groups were used in clinical practice.

Can the presence of specialized addiction staff in primary health care increase the number of alcohol-related medical consultations - A controlled intervention study

Background

Few individuals with alcohol use disorders receive treatment. Primary care has been suggested as an arena for early treatment for these disorders.

Aim

To evaluate whether the presence of a specialized addiction nurse can increase alcohol-related physician consultations in a primary care setting.

Method

This controlled intervention study included one intervention and one control primary care unit in Malmö, Sweden. At the intervention unit, an addiction nurse experienced in alcohol use disorder treatment was present 20 h weekly for 12 months. At both units, an educational lecture on alcohol use disorders was given at study start. The outcome was physicians' monthly number of alcohol-related diagnostic codes. Data were compared between intervention and control units using Poisson Regression. Eight statistical models were analyzed and Akaike information criterion was used to select the final model.

Results

The intervention was significantly associated with an increased number of registered alcohol-related diagnostic codes (risk ratio 1.33, 95 confidence interval 1.08-1.62). However, in sensitivity analyses, such a slope effect was more uncertain and no step effect was seen. A significant association was seen between the educational lecture and an increase in the number of registered alcohol-related codes at the sites (risk ratio 2.47, 1.37-4.46).

Conclusion

The presence of specialized addiction staff in a primary healthcare setting might increase the number of alcohol-related physician consultations in primary care, although more research is needed. An educational lecture about alcohol use disorders could be a simple but effective intervention to increase alcohol-related physician consultations in primary care.

Effectiveness of Nutritional Intervention Led by Clinical Dietitian in Patients at Risk of Malnutrition at the Primary Healthcare Level in Slovenia - Evaluation Study

Introduction

Clinical dietitians play a crucial role in the nutritional support of patients at risk of malnutrition in primary care settings. The study aimed to evaluate the effect of an individualized nutritional intervention on clinically relevant outcomes for patients with chronic disease at nutritional risk.

Methods

A longitudinal evaluation study was conducted in two Slovenian primary health centres. We used pre-test and post-test design. Patients with chronic disease were screened using the Malnutrition Universal Screening Tool and additional risk factors (≥70 years and BMI <22 kg/m2; lower food intake in the last five days). Patients at nutritional risk were referred to a clinical dietitian for individual nutritional intervention. The effect of the nutritional intervention was assessed six months after the patients' first visit with a clinical dietitian.

Results

The sample included 94 patients. Nutritional risk was reduced significantly in high-risk and moderate-risk patients. In a subgroup of patients with a MUST score ≥1 (77 patients), body weight, BMI, Fat-Free Mass Index (FFMI), energy intake, and protein intake increased significantly (p<0.001). At the same time, the phase angle significantly increased (p<0.001), but there were no statistically significant changes in the improvement of grip strength. In a subgroup of patients with MUST score 0 (17 patients), we observed an increase in their median daily energy intake (p<0.001) and median protein intake (p=0.003).

Conclusion

Nutritional intervention delivered by a clinical dietitian improved patients' nutritional intake and nutritional and functional status.

Social needs screening in primary care: A tool in the fight for health equity?

Progress on addressing health inequalities is slow and in many places around the world the gap between the privileged and the disadvantaged is widening. This is driven largely by an unfair and unequal distribution of the social determinants of health. While upstream policy and agenda commitment is needed to improve social determinants of health at a population level, healthcare also has a role. Currently social information is sporadically collected and used in healthcare. Improving our understanding of social problems is crucial in targeting services and to reduce the overreliance on area-level measures of deprivation. This has the potential to improve patient care as well as more accurately capture socio-economic disadvantage. Here we argue that there is a role for primary care in screening for social needs to help address inequalities. Social needs screening, more commonly used in North America than Europe, aims to systematically collect social information in health and care settings. Healthcare professionals ask patients about social issues including employment, finances, housing, education and social isolation and this information is used to prompt referral to community services to address any need identified. Social needs screening has potential to address negative impacts of social determinants of health at an individual and population level. Providing a reliable measure of social need, screening gives healthcare professionals an opportunity to tailor and improve quality of care for patients and offer individualised support. It has been shown to improve individual social and health outcomes and positively impact healthcare utilisation. At a population level, social needs screening can improve the data on social determinants of health and therefore support policy makers and service delivery leaders to target resources and services more effectively to the communities most in need. Implementing social needs screening must take account of local healthcare service capacity and available community resources but where sustainable, effective programmes can be introduced, the potential benefits are manifold. While primary care alone cannot solve the root causes of health inequalities, we argue it could be a powerful actor in the fight for health equity.

Cancer follow-up in primary care after treatment with curative intent: Views of patients with breast and colorectal cancer

OBJECTIVE

Increased cancer survival leads to more patients requiring oncological follow-up. Debate about how best to coordinate this care has led to the proposed involvement of general practitioners (GPs) rather than continued reliance on hospital care. However, we still require patient opinions to inform this debate.

METHODS

This qualitative interview study explored opinions about organization of follow-up care of patients treated curatively for breast and colorectal cancer. Thematic analysis was applied.

RESULTS

We interviewed 29 patients and identified three themes concerning care substitution: "benefits and barriers," "requirements," and "suitable patient groups." Benefits included accessibility, continuity, contextual knowledge, and psychosocial support. Barriers included concerns about cancer-specific expertise of GPs and longer waiting times. Requirements were sufficient time and remuneration, sufficient training, clear protocols, and shared-care including efficient communication with specialists.

CONCLUSIONS

According to patients with cancer, formal GP involvement appears feasible, although important barriers must be overcome before instituting care substitution. A possible solution are personalized follow-up plans based on three-way conversations with the specialist and the GP after the initial hospital care.

PRACTICE IMPLICATIONS

With adequate training, time, and remuneration, formal GP involvement could ensure more comprehensive care, possibly starting with less complex cases.

Primary Care and Health Care of Transgender and Gender-Diverse Older Adults

Clinicians working with older transgender and gender-diverse (TGD) individuals need to acquire the necessary knowledge and skills to provide care that is high quality and culturally appropriate. This includes supporting patients in their exploration of gender and attainment of gender-affirming medical interventions. Clinicians should strive to create environments that are inclusive and safe, and that will facilitate health care access and build constructive provider-patient relationships. Clinicians should be aware of best practices, including that age-appropriate health screenings should be anatomy based, and ensure that TGD older adults on gender-affirming hormone therapy (GAHT) receive ongoing laboratory monitoring and physical assessments, including serum hormone levels and biomarkers. Older TGD adults underutilize advance care planning, and need individualized assessments that consider their unique family structures, social support, and financial situation. End-of-life care services should ensure that TGD individuals are treated with dignity and respect.

Facing the digital frontier: exploring user acceptance of electronic health records in an urban, rural and remote setting in the Philippines

OBJECTIVES

A thorough understanding of user needs and behavioural intent-to-use underpins the development of a responsive health information system. This study aimed to examine health workers' intent-to-use an electronic health record (EHR) system in an urban, rural and remote setting in the Philippines.

METHODS

Following the Unified Theory of Acceptance and Use of Technology framework, user acceptance and the factors influencing intent-to-use the EHR were examined through a self-administered questionnaire. A total of 128 EHR users, comprising physicians, nurses, midwives, barangay health workers and administrative staff, were surveyed. Median scores for each domain were compared across the sites using the Kruskal-Wallis test. Ridge regression analysis was used to identify factors associated with behavioural intent-to-use.

RESULTS

Over 94% of users across all sites reported their intent-to-use the EHR in the near future. Of the seven predictor variables examined, only self-efficacy was found to be significantly associated with behavioural intent-to-use. Intent-to-use the EHR increased by 31% (p=0.007) for each unit increase in self-efficacy score among participants.

DISCUSSION

Acceptance was high across the three sites, with self-efficacy being a predictor of intent-to-use the technology. This suggests that users are more likely to adopt an EHR if they believe they have the capacity to successfully navigate the technology and perform their designated tasks with it.

CONCLUSION

Co-producing interventions with primary care providers is crucial in sustaining EHR systems. Rather than developing a technology based on the surveillance needs of policymakers, an EHR developed from the grassroots was shown to be well-received by end-users.

Homecare workers - an untapped resource in preventing emergency department visits among older individuals? A qualitative interview study from Sweden

BACKGROUND

Older individuals with functional decline and homecare are frequent visitors to emergency departments (ED). Homecare workers (HCWs) interact regularly with their clients and may play a crucial role in their well-being. Therefore, this study explores if and how HCWs perceive they may contribute to the prevention of ED visits among their clients.

METHODS

In this qualitative study, 12 semi-structured interviews were conducted with HCWs from Sweden between July and November 2022. Inductive thematic analysis was used to identify barriers and facilitators to prevent ED visits in older home-dwelling individuals.

RESULTS

HCWs want to actively contribute to the prevention of ED visits among clients but observe many barriers that hinder them from doing so. Barriers refer to care organisation such as availability to primary care staff and information transfer; perceived attitudes towards HCWs as co-workers; and client-related factors. Participants suggest that improved communication and collaboration with primary care and discharge information from the ED to homecare services could overcome barriers. Furthermore, they ask for support and geriatric education from primary care nurses which may result in increased respect towards them as competent staff members.

CONCLUSIONS

HCWs feel that they have an important role in the health management of older individuals living at home. Still, they feel as an untapped resource in the prevention of ED visits. They deem that improved coordination and communication between primary care, ED, and homecare organisations as well as proactive care would enable them to add significantly to the prevention of ED visits.

A polygenic risk score added to a QRISK®2 cardiovascular disease risk calculator demonstrated robust clinical acceptance and clinical utility in the primary care setting

AIMS

The aim of the study was to assess the real-world feasibility, acceptability, and impact of an integrated risk tool for cardiovascular disease (CVD IRT, combining the standard QRISK®2 risk algorithm with a polygenic risk score), implemented within routine primary practice in the UK National Health Service.

METHODS AND RESULTS

The Healthcare Evaluation of Absolute Risk Testing Study (NCT05294419) evaluated participants undergoing primary care health checks. Both QRISK2 and CVD IRT scores were returned to the healthcare providers (HCPs), who then communicated the results to participants. The primary outcome of the study was feasibility of CVD IRT implementation. Secondary outcomes included changes in CVD risk (QRISK2 vs. CVD IRT) and impact of the CVD IRT on clinical decision-making. A total of 832 eligible participants (median age 55 years, 62% females, 97.5% White ethnicity) were enrolled across 12 UK primary care practices. Cardiovascular disease IRT scores were obtained on 100% of the blood samples. Healthcare providers stated that the CVD IRT could be incorporated into routine primary care in a straightforward manner in 90.7% of reports. Participants stated they were 'likely' or 'very likely' to recommend the use of this test to their family or friends in 86.9% of reports. Participants stated that the test was personally useful (98.8%) and that the results were easy to understand (94.6%). When CVD IRT exceeded QRISK2, HCPs planned changes in management for 108/388 (27.8%) of participants and 47% (62/132) of participants with absolute risk score changes of >2%.

CONCLUSION

Amongst HCPs and participants who agreed to the trial of genetic data for refinement of clinical risk prediction in primary care, we observed that CVD IRT implementation was feasible and well accepted. The CVD IRT results were associated with planned changes in prevention strategies.

Proactive Polypharmacy Management Using Large Language Models: Opportunities to Enhance Geriatric Care

Polypharmacy remains an important challenge for patients with extensive medical complexity. Given the primary care shortage and the increasing aging population, effective polypharmacy management is crucial to manage the increasing burden of care. The capacity of large language model (LLM)-based artificial intelligence to aid in polypharmacy management has yet to be evaluated. Here, we evaluate ChatGPT's performance in polypharmacy management via its deprescribing decisions in standardized clinical vignettes. We inputted several clinical vignettes originally from a study of general practicioners' deprescribing decisions into ChatGPT 3.5, a publicly available LLM, and evaluated its capacity for yes/no binary deprescribing decisions as well as list-based prompts in which the model was prompted to choose which of several medications to deprescribe. We recorded ChatGPT responses to yes/no binary deprescribing prompts and the number and types of medications deprescribed. In yes/no binary deprescribing decisions, ChatGPT universally recommended deprescribing medications regardless of ADL status in patients with no overlying CVD history; in patients with CVD history, ChatGPT's answers varied by technical replicate. Total number of medications deprescribed ranged from 2.67 to 3.67 (out of 7) and did not vary with CVD status, but increased linearly with severity of ADL impairment. Among medication types, ChatGPT preferentially deprescribed pain medications. ChatGPT's deprescribing decisions vary along the axes of ADL status, CVD history, and medication type, indicating some concordance of internal logic between general practitioners and the model. These results indicate that specifically trained LLMs may provide useful clinical support in polypharmacy management for primary care physicians.

Burden of antimicrobial prescribing in primary care attributable to sore throat: a retrospective cohort study of patient record data

BACKGROUND

Reducing antibiotic use in Australia, and the subsequent impact on antimicrobial resistance, requires multiple, sustained approaches with appropriate resources and support. Additional strategies to reduce antibiotic prescribing include effective vaccines, against pathogens such as Streptococcus pyogenes, the most common bacterial cause of sore throat. As part of efforts towards assessing the benefits of introducing new strategies to reduce antimicrobial prescribing, we aimed to determine the burden of antimicrobial prescribing for sore throat in general practice.

METHODS

General practice activity data from 2013 - 2017 derived from the first 8 practices participating in the 'Primary Care Audit, Teaching and Research Open Network' (Patron) program were analysed according to reason for visit (upper respiratory tract infection, URTI, or sore throat) and antibiotic prescription. The main outcome measures were percentage of sore throat or URTI presentations with antibiotic prescription by age.

RESULTS

A total of 722,339 visits to general practice were made by 65,449 patients; 5.7% of visits were for URTI with 0.8% meeting the more specific criteria for sore throat. 66.1% of sore throat visits and 36.2% of URTI visits resulted in antibiotic prescription. Penicillin, the recommended antibiotic for sore throat when indicated, was the antibiotic of choice in only 52.9% of sore throat cases prescribed antibiotics. Broader spectrum antibiotics were prescribed more frequently in older age groups.

CONCLUSIONS

Frequency of antibiotic prescribing for sore throat is high and broad, despite Australian Therapeutic guideline recommendations. Multiple, sustained interventions to reduce prescribing, including availability of effective S. pyogenes vaccines that could reduce the incidence of streptococcal pharyngitis, could obviate the need to prescribe antibiotics and support ongoing efforts to promote antimicrobial stewardship.

Identifying barriers and facilitators to primary care practitioners implementing health assessments for people with intellectual disability: a Theoretical Domains Framework-informed scoping review

INTRODUCTION

People with intellectual disability experience poorer health outcomes compared with the general population, partly due to the difficulties of accessing preventive care in primary care settings. There is good evidence that structured annual health assessments can enhance quality of care for people with intellectual disability, and their use has become recommended policy in several high-income countries. However, uptake remains low. The Theoretical Domains Framework (TDF) offers a conceptual structure for understanding barriers to implementation and has been usefully applied to inform implementation of health assessments for other high-need groups, but not for people with intellectual disability. We conducted a scoping review of the literature, using the TDF, to identify barriers and facilitators influencing primary care practitioners' implementation of annual health assessments for people with intellectual disability as part of routine primary care practice.

METHODS

This study was conducted according to the JBI methodological approach for scoping reviews. Searches were conducted in Medline (OVID-SP), Embase (OVID-SP), PsycINFO (OVID-SP), CINHAL (EBSCO), Scopus (Elsevier) and Web of Science (Clarivate) for relevant peer-reviewed publications up to May 2023. Screening, full-text review and data extraction were completed by two independent reviewers. Data were extracted and mapped to the TDF to identify relevant barriers and facilitators.

RESULTS

The search yielded 1057 publications, with 21 meeting the inclusion criteria. Mapping data to the TDF, the most frequently identified domains were (a) environmental context and resources, (b) skills, (c) knowledge and (d) emotion. Predominant factors impacting on implementation included practitioners' lack of awareness about health assessments and their identified benefits; inadequate training and experience by practitioners in the delivery of health assessments for people with intellectual disability; insufficient time to provide health assessments; and practitioner burnout.

CONCLUSION

Using a theory-informed behavioural framework, our review aids understanding of the barriers and facilitators to improving the implementation of health assessments as part of routine care for people with intellectual disability. However, there is a clear need for further qualitative research to examine the perceptions of primary care practitioners regarding implementation barriers and facilitators to health assessments in general, including views from practitioners who are not currently undertaking health assessments.

How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the implementation of goal-oriented primary care

BACKGROUND

Although the importance of context in implementation science is not disputed, knowledge about the actual impact of external context variables on implementation processes remains rather fragmented. Current frameworks, models, and studies merely describe macro-level barriers and facilitators, without acknowledging their dynamic character and how they impact and steer implementation. Including organizational theories in implementation frameworks could be a way of tackling this problem. In this study, we therefore investigate how organizational theories can contribute to our understanding of the ways in which external context variables shape implementation processes. We use the implementation process of goal-oriented primary care in Belgium as a case.

METHODS

A qualitative study using in-depth semi-structured interviews was conducted with actors from a variety of primary care organizations. Data was collected and analyzed with an iterative approach. We assessed the potential of four organizational theories to enrich our understanding of the impact of external context variables on implementation processes. The organizational theories assessed are as follows: institutional theory, resource dependency theory, network theory, and contingency theory. Data analysis was based on a combination of inductive and deductive thematic analysis techniques using NVivo 12.

RESULTS

Institutional theory helps to understand mechanisms that steer and facilitate the implementation of goal-oriented care through regulatory and policy measures. For example, the Flemish government issued policy for facilitating more integrated, person-centered care by means of newly created institutions, incentives, expectations, and other regulatory factors. The three other organizational theories describe both counteracting or reinforcing mechanisms. The financial system hampers interprofessional collaboration, which is key for GOC. Networks between primary care providers and health and/or social care organizations on the one hand facilitate GOC, while on the other hand, technology to support interprofessional collaboration is lacking. Contingent variables such as the aging population and increasing workload and complexity within primary care create circumstances in which GOC is presented as a possible answer.

CONCLUSIONS

Insights and propositions that derive from organizational theories can be utilized to expand our knowledge on how external context variables affect implementation processes. These insights can be combined with or integrated into existing implementation frameworks and models to increase their explanatory power.

Towards reducing diagnostic delay in endometriosis in primary care: a qualitative study

BACKGROUND

Due to a heterogeneity of symptoms, a lack of an adequate diagnostic test and a lack of awareness, diagnostic delay in endometriosis in primary care on average amounts to 35 months.

AIM

To determine which interventions are most feasible to reduce time to diagnosis in primary care, focusing on GPs' preferences, the intervention's content, design and implementation.

DESIGN & SETTING

We conducted a qualitative study by performing focus groups with GPs and GP trainees between July and October 2021.

METHOD

Data collection was continued until saturation was obtained. Focus groups were transcribed and openly encoded. Themes were formulated by three independent researchers.

RESULTS

Divided over five focus groups 22 GPs and 13 GP trainees participated. Three themes were formulated: increasing awareness, combined intervention and reaching unaware GPs.Suggestions for a combined intervention strategy were adaptation of guidelines, a diagnostic support tool and compulsory education. To reach unaware GPs, participants felt that education should be offered in regional networks and education for GP trainees should be mandatory. A guideline on menstrual symptoms should be considered, and the term endometriosis should be added to the differential diagnosis paragraphs of existing guidelines. A diagnostic support tool should be linked to a guideline and consist of a flowchart with steps starting with the first presentation of symptoms leading to the diagnosis of endometriosis.

CONCLUSION

According to GPs, a combined intervention strategy consisting of an adapted guideline, a diagnostic support tool and education might be successful interventions in reduction of diagnostic delay in endometriosis.

Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening

BACKGROUND

Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas.

OBJECTIVES

Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC.

METHODS

CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization.

DISCUSSION

Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs.

TRIAL REGISTRATION

National Clinical Trial Identifier: NCT05453630.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Procedural Fairness in Physician-Patient Communication: A Predictor of Health Outcomes in a Cohort of Adults with Overweight or Obesity

BACKGROUND

This study aimed to explore whether patients' perception of procedural fairness in physicians' communication was associated with willingness to follow doctor's recommendations, self-efficacy beliefs, dietary behaviors, and body mass index.

METHODS

This was a secondary analysis of baseline data from 489 primary care patients with a BMI ≥ 25 kg/m2 (43.6% Black, 40.7% Hispanic/Latino, 55.8% female, mean age = 50 years), who enrolled in a weight management study in two New York City healthcare institutions. We conducted ordinary least squares path analyses with bootstrapping to explore direct and indirect associations among procedural fairness, willingness to follow recommendations, self-efficacy, dietary behaviors, and body mass index, while controlling for age and gender.

RESULTS

Serial, multiple mediator models indicated that higher procedural fairness was associated with an increased willingness to follow recommendations which, in turn, was associated with healthier dietary behaviors and a lower BMI (indirect effect =  - .02, SE = .01; 95% CI [- .04 to - .01]). Additionally, higher procedural fairness was associated with elevated dietary self-efficacy, which was, in turn, was associated with healthier dietary behaviors and lower BMI (indirect effect =  - .01, SE = .003; 95% CI [- .02 to - .002]).

CONCLUSIONS

These findings highlight the importance of incorporating procedural fairness in physician-patient communication concerning weight management in diverse primary care patients.

Development and validation of a Context-sensitive Positive Health Questionnaire (CPHQ): A factor analysis and multivariate regression study

BACKGROUND

The concept of Positive Health (PH) has gained increasing attention as a way of measuring individuals' ability to adapt in the face of contextual challenges. However, a suitable measurement instrument for PH that encompasses contextual factors has not yet been developed. This paper responds to this need by developing a Context-specific Positive Health (CPH) measurement instrument that aligns with the Capability Approach (CA).

METHODS

The measurement instrument was developed and tested among a representative sample of 1002 Dutch internet survey panel members with diverse sociodemographic backgrounds. The instrument was developed in two stages: a preparation phase consisting of focus groups and expert consultations, and a validation among a representative panel of Dutch citizens. The goal of the preparation phase, was to pilot test and refine previously proposed Positive Health questionnaires into an initial version of the CPHQ. The validation phase aimed to examine the initial CPHQ's factorial validity using Factor Analysis, and its concurrent validity using Multivariate Regression Analysis.

RESULTS

The developed questionnaire demonstrated adequate factorial and concurrent validity. Furthermore, it explicitly includes an assessment of resilience, this being a key component of PH.

CONCLUSIONS

The introduced measurement tool, the CPHQ, comprises 11 dimensions that we have labeled as follows: relaxation, autonomy, fitness, perceived environmental safety, exclusion, social support, financial resources, political representation, health literacy, resilience, and enjoyment. In this article, we present four major contributions. Firstly, we embedded the measurement in a theoretical framework. Secondly, we focused the questionnaire on a key concept of Positive Health - the "ability to adapt." Thirdly, we addressed issues of health inequality by considering contextual factors. Finally, we facilitated the development of more understandable measurement items.

Pre-COVID-19-pandemic RSV epidemiology and clinical burden in pediatric primary care in Italy: a comparative analysis across two regions for the 2019/2020 season

BACKGROUND

Respiratory syncytial virus (RSV) infection in children under 5 years have a significant clinical burden, also in primary care settings. This study investigates the epidemiology and burden of RSV in Italian children during the 2019/20 pre-pandemic winter season.

METHODS

A prospective cohort study was conducted in two Italian regions. Children with Acute Respiratory Infection (ARI) visiting pediatricians were eligible. Nasopharyngeal swabs were collected and analyzed via multiplex PCR for RSV detection. A follow-up questionnaire after 14 days assessed disease burden, encompassing healthcare utilization and illness duration. Statistical analyses, including regression models, explored associations between variables such as RSV subtype and regional variations.

RESULTS

Of 293 children with ARI, 41% (119) tested positive for RSV. Median illness duration for RSV-positive cases was 7 days; 6% required hospitalization (median stay: 7 days). Medication was prescribed to 95% (110/116) of RSV cases, with 31% (34/116) receiving antibiotics. RSV subtype B and regional factors predicted increased healthcare utilization. Children with shortness of breath experienced a 36% longer illness duration.

CONCLUSIONS

This study highlights a significant clinical burden and healthcare utilization associated with RSV in pre-pandemic Italian primary care settings. Identified predictors, including RSV subtype and symptomatology, indicate the need for targeted interventions and resource allocation strategies. RSV epidemiology can guide public health strategies for the implementation of preventive measures.

Health system implementation of the PROMIS Cognitive Function Screener in the Medicare Annual Wellness Visit: framing as abilities versus concerns

BACKGROUND

Cognitive assessment is a required component of the Medicare Annual Wellness Visit (AWV). In this prospective study, we evaluated acceptability and usefulness of a patient-reported outcome measure (the PROMIS® Cognitive Function Screener, or PRO-CS) to screen for cognitive impairment during the AWV. We compared two versions of the PRO-CS: Abilities and Concerns.

METHODS

We developed PRO-CS Abilities and PRO-CS Concerns using items from the PROMIS Cognitive Function item banks. We partnered with a large health system in Pennsylvania to implement an electronic health record (EHR)-integrated version of the 4-item PRO-CS into their AWV workflow. PRO-CS Abilities was implemented in June 2022 and then replaced with PRO-CS Concerns in October 2022. We used EHR data to evaluate scores on Abilities versus Concerns and their association with patient characteristics. We gathered feedback from providers on experiences with the PRO-CS and conducted cognitive interviews with patients to evaluate their preferences for Abilities versus Concerns.

RESULTS

Between June 2022 and January 2023, 3,088 patients completed PRO-CS Abilities and 2,614 patients completed PRO-CS Concerns. Mean T-scores for Abilities (54.8) were slightly higher (indicating better cognition) than for Concerns (52.6). 10% of scores on Abilities and 13% of scores on Concerns indicated concern for cognitive impairment (T-score < 45). Both Abilities and Concerns were associated with clinical characteristics as hypothesized, with lower scores for patients with cognitive impairment diagnoses and those requiring assistance with instrumental activities of daily living. Abilities and Concerns had similar negative correlations with depression (r= -0.31 versus r= -0.33) and anxiety (r= -0.28 for both), while Abilities had a slightly stronger positive correlation with self-rated health (r = 0.34 versus r = 0.28). In interviews, providers commented that the PRO-CS could be useful to facilitate conversations about cognition, though several providers noted potential limitations of patient self-report. Feedback from patients indicated a preference for PRO-CS Concerns.

CONCLUSIONS

Our findings suggest potential utility of the PRO-CS for cognitive screening in the Medicare AWV. PRO-CS Abilities and Concerns had similar associations with patient clinical characteristics, but the Concerns version was more acceptable to patients.

Procedural skills workshops for primary care physicians in Israel: a comprehensive analysis

BACKGROUND

Some of the most common complaints addressed by primary care physicians (PCPs) require manual procedures, such as lacerations repair, abscesses drainage, ingrown toenails removal, dry needling for myofascial pain syndrome, and Epley maneuver for treating benign paroxysmal positional vertigo (BPPV). The aim of this study was to describe the procedural skills workshops program for PCPs implemented in Maccabi Healthcare Services and to investigate how many PCPs have participated and used the skills since the program's inception in 2017.

METHODS

In this observational study, we followed all participants in courses from 2017 to 2021. We extracted all procedures performed during these years by PCPs who learned the skill in MHS.

RESULTS

During the study period, 620 PCPs participated in workshops for dry needling, soft-tissue and joint injections, BPPV treatment, minor surgical procedures, and spirometry. Most procedures performed were dry needling (average annual number 3,537) and minor surgical procedures (average annual number 361). The average annual use per physician was highest for dry needling (annual average use per physician who used the learned skill was 50.9), followed by soft tissue and joint injections (16.8), minor surgical procedures (14.8), and BPPV treatment (7.5).

CONCLUSION

procedural skills workshops may expand PCPs' therapeutic arsenal, thus empowering PCPs and providing more comprehensive care for patients. Some manual skills, such as dry needling, soft tissue injections, and the Epley maneuver, were more likely to be used by participants than other skills, such as spirometry and soft tissue injections.

Understanding social needs screening and demographic data collection in primary care practices serving Maryland Medicare patients

BACKGROUND

Health outcomes are strongly impacted by social determinants of health, including social risk factors and patient demographics, due to structural inequities and discrimination. Primary care is viewed as a potential medical setting to assess and address individual health-related social needs and to collect detailed patient demographics to assess and advance health equity, but limited literature evaluates such processes.

METHODS

We conducted an analysis of cross-sectional survey data collected from n = 507 Maryland Primary Care Program (MDPCP) practices through Care Transformation Requirements (CTR) reporting in 2022. Descriptive statistics were used to summarize practice responses on social needs screening and demographic data collection. A stepwise regression analysis was conducted to determine factors predicting screening of all vs. a targeted subset of beneficiaries for unmet social needs.

RESULTS

Almost all practices (99%) reported conducting some form of social needs screening and demographic data collection. Practices reported variation in what screening tools or demographic questions were employed, frequency of screening, and how information was used. More than 75% of practices reported prioritizing transportation, food insecurity, housing instability, financial resource strain, and social isolation.

CONCLUSIONS

Within the MDPCP program there was widespread implementation of social needs screenings and demographic data collection. However, there was room for additional supports in addressing some challenging social needs and increasing detailed demographics. Further research is needed to understand any adjustments to clinical care in response to identified social needs or application of data for uses such as assessing progress towards health equity and the subsequent impact on clinical care and health outcomes.

Fall risk factors among poly-medicated older Lebanese patients in primary care settings: a secondary cross-sectional analysis of the "MGPIDP-L project"

BACKGROUND

Falling is a major concern for the health of older adults and significantly affects their quality of life. Identifying the various risk factors and the differences between older patients can be challenging. The objective of this study was to identify the risk factors for falls among polymedicated community-dwelling older Lebanese patients following a medication review.

METHODS

In this analytical cross-sectional study, we examined the risk factors for falls in 850 patients aged ≥ 65 years who were taking ≥ 5 medications daily. The study involved conducting a medication review over the course of a year in primary care settings and using multivariate logistic regression analysis to analyze the data.

RESULTS

Our results showed that 106 (19.5%) of the 850 included patients had fallen at least once in the three months prior to the medication review. Loss of appetite and functional dependence were identified as the most significant predictors of falls ORa = 3.020, CI [2.074-4.397] and ORa = 2.877, CI [1.787-4.632], respectively. Other risk factors for falls included drowsiness ORa = 2.172, CI [1.499-3.145], and the use of beta-blockers ORa = 1.943, CI [1.339-2.820].

CONCLUSION

Our study highlights the importance of addressing multiple risk factors for falls among Lebanese older adults and emphasizes the need for customized interventions and ongoing monitoring to prevent falls and improve health outcomes. This study sheds light on a critical issue in the Lebanese older population and provides valuable insight into the complex nature of falls among poly-medicated Lebanese community-dwelling older adults.

TRIAL REGISTRATION

2021REC-001- INSPECT -09-04.

Disparities in Access to a Regular Primary Care Physician Among First-Generation Migrants with Early Psychosis in Ontario, Canada

Disparities in primary care utilization among migrants with early psychosis may be related to lack of access to a regular primary care physician. This study aimed to investigate access to a regular primary care physician among first-generation migrants with early psychosis. People aged 14-35 years with first onset non-affective psychotic disorder in Ontario, Canada were identified in health administrative data (N = 39,440). Access to a regular primary care physician through enrollment in the year prior to diagnosis was compared between first-generation migrants (categorized by country of birth) and the general population using modified Poisson regression. Most migrant groups had a lower prevalence of regular primary care physician access relative to the general population, particularly migrants from Africa (African migrants: 81% vs. non-migrants: 89%). Adjustment for sociodemographic and clinical factors attenuated these differences, although the disparities for migrants from Africa remained (PR = 0.96, 95%CI = 0.94-0.99). Interventions aimed at improving primary care physician access in migrant groups may facilitate help-seeking and improve pathways to care in early psychosis.

General practitioners' well-being in Belgium: results from the cross-sectional PRICOV-19 study

BACKGROUND

The mental health and well-being of GPs is a critical issue as they play a vital role in providing healthcare services to individuals and communities. Research has shown that GPs often face high levels of stress, burnout, and mental health problems due to their demanding work environment. During the COVID-19 pandemic, GPs faced additional challenges which further impacted their mental health and well-being. This study aims to investigate the impact of systemic work-related stressors on the level of well-being of GPs in Belgium during the pandemic, with a particular emphasis on identifying regional variations between Flanders, Wallonia, and Brussels-Capital.

METHODS

Data were collected with a self-reported online questionnaire from 479 GPs Belgian practices between December 2020 and August 2021 as part of the international PRICOV-19 study that explored the organization of general practices during COVID-19 in 38 countries to guarantee safe, effective, patient-centered, and equitable care. Well-being was evaluated by the Mayo Clinic's expanded 9-item well-being index.

RESULTS

The findings of this study reveal notable regional discrepancies in the degree of well-being experienced by Belgian GPs, with the Walloon region displaying the lowest level of well-being (37%) in a population highly susceptible to professional distress (57%). Among the key stressors contributing to such distress, financial difficulties among patients (p < 0.011), the fee-for-service payment system (p = 0.013), a lack of work-related purpose (p = 0.047), and inadequate work-life balance (p < 0.001) were identified as significant factors. When examining the influence of regional disparities, it was found that the sole significant interaction between work-related stressors and region regarding the probability of experiencing distress was related to the possibility of workload sharing among practice personnel.

CONCLUSION

The findings from this study underscore the imperative for more comprehensive research aimed at scrutinizing the differences in well-being across the three regions in Belgium and identifying the systemic factors that influence the practice environment, as opposed to exclusively concentrating on enhancing individual resilience.

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

Feasibility of diabetes self-management coaching program for individuals with type 2 diabetes in the Ethiopian primary care setting: a protocol for a feasibility mixed-methods parallel-group randomized controlled trial

BACKGROUND

Diabetes mellitus is the third most prevalent chronic metabolic disorder and a significant contributor to disability and impaired quality of life globally. Diabetes self-management coaching is an emerging empowerment strategy for individuals with type 2 diabetes, enabling them to achieve their health and wellness goals. The current study aims to determine the feasibility of a diabetes self-management coaching program and its preliminary effectiveness on the clinical and psychosocial outcomes in the Ethiopian primary healthcare context.

METHODS

The study will employ a mixed-method feasibility randomized controlled trial design. Forty individuals with type 2 diabetes will be randomly allocated to treatment and control groups using block randomization. The primary feasibility outcomes include acceptability, eligibility, recruitment, and participant retention rates, which will be computed using descriptive analysis. The secondary outcomes are self-efficacy, self-care activity, quality of life, and glycated hemoglobin A1c. For normally distributed continuous variables, the mean difference within and between the groups will be determined by paired sample Student t-test and independent sample Student t-test, respectively. Non-parametric tests such as the Mann-Whitney U test, the Wilcoxon signed rank test, and the Friedman analysis of variance test will determine the median difference for variables that violated the normality assumption. A repeated measure analysis of variance will be considered to estimate the variance between the baseline, post-intervention, and post-follow-up measurements. A sample of 10 volunteers in the treatment group will participate in the qualitative interview to explore their experience with the diabetes self-management coaching program and overall feasibility. The study will follow a qualitative content analysis approach to analyze the qualitative data. Qualitative and quantitative findings will be integrated using a joint display technique.

DISCUSSION

Evidence reveals diabetes self-management coaching programs effectively improve HbA1c, self-efficacy, self-care activity, and quality of life. This study will determine the feasibility of a future large-scale randomized controlled trial on diabetes self-management coaching. The study will also provide evidence on the preliminary outcomes and contribute to improving the diabetes self-management experience and quality of life of individuals with type 2 diabetes.

TRIAL REGISTRATION

The trial was registered online at ClinicalTrials.gov on 12/04/2022 and received a unique registration number, NCT05336019, and the URL of the registry is https://beta.

CLINICALTRIALS

gov/study/NCT05336019 .

Patient perspectives on pharmacogenomic (PGx) testing for antidepressant prescribing in primary care: a qualitative description study

Many patients with major depressive disorder (MDD) try multiple antidepressants before finding one that works well and is tolerable. Pharmacogenomic (PGx) testing was developed to facilitate more efficacious prescribing. This technology has not been robustly implemented clinically. Patient perspectives are critical to policy decisions, but the views of patients with MDD about the use of PGx testing to guide antidepressant prescribing have not been extensively examined, particularly in publicly funded healthcare systems. The purpose of this qualitative description study was to produce actionable patient perspectives evidence to inform future technology assessment of PGx testing. We conducted semi-structured interviews with 21 adults with MDD for which antidepressants were indicated in Ontario, Canada, and used the Ontario Decision Determinants Framework to conduct an unconstrained deductive content analysis. Patients expressed views about the overall clinical benefit of PGx testing in depression care, preferences for deployment of testing, perspectives on ethical considerations, opinions about equity and patient care, and beliefs regarding the feasibility of adopting PGx testing into the healthcare system. They also worried about the possibility of conflicts of interest between PGx test manufacturers and pharmaceutical companies. This study provides policymakers with patient priorities to facilitate the development of patient-centred policies. It highlights that formal adoption of PGx testing into the healthcare system requires a focus on equity of access and health outcomes.

Adapting care provision in family practice during the COVID-19 pandemic: a qualitative study exploring the impact of primary care reforms in four Canadian regions

BACKGROUND

Over the past two decades, Canadian provinces and territories have introduced a series of primary care reforms in an attempt to improve access to and quality of primary care services, resulting in diverse organizational structures and practice models. We examine the impact of these reforms on family physicians' (FPs) ability to adapt their roles during the COVID-19 pandemic, including the provision of routine primary care.

METHODS

As part of a larger case study, we conducted semi-structured qualitative interviews with FPs in four Canadian regions: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. During the interviews, participants were asked about their personal and practice characteristics, the pandemic-related roles they performed over different stages of the pandemic, the facilitators and barriers they experienced in performing these roles, and potential roles FPs could have filled. Interviews were transcribed and a thematic analysis approach was applied to identify recurring themes in the data.

RESULTS

Sixty-eight FPs completed an interview across the four regions. Participants described five areas of primary care reform that impacted their ability to operate and provide care during the pandemic: funding models, electronic medical records (EMRs), integration with regional entities, interdisciplinary teams, and practice size. FPs in alternate funding models experienced fewer financial constraints than those in fee-for-service practices. EMR access enhanced FPs' ability to deliver virtual care, integration with regional entities improved access to personal protective equipment and technological support, and team-based models facilitated the implementation of infection prevention and control protocols. Lastly, larger group practices had capacity to ensure adequate staffing and cover additional costs, allowing FPs more time to devote to patient care.

CONCLUSIONS

Recent primary care system reforms implemented in Canada enhanced FPs' ability to adapt to the uncertain and evolving environment of providing primary care during the pandemic. Our study highlights the importance of ongoing primary care reforms to enhance pandemic preparedness and advocates for further expansion of these reforms.

Exploring home rehabilitation therapists' experiences of supporting older persons to physical exercise after acute hospitalization: a qualitative interview study

PURPOSE

After hospitalization, older persons may face a decline in physical function and daily independence. In-hospital exercise interventions can mitigate this decline, and continued support from primary healthcare post-discharge may enhance sustainability. This study aimed to explore home rehabilitation therapists' experiences of supporting physical exercise after acute hospitalization, including exercise programs initiated during hospital stay.

METHODS

This qualitative study was conducted alongside a randomized-controlled trial to investigate prerequisites for a transitional care intervention. Twelve interviews were conducted with physiotherapists, occupational therapists, and managers across seven rehabilitation therapy services in Stockholm, Sweden. Data were analyzed using reflexive thematic analysis.

RESULTS

The analysis generated the theme Striving for individualized support for physical exercise, although limited resources and a fragmented home care risk to direct support away from those who need it the most. It was based on four subthemes: The starting point is always the patient's current needs, goals, and prerequisites, Continuing the exercise initiated during hospitalization by adapting it to the patient's situation at home, Work premises not tailored to patients with complex care needs, and A home care organization that lacks coordination and unified purpose.

CONCLUSIONS

Interventions supporting older persons to physical exercise after acute hospitalization need to be tailored to the individual, support motivation, and be adapted to the patient's home situation. Challenges may arise when care recourses lack alignment with the patients' needs, and when the collaboration among care providers is limited. The findings contribute valuable insights for future studies incorporating transitional care interventions in similar context.

Factors for the integration of prevention in primary care: an overview of reviews

BACKGROUND

The global burden of non-communicable diseases is increasing and the need for prevention is huge. Policies have yet to produce results and prevention indicators remain low. Primary care (PC) represents an opportunity to optimise the practice of prevention, but GPs are coming up against barriers that are holding back their prevention practices.

AIM

The aim of this overview of reviews is to identify the barriers and facilitators for the implementation of routine prevention practices in PC.

DESIGN AND SETTING

This study is an international overview of reviews focusing on the integration of prevention in PC settings.

METHOD

The search was conducted on July 2022 in MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. Included reviews are: systematic reviews or scoping reviews adopting a systematic approach.

RESULTS

The 35 reviews included identify multiple barriers and facilitators related to the integration of prevention in PC. These factors are very heterogeneous as regards their source (the patient, the professional and the health system) and their level of action (individual, organisational or contextual). The results show the need to organise PC at the professional level (e.g. in training), at the local level (e.g. partnerships) and at the political level (e.g. funding model).

CONCLUSION

The factors influencing the integration of prevention in PC are multiple and act at different levels (individual, organisational and health system level). Organisation factors play a major role and seem to be a means of overcoming the difficulties encountered by healthcare professionals in developing preventive practices.

Unexpected gaps in knowledge of familial hypercholesterolaemia among Dutch general practitioners

BACKGROUND

Familial hypercholesterolaemia (FH) warrants early diagnosis to prevent premature atherosclerotic cardiovascular disease (CVD). However, underdiagnosis and undertreatment of FH persist. This study aimed to assess the knowledge and practice of FH care among general practitioners (GPs) in the Netherlands.

METHODS

An internationally standardised, online questionnaire was sent to Dutch GPs between February 2021 and July 2022. The survey assessed knowledge and awareness of FH, encompassing general familiarity, awareness of management guidelines, inheritance, prevalence, CVD risk, and clinical practice related to FH. Comparative analysis was performed using data on primary care physicians from Western Australia, the Asia-Pacific region and the United Kingdom.

RESULTS

Of the 221 participating GPs, 62.4% rated their familiarity with FH as above average (score > 4 on a 1-7 scale), with 91.4% considering themselves familiar with FH treatment and referral guidelines. Correct identification of the FH definition, typical lipid profile, inheritance pattern, prevalence and CVD risk was reported by 83.7%, 87.8%, 55.7%, 19.5%, and 13.6% of the respondents, respectively. Of the participants, 58.4% answered fewer than half of the 8 knowledge questions correctly. Dutch GPs reported greater FH familiarity and guideline awareness compared with their international counterparts but exhibited similar low performance on FH knowledge questions.

CONCLUSION

Despite the Netherlands' relatively high FH detection rate, substantial knowledge gaps regarding FH persist among Dutch GPs, mirroring global trends. Enhanced FH education and awareness in primary care are imperative to improve FH detection and ensure adequate treatment. Targeting the global suboptimal understanding of FH might require international efforts.

Adapting standardized patient training to improve patients' understanding and preparedness for health care encounters

OBJECTIVE

To examine the impact of standardized patient (SP) training on SPs' real-life healthcare encounters and explore whether SP training elements can be adapted to increase actual patients' understanding, communication and participation in a patient-centered care model.

METHODS

Data were collected from surveys and focus groups with standardized patients and a survey of primary care physicians. Findings were used to create an educational video with pre- and post-viewing surveys of patients' understanding of engagement strategies and plans to use them in future encounters.

RESULTS

SPs reported medical visits were more productive because of their ability to understand the visit's framework; crediting their SP training. Patients reported the video will help in planning future medical visits by providing information that increases their understanding of their role in the care process.

CONCLUSIONS

SPs' understanding of the visit and its impact on knowledge, skills and affective domains can be transferred to patients in the form of specific strategies that enhance communication and patient participation during medical visits.

PRACTICE IMPLICATIONS

A brief educational intervention for patients using SPs' understanding of the medical visit may contribute to enhanced patient participation in future health care encounters and could increase patient engagement in patient-centered models of care.

Implementation and Evaluation of Educational Workshops to Increase Primary Care Provider and Medical Student Comfort in Psychiatric Care

OBJECTIVE

Mental health treatment is often initiated in primary care settings, but many primary care providers (PCPs), residents, and medical students report discomfort in managing psychiatric conditions. This study evaluated the effect of an educational workshop that featured an evidence-based psychopharmacology clinical decision support tool (CDST) on trainee confidence and willingness to treat psychiatric conditions.

METHODS

Participants completed pre- and post-workshop surveys. Nine months after the workshop, a subset of trainees participated in a focus group.

RESULTS

Of the participants, 62.5% of the obstetrics-gynecology (OB-GYN) resident physicians (10/16) and 100% of the medical students (18/18) completed both pre- and post-surveys. Following the workshop, OB-GYN resident physicians reported significantly improved confidence in treating psychiatric disorders (p < 0.001), sense of having psychiatric support tools (p < 0.001), and knowledge of treating psychiatric disorders (p = 0.021). Medical students reported significantly improved confidence in treating psychiatric disorders (p < 0.001), willingness to devise treatment plans for psychiatric disorders (p = 0.024), sense of having psychiatric support tools (p < 0.001), knowledge of treating psychiatric disorders (p < 0.001), and comfort in presenting a psychiatric treatment plan to an attending (p = 0.003). Most focus group participants (93.75%; 15/16) reported that they continued to use the CDST, and it increased their confidence in formulating psychiatric treatment plans.

CONCLUSIONS

These findings suggest that educational workshops that introduce high-quality psychopharmacology CDSTs may be an effective method for improving provider comfort in treating psychiatric disorders.

Identifying effective vaccine champions: Findings from a national survey of primary care professionals

BACKGROUND

Vaccine champions are common in primary care, but little is known about which champions are effective.

METHODS

In 2022, we surveyed 2,144 US primary care professionals (PCPs) who reported working with vaccine champions. Respondents rated the champion with whom they worked most closely on their effectiveness at improving vaccination rates.

RESULTS

About half (49 %) of PCPs perceived their closest champion as highly effective. PCPs perceived advanced practice providers and nursing staff as highly effective somewhat more often than physicians (52 % and 58 % vs 43 %, p <.001). Other correlates of perceived effectiveness included being a formally appointed versus informal champion, working extremely versus less closely with PCPs, and using a high (4-5) versus low (0-1) number of implementation strategies to improve vaccination rates (all p <.001).

CONCLUSIONS

Results suggest vaccine champions may benefit from having formal roles and opportunities to work closely with colleagues to improve vaccination rates using multiple strategies.

Antibiotic Stewardship Interventions for Urinary Tract Infections in Outpatient Settings: A Narrative Review

Inappropriate antibiotic choice or duration of therapy for urinary tract infections (UTIs) in outpatients is common and is a major contributor to antibiotic overuse. Most studies on outpatient antibiotic stewardship for UTIs follow a pre-design or post-design with a multifaceted intervention; these trials generally have found improvement in appropriateness of antibiotic use for UTI. Audit and feedback was one of the most commonly employed strategies across these trials but may not be sustainable. Future research on antibiotic stewardship for UTIs in outpatients should measure both effectiveness and implementation success.

Developing a core outcome set for evaluating medication adherence interventions for adults prescribed long-term medication in primary care

BACKGROUND

Approximately half of people prescribed medications do not take them as prescribed. There is a significant unmet need regarding the barriers to medication adherence not being addressed in primary care. There is no agreement on which outcomes should be measured and reported in trials of medication adherence interventions.

OBJECTIVE

To develop a core outcome set (COS) for trials of medication adherence interventions in primary care for adults prescribed medications for long-term health conditions.

METHODS

A list of potentially relevant outcomes from the literature was developed. Using a two-round Delphi survey of stakeholder groups representing patients and their carers; primary care staff; and academic researchers with an interest in medication adherence; each outcome was scored in terms of importance for determining the effectiveness of medication adherence interventions in primary care. This was followed by two consensus workshops, where importance, as well as feasibility and acceptability of measurement, were considered in order to finalise the COS.

RESULTS

One hundred and fifty people took part in Delphi Round 1 and 101 took part in Round 2. Eight people attended the workshops (four attendees per workshop). Seven outcomes were identified as most important, feasible and acceptable to collect in medication adherence trials: Health-related quality of life, number of doses taken, persistence with medicines, starting (initiating) a medicine, relevance of the medication adherence intervention for an individual, mortality, and adverse medicine events.

CONCLUSIONS

This COS represents the minimum outcomes that should be collected and reported in all medication adherence trials undertaken in primary care. When developing and finalizing the COS, feasibility and acceptability of collection of outcomes has been considered. In addition to the COS, medication adherence trials can choose to include outcomes to suit their specific context such as the health condition associated with their medication adherence intervention.

[Community reorientation of primary care in a health area: ROCAP project]

AIM

Evaluate the effectiveness of an intervention to incorporate group and community activities on a sustained basis in all the Basic Health Zones (ZBS) of a health area.

DESIGN

During January and February 2019, two members of the research team traveled to each ZBS to interview the medical and nursing coordinators who had previously received an ad hoc initial assessment questionnaire (QAI) by email.

PLACE

The scope is the 11 ZBS of a health area.

PARTICIPANTS

The study population is the ZBS and the respective teams represented by the medical and nursing coordinations.

INTERVENTIONS

Promote a community health commission, carry out training actions, record activities in clinical history and incorporate management objectives.

MAIN MEASUREMENTS

Quantitative and qualitative analysis was carried out pre and post after the first year of intervention.

RESULTS

In the pre-evaluation: 6 primary care teams (EAP) reported having group activities, 4 were participating in local action projects, 4 had a professional referent for community activities, 3 participated in projects with populations in vulnerable situations and 4 stated have specific meetings on community health. After the intervention: 11 EAPs had group activities, 8 had a reference professional, 6 were participating in local action projects, 4 collaborated in projects with vulnerable populations and 5 held meetings on community health.

CONCLUSIONS

The intervention proved effective after its first year of implementation, since all the EAPs carried out group activities and collaborated with the local councils in the area; the majority had leading professionals in community care and, to a lesser extent, participation in local action projects and in vulnerable populations increased.

Challenges and opportunities in preparing dentists for primary care

With the growing understanding of the relationship between oral and systemic diseases there is an increasing interest in integrating dental providers more completely into the health care delivery system. Technology advancements in traditional dental disease diagnosis and management as well as in salivary diagnostics for systemic disease provide great opportunities for the profession but numerous challenges for dental educators who are impacted by the intersection of numerous, sometimes competing interests. While economic factors play a significant role in curricular innovation and change, in the United States the accrediting process for dental education programs can be an equally vexing challenge. Movement away from primarily a competency-based assessment model to a model focusing on the establishment of Entrustable Professional Activities (EPAs) may provide a needed catalyst to enhance dental education to graduate dentists who embrace an expanded role as primary care providers.

Assessing efficacy of a web-based smoking cessation tool - QuitAdvisorMD: Protocol for a practice-based, clustered, randomized control trial

Background

Smoking remains the leading cause of preventable death, yet physicians inconsistently provide best-practices cessation advice to smokers. Point-of-care digital health tools can prompt and assist physicians to provide improved smoking cessation counseling. QuitAdvisorMD is a comprehensive web-based counseling and management digital health tool designed to guide smoking cessation counseling at the point-of-care. The tool enables clinicians to assess patient readiness to change and then deliver stage-appropriate interventions, while also incorporating Motivational Interviewing techniques. We present the research protocol to assess the efficacy of QuitAdvisorMD to change frequency and quality of smoking cessation counseling and its effect on patient quit rates.

Methods

A practice-based, clustered, randomized controlled trial will be used to evaluate QuitAdvisorMD. Cluster design will be used where patients are clustered within primary care practices and practices will be randomized to either the intervention (QuitAdvisorMD) or control group. The primary outcome is frequency and quality of clinician initiated smoking cessation counseling. Secondary outcomes include, 1) changes in physician knowledge, skills and perceived self-efficacy in providing appropriate stage-based smoking cessation counseling and 2) patient quit attempts. Analyses will be conducted to determine pre- and post-test individual clinician outcomes and between intervention and control group practices for patient outcomes.

Conclusion

Results from this study will provide important insights regarding the ability of an integrated, web-based counseling and management tool (QuitAdvisorMD) to impact both the quality and efficacy of smoking cessation counseling in primary care settings.

Involving community pharmacists in interprofessional collaboration in primary care: a systematic review

BACKGROUND

The World Health Organization supports interprofessional collaboration in primary care. On over the past 20 years, community pharmacists had been taking a growing number of new responsibilities and they are recognized as a core member of collaborative care teams as patient-centered care providers. This systematic review aimed to describe interprofessional collaboration in primary care involving a pharmacist, and its effect on patient related outcomes.

METHODS

A systematic review of randomized controlled trials cited in the MEDLINE, EMBASE, PsycInfo and CINAHL in English and French was conducted from inception to November 2022. Studies were included if they described an intervention piloted by a primary care provider and included a pharmacist and if they evaluated the effects of intervention on a disease or on patient related outcomes. The search generated 3494 articles. After duplicates were removed and titles and abstracts screened for inclusion, 344 articles remained.

RESULTS

Overall, 19 studies were included in the review and assessed for quality. We found 14 studies describing an exclusive collaboration between physician and pharmacist with for all studies a three-step model of pharmacist intervention: a medication review, an interview with the patient, and recommendations made to physician. Major topics in the articles eligible for inclusion included cardiovascular diseases with blood pressure, diabetes, dyslipidemia, and risk of cardiovascular diseases. Positive effects concerned principally blood pressure.

CONCLUSIONS

Collaboration involving pharmacists is mainly described in relation to cardiovascular diseases, for which patient-centered indicators are most often positive. It underscores the need for further controlled studies on pharmacist-involved interprofessional collaboration across various medical conditions to improve consensus on core outcomes measures.

Type 2 diabetes-related health measures during the initial COVID-19 surge at an academic internal medicine practice

The COVID-19 pandemic disrupted chronic disease management in the United States and across the world. This study reports minimal effects of the initial COVID-19 surge on body mass index, blood pressure, cholesterol, and blood glucose control in ambulatory general internal medicine patients with Type 2 diabetes at a single academic center.

The effectiveness of a suicide prevention program in primary care clinics supported by community public health resources: A difference-in-differences analysis

The importance of appropriate and intensive follow-up management for individuals identified with suicide risk through screening is highlighted. The Link between Primary Care Clinic and Public Health Resources Intervention(LinkPC-PH), a suicide prevention program in primary care clinics supported by community public health resources, was implemented at the district level in 2017. The purpose of the present study is to evaluate the effectiveness of the LinkPC-PH intervention by comparing suicide rates before(2014-2016) and after(2017-2019) implementation of the intervention using a difference-in-differences design. The LinkPC-PH comprises several dimensions of intervention including screening, risk assessment of suicidality, and referral in primary care clinics and crisis contact within 24 hours, case management, and safety planning led by public health professionals. After adjustment for district-level confounders, an intervention-implemented district had 2.87 fewer suicide deaths per 100,000 people in a population sample at post-intervention than would have been expected from the same trend in suicide rates as non-implemented intervention districts. In other words, the suicide rate in the intervention area decreased by 25% following the intervention. These results empirically substantiate suicide prevention programs in primary care clinics by community public health resources for reduced suicide rates to support effective community-based suicide prevention interventions.

Psychotropic medicine use without current or prior medical advice, storage at home and association with perceived stress in a primary health care setting in Greece

OBJECTIVE

Psychotropic medicines use alters according to socio-economic factors and perceived stress. The study aimed to assess the prevalence of use of psychotropic medicines and supplements (PMS) without medical advice, including storage at home, and its relationship with socio-demographic characteristics and perceived stress in primary care patients.

MATERIALS AND METHODS

A cross-sectional sample of adult attendees in an urban primary care unit in Crete, Greece, were surveyed during regularly scheduled appointments during a three-week period in October 2020. A questionnaire was distributed to investigate PMS use during the last 12 months. The validated Greek version of Perceived Stress Scale (PSS-14) was adopted to measure perceived stress.

RESULTS

Of 263 respondents (mean age 46.3±14.5 years; 66.5% females), 101 (38.4%; 95%CI 33.1-43.7%) recalled having psychotropic medicines stored at home cabinets and 72 (27.4%; 95%CI 22.4-32.3%) reported using PMS without medical advice in the last 12 months.

CONCLUSIONS

This study revealed a high prevalence of PMS use without medical advice, including storage at home. People>59 years of age, experiencing irregular sleep and scoring high in PSS, displayed increased prevalence of storing PMS at home or using them without medical advice. The findings could potentially inform primary care providers to focus on patients most likely to be users of PMS without medical advice.

Effect of the COVID-19 pandemic on mental health visits in primary care: an interrupted time series analysis from nine INTRePID countries

Background

The COVID-19 pandemic impacted mental health disorders, affecting both individuals with pre-existing conditions and those with no prior history. However, there is limited evidence regarding the pandemic's impact on mental health visits to primary care physicians. The International Consortium of Primary Care Big Data Researchers (INTRePID) explored primary care visit trends related to mental health conditions in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden, and the USA.

Methods

We conducted an interrupted time series analysis in nine countries to examine changes in rates of monthly mental health visits to primary care settings from January 1st, 2018, to December 31st, 2021. Sub-group analysis considered service type (in-person/virtual) and six categories of mental health conditions (anxiety/depression, bipolar/schizophrenia/other psychotic disorders, sleep disorders, dementia, ADHD/eating disorders, and substance use disorder).

Findings

Mental health visit rates increased after the onset of the pandemic in most countries. In Argentina, Canada, China, Norway, Peru, and Singapore, this increase was immediate ranged from an incidence rate ratio of 1·118 [95% CI 1.053-1.187] to 2.240 [95% CI 2.057-2.439] when comparing the first month of pandemic with the pre-pandemic trend. Increases in the following months varied across countries. Anxiety/depression was the leading reason for mental health visits in most countries. Virtual visits were reported in Australia, Canada, Norway, Peru, Sweden, and the USA, accounting for up to 40% of the total mental health visits.

Interpretation

Findings suggest an overall increase in mental health visits, driven largely by anxiety/depression. During the COVID-19 pandemic, many of the studied countries adopted virtual care in particular for mental health visits. Primary care plays a crucial role in addressing mental ill-health in times of crisis.

Funding

Canadian Institutes of Health Research grant #173094 and the Rathlyn Foundation Primary Care EMR Research and Discovery Fund.

Real-World Use of Oral and Subcutaneous Semaglutide in Routine Clinical Practice in the UK: A Single-Centre, Retrospective Observational Study

INTRODUCTION

Semaglutide, the only glucagon-like peptide-1 receptor agonist (GLP-1 RA) available in subcutaneous and oral formulation for treatment of type 2 diabetes (T2D), has demonstrated clinically significant improvements in glycaemic control and weight in clinical trials. This study aimed to gain insights into the use of both formulations and evaluate their clinical effectiveness in a secondary care clinic in Wales.

METHODS

This was a retrospective observational analysis of adults with T2D initiated on oral or subcutaneous semaglutide. Changes from baseline in glycated haemoglobin (HbA1c), weight and other metabolic parameters were evaluated.

RESULTS

At baseline, participants (n = 103) had a mean age of 57.3 years, mean HbA1c of 79.1 mmol/mol (9.38%), mean weight of 111.8 kg and body mass index (BMI) of 39.6 kg/m2 (no statistically significant differences between oral and subcutaneous groups). At 6-month follow-up, statistically significant improvements in HbA1c (- 19.3 mmol/mol [- 1.77%] and - 20.8 mmol/mol [- 1.90%]), body weight (- 9.0 kg and - 7.2 kg), and BMI (- 3.3 kg/m2 and - 2.5 kg/m2) were observed for oral and subcutaneous semaglutide, respectively. No statistically significant differences between the formulations were observed, and safety profiles were comparable.

CONCLUSIONS

Both formulations of semaglutide provided clinically and statistically significant reductions in HbA1c and weight in real-world practice. Oral GLP-1 RA may offer a practical and effective option for the management of T2D.

Effectiveness of a training program for the management of risky alcohol use in primary care professionals based on motivational interviewing

OBJECTIVE

To assess the effectiveness of a training program for Primary Care (PC) professionals developed to increase knowledge, attitudes, and skills for managing patients with risky alcohol use and in the motivational interview.

DESIGN

Multicenter, two-arm parallel, randomized, open-label controlled clinical trial.

SETTING

PC of the Andalusian Health Service.

PARTICIPANTS

The study was completed by 80 healthcare professionals from 31 PC centers.

INTERVENTIONS

In both experimental and control groups, a workshop on managing patients with risky alcohol consumption and the resolution of two videotaped clinical cases with standardized patients were conducted. The experimental group attended a workshop on motivational interviewing.

MAIN MEASUREMENTS

Knowledge about managing risky alcohol use, clinical performance in patients with this health problem, and assessment of the motivational interview.

RESULTS

Mean age was 39.50±13.06 - SD - (95% CI: 36.59-42.41); 71.3% (95% CI: 61.1-80.9%) were women. The average score of both groups in the knowledge questionnaire before the training program was 15.10±4.66, becoming 21.99±3.93 points after the training (95% CI: 5.70-7.92; p<0.001). The experimental group showed an average score of 18.53±13.23 before the intervention with the motivational interview and 28.33±11.86 after this intervention (p=0.002). In contrast, no significant variation was found in the score of the control group.

CONCLUSIONS

A training program aimed at PC professionals designed to increase knowledge on how to manage risky alcohol use and acquire communication skills in motivational interviewing is effective.

A Community Survey of Referral Sources to Identify Primary Care and Gender-Affirming Care Providers

Introduction

Barriers exist in access to primary care as well as specialty healthcare such as gender-affirming care. Understanding the referral sources used to identify new providers for these types of care can help healthcare systems facilitate access.

Methods

Using data from a community-based survey, demographics and information relevant to finding new healthcare providers were assessed.

Results

Data from 165 participants suggest that seeking a new primary care provider was perceived as challenging. The most common referral sources for primary care providers were family/friends, a doctor, or a medical center website. The most common referral sources for gender-affirming care providers were a doctor, family/friends, or social media. There were significant differences in the types of referral sources most likely to be utilized for primary versus gender-affirming care.

Conclusions

Personal connections, including trusted doctors, can be important sources of provider referrals. Additional resources may be needed to facilitate their ability to make quality connections. Community resources and social media can be important sources when existing social networks may not have knowledge about the needs of particular communities, especially those who may be at risk of discrimination. More inclusive and secure referral sources may be needed to ensure gender-affirming care referrals are made.

Low-Density-Lipoprotein Cholesterol and Mortality Outcomes Among Healthy Older Adults: A Post Hoc Analysis of ASPREE Trial

BACKGROUND

The prognostic implication of cholesterol levels in older adults remains uncertain. This study aimed to examine the relationship between low-density-lipoprotein cholesterol (LDL-c) and mortality outcomes in older individuals.

METHODS

This post hoc analysis examined the associations of LDL-c levels with mortality risks from all-cause, cardiovascular disease (CVD), cancer, and combined non-CVD/noncancer conditions in a cohort of individuals aged ≥65 years from the ASPirin in Reducing Events in the Elderly trial (NCT01038583). At baseline, participants had no diagnosed dementia, physical disability, or CVD, and were not taking lipid-lowering agents. Outcome analyses were performed using multivariable Cox models.

RESULTS

We analyzed 12 334 participants (mean age: 75.2 years). Over a median 7-year follow-up, 1 250 died. Restricted cubic splines found a U-shaped relation for LDL-c and all-cause mortality, cancer mortality, and noncancer/non-CVE mortality (nadir: 3.3-3.4 mmol/L); the risk of CVD mortality was similar at LDL-c below 3.3 mmol/L and increased above 3.3 mmol/L. Similar trends were observed in analyses modeling LDL-c by quartiles. When modeling LDL-c as a continuous variable, the risk of all-cause mortality, cancer mortality, and noncancer/non-CVD mortality was decreased by 9%, 16%, and 18%, respectively, per 1-mmol/L higher LDL-c, and the risk of CVD mortality was increased by 19% per 1-mmol/L higher LDL-c. Reduced all-cause and non-CVD/noncancer mortality risks were only significant in males but not females (pinteraction < .05).

CONCLUSIONS

There were U-shaped relationships between LDL-c and all-cause mortality, cancer mortality, and noncancer/non-CVD mortality in healthy older adults. Higher LDL-c levels were associated with an increased risk of CVD mortality. Future studies are warranted to confirm our results.