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Background Hidradenitis suppurativa (HS) is a persistent skin disorder that is characterized by painful lesions or pus-filled lumps, mostly occurring in areas where the skin flexes. It is a disfiguring condition that significantly reduces the quality of life of those affected. Developing new, effective treatments for HS is crucial, but it is important that it be recognized and diagnosed early, especially in primary care settings. Objectives To assess the epidemiology and clinical correlates of HS in a primary care setting. The study utilized the Italian Health Search Database (HSD). A case-control design was adopted to investigate the clinical correlates of HS. Cases were classified as either "definite" or "probable" using an operational algorithm. Up to 10 controls were matched to each case based on factors such as calendar period, age, sex, and duration of follow-up. Results Cumulative prevalence of HS increased from 0.06% in 2002 to 0.46% in 2021. When only "definite" cases were considered, the prevalence was almost 10 times lower (0%–0.02%). Several clinical correlates were found to be positively associated with HS, including obesity, dyslipidemia, hypertension, autoimmune/inflammatory diseases, and depression. Conclusions This study found that correct diagnoses of HS were made, as demonstrated by the expected relationship with clinical correlates. These associations were consistent when probable cases were included in the analysis. This evidence could serve as a foundation for proposing a decision support system for general practitioners to help identify HS in individuals with certain coexisting conditions. [ABSTRACT FROM AUTHOR]

Background Global health care quality improvement efforts have focussed on management practices. However, knowledge in primary care settings, especially in developing countries, such as China, is lacking. Objective To examine the organizational and physician features associated with health care quality in China's community health centres (CHCs). Methods We conducted a cross-sectional survey of 224 primary care physicians (PCPs) in 38 CHCs in Jinan, Tianjin, Shenzhen, and Shanghai. Clinical and prevention care quality with a 5-level scale (1 = never, 5 = always) reported by the PCPs were used to measure the quality of care. Two-level hierarchical linear models were estimated to examine the organization and physician-level variables associated with primary care quality. Results The average clinical care quality score was 4.08 and 3.59 for preventative care out of 5. At the organizational level, organizational culture and organizational support were the strongest predictors of physician-reported quality of care. At the physician level, professional fulfilment, psychological safety, and organizational citizenship behaviour were positively associated with care quality. Conclusions Chinese CHCs clinical quality ranked high by PCPs, but the quality of preventative care provision required improvement. To improve primary care quality, managers of CHCs should implement optimal organizational structures, supportive organizational cultures, and strong organizational support at the organization level and cultivate high professional fulfilment, safe, and trustful relationships with colleagues at the physician level. [ABSTRACT FROM AUTHOR]

Background The current hepatitis B (HBV) and hepatitis C virus (HCV) screening practices may fail to detect many infected patients who could benefit from new therapeutic agents to limit progression to cirrhosis and hepatocellular carcinoma. Objectives This study assessed the test positivity rate and cascade of care of viral hepatitis patients in primary care in a low endemic region as well as the testing policy of abnormal alanine aminotransferase (ALT) level. Methods This is a retrospective clinical audit among primary health care practices in Flanders, Belgium, assessing patients with an active medical file between 2019 and 2021. Results A total of 84/89 (94.4%) primary health care practices participated representing 621,573 patients of which 1069 patients (0.17%) were registered as having viral hepatitis, not further specified. Detailed information was available from 38 practices representing 243,723/621,573 (39.2%) patients of which 169 (0.07%) were HBsAg positive and 99 (0.04%) anti-HCV positive. A total of 96/134(71.6%) chronic HBV-infected and 31/77(40.3%) chronic HCV-infected patients were referred to a hepatologist. A total of 30,573/621,573(4.9%) patients had an abnormal ALT level, and by at random selection, more detailed information was obtained on 211 patients. Information on high-risk groups was missing in up to 60%. In patients with abnormal ALT level, HBsAg and anti-HCV testing were conducted in 37/211(17.5%) and 25/211(11.8%), respectively. Conclusion In a low endemic region, the testing rate and cascade of care of HBV and HCV-infected patients can be improved in primary care, especially in high-risk groups and patients with abnormal ALT levels. [ABSTRACT FROM AUTHOR]

Background The existence of a stable usual source of care (USC) is fundamental to the provision of quality health care. However, no longitudinal studies have examined whether core primary care attributes influence the stability of USC status. Objectives We aimed to examine the association between primary care attributes (first contact, longitudinality, coordination, comprehensiveness, and community orientation) and the loss or change of USC. Methods This nationwide cohort study was conducted during the coronavirus disease 2019 pandemic using a representative sample of the Japanese adult population aged 40–75 years. The primary outcome measures were loss of USC and voluntary change in USC during the 12-month follow-up period. Primary care attributes were evaluated in the baseline survey using the Japanese version of Primary Care Assessment Tool (JPCAT). Results Data were analyzed for 725 participants who had a USC at baseline. Among them, 93 (12.8 %) lost their USC and 46 (6.3%) changed their USC during the follow-up period. Multivariable multinominal logistic regression analyses showed that the JPCAT total score was associated with decreased loss of USC and change in USC. Among the JPCAT domains, longitudinality, comprehensiveness (services available), and community orientation were associated with reductions in both USC loss and change. Conclusions Our study indicates that primary care attributes play an important role in preventing the loss or change of USC and contribute to the stability of USC status. These findings provide additional rationale for policymakers, healthcare providers, and managers to seek to strengthen core attributes of primary care. [ABSTRACT FROM AUTHOR]

Background and Objectives Hearing loss frequently goes undiagnosed and untreated, with serious sequelae. Hearing screening facilitates diagnosis and treatment but is not routinely conducted in primary care. This study addresses the attitudes and insights of patients and primary care clinic personnel relative to the routinization of hearing screening in primary care for older adults. Research Design and Methods Data presented are from the qualitative portion of a larger study. The main study compared screening completion for 3 approaches to coordinating telephone-based hearing screening with primary care—1 offering hearing screening within the primary care encounter and 2 providing information for at-home screening (1 with and 1 without provider encouragement). Focus groups/interviews were conducted with personnel (n  = 38) at the 6 participating clinics, patients who completed screening and were referred for diagnosis (n  = 14), and patients who did not complete screening (n  = 10). Analysis used the general inductive approach. Results Most patients had unaddressed hearing concerns prior to the study. Negative attitudes toward hearing loss/treatment were common, and experiences of family and friends influenced attitudes, but lack of urgency was the primary barrier to screening completion. Respondents favored routine primary care-based hearing screening for older adults, but clinic personnel noted challenges of time, space, workflow, and reimbursement. Discussion and Implications Findings favor greater routinization of hearing screening in primary care. Routinization will be enhanced by improved reimbursement for screening and follow-up; specialist engagement with primary care and the public (including leveraging older adults' social networks); and further research on specific integration options. [ABSTRACT FROM AUTHOR]

Background Health issues caused and/or exacerbated by work are common in patients seeking primary health care. Yet, primary care providers generally receive little or no training in the assessment and management of occupational injuries and illnesses. Aims To conduct a pilot project to develop, implement and evaluate a programme to teach occupational and environmental medicine to primary healthcare providers. Methods We followed the Extensions for Community Healthcare Outcomes (ECHO) model to connect primary healthcare providers with experts in Occupational and Environmental Medicine (OEM). We employed an observational pre–post study design to assess changes in self-efficacy, knowledge, attitudes and beliefs towards OEM. Results From September 2021 to June 2022, we offered two cycles of 12 sessions each. Participants came from medicine, nursing, psychology, occupational and physical therapy, chiropractic, kinesiology, social work, and pharmacy. Sixty-seven participants completed both pre- and post-ECHO questionnaires. Self-efficacy and knowledge ratings significantly increased after attendance at ECHO compared to the pre-ECHO responses. Attitudes and beliefs were unchanged in most of the items assessed. Participants rated their satisfaction with ECHO between 59% and 97%. Conclusions Our pilot study demonstrated the challenges in implementing the first ECHO OEM in Canada. Findings show acceptability and satisfaction, improved self-efficacy, and small increases in knowledge, but not overall attitudes and beliefs. There is a need to understand barriers to participation and to target participants with less knowledge and experience in occupational and environmental medicine. [ABSTRACT FROM AUTHOR]

Background This study aimed to compare colorectal cancer (CRC) awareness between screening-eligible and ineligible individuals in Palestine. Methods Convenience sampling was utilized to recruit Palestinian adults from diverse settings, including hospitals, primary healthcare centers and public spaces across 11 governorates. The evaluation of CRC awareness in terms of signs/symptoms, risk factors and causation myths was conducted using Arabic-translated, modified versions of the validated instruments, the Bowel Cancer Awareness Measure and the Cancer Awareness Measure-Mythical Causes Scale. Results The final analysis included 2698 participants, with 2158 (80.9%) eligible for CRC screening and 540 (19.1%) ineligible for it. The most recognized CRC sign/symptom was 'lump in the abdomen' in both screening-eligible (n = 386, 71.5%) and ineligible (n = 1582, 73.3%) groups. 'Lack of physical activity' was the most recognized risk factor in both groups (eligible: n = 451, 83.5%; ineligible: n = 1766, 81.8%). The most reported causation myth in both groups was 'having a physical trauma' (eligible: n = 340, 63.0%; ineligible: n = 1353, 62.7%). In the screening-eligible group, only 210 participants (38.9%) demonstrated high awareness of CRC signs/symptoms, 213 participants (39.4%) showed high awareness of CRC risk factors and only 46 participants (8.5%) displayed high awareness of CRC causation myths. There were no significant associations between being eligible for screening colonoscopy and the awareness levels of CRC signs/symptoms, risk factors and causation myths. Conclusion Overall, awareness levels of CRC signs/symptoms, risk factors and causation myths were notably low among screening-eligible participants. There were no differences in awareness levels between individuals eligible for colonoscopy and those who were not. [ABSTRACT FROM AUTHOR]

Introduction Smokeless tobacco (SLT) use in low- and middle-income countries has adverse health consequences. We hypothesize that it is feasible to test an intervention of mobile phone messages and face-to-face counseling sessions for SLT cessation in India. Aims and Methods We conducted an exploratory, individual parallel two group, randomized controlled trial (RCT), with baseline and end-point (3 months from randomization) assessments in urban primary health centers in Odisha, India. A total of 250 current (i.e. users in the last 3 months) SLT users or dual users (ie, smokers and SLT users) were recruited to the trial (125 in each group). Participants were randomized to either routine care, face-to-face counseling, and reminder mobile messages or routine care only. The primary outcomes were to assess the feasibility of running a full RCT including recruitment, compliance, and retention. Results A total of seven (77.8%) out of nine primary care centers took part in the trial. Out of the 315 SLT users invited to participate, 250 provided consent and were randomized [79.4% (95% CI: 74.5, 83.7)]. Out of the 250 randomized SLT users, 238 [95% (95% CI: 91.8, 97.5)] were followed up at 3 months (117 in the intervention group and 121 in the control group). Of the participants in the intervention group, 74 (63.8%) reported that they received the mobile messages. Conclusions This exploratory trial demonstrated the feasibility of delivering and evaluating an intervention of mobile phone messages and face-to-face counseling for SLT users in Indian primary care in a full randomized trial Implications This study found that combining mobile messages with face-to-face counseling for smokeless tobacco users visiting primary health care settings in India is feasible in terms of recruitment of users, compliance with the intervention, and retention of study participants within the trial. The biochemically verified smokeless tobacco abstinence rate was higher in the intervention group compared with the control group. There was poor agreement between self-reported tobacco cessation and the measured salivary cotinine in smokeless tobacco users. The findings support the feasibility and acceptability of the intervention signaling the need for a larger clinical trial to test the effectiveness of the intervention. [ABSTRACT FROM AUTHOR]

The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)—and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms. [ABSTRACT FROM AUTHOR]

Introduction Ongoing health reforms in the Military Health System (MHS) are expected to shift locations of ambulatory care for up to 1.9 million beneficiaries. We sought to model the impact of this policy by determining potentially avoidable hospitalizations in the MHS based on different primary care settings. Materials and Methods We used the MHS Data Repository to conduct a retrospective cross-sectional study of TRICARE Prime and Prime Plus beneficiaries aged 18 to 64 years during fiscal years 2018–2019. Crude and adjusted risk ratios for each Agency for Healthcare Research and Quality prevention quality indicator based on primary care setting were calcualated to determine the total probability of admission for any of the Agency for Healthcare Research and Quality prevention indicators. Results We identified a total of 260,690 hospital admissions by patients in the MHS with a designated primary care manager (PCM) from fiscal year 2018 to 2019. Of the total admissions, 11,067 (4.25%) were for Agency for Healthcare Research and Quality prevention quality indicators, 3.63% by direct care PCM at a military treatment facility, and 0.61% by a civilian private sector PCM. Risk of admission was lower for private sector PCMs for urinary tract infection, hypertension, perforated appendix, and angina without the procedure. We did not observe a statistically significant adjusted odds ratio of admission in patients managed by private sector PCMs (1.04 adjusted odds ratio; 95% CI, 0.97-1.11). Conclusions Our findings indicate no difference in the likelihood of avoidable hospitalizations for beneficiaries with a private sector PCM when looking at all conditions together. Patients with a private sector PCM are protected against hospitalization for several conditions. Our findings indicate no adverse impact on avoidable hospitalizations for beneficiaries transitioned to private sector care from direct care. [ABSTRACT FROM AUTHOR]

Purpose Results of the 2023 ASHP National Survey of Pharmacy Practice in Hospital Settings are presented. Methods Pharmacy directors at 1,497 general and children's medical-surgical hospitals in the United States were surveyed using a mixed-mode method of contact by email and mail. Survey completion was online using Qualtrics. IQVIA supplied data on hospital characteristics; the survey sample was drawn from IQVIA's hospital database. Results The response rate was 21.6%. Inpatient pharmacists independently prescribe medications in 26.7% of hospitals. Advanced analytics are used in 5.7% of hospitals. Basic analytics are used in 87.3% of hospitals. Pharmacists work in ambulatory or primary care clinics in 54.2% of hospitals operating outpatient clinics. Most hospitals (86.1%) use automated dispensing cabinets as the primary method of maintenance dose distribution. Machine-readable coding is used in 73.6% of hospitals to verify doses during dispensing in the pharmacy. Autoverification functionality in the electronic health record system is used in 73.4% of hospitals. Most hospitals report some integration of pharmacy services to optimize patient care transitions (60.0%), while 24.9% report no integration. Traditional technician activities still predominate, but more advanced roles are emerging. Technologies to assist sterile product preparation are used in 62.8% of hospitals. Conclusion Drug distribution continues to trend toward decentralized models with medications available closer to patients. Technologies are enabling this transition to occur without a significant negative impact on patient safety. The pharmacy workforce is stable, and more advanced responsibilities are being assigned to pharmacy technicians, enabling pharmacists to increase their clinical role. [ABSTRACT FROM AUTHOR]

Objective The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal (MSK) conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist–led pathway in addition to general practitioner (GP)–led care compared to GP-led care alone. Methods A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist–led pathway. Data from adults with MSK conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. Results Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or MSK presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. Conclusions Patients with MSK conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist–led pathway compared to GP-led care. Impact Patients with MSK conditions receiving primary care in the form of direct-access physical therapist–led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist–led model of care. [ABSTRACT FROM AUTHOR]

Objectives To evaluate a strategy designed to optimize care and increase uptake of urate-lowering therapy (ULT) during hospitalizations for gout flares. Methods We conducted a prospective cohort study to evaluate a strategy that combined optimal in-hospital gout management with a nurse-led, follow-up appointment, followed by handover to primary care. Outcomes, including ULT initiation, urate target attainment and re-hospitalization rates, were compared between patients hospitalized for flares in the 12 months post-implementation and a retrospective cohort of hospitalized patients from 12 months pre-implementation. Results One hundred and nineteen and 108 patients, respectively, were hospitalized for gout flares in the 12 months pre- and post-implementation. For patients with 6-month follow-up data available (n  = 94 and n  = 97, respectively), the proportion newly initiated on ULT increased from 49.2% pre-implementation to 92.3% post-implementation (age/sex-adjusted odds ratio [aOR] 11.5; 95% CI 4.36, 30.5; P  < 0.001). After implementation, more patients achieved a serum urate ≤360 μmol/l within 6 months of discharge (10.6% pre-implementation vs 26.8% post-implementation; aOR 3.04; 95% CI 1.36, 6.78; P  = 0.007). The proportion of patients re-hospitalized for flares was 14.9% pre-implementation vs 9.3% post-implementation (aOR 0.53; 95% CI 0.22, 1.32; P  = 0.18). Conclusion Over 90% of patients were initiated on ULT after implementing a strategy to optimize hospital gout care. Despite increased initiation of ULT during flares, recurrent hospitalizations were not more frequent following implementation. Significant relative improvements in urate target attainment were observed post-implementation; however, for the majority of hospitalized gout patients to achieve urate targets, closer primary–secondary care integration is still needed. [ABSTRACT FROM AUTHOR]

Multimorbidity, defined as having 2 or more chronic conditions, is a growing public health concern, but research in this area is complicated by the fact that multimorbidity is a highly heterogenous outcome. Individuals in a sample may have a differing number and varied combinations of conditions. Clustering methods, such as unsupervised machine learning algorithms, may allow us to tease out the unique multimorbidity phenotypes. However, many clustering methods exist, and choosing which to use is challenging because we do not know the true underlying clusters. Here, we demonstrate the use of 3 individual algorithms (partition around medoids, hierarchical clustering, and probabilistic clustering) and a clustering ensemble approach (which pools different clustering approaches) to identify multimorbidity clusters in the AIDS Linked to the Intravenous Experience cohort study. We show how the clusters can be compared based on cluster quality, interpretability, and predictive ability. In practice, it is critical to compare the clustering results from multiple algorithms and to choose the approach that performs best in the domain(s) that aligns with plans to use the clusters in future analyses. [ABSTRACT FROM AUTHOR]

Background Asthma is one of the most frequent reasons children visit a general practitioner (GP). The diagnosis of childhood asthma is challenging, and a variety of diagnostic tests for asthma exist. GPs may refer to clinical practice guidelines when deciding which tests, if any, are appropriate, but the quality of these guidelines is unknown. Objectives To determine (i) the methodological quality and reporting of paediatric guidelines for the diagnosis of childhood asthma in primary care, and (ii) the strength of evidence supporting diagnostic test recommendations. Design Meta-epidemiological study of English-language guidelines from the United Kingdom and other high-income countries with comparable primary care systems including diagnostic testing recommendations for childhood asthma in primary care. The AGREE-II tool was used to assess the quality and reporting of the guidelines. The quality of the evidence was assessed using GRADE. Results Eleven guidelines met the eligibility criteria. The methodology and reporting quality varied across the AGREE II domains (median score 4.5 out of 7, range 2–6). The quality of evidence supporting diagnostic recommendations was generally of very low quality. All guidelines recommended the use of spirometry and reversibility testing for children aged ≥5 years, however, the recommended spirometry thresholds for diagnosis differed across guidelines. There were disagreements in testing recommendations for 3 of the 7 included tests. Conclusions The variable quality of guidelines, lack of good quality evidence, and inconsistent recommendations for diagnostic tests may contribute to poor clinician adherence to guidelines and variation in testing for diagnosing childhood asthma. [ABSTRACT FROM AUTHOR]

Background China is currently making efforts to transform the current hospital-centric service delivery system to people-centred primary health care (PHC)-based delivery system, with service delivery organized around the health needs and expectations of people. To help direct China's PHC reform efforts, a profile of high-quality PHC from the public's perspective is required. Objectives To profile high-quality PHC from the perspective of the Chinese public. Methods Semistructured interviews were conducted in 6 provinces (Henan, Shandong, Zhejiang, Shaanxi, Shanxi, and Heilongjiang) in China. In total, 58 interviewees completed the recorded interview. For transcription, trained research assistant listened to the recording of the interviews, summarizing each 30-s segment in English. Next, thematic analysis was performed on the narrative summaries to identify thematic families. Results Seven themes and 16 subthemes were generated from the analysis of our interview data. In order of their frequency, the interviewees expressed a high expectation for interpersonal communication and technical quality; followed by access, comprehensive care, cost, continuity, and coordination. Conclusions Using qualitative data from 6 provinces in China, knowledge was generated to reveal the public's views and expectations for high-quality PHC. Our results confirm the urgent need for quality improvement efforts to improve patient experience and technical quality. The government also needs to further improve the delivery system and medical training programme to better meet public expectation in these areas, especially in establishing an innovative integrated primary care model, and strengthening interpersonal and clinical competency training for family doctors. [ABSTRACT FROM AUTHOR]

Background: Interruptions can impact consultation duration, doctors and patients' satisfaction, and quality of care provided. Although most of them seem to have a negative impact, affecting doctor-patient relationship and interfering with clinical reasoning, which increases the risk of error, there is still no evidence on their global impact on consultations.Objectives: To evaluate the number and duration of interruptions during general practice consultations. To compare physicians and patients' perceptions of their urgency and impact, as well as the overall satisfaction with the consultation.Methods: Cross-sectional study of a representative sample of annual face-to-face general practice consultations at a Health Centre. Between January and March 2022, anonymous questionnaires were given to physicians and patients after consultation. We performed a descriptive and inferential statistical analysis.Results: A total of 403 consultations were included. Physicians reported more interruptions than patients (108 vs. 87, P < 0.001). From patients' perspective those interruptions were more urgent (34.5%) compared with physicians' perspective (20.6%; P = 0.029). Patients undervalued their impact on consultations (7.1% of interruptions with a negative impact among patients vs. 24.7% among doctors; P < 0.001). Interruptions did not interfere with patients' satisfaction with consultation (P = 0.135) but were associated with lower physicians' satisfaction with consultation (P = 0.003).Conclusion: Physicians are more critical regarding consultations interruptions, being more aware of their incidence and reporting more often a negative impact, which translates into lower satisfaction with interrupted consultations. Patients devalue the occurrence of interruptions, showing no concern about their impact on security or privacy, and their satisfaction is not affected by them. [ABSTRACT FROM AUTHOR]

Background: Obesity is a non-communicable chronic disease which carries a high cost for the Brazilian Unified Health System. Standardized protocols can help primary health care (PHC) professionals manage the disease.Objectives: To describe the validation process of a protocol concerning dietary guidelines for adults with obesity in PHC by non-nutrition professionals.Methods: A validation study of a dietary advice protocol consisting of 6 recommendations was conducted according to Brazilian Dietary Guidelines. The topics incorporated into the recommendations were submitted to a panel of judges for content validity and achieved a Scale Content Validity Index (S-CVI) score >0.80. Subsequently, an online workshop was held and consisted of guiding questions to adequately improve current protocols. Face validity was assessed in a mediation workshop conducted with PHC non-nutrition professionals. Following the validation process, necessary adjustments were made to the eating protocol.Results: The validation process was conducted by a panel of 20 judges and 10 PHC professionals. The content was validated using a 0.98 S-CVI. The online workshop expert panel agreed the instrument provides a trustworthy foundation for appropriate dietary guidelines. Moreover, the judges suggested changes to the flowchart designed to support the professionals' decisions, discussed the absence of quantitative prescription guidelines, and offered additional suggestions to strengthen equity and encourage autonomy in non-nutrition healthcare professionals in PHC.Conclusion: This study describes the validation process of a dietary advice protocol for people with obesity, as well as the importance of its integration into PHC. [ABSTRACT FROM AUTHOR]

Objective: To explore consultation patterns, management practices, and costs of foot, ankle, and leg problems in Australian primary care.Study Design: We analyzed data from the Bettering the Evaluation and Care of Health program, April 2000 to March 2016. Foot, ankle, and leg problems were identified using the International Classification of Primary Care, Version 2 PLUS terminology. Data were summarized using descriptive statistics examining general practitioner (GP) and patient characteristics associated with a foot, ankle, or leg problem being managed. Cost to government was estimated by extracting fees for GP consultations, diagnostic imaging, and pathology services from the Medicare Benefits Schedule (MBS) database. Costs for prescription-only medicines were extracted from the Pharmaceutical Benefits Schedule and for nonprescribed medications, large banner discount pharmacy prices were used.Results: GPs recorded 1,568,100 patient encounters, at which 50,877 foot, ankle, or leg problems were managed at a rate of 3.24 (95% confidence intervals [CIs] 3.21-3.28) per 100 encounters. The management rate of foot, ankle, or leg problems was higher for certain patient characteristics (older, having a health care card, socioeconomically disadvantaged, non-Indigenous, and being English speaking) and GP characteristics (male sex, older age, and Australian graduate). The most frequently used management practice was the use of medications. The average cost (Australian dollars) per encounter was A$52, with the total annual cost estimated at A$256m.Conclusions: Foot, ankle, and leg problems are frequently managed by GPs, and the costs associated with their management represent a substantial economic impact in Australian primary care. [ABSTRACT FROM AUTHOR]

Objective This study aims to investigate the feasibility of using Large Language Models (LLMs) to engage with patients at the time they are drafting a question to their healthcare providers, and generate pertinent follow-up questions that the patient can answer before sending their message, with the goal of ensuring that their healthcare provider receives all the information they need to safely and accurately answer the patient's question, eliminating back-and-forth messaging, and the associated delays and frustrations. Methods We collected a dataset of patient messages sent between January 1, 2022 to March 7, 2023 at Vanderbilt University Medical Center. Two internal medicine physicians identified 7 common scenarios. We used 3 LLMs to generate follow-up questions: (1) Comprehensive LLM Artificial Intelligence Responder (CLAIR): a locally fine-tuned LLM, (2) GPT4 with a simple prompt, and (3) GPT4 with a complex prompt. Five physicians rated them with the actual follow-ups written by healthcare providers on clarity, completeness, conciseness, and utility. Results For five scenarios, our CLAIR model had the best performance. The GPT4 model received higher scores for utility and completeness but lower scores for clarity and conciseness. CLAIR generated follow-up questions with similar clarity and conciseness as the actual follow-ups written by healthcare providers, with higher utility than healthcare providers and GPT4, and lower completeness than GPT4, but better than healthcare providers. Conclusion LLMs can generate follow-up patient messages designed to clarify a medical question that compares favorably to those generated by healthcare providers. [ABSTRACT FROM AUTHOR]

Objectives: Authentic work-based learning is crucial to facilitate the development and preparedness for training healthcare professionals. Such experiences are challenging to design and secure within the clinical environment. One School of Pharmacy established a student-led clinic to provide undergraduate pharmacy students the opportunity to practise physical assessment and communication skills with members of the public. The aim of this study was to explore students' thoughts and perspectives on this experience. Methods: Undergraduate students were invited to participate in a semi-structured interview after their clinic experience. Transcriptions of the interviews were analysed by reflexive thematic analysis. Results: Twelve students agreed to an interview that took place between October and December 2022. Three themes were identified from the qualitative data which related to external factors that influenced student experience of the clinic, for example, organizational issues and impact of the physical environment; interactions within the clinic environment; and internalized learning for example, professional growth and development, and the appreciating the learning opportunity. Conclusions: In the current climate, where securing valuable work-based learning opportunity is challenging, student-led clinics offer an environment that is well-received by students and appears to facilitate student professional development. Student clinics are receiving more attention and investment across undergraduate healthcare programmes around the world given advantages such as these. However, they need to be well integrated and structured into the existing training and education and students need appropriate induction to prepare them for the experience and manage expectations. [ABSTRACT FROM AUTHOR]

Background and Objectives This study validates the Flourish Index–Revised (FI-R), a tool evaluating integrated healthcare models. The original Flourish Index (FI) was developed in 2018 and has been refined to align with the FlourishCare (FC) Model (Model) for geriatric primary care. Research Design and Methods The Model provides integrated biopsychosocial healthcare to older adults. The FI-R uses 25 quality-of-care indicators and 7 contextual community indicators. The FI-R was validated with Categorial Principal Components Analysis (CATPCA) using a sample of 949 patients 50+ who were mostly female (73%), non-Hispanic White (70%), living in urban areas (90%), and married (29%), single (22%), or divorced (19%). The mean age was 73.46 (standard deviation [ SD ] = 10.86) and mean years of education was 14.30 (SD  = 2.14). Results CATPCA showed a 4-dimensional structure of biological, psychological, and 2 social determinants of health (SDOH) subdomains: health behaviors and community. Final selection of indicators was based on total variance accounted for >0.30, absolute values of item loadings >0.45, and not having cross-loadings >0.45 on 2 factors. Internal consistency (Cronbach's alpha) for the determinants were biological = 0.75, psychological = 0.76, SDOH:community = 0.70, SDOH:health behaviors = 0.50, and total FI-R = 0.95. Sensitivity to change was shown for the total FI-R, psychological determinants, and SDOH:health behaviors, but not for biological determinants. Discussion and Implications The validation of the FI-R shows promise for its usability to evaluate integrated healthcare models using existing measures in electronic health systems. More work is needed to improve the incorporation of SDOH:sociodemographics into the FI-R. [ABSTRACT FROM AUTHOR]

Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil [Primary Care Access and Quality (PMAQ)] and exploring the association of alternative design typologies with the performance of primary health care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team (FHT) performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to FHT workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20–80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes. [ABSTRACT FROM AUTHOR]

Coccidioidomycosis, histoplasmosis, and blastomycosis are underrecognized and frequently misdiagnosed fungal infections that can clinically resemble bacterial and viral community-acquired pneumonia. This guidance is intended to help outpatient clinicians test for these fungal diseases in patients with community-acquired pneumonia to reduce misdiagnoses, unnecessary antibacterial use, and poor outcomes. [ABSTRACT FROM AUTHOR]

Introduction FebriDx® is a CE-marked, single-use point-of-care test with markers for bacterial [C-reactive protein (CRP)] and viral [myxovirus resistance protein A (MxA)] infection, using finger-prick blood samples. Results are available after 10–12 min. We explored the usability and potential impact of FebriDx® in reducing antibiotic prescriptions for lower respiratory tract infection (LRTI) in primary care, and the feasibility of conducting a randomized controlled trial (RCT). Methods Patients (aged ≥1 year) with LRTI deemed likely to receive antibiotic prescription were recruited at nine general practices and underwent FebriDx® testing. Data collection included FebriDx® results, antibiotic prescribing plan (before and after testing) and re-consultation rates. Staff completed System Usability Scale questionnaires. Results From 31 January 2023 to 9 June 2023, 162 participants participated (median age 57 years), with a median symptom duration of 7 days (IQR 5–14). A valid FebriDx® result was obtained in 97% (157/162). Of 155 patients with available results, 103 (66%) had no detectable CRP or MxA, 28 (18%) had CRP only, 5 (3%) had MxA only, and 19 (12%) had both CRP and MxA. The clinicians' stated management plan was to prescribe antibiotics for 86% (134/155) before testing and 45% (69/155) after testing, meaning a 41% (95% CI: 31%, 51%) difference after testing, without evidence of increased re-consultation rates. Ease-of-use questionnaires showed 'good' user-friendliness. Conclusions Use of FebriDx® to guide antibiotic prescribing for LRTI in primary care was associated with a substantial reduction in prescribing intentions. These results support a fully powered RCT to confirm its impact and safety. [ABSTRACT FROM AUTHOR]

Objectives To identify and assess the effectiveness of national antibiotic optimization interventions in primary and secondary care in England (2013–2022). Methods A systematic scoping review was conducted. Literature databases (Embase and Medline) were used to identify interventions and evaluations. Reports included the UK AMR Strategy (2013–2018), National Action Plan (2019–2024) and English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) reports (2014–2022). The design, focus and quality of evaluations and the interventions' effectiveness were extracted. Findings Four hundred and seventy-seven peer-reviewed studies and 13 reports were screened. One hundred and three studies were included for review, identifying 109 interventions in eight categories: policy and commissioning (n  = 9); classifications (n  = 1); guidance and toolkits (n  = 22); monitoring and feedback (n  = 17); professional engagement and training (n  = 19); prescriber tools (n  = 12); public awareness (n  = 17); workforce and governance (n  = 12). Most interventions lack high-quality effectiveness evidence. Evaluations mainly focused on clinical, microbiological or antibiotic use outcomes, or intervention implementation, often assessing how interventions were perceived to affect behaviour. Only 16 interventions had studies that quantified effects on prescribing, of which six reported reductions. The largest reduction was reported with structural-level interventions and attributed to a policy and commissioning intervention (primary care financial incentives). Behavioural interventions (guidance and toolkits) reported the greatest impact in hospitals. Conclusions Many interventions have targeted antibiotic use, each pulling different levers across the health system simultaneously. On the basis of these studies, structural-level interventions may have the greatest impact. Collectively, the combination of interventions may explain England's decline in prescribing but direct evidence of causality is unavailable. [ABSTRACT FROM AUTHOR]

The purpose of this study is to gain a better understanding of the role and extent of health promotion lifestyle interventions targeting adults in primary care, and especially those who are considered overall healthy, i.e. to study the outcomes of research applying salutogenesis. We performed a literature review, with three specific aims. First, to identify studies that have targeted the healthy population in intervention within the primary health care field with health promotion activities. Second, to describe these interventions in terms of which health problems they have targeted and what the interventions have entailed. Third, to assess what these programs have resulted in, in terms of health outcomes. This scoping review of 42 studies, that applied salutogenesis in primary care interventions shows that health promotion targeting healthy individuals is relevant and effective. The PRISMA-ScR guidelines for reporting on scoping review were used. Most interventions were successful in reducing disease-related risks including CVD, CVD mortality, all-cause mortality, but even more importantly success in behavioural change, sustained at follow-up. Additionally, this review shows that health promotion lifestyle interventions can improve mental health, even when having different aims. [ABSTRACT FROM AUTHOR]

Background Chronic pain and depression are highly comorbid, but the lack of consensus on the best treatment strategies puts patients at high risk of suboptimal care-coordination as well as health and social complications. Therefore, this study aims to quantitatively assesses how effective different primary care interventions have been in treating the comorbid state of chronic pain and depression. In particular, this study evaluates both short-term outcomes—based specifically on measures of chronic pain and depression during an intervention itself—and long-term outcomes or measures of pain and depression in the months after conclusion of the formal study intervention. Methods This study is a systematic review and meta-analysis of randomised-controlled trials (RCTs) enrolling patients with concurrent chronic pain and depression. Intensity and severity of pain and depression symptoms were the primary outcomes. The main inclusion criteria were RCTs that: (i) enrolled patients diagnosed with depression and chronic pain, (ii) occurred in primary care settings, (iii) reported baseline and post-intervention outcomes for chronic pain and depression, (iv) lasted at least 8 weeks, and (v) used clinically validated outcome measures. Risk of bias was appraised with the Risk of Bias 2 tool, and GRADE guidelines were used to evaluate the quality of evidence. Results Of 692 screened citations, 7 multicomponent primary care interventions tested across 891 patients were included. Meta-analyses revealed significant improvements in depression at post-intervention (SMD = 0.44, 95% CI [0.17, 0.71], P = 0.0014) and follow-up (SMD = 0.41, 95% CI [0.01, 0.81], P = 0.0448). Non-significant effects were observed for chronic pain at post-intervention (SMD = 0.27, 95% CI [−0.08, 0.61], P = 0.1287) and follow-up (SMD = 0.13, 95% CI [−0.3, 0.56], P = 0.5432). Conclusions Based on the results of the meta-analysis, primary care interventions largely yielded small to moderate positive effects for depressive symptoms and no significant effects on pain. In one study, stepped-care to be more effective in treatment of comorbid chronic pain and depression than other interventions both during the intervention and upon post-intervention follow-up. As such, depression appears more amenable to treatment than pain, but the number of published RCTs assessing both conditions is limited. More research is needed to further develop optimal treatment strategies. [ABSTRACT FROM AUTHOR]

Background Loneliness is a global issue, and primary care physicians play an important role in assessing and intervening with loneliness. This study aimed to examine the association between having a usual source of care (USC) or a good quality of primary care, and loneliness. Methods This cross-sectional study was conducted in Japan in 2022. A total of 6,000 residents were randomly sampled from the general population, aged 20–74 years. The outcome was the total score of the University of California, Los Angeles (UCLA) 3-item loneliness scale. The exposure included USC and the Person-Centered Primary Care Measure (PCPCM), which assesses the quality of primary care. We conducted a linear regression analysis to adjust for age, sex, educational status, annual household income, self-rated health, living status (whether alone or not), and the existence of physical health problems. Results Of the 6,000 residents, 1,277 responded to the survey. The median score of the UCLA 3-item loneliness scale was 6.0 and the mean total score of the PCPCM was 2.62. Of the 1,277 individuals, 713 (55.8%) had USC. Having USC was significantly associated with lower scores on the UCLA 3-item loneliness scale; the coefficient was −0.34 (95% confidence interval (CI): −0.57 to −0.12). Also, the total PCPCM score was significantly associated with lower loneliness scores; the coefficient was −0.56 (P < 0.001, 95% CI: −0.78 to −0.35). Conclusions Having USC and a better quality primary care were associated with a lower loneliness score. The quality of primary care could be a factor to mitigate patient loneliness. [ABSTRACT FROM AUTHOR]

Background Continuity of primary care (CPC) is associated with reduced mortality and improved health status. This study assessed the level of CPC and changes in CPC over 6 years among adults with experience of homelessness and mental illness who received a Housing First intervention. Methods Participants were adults (≥18 years old) with a serious mental disorder and experiencing chronic homelessness enrolled between October 2009 and June 2011 in the Toronto site of the Canadian At Home/Chez Soi study and followed until March 2017. Participants were randomized to Housing First with intensive case management (HF-ICM), Housing First with assertive community treatment (HF-ACT), or treatment as usual. For this report, 280 intervention group participants (HF-ICM, n = 193 and HF-ACT, n = 87) were analysed using data from health records. The main outcome was CPC measured by the Continuity of Care Index as a continuous and categorical variable among participants during 3 consecutive 2-year periods. Results Most HF-ICM participants had low levels of CPC, with 68%–74% of this group having low CPC across all time periods. Similarly, most HF-ACT participants had low levels of CPC, with 63%–78% of this group having low CPC across all time periods. Conclusions Among this group of individuals with mental illness who were experiencing homelessness, CPC remained low over 6 years of follow-up. This study highlights that housing and mental health interventions may need to place greater emphasis on improving CPC using effective strategies that are specifically geared towards this important goal among their clients. [ABSTRACT FROM AUTHOR]

Objective(s) Chronic kidney disease (CKD) is an insidious disease that requires early nephroprotective measures to delay progression to end-stage kidney disease. The objective of this study was to describe the management of patients with CKD in primary care, including clinical and biological monitoring and prescribed treatments. A retrospective, single-centre study was conducted on adult patients who were treated in the Maison de Neufchâtel (France) between 2012 and 2017 at least once a year. The inclusion criteria were 2 estimated glomerular filtration rate (eGFR) measurements <60 mL/min more than 3 months apart. Two subgroups were constituted according to whether CKD was coded in the electronic medical records (EMRs). Results A total of 291 (6.7%, CI95% 5.9–7.4) patients with CKD were included. The mean eGFR was 51.0 ± 16.4 mL/min. Hypertension was the most frequent health problem reported (n = 93, 32%). Nephrotective agents were prescribed in 194 (66.7%) patients, non-steroidal anti-inflammatory drugs (NSAIDs) in 22 (8%) patients, and proton-pump inhibitors (PPIs) in 147 (47%) patients. CKD coding in EMRs was associated with dosage of natraemia (n = 34, 100%, P < 0.01), albuminuria (n = 20, 58%, P < 0.01), vitamin D (n = 14, 41%, P < 0.001), and phosphorus (n = 11, 32%, P < 0.001). Eighty-one patients (31.5%) with low eGFR without an entered code for CKD were prescribed an albuminuria dosage. Clinical monitoring could not be analysed due to poor coding. Conclusion This pilot study reinforces the hypothesis that CKD is underscreened and undermanaged. More systematic coding of medical information in EMRs and further studies on medical centre databases should improve primary care practices. [ABSTRACT FROM AUTHOR]

Social determinants of health and unmet social needs are directly related to cancer outcomes, from diagnosis to survivorship. If identified, unmet social needs can be addressed in oncology care by changing care plans in collaboration with patients' preferences and accounting for clinical practice guidelines (eg, reducing the frequency of appointments, switching treatment modalities) and connecting patients to resources within healthcare organizations (eg, social work support, patient navigation) and with community organizations (eg, food banks, housing assistance programs). Screening for social needs is the first step to identifying those who need additional support and is increasingly recognized as a necessary component of high-quality cancer care delivery. Despite evidence about the relationship between social needs and cancer outcomes and the abundance of screening tools, the implementation of social needs screening remains a challenge, and little is known regarding the adoption, reach, and sustainability of social needs screening in routine clinical practice. We present data on the adoption and implementation of social needs screening at two large academic cancer centers and discuss three challenges associated with implementing evidence-based social needs screening in clinical practice: (1) identifying an optimal approach for administering social needs screening in oncology care, (2) adequately addressing identified unmet needs with resources and support, and (3) coordinating social needs screening between oncology and primary care. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic caused widespread disruptions in cancer care. We hypothesized that the greatest disruptions in diagnosis occurred in screen-detected cancers. We identified patients (≥18 years of age) with newly diagnosed cancer from 2019 to 2020 in the US National Cancer Database and calculated the change in proportion of early-stage to late-stage cancers using a weighted linear regression. Disruptions in early-stage diagnosis were greater than in late-stage diagnosis (17% vs 12.5%). Melanoma demonstrated the greatest relative decrease in early-stage vs late-stage diagnosis (22.9% vs 9.2%), whereas the decrease was similar for pancreatic cancer. Compared with breast cancer, cervical, melanoma, prostate, colorectal, and lung cancers showed the greatest disruptions in early-stage diagnosis. Uninsured patients experienced greater disruptions than privately insured patients. Disruptions in cancer diagnosis in 2020 had a larger impact on early-stage disease, particularly screen-detected cancers. Our study supports emerging evidence that primary care visits may play a critical role in early melanoma detection. [ABSTRACT FROM AUTHOR]

Background A study previously conducted in primary care practices found that implementation of an educational session and peer comparison feedback was associated with reduced antibiotic prescribing for respiratory tract diagnoses (RTDs). Here, we assess the long-term effects of this intervention on antibiotic prescribing following cessation of feedback. Methods RTD encounters were grouped into tiers based on antibiotic prescribing appropriateness: tier 1, almost always indicated; tier 2, possibly indicated; and tier 3, rarely indicated. A χ2 test was used to compare prescribing between 3 time periods: pre-intervention, intervention, and post-intervention (14 months following cessation of feedback). A mixed-effects multivariable logistic regression analysis was performed to assess the association between period and prescribing. Results We analyzed 260 900 RTD encounters from 29 practices. Antibiotic prescribing was more frequent in the post-intervention period than in the intervention period (28.9% vs 23.0%, P <.001) but remained lower than the 35.2% pre-intervention rate (P <.001). In multivariable analysis, the odds of prescribing were higher in the post-intervention period than the intervention period for tier 2 (odds ratio [OR], 1.19; 95% confidence interval [CI]: 1.10–1.30; P <.05) and tier 3 (OR, 1.20; 95% CI: 1.12–1.30) indications but was lower compared to the pre-intervention period for each tier (OR, 0.66; 95% CI: 0.59–0.73 tier 2; OR, 0.68; 95% CI: 0.61–0.75 tier 3). Conclusions The intervention effects appeared to last beyond the intervention period. However, without ongoing provider feedback, there was a trend toward increased prescribing. Future studies are needed to determine optimal strategies to sustain intervention effects. [ABSTRACT FROM AUTHOR]

Context Vitamin D plays an important role in immune function, and the deficiency thereof has been associated with several infections, most notably respiratory tract infections. However, data from intervention studies investigating the effect of high-dose vitamin D supplementation on infections have been inconclusive. Objective The aim of this study was to evaluate the level of evidence regarding the efficacy of vitamin D supplementation above the standard dose (400 IU) in preventing infections in apparently healthy children < 5 years of age. Data Sources PubMed, Scopus, Science Direct, Web of Science, Google Scholar, CINAHL, and MEDLINE electronic databases were searched between August 2022 and November 2022. Seven studies met the inclusion criteria. Data Extraction Meta-analyses of outcomes in more than one study were performed using Review Manager software. Heterogeneity was evaluated using the I2 statistic. Randomized controlled trials in which vitamin D was supplemented at > 400 IU compared with placebo, no treatment, or standard dose were included. Data Analysis Seven trials that enrolled a total of 5748 children were included. Odds ratios (ORs) with 95%CIs were calculated using random- and fixed-effects models. There was no significant effect of high-dose vitamin D supplementation on the incidence of upper respiratory tract infection (OR, 0.83; 95%CI, 0.62–1.10). There was a 57% (95%CI, 0.30–0.61), 56% (95%CI, 0.27–0.07), and 59% (95%CI, 0.26–0.65) reduction in the odds of influenza/cold, cough, and fever incidence, respectively, with daily supplementation of vitamin D > 1000 IU. No effect was found on bronchitis, otitis media, diarrhea/gastroenteritis, primary care visits for infections, hospitalizations, or mortality. Conclusion High-dose vitamin D supplementation provided no benefit in preventing upper respiratory tract infections (moderate certainty of evidence) but reduced the incidence influenza/cold (moderate certainty of evidence), cough, and fever (low certainty of evidence). These findings are based on a limited number of trials and should be interpreted with caution. Further research is needed. Systematic Review Registration PROSPERO registration number CRD42022355206. [ABSTRACT FROM AUTHOR]

The UK Biobank study contains several sources of diagnostic data, including hospital inpatient data and data on self-reported conditions for approximately 500,000 participants and primary-care data for approximately 177,000 participants (35%). Epidemiologic investigations require a primary disease definition, but whether to combine data sources to maximize statistical power or focus on only 1 source to ensure a consistent outcome is not clear. The consistency of disease definitions was investigated for venous thromboembolism (VTE) by evaluating overlap when defining cases from 3 sources: hospital inpatient data, primary-care reports, and self-reported questionnaires. VTE cases showed little overlap between data sources, with only 6% of reported events for persons with primary-care data being identified by all 3 sources (hospital, primary-care, and self-reports), while 71% appeared in only 1 source. Deep vein thrombosis–only events represented 68% of self-reported VTE cases and 36% of hospital-reported VTE cases, while pulmonary embolism–only events represented 20% of self-reported VTE cases and 50% of hospital-reported VTE cases. Additionally, different distributions of sociodemographic characteristics were observed; for example, patients in 46% of hospital-reported VTE cases were female, compared with 58% of self-reported VTE cases. These results illustrate how seemingly neutral decisions taken to improve data quality can affect the representativeness of a data set. [ABSTRACT FROM AUTHOR]

Introduction Community-based services to sustain independence for older people have varying configurations. A typology of these interventions would improve service provision and research by providing conceptual clarity and enabling the identification of effective configurations. We aimed to produce such a typology. Method We developed our typology by qualitatively synthesising community-based complex interventions to sustain independence in older people, evaluated in randomised controlled trials (RCTs), in four stages: (i) systematically identifying relevant RCTs; (ii) extracting descriptions of interventions (including control) using the Template for Intervention Description and Replication; (iii) generating categories of key intervention features and (iv) grouping the interventions based on these categories. PROSPERO registration: CRD42019162195. Results Our search identified 129 RCTs involving 266 intervention arms. The Community-based complex Interventions to sustain Independence in Older People (CII-OP) typology comprises 14 action components and 5 tailoring components. Action components include procedures for treating patients or otherwise intended to directly improve their outcomes; regular examples include formal homecare; physical exercise; health education; activities of daily living training; providing aids and adaptations and nutritional support. Tailoring components involve a process that may result in care planning, with multiple action components being planned, recommended or prescribed. Multifactorial action from care planning was the most common tailoring component. It involves individualised, multidomain assessment and management, as in comprehensive geriatric assessment. Sixty-three different intervention types (combinations) were identified. Conclusions Our typology provides an empirical basis for service planning and evidence synthesis. We recommend better reporting about organisational aspects of interventions and usual care. [ABSTRACT FROM AUTHOR]

Background Around 15% of adults aged over 65 live with moderate or severe frailty. Contractual requirements for management of frailty are minimal and neither incentivised nor reinforced. Previous research has shown frailty identification in primary care is ad hoc and opportunistic, but there has been little focus on the challenges of frailty management, particularly within the context of recent introduction of primary care networks and an expanding allied health professional workforce. Aim Explore the views of primary care clinicians in England on the management of frailty. Design and setting Semi-structured interviews were conducted with clinicians across England, including general practitioners (GPs), physician associates, nurse practitioners, paramedics and clinical pharmacists. Thematic analysis was facilitated through NVivo (Version 12). Results A total of 31 clinicians participated. Frailty management was viewed as complex and outside of clinical guidelines with medication optimisation highlighted as a key example. Senior clinicians, particularly experienced GPs, were more comfortable with managing risk. Relational care was important in prioritising patient wishes and autonomy, for instance to remain at home despite deteriorations in health. In settings where more formalised multidisciplinary frailty services had been established this was viewed as successful by clinicians involved. Conclusion Primary care clinicians perceive frailty as best managed through trusted relationships with patients, and with support from experienced clinicians. New multidisciplinary working in primary care could enhance frailty services, but must keep continuity in mind. There is a lack of evidence or guidance for specific interventions or management approaches. [ABSTRACT FROM AUTHOR]

Background Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs. Objective To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC. Methods A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse–patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale. Results A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P  = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P  = 0.29). There was also no significant effect on quality of life (∆ = −0.02, 95%CI: [−0.09, 0.05], P  = 0.53) or self-rated health (∆ = −2.48, 95%CI: [−9.95, 4.99], P  = 0.51). Conclusions The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams. [ABSTRACT FROM AUTHOR]

Background Community pharmacists potentially have an important role to play in identification of frailty and delivery of interventions to optimise medicines use for frail older adults. However, little is known about their knowledge or views about this role. Aim To explore community pharmacists' knowledge of frailty and assessment, experiences and contact with frail older adults, and perceptions of their role in optimising medicines use for this population. Methods Semi-structured interviews conducted between March and December 2020 with 15 community pharmacists in Northern Ireland. Interviews were transcribed verbatim and analysed thematically. Results Three broad themes were generated from the data. The first, 'awareness and understanding of frailty', highlighted gaps in community pharmacists' knowledge regarding presentation and identification of frailty and their reluctance to broach potentially challenging conversations with frail older patients. Within the second theme, 'problem-solving and supporting medication use', community pharmacists felt a large part of their role was to resolve medicines-related issues for frail older adults through collaboration with other primary healthcare professionals but feedback on the outcome was often not provided upon issue resolution. The third theme, 'seizing opportunities in primary care to enhance pharmaceutical care provision for frail older adults', identified areas for further development of the community pharmacist role. Conclusions This study has provided an understanding of the views and experiences of community pharmacists about frailty. Community pharmacists' knowledge deficits about frailty must be addressed and their communication skills enhanced so they may confidently initiate conversations about frailty and medicines use with older adults. [ABSTRACT FROM AUTHOR]

Partnership between early childhood development interventions and primary health care services can help catalyse health care uptake by socially vulnerable families. This study aimed to assess the real-life effects of a large-scale home visiting programme [Primeira Infância Melhor (PIM)] in Brazil on the use of preventive (prenatal visits, well child visits, dentist visits and vaccination) and recovery (emergency room visits and hospitalization) health services. A quasi-experiment nested in a population-based birth cohort study was conducted. The intervention group was firstly defined as all children enrolled in PIM up to age 6 months, and afterwards stratified between those enrolled during pregnancy or after birth up to 6 months. Children receiving PIM were matched with controls on propensity scores based on 27 confounders to estimate effects on health service use from prenatal to age 2 years. Double adjustment was applied in outcome Quasi-Poisson regressions. No evidence was found for effects of PIM starting anytime up to 6 months (262 pairs), or for the children enrolled only after birth (133 pairs), on outcomes occurring after age 6 months. When the programme started during pregnancy (129 pairs), there was a 13% higher prevalence of adequate prenatal visits (prevalence ratio = 1.13; 95% confidence interval 1.01–1.27), but no effect on use of any other health service. Sensitivity analyses suggested longer participation in the programme with reduced visitor turnover might improve its impact on prenatal visits. Integration between PIM and primary health care was not adequate to affect overall patterns of contacts with health services. Nevertheless, prenatal home visits showed potential to increase health service contact during a sensitive period of development, indicating the need to start such programmes before birth, when there is more time for maternal care, and family engagement in a network of services is facilitated. [ABSTRACT FROM AUTHOR]

Purpose This paper compares and contrasts the implementation of pharmacist-led services for 3 different sexual and gender minority populations across California, Mississippi, and Florida. Summary Implementation of pharmacist-led services tailored to sexual and gender minorities may be a potential mechanism to address health disparities in these populations. Clinical pharmacists have the potential to provide care with cultural humility and improve health outcomes by optimizing medication regimens, reducing adverse drug events, enhancing medication acquisition, and improving medication adherence. Conclusion The services provided by clinical pharmacists varied across sites and included management of gender-affirming hormone therapy, HIV antiretroviral medication adherence programming, primary care and chronic disease state management, and involvement in care related to mental health, psychiatry, and substance use as well as sexual health. Various legislative and regulatory barriers and differences in scope of practice for pharmacists were also identified. This paper advocates for the expansion of pharmacy-led services and the adoption of a culturally humble approach to patient care. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to compare the performance of three PsA screening questionnaires in a primary care psoriasis surveillance study. Methods Participants with psoriasis, and not known to have PsA, were identified from general practice databases and invited to attend a secondary care centre for a clinical assessment. The three patient-completed screening questionnaires (PEST, CONTEST and CONTESTjt) were administered, along with other patient-reported measures, and a clinical examination of skin and joints was performed. Participants who demonstrated signs of inflammatory arthritis suggestive of PsA were referred, via their GP, for a further assessment in a secondary care rheumatology clinic. Results A total of 791 participants attended the screening visit, and 165 participants were judged to have signs and symptoms of inflammatory arthritis, of which 150 were referred for assessment. Of these, 126 were seen and 48 were diagnosed with PsA. The results for each questionnaire were as follows: PEST: sensitivity 0.625 (95% CI 0.482, 0.749), specificity 0.757 (0.724, 0.787); CONTEST: sensitivity 0.604 (0.461, 0.731), specificity 0.768 (0.736, 0.798); and CONTESTjt: sensitivity 0.542 (0.401, 0.676), specificity 0.834 (0.805, 0.859). CONTESTjt demonstrated marginally superior specificity to PEST, though the area under the ROC curve was similar for all three instruments. Conclusion Minimal differences between the three screening questionnaires were found in this study, and no preferred questionnaire is indicated by these results. The choice of which instrument to choose will depend on other factors, such as simplicity and low patient burden. [ABSTRACT FROM AUTHOR]

Objective To identify common opioid tapering trajectories among patients commencing opioid taper from long-term opioid therapy for chronic non-cancer pain and to examine patient-level characteristics associated with these different trajectories. Design A retrospective cohort study. Setting Australian primary care. Subjects Patients prescribed opioid analgesics between 2015 and 2020. Methods Group-based trajectory modeling and multinomial logistic regression analysis were conducted to determine tapering trajectories and to examine demographic and clinical factors associated with the different trajectories. Results A total of 3369 patients commenced a taper from long-term opioid therapy. Six distinct opioid tapering trajectories were identified: low dose / completed taper (12.9%), medium dose / faster taper (12.2%), medium dose / gradual taper (6.5%), low dose / noncompleted taper (21.3%), medium dose / noncompleted taper (30.4%), and high dose / noncompleted taper (16.7%). A completed tapering trajectory from a high opioid dose was not identified. Among patients prescribed medium opioid doses, those who completed their taper were more likely to have higher geographically derived socioeconomic status (relative risk ratio [RRR], 1.067; 95% confidence interval [CI], 1.001–1.137) and less likely to have sleep disorders (RRR, 0.661; 95% CI, 0.463–0.945) than were those who didn't complete their taper. Patients who didn't complete their taper were more likely to be prescribed strong opioids (eg, morphine, oxycodone), regardless of whether they were tapered from low (RRR, 1.444; 95% CI, 1.138–1.831) or high (RRR, 1.344; 95% CI, 1.027–1.760) doses. Conclusions Those prescribed strong opioids and high doses appear to be less likely to complete tapering. Further studies are needed to evaluate the clinical outcomes associated with the identified trajectories. [ABSTRACT FROM AUTHOR]

Background Quality indicators (QIs) can be used to obtain valuable insights into prescribing quality. Five quantitative and nine diagnosis-linked QIs, aiming to provide general practitioners (GP) with feedback on their antibiotic prescribing quantity and quality, were previously developed and evaluated in a controlled study. Objective To confirm, in a larger non-controlled study, the feasibility of using routinely collected and extracted electronic patient records to calculate the diagnosis-linked QI outcomes for antibiotic prescribing, and their reliability and validity. Methods Retrospective study involving 299 Dutch general practices using routine care data (2018–2020). QIs describe total antibiotic and subgroup prescribing, prescribing percentages and first-choice prescribing for several clinical diagnoses. Practice variation in QI outcomes, inter-QI outcome correlations and sensitivity of QI outcomes to pandemic-induced change were determined. Results QI outcomes were successfully obtained for 278/299 practices. With respect to reliability, outcomes for 2018 and 2019 were comparable, between-practice variation in outcomes was similar to the controlled pilot, and inter-QI outcome correlations were as expected, for example: high prescribing of second choice antibiotics with low first-choice prescribing for clinical diagnoses. Validity was confirmed by their sensitivity to pandemic-induced change: total antibiotic prescribing decreased from 282 prescriptions/1000 registered patients in 2018 to 216 in 2020, with a decrease in prescribing percentages for upper and lower respiratory infections, from 26% to 18.5%, and from 28% to 16%. Conclusions This study confirmed the fit-for-purpose (feasibility, reliability and validity) of the antibiotic prescribing QIs (including clinical diagnosis-linked ones) using routinely registered primary health care data as a source. This feedback can therefore be used in antibiotic stewardship programmes to improve GPs' prescribing routines. [ABSTRACT FROM AUTHOR]

Background The utility of the occupational medicine diploma in the UK is yet to be explored. The NHS 'Growing Occupational Health (OH) and Wellbeing' programme provides opportunities for diplomates to increase their OH work. Aims To assess what proportion of diplomates carry out OH work, the type of work being undertaken, to identify obstacles impeding OH work, to capture their interest in future work opportunities and what additional support they require. Methods A link to an online questionnaire was sent to diplomates via several professional bodies; we estimate that 2428 diplomates received this. The survey was open from 24 March to 31 May 2022. Results Replies were received from 310/2428 (13%) diplomates. Fifty-two per cent of respondents were males and 35% were female. Respondents were diverse in terms of age and geographical region. Main employment settings: 13% primary care, 43% secondary care, 31% private sector, 24% public sector and 20% self-employed. Seventy-two per cent of diplomates had undertaken OH clinical work since completion of their diploma, and 90% of those were undertaking OH clinical work at the time of the survey. Specific obstacles to accessing OH work highlighted included existing workload constraints, lack of employment opportunities with OH providers and lack of time. Conclusions Many (126/310; 41%) respondents had considered increasing their OH work in the previous 12 months. Increasing mentorship from senior OH clinicians to diplomates was suggested by 4% of respondents to enhance the utility of diplomates. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, the majority of patients received ambulatory treatment, highlighting the importance of primary health care (PHC). However, there is limited knowledge regarding PHC workload in Europe during this period. The utilization of COVID-19 PHC indicators could facilitate the efficient monitoring and coordination of the pandemic response. The objective of this study is to describe PHC indicators for disease surveillance and monitoring of COVID-19's impact in Europe. Methods: Descriptive, cross-sectional study employing data obtained through a semi-structured ad hoc questionnaire, which was collectively agreed upon by all participants. The study encompasses PHC settings in 31 European countries from March 2020 to August 2021. Keyinformants from each country answered the questionnaire. Main outcome: the identification of any indicator used to describe PHC COVID-19 activity. Results: Out of the 31 countries surveyed, data on PHC information were obtained from 14. The principal indicators were: total number of cases within PHC (Belarus, Cyprus, Italy, Romania and Spain), number of follow-up cases (Croatia, Cyprus, Finland, Spain and Turkey), GP's COVID-19 tests referrals (Poland), proportion of COVID-19 cases among respiratory illnesses consultations (Norway and France), sick leaves issued by GPs (Romania and Spain) and examination and complementary tests (Cyprus). All COVID-19 cases were attended in PHC in Belarus and Italy. Conclusions: The COVID-19 pandemic exposes a crucial deficiency in preparedness for infectious diseases in European health systems highlighting the inconsistent recording of indicators within PHC organizations. PHC standardized indicators and public data accessibility are urgently needed, conforming the foundation for an effective European-level health services response framework against future pandemics. [ABSTRACT FROM AUTHOR]

The World Health Organization and American Academy of Paediatrics recommend exclusive breastfeeding until 6 months of age, with continued breastfeeding along with complementary solid foods for up to 2 years and beyond. Despite the well-established importance of breastfeeding, Irish rates remain the lowest in Europe. Healthcare professionals' breastfeeding knowledge and skills have a positive impact on increasing breastfeeding rates. There is limited evidence of the knowledge, attitudes or practices of general practitioners (GPs) and general practice nurses (GPNs), which is essential to breastfeeding in Ireland. The aim of this study was to evaluate the breastfeeding knowledge, attitudes and practices of GPs and GPNs in one community healthcare organisation (CHO) in Ireland. A co-designed evaluation study was used following low-risk ethical exemption (LS-LR-22-161). A modified version of a validated breastfeeding questionnaire was developed. A Project Steering Committee was established that included patient, and public involvement stakeholders. The anonymised survey was distributed via online Qualtrics platform (November 2022–February 2023). STROBE Guidelines were utilised. The overall response rate was 25.9% (n  = 121) and valid responses were reported in the article. The total population size was n  = 468 (GPs n  = 290 and GPNs n  = 178). Our pilot study identified that 42.7% (n  = 47/110) of respondents never attended a breastfeeding education programme, and 53.9% (n  = 55/102) identified that their knowledge could be improved. The majority of respondents, 92.9% (n  = 92/99) wish to complete further education in breastfeeding. The results of this pilot study in one CHO in Ireland indicate a gap in knowledge and a need for specific breastfeeding and lactation theoretical and skills training for GPs and GPNs working in primary care to support, promote and protect breastfeeding. [ABSTRACT FROM AUTHOR]

Background With the onset of the COVID-19 pandemic, telemedicine was rapidly implemented in care settings globally. To understand what factors affect the successful completion of telemedicine visits in our urban, academic family medicine clinic setting, we analysed telemedicine visits carried out during the pandemic. Methods We conducted a retrospective chart review of telemedicine visits from 2 clinical units within a family medicine centre. To investigate the association between incomplete visits and various factors (age, gender, presenting complaints, physician level of training [resident or staff] and patient-physician relational continuity), we performed a multivariable logistic regression on data from August 2020, February 2021, and May 2021. An incomplete visit is one that requires a follow-up in-person visit with a physician within 3 days. Results Of the 2,138 telemedicine patient visits we investigated, 9.6% were incomplete. Patients presenting with lumps and bumps (OR: 3.84, 95% CI: 1.44, 10.5), as well as those seen by resident physicians (OR: 1.77, 95% CI: 1.22, 2.56) had increased odds of incomplete visits. Telemedicine visits at the family medicine clinic (Site A) with registered patients had lower odds of incomplete visits (OR: 0.24, 95% CI: 0.15, 0.39) than those at the community clinic (Site B), which provides urgent/episodic care with no associated relational continuity between patients and physicians. Conclusion In our urban clinical setting, only a small minority of telemedicine visits required an in-person follow-up visit. This information may be useful in guiding approaches to triaging patients to telemedicine or standard in-person care. [ABSTRACT FROM AUTHOR]

Background According to some health programmes, implementing primary health care through community health workers (CHWs) facilitates the connection between community and health services in Latin America. However, these are isolated processes that face different obstacles and would benefit from an overview of the corresponding health policies and programmes. Objective To provide an overview of CHW participation in 6 Latin American countries. Methods This exploratory qualitative study was based on 3 sources of information: a literature review, a review of public health policy documents, and interviews with experts who have led CHW programmes in 6 Latin American countries. Results The role of CHWs in Latin America and some advances in public health policies in the region were evidenced. However, limitations arising from variable implementation of the WHO guidelines on health programmes with CHWs were also apparent. Conclusions CHWs contribute to the primary healthcare processes in the 6 Latin American countries studied in versatile and comprehensive ways. However, they constitute an underutilized human resource because they must provide various services that are not always relevant in different work contexts. Therefore, we propose a classification of the CHW profile, using the level of access to healthcare services of the population they serve as the main differentiator. This way, CHWs will not have to provide a wide range of services but only those most relevant to the specific needs of each community. [ABSTRACT FROM AUTHOR]