Evaluación quinquenal de los ejes sanitarios de un programa nacional de Atención Primaria de la Salud / Five-year evaluation of the sanitary axes of a national program of Primary Health Care

Se realizó una evaluación quinquenal de los ejes sanitarios (que dan lugar a objetivos estratégicos con sus correspondientes metas e indicadores, áreas de intervención y líneas de acción) dentro del marco de la gestión sanitaria de uno de los 10 principales agentes de la seguridad social argentinos quien implementaba desde hacía 20 años un Programa Nacional de Atención Primaria de la Salud (PNAPS). El mismo promedió alrededor de 800 mil beneficiarios anuales dentro de una red asistencial nacional propia en el primer nivel de atención compuesta por 45 Centros de Atención Primaria (CAPs). Se implementó una investigación evaluativa que incluyó un trazado de línea de base con la valoración de cinco Ejes Sanitarios (ES). Se trata de un diseño de corte transversal de un periodo de 5 años. Se definieron metas, indicadores y recomendaciones para cada uno de los ES, recopilando información de fuentes diferentes y complementarias para su análisis. Los resultados mostraron una evolución favorable en el período evaluado, aunque el cumplimiento de las metas estuvo bastante alejado de lo propuesto de manera teórica. Conclusiones: este trabajo aporta información valiosa y original para subsidiar la toma de decisiones e incentivar la investigación en el ámbito de la APS, buscando reformular los actuales modelos de gestión y de atención de la salud (AU)

A five-year evaluation of the health axes (which give rise to strategic objectives with their corresponding goals and indicators, areas of intervention and lines of action) was carried out within the framework of health management of one of the 10 main argentine social security agents who had been implementing a National Primary Health Care Program (PNAPS) for 20 years. It averaged around 800,000 annual beneficiaries within its own national care network at the first level of care made up of 45 Primary Care Centers (CAPs). An evaluative investigation was implemented that included a baseline drawing with the assessment of five Sanitary Axis (ES). It is a cross-sectional design of a period of 5 years. Goals, indicators and recommendations were defined for each of the ES, collecting information from different and complementary sources for analysis. Results: they showed a favorable evolution in the period evaluated, although the fulfillment of the goals was quite far from what was theoretically proposed. The results of this work provides valuable and original information to support decision-making and encourage research in the field of PHC, seeking to reformulate current management and health care models (AU)

Substitution or addition: An observational study of a new primary care initiative in the Netherlands.

OBJECTIVE: In 2014, the Primary Care Plus (PC+) model was introduced in the Netherlands to shift low-complex specialised care from the hospital to the primary care setting. While positive effects of PC+ have been documented at individual patient level concerning health-related quality of life, perceived quality of care and care costs, its impacts on service use at the population level remain uncertain. METHODS: In this observational study, we used retrospective health insurance reimbursement claims data from the largest health insurer in the intervention region to determine service use. We assessed PC+ and secondary care insurance claims (i.e. claims of the regional hospital and claims of other secondary care settings in and outside the region visited by patients from the intervention region) from 2015 to 2018 and compared these to the national level. RESULTS: The total number of claims related to low-complex specialised care in the intervention region showed an increase over time. The increase in claims was related to PC+. The number of claims related to the regional hospital and other secondary care settings decreased over time. During the same period, a declining trend in claims at the national level was observed. CONCLUSION: The introduction of the PC+ model in one region in the Netherlands was associated with an increase in the use of low-complex specialised care. This suggests that the ability of the PC+ model to substitute for specialist care at population level may be limited. Going forward, it will be important to continue monitoring and evaluating service use as substitution effects may materialise only over a longer timeframe.

Primary care patterns among dual eligibles with Alzheimer's disease and related dementias.

BACKGROUND: Primary care is essential for persons with Alzheimer's disease and related dementias (ADRD). Prior research suggests that the propensity to provide high-quality, continuous primary care varies by provider setting, but the settings used by Medicare-Medicaid dual-eligibles with ADRD have not been described at the population level. METHODS: Using 2012-2018 Medicare data, we identified dual-eligibles with ADRD. For each person-year, we identified primary care visits occurring in six settings. We calculated descriptive statistics for beneficiaries with a majority of visits in each setting, and conducted a k-means cluster analysis to determine utilization patterns, using the standardized count of primary care visits in each setting. RESULTS: Each year from 2012 to 2018, at least 45.6% of dual-eligibles with ADRD received a majority of their primary care in nursing facilities, while at least 25.2% did so in physician offices. Over time, the share relying on nursing facilities for primary care decreased by 5.2 percentage points, offset by growth in Federally Qualified Health Centers (FQHCs) and miscellaneous settings (2.3 percentage points each). Dual-eligibles relying on nursing facilities had more annual primary care visits (16.1) than those relying on other settings (range: 6.8-10.7 visits). Interpersonal care continuity was also higher in nursing facilities (97.0%) and physician offices (87.9%) than in FQHCs (54.2%), rural health clinics (RHCs, 46.6%), or hospital-based clinics (56.8%). Among dual-eligibles without care continuity, 82.7% were assigned to a cluster with few primary care visits. CONCLUSIONS: A trend toward care in different settings likely reflects improved access to patient-centered primary care. Low rates of interpersonal care continuity in FQHCs, RHCs, and physician offices may warrant concern, unless providers in these settings function as a care team. Nonetheless, every healthcare system encounter presents an opportunity to designate a primary care provider for dual-eligibles with ADRD who use little or no primary care.

¿Cómo evolucionó la distribución de médicas y médicos especialistas en Argentina?: un análisis demográfico de la profesión médica al 2020 / How did the distribution of doctors and medical specialists evolve in Argentina?: a demographic analysis of the medical profession to 2020

Las políticas sobre trabajadores/as de salud deben garantizar su distribución adecuada. En Argentina dicha distribución es desigual, sobre todo en especialistas en atención primaria de la salud (APS). El objetivo de este trabajo fue describir la distribución de médicos/as, especialistas lineales y en APS en Argentina, durante el año 2020, teniendo en cuenta la situación económica y sanitaria de cada jurisdicción. Se trata de un trabajo descriptivo y analítico, que utilizó fuentes de datos primarias y secundarias. Se correlacionó la tasa de mortalidad infantil y el producto bruto per cápita de cada jurisdicción ordenándolas de mejores a peores indicadores. La tasa de médicos fue 3,88 médicos/as cada 1000 habitantes, 72% concentrándose en 4 jurisdicciones (Ciudad Autónoma de Buenos Aires, Provincia de Buenos Aires, Córdoba y Santa Fe). El 53% son especialistas y el 27,6% lo son en APS. CABA tuvo una tasa de 16,5 médicos/as por mil; Santiago del Estero y Formosa alcanzaron valores de 1,8 y 1,9 médicas/os por mil habitantes respectivamente. Con respecto a 2014, se observó disminución de especialistas en APS (-14,8%), registrándose las mayores pérdidas en Santiago del Estero, Formosa y Catamarca (-84,5%; -70,1% y -87,3%). La situación nacional sobre la distribución de médicos/as en Argentina desde 1954 a la actualidad fue empeorando en detrimento de las provincias con mayores necesidades. La baja adherencia al sistema de residencias a especialidades de APS pronostica un empeoramiento de la situación de no haber cambios estructurales. Será necesario un fortalecimiento del rol rector del estado en el abordaje de esta problemática (AU)

Policies on health workers must guarantee their adequate distribution. In Argentina, this distribution is unequal, particularly among primary care specialists (PHC).The objective of this article is to describe the distribution of physicians, PHC and non-PHC specialists in Argentina in 2020, considering the economic and health situation of each jurisdiction.We conducted a descriptive cross-sectional study with an analytical stage using primary and secondary data sources. The jurisdictions were classified according to the correlation between infant mortality rate and gross product per capita.The rate of physicians in Argentina in 2020 was 3.88 physicians per 1,000 inhabitants. 72% are concentrated in 4 jurisdictions (City of Buenos Aires, Province of Buenos Aires, Córdoba and Santa Fe). 53% are specialists and 27.6% are PHC specialists. The City of Buenos Aires has a rate of 16.5 physicians per thousand; and Santiago del Estero and Formosa reach values of 1.8 and 1.9 physicians per thousand inhabitants, respectively.There was a decrease in PHC specialists (-14.8%), with major losses recorded in Santiago del Estero, Formosa and Catamarca (-84.5%; -70.1% and -87.3%, respectively).The distribution of physicians in Argentina from 1954 to the present has worsened to the detriment of the provinces with the greatest needs. The lack of adheren-ce to the specialty of PHC predicts a worsening of the situation if there are no structural changes. It is necessary to strengthen the leading role of the state in addressing this problem (AU)

Trends in quality of primary care in the United States, 2007-2016.

During the past decade, many reforms were proposed and implemented for improving primary care in the US. This study assessed improvements in quality of primary care, using a nationally representative database. We conducted a retrospective trend analysis of National Inpatient Sample data (2007-2016). The quality of primary care was assessed using Prevention Quality Indicators (PQIs), which consist of 13 sets of preventable hospitalization conditions. PQI hospitalization decreased from 154,565 to 151,168 per million hospitalizations during the study period (relative decrease, 2.2%; P = 0.041). Age-adjusted hospitalization rate increased for diabetes short-term complications (relative increase, 46.9%; P < 0.001) and lower-extremity amputations (relative increase, 15.1%; P = 0.035). Age stratified trends showed that hospitalization rates decreased significantly in all age-groups for diabetes short-term complications. For lower-extremity amputations, hospitalization rates increased significantly in younger age groups and decreased significantly in the older age groups. All other PQIs showed either decreasing or no change in trends. Adults aged 18-64 years should be the focus for future prevention attempts for diabetes complications. Identifying and acting on the factors responsible for these changes could help in reversing the concerning trends observed in this study. Existing strategies should focus on improving access to diabetes care and self-management.

Consultation rates in people with type 2 diabetes with and without vascular complications: a retrospective analysis of 141,328 adults in England.

OBJECTIVE: To assess trends in primary and specialist care consultation rates and average length of consultation by cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), or cardiometabolic multimorbidity exposure status. METHODS: Observational, retrospective cohort study used linked Clinical Practice Research Datalink primary care data from 01/01/2000 to 31/12/2018 to assess consultation rates in 141,328 adults with newly diagnosed T2DM, with or without CVD. Patients who entered the study with either a diagnosis of T2DM or CVD and later developed the second condition during the study are classified as the cardiometabolic multimorbidity group. Face to face primary and specialist care consultations, with either a nurse or general practitioner, were assessed over time in subjects with T2DM, CVD, or cardiometabolic multimorbidity. Changes in the average length of consultation in each group were investigated. RESULTS: 696,255 (mean 4.9 years [95% CI, 2.02-7.66]) person years of follow up time, there were 10,221,798 primary and specialist care consultations. The crude rate of primary and specialist care consultations in patients with cardiometabolic multimorbidity (N = 11,881) was 18.5 (95% CI, 18.47-18.55) per person years, 13.5 (13.50, 13.52) in patients with T2DM only (N = 83,094) and 13.2 (13.18, 13.21) in those with CVD (N = 57,974). Patients with cardiometabolic multimorbidity had 28% (IRR 1.28; 95% CI: 1.27, 1.31) more consultations than those with only T2DM. Patients with cardiometabolic multimorbidity had primary care consultation rates decrease by 50.1% compared to a 45.0% decrease in consultations for those with T2DM from 2000 to 2018. Specialist care consultation rates in both groups increased from 2003 to 2018 by 33.3% and 54.4% in patients with cardiometabolic multimorbidity and T2DM, respectively. For patients with T2DM the average consultation duration increased by 36.0%, in patients with CVD it increased by 74.3%, and in those with cardiometabolic multimorbidity it increased by 37.3%. CONCLUSIONS: Annual primary care consultation rates for individuals with T2DM, CVD, or cardiometabolic multimorbidity have fallen since 2000, while specialist care consultations and average consultation length have both increased. Individuals with cardiometabolic multimorbidity have significantly more consultations than individuals with T2DM or CVD alone. Service redesign of health care delivery needs to be considered for people with cardiometabolic multimorbidity to reduce the burden and health care costs.

Ramadan is not associated with increased infection risk in Pakistani and Bangladeshi populations: Findings from controlled interrupted time series analysis of UK primary care data.

BACKGROUND: The effect of fasting on immunity is unclear. Prolonged fasting is thought to increase the risk of infection due to dehydration. This study describes antibiotic prescribing patterns before, during, and after Ramadan in a primary care setting within the Pakistani and Bangladeshi populations in the UK, most of whom are Muslims, compared to those who do not observe Ramadan. METHOD: Retrospective controlled interrupted time series analysis of electronic health record data from primary care practices. The study consists of two groups: Pakistanis/Bangladeshis and white populations. For each group, we constructed a series of aggregated, daily prescription data from 2007 to 2017 for the 30 days preceding, during, and after Ramadan, respectively. FINDINGS: Controlling for the rate in the white population, there was no evidence of increased antibiotic prescription in the Pakistani/Bangladeshi population during Ramadan, as compared to before Ramadan (IRR: 0.994; 95% CI: 0.988-1.001, p = 0.082) or after Ramadan (IRR: 1.006; 95% CI: 0.999-1.013, p = 0.082). INTERPRETATION: In this large, population-based study, we did not find any evidence to suggest that fasting was associated with an increased susceptibility to infection.

Changing antibiotic prescribing practices in outpatient primary care settings in China: Study protocol for a health information system-based cluster-randomised crossover controlled trial.

BACKGROUND: The overuse and abuse of antibiotics is a major risk factor for antibiotic resistance in primary care settings of China. In this study, the effectiveness of an automatically-presented, privacy-protecting, computer information technology (IT)-based antibiotic feedback intervention will be evaluated to determine whether it can reduce antibiotic prescribing rates and unreasonable prescribing behaviours. METHODS: We will pilot and develop a cluster-randomised, open controlled, crossover, superiority trial. A total of 320 outpatient physicians in 6 counties of Guizhou province who met the standard will be randomly divided into intervention group and control group with a primary care hospital being the unit of cluster allocation. In the intervention group, the three components of the feedback intervention included: 1. Artificial intelligence (AI)-based real-time warnings of improper antibiotic use; 2. Pop-up windows of antibiotic prescription rate ranking; 3. Distribution of educational manuals. In the control group, no form of intervention will be provided. The trial will last for 6 months and will be divided into two phases of three months each. The two groups will crossover after 3 months. The primary outcome is the 10-day antibiotic prescription rate of physicians. The secondary outcome is the rational use of antibiotic prescriptions. The acceptability and feasibility of this feedback intervention study will be evaluated using both qualitative and quantitative assessment methods. DISCUSSION: This study will overcome limitations of our previous study, which only focused on reducing antibiotic prescription rates. AI techniques and an educational intervention will be used in this study to effectively reduce antibiotic prescription rates and antibiotic irregularities. This study will also provide new ideas and approaches for further research in this area. TRIAL REGISTRATION: ISRCTN, ID: ISRCTN13817256. Registered on 11 January 2020.

Culturally Sensitive Interventions in Pediatric Primary Care Settings: A Systematic Review.

CONTEXT: Culturally sensitive interventions in the pediatric primary care setting may help reduce health disparities. Less is known on the development of these interventions, their target groups, and their feasibility, acceptability, and impact on health outcomes. OBJECTIVE: We conducted a systematic review to describe culturally sensitive interventions developed for the pediatric primary care setting. DATA SOURCES: PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo (January 2000 to July 2020). STUDY SELECTION: Studies were eligible for inclusion if they were (1) original research on an intervention with an evaluation, (2) within a pediatric primary care setting, (3) not limited to education for providers, (4) not limited to interpreter use, and (5) based in the United States. DATA EXTRACTION: The following were extracted: study topic, study design, intervention, cultural sensitivity strategies and terminology, setting, target group, sample size, feasibility, acceptability, and health outcomes. RESULTS: Twenty-five studies described 23 interventions targeting a variety of health topics. Multiple cultural sensitivity strategies were used, most commonly sociocultural (83%). Most interventions (57%) were focused on Hispanic/Latino families. Interventions were generally reported as being feasible and acceptable; some also changed health outcomes. LIMITATIONS: Small samples and heterogenous methods subject to bias were used. Relevant articles may have been missed because of the variety of terms used to describe cultural sensitivity. CONCLUSIONS: The included articles provide preliminary evidence that culturally sensitive interventions can be feasible and effective and may help eliminate disparities for patients from communities with barriers to equitable care.

Cannabis Essentials: Tools for Clinical Practice.

Cannabis use in the United States is increasing annually in people of all ages. This increase is fueled by state-level legalization, decreased risk perception, and increased social acceptability. Cannabis and its active components, cannabinoids, have been studied for medical uses and marketed in many commercial forms. Cannabis can impair short-term memory, judgment, and coordination, and there is substantial evidence that it can adversely affect multiple organ systems. Cannabinoids have potential adverse drug interactions with commonly prescribed analgesic, psychotropic, and cardiovascular medications. Current evidence supports cannabinoid use only for a limited number of conditions (chemotherapy-induced nausea and vomiting, specific pain and spasticity syndromes, and certain forms of childhood epilepsy); thus, physicians recommending cannabinoids need to weigh the potential harms vs. perceived benefits. The U.S. Preventive Services Task Force recommends universal screening for unhealthy drug use, including cannabis, in adults 18 years and older. However, the American Academy of Family Physicians does not support this recommendation because of the lack of evidence of benefit in screening patients for unhealthy drug use, except for opioid use disorder. Treatment of cannabis use disorder is largely behavioral and requires a patient-centered, multifaceted approach with a focus on patient education. Pharmacotherapy for cannabis use disorder is limited and experimental. Harm reduction strategies and education about cannabis withdrawal syndrome should be provided to patients. Interpretation of urine drug testing for cannabis is challenging because of the persistence of metabolites for four to five days after a single use and for one month after chronic daily use.

Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019.

BACKGROUND: Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care. OBJECTIVE: To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination. DESIGN: Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time. SETTING: Traditional fee-for-service Medicare. PATIENTS: 20% sample of Medicare beneficiaries. MEASUREMENTS: Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients. RESULTS: The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019. LIMITATION: Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel. CONCLUSION: Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs. PRIMARY FUNDING SOURCE: National Institute on Aging.

National Trends and Outcomes Associated With Presence and Type of Usual Clinician Among Older Adults With Multimorbidity.

Importance: Declining primary care visit rates and increasing specialist visit rates among older adults with multimorbidity raise questions about the presence, specialty, and outcomes associated with usual clinicians of care for these adults. Objective: To examine trends in the presence and specialty of usual clinicians and the association with preventive care receipt and spending. Design, Setting, and Participants: This survey study used repeated cross-sectional analyses of Medicare Current Beneficiary Survey data from 2010, 2013, and 2016. Participants were community-dwelling Medicare Advantage and traditional Medicare members with at least 2 chronic conditions. Data were analyzed from March 1, 2020, to February 5, 2021. Main Outcomes and Measures: Trends and factors associated with self-reported usual clinician presence and specialty. Multivariable regression was used to examine associations between usual clinician presence and specialty with preventive care receipt and spending, controlling for respondent sociodemographic and clinical characteristics. Results: A total of 25 490 unweighted respondent-years were examined, representing 90 324 639 respondent-years across the United States. Overall, 58.4% of respondent-years belonged to women, and the mean (SD) age of respondents was 77.5 (7.5) years. From 2010 to 2016, those reporting usual clinicians dropped from 94.2% to 91.0% (P < .001). Across study years, respondents were more likely to report a usual clinician if they were women (adjusted marginal difference [AMD], 2.5 percentage points; 95% CI, 1.5-3.5 percentage points) or had higher income (≥$50 000 vs <$15 000: AMD, 2.2 percentage points; 95% CI, 1.1-3.4 percentage points) and less likely if they were Black beneficiaries (vs White: AMD, -2.8 percentage points; 95% CI, -4.3 to -1.3 percentage points) or had traditional Medicare (vs Medicare Advantage: AMD, -3.2 percentage points; 95% CI. -4.1 to -2.3 percentage points). Among 23 279 respondents with usual clinicians, those reporting specialists as their usual clinicians decreased from 5.3% to 4.1% (P < .001). Across the study period, respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (vs Medicare Advantage: AMD, 2.3 percentage points; 95% CI, 1.6 to 2.9 percentage points), were Black or non-White Hispanic (Black vs White: AMD, 1.5 percentage points; 95% CI, 0.2 to 2.8 percentage points; non-White Hispanic vs White: AMD, 3.8 percentage points; 95% CI, 1.9 to 5.7 percentage points), or lived in the Northeast (vs Midwest: AMD, 3.6 percentage points; 95% CI, 2.1 to 5.2 percentage points). Compared with those without usual clinicians, respondents with usual clinicians were more likely to receive all examined preventive services, such as cholesterol screening (AMD, 6.7 percentage points; 95% CI, 5.4 to 8.1 percentage points) and influenza vaccines (AMD, 11.6 percentage points; 95% CI, 9.2 to 14.0 percentage points). Among respondents with usual clinicians, those reporting specialist usual clinicians (vs primary care) were less likely to receive influenza vaccines (AMD, -5.6 percentage points; 95% CI, -9.2 to -2.1). Conclusions and Relevance: In this study, older adults with multimorbidity were less likely to have a usual clinician over the study period, with potential implications for preventive care receipt. Our results suggest a key role for usual clinicians, especially primary care clinicians, in vaccination uptake for this population.

Prevalence and determinants of healthcare avoidance during the COVID-19 pandemic: A population-based cross-sectional study.

BACKGROUND: During the Coronavirus Disease 2019 (COVID-19) pandemic, the number of consultations and diagnoses in primary care and referrals to specialist care declined substantially compared to prepandemic levels. Beyond deferral of elective non-COVID-19 care by healthcare providers, it is unclear to what extent healthcare avoidance by community-dwelling individuals contributed to this decline in routine healthcare utilisation. Moreover, it is uncertain which specific symptoms were left unheeded by patients and which determinants predispose to healthcare avoidance in the general population. In this cross-sectional study, we assessed prevalence of healthcare avoidance during the pandemic from a patient perspective, including symptoms that were left unheeded, as well as determinants of healthcare avoidance. METHODS AND FINDINGS: On April 20, 2020, a paper COVID-19 survey addressing healthcare utilisation, socioeconomic factors, mental and physical health, medication use, and COVID-19-specific symptoms was sent out to 8,732 participants from the population-based Rotterdam Study (response rate 73%). All questionnaires were returned before July 10, 2020. By hand, prevalence of healthcare avoidance was subsequently verified through free text analysis of medical records of general practitioners. Odds ratios (ORs) for avoidance were determined using logistic regression models, adjusted for age, sex, and history of chronic diseases. We found that 1,142 of 5,656 included participants (20.2%) reported having avoided healthcare. Of those, 414 participants (36.3%) reported symptoms that potentially warranted urgent evaluation, including limb weakness (13.6%), palpitations (10.8%), and chest pain (10.2%). Determinants related to avoidance were older age (adjusted OR 1.14 [95% confidence interval (CI) 1.08 to 1.21]), female sex (1.58 [1.38 to 1.82]), low educational level (primary education versus higher vocational/university 1.21 [1.01 to 1.46), poor self-appreciated health (per level decrease 2.00 [1.80 to 2.22]), unemployment (versus employed 2.29 [1.54 to 3.39]), smoking (1.34 [1.08 to 1.65]), concern about contracting COVID-19 (per level increase 1.28 [1.19 to 1.38]) and symptoms of depression (per point increase 1.13 [1.11 to 1.14]) and anxiety (per point increase 1.16 [1.14 to 1.18]). Study limitations included uncertainty about (perceived) severity of the reported symptoms and potentially limited generalisability given the ethnically homogeneous study population. CONCLUSIONS: In this population-based cross-sectional study, 1 in 5 individuals avoided healthcare during lockdown in the COVID-19 pandemic, often for potentially urgent symptoms. Healthcare avoidance was strongly associated with female sex, fragile self-appreciated health, and high levels of depression and anxiety. These results emphasise the need for targeted public education urging these vulnerable patients to timely seek medical care for their symptoms to mitigate major health consequences.

Association of a Medicare Outpatient Payment Reform With Hospital-Primary Care Integration: Heterogeneity Across Markets and Physicians.

BACKGROUND: Hospital-physician integration increased rapidly in the past decade, threatening the affordability of care with minimal gains in quality. Medicare recently reformed its facility fee payments to hospitals for office consultations delivered by hospital-integrated physicians. This policy reform, affecting 200 million office visits annually, may have inadvertently encouraged hospitals to integrate with certain primary care physicians. OBJECTIVE: The objective of this study was to determine whether the policy reform was associated with hospital-primary care integration. RESEARCH DESIGN: I used a large sample of primary care physicians (n=98,884) drawn from Medicare claims data. I estimated cross-sectional multivariable linear probability models to measure whether the change in physicians' value-to-hospitals was associated with integration. RESULTS: The reform created heterogenous results: some physicians' value-to-hospitals decreased, while others increased (first percentile to 99th percentile, -$16,000 to $47,000). This change in value had a small association with integration: for every $10,000 increase, a physician was about 0.34 percentage points (95% confidence interval: 0.16-0.52) more likely to become integrated. Among high-volume physicians, the reform had larger effects: physicians whose value-to-hospitals grew by $20,000 or more were nearly 3 percentage points more likely to become integrated. Changes in value had no effect in concentrated hospital markets and rural areas. CONCLUSIONS: Effects of Medicare's site-based payments on hospital-primary care integration were concentrated among a small subset of physicians. Reforms to Medicare payment policy could influence integration among this group.

Pharmacogenomic testing to support prescribing in primary care: a structured review of implementation models.

The application of pharmacogenomics could meaningfully contribute toward medicines optimization within primary care. This review identified 13 studies describing eight implementation models utilizing a multi-gene pharmacogenomic panel within a primary care or community setting. These were small feasibility studies (n <200). They demonstrated importance and feasibility of pre-test counseling, the role of the pharmacist, data integration into the electronic medical record and point-of-care clinical decision support systems (CDSS). Findings were considered alongside existing primary care prescribing practices and implementation frameworks to demonstrate how issues may be addressed by existing nationalized healthcare and primary care infrastructure. Development of point-of-care CDSS should be prioritized; establishing clinical leadership, education programs, defining practitioner roles and responsibilities and addressing commissioning issues will also be crucial.