Hospitalizaciones evitables por problemas de salud sensibles a cuidados ambulatorios: construcción y validación de la lista Uruguaya de patologías

Introducción: Las hospitalizaciones por Ambulatory Care Sensitive Conditions es un indicador que mide la utilización de los servicios hospitalarios por problemas de salud que podrían haber sido prevenidos en el primer nivel de atención. El concepto se refiere a los procesos en que la atención ambulatoria efectiva puede ayudar a disminuir los riesgos de hospitalización, en un segundo nivel de atención. El objetivo del estudio fue construir y validar una lista uruguaya de problemas de salud sensibles a cuidados ambulatorios (PSSCA) según CIE-10. Metodología: Para la construcción de la lista inicial de códigos de PSSCA se realizó una revisión de los listados existentes y se propuso un listado inicial que fue validado a través del Método Delphi. Se propone un listado de 99 códigos diagnósticos de PSSCA adaptado a nuestro entono sanitario. Los mismos permiten identificar y cuantificar problemas de salud que pueden producir hospitalizaciones potenciamente evitables mediante cuidados ambulatorios accesibes y oportunos en el primer nivel de atención. Resultados: Se conformó un panel de 12 expertos. A partir de los datos obtenidos, considerando los 99 diagnósticos clasificados por CIE-10, éstos se pueden subclasificar en función de si la patología es infecciosa o no, obteniendo un resultado general de 62 patologías en un total de 99 que pueden ser clasificadas como infecciosas, lo que se corresponde a un 62 %. Discusión: De la comparación de la lista uruguaya de PSSCA a la que hemos arribado y las listas validadas utilizadas para la construcción inicial del listado de patologías propuesto, podemos decir que la primera presenta un mayor porcentaje de coincidencia con la lista de patologías de Bello Horizonte. Podemos mencionar que la mayoría de los problemas de salud identificados con base en el listado de PSSCA, son sensibles de ser resueltos con la atención primaria oportuna y de calidad que podría evitar o disminuir de una manera significativa su hospitalización. Conclusiones: Este trabajo describe el proceso de construcción y validación de una lista de códigos de PSSCA adaptados al contexto uruguayo a través del método Delphi. Hemos arribado a un listado que comprende un total de 99 diagnósticos, agrupadas en un total de diecinueve categorías que considera la especificidad del contexto uruguayo del indicador.

Introduction: Hospitalizations for Ambulatory Care Sensitive Conditions is an indicator that measures the use of hospital services for health problems that could have been prevented at the first level of care. The concept refers to the processes in which effective outpatient care can help reduce the risks of hospitalization, at a second level of care. The objective of the study was to build and validate a Uruguayan list of health problems sensitive to outpatient care (PSS-CA) according to ICD-10. Methodology: To construct the initial list of PSSCA codes, a review of the existing lists was carried out and an initial list was proposed that was validated through the Delphi Method. A list of 99 PSSCA diagnostic codes adapted to our healthcare environment is proposed. They make it possible to identify and quantify health problems that can lead to potentially avoidable hospitalizations through accessible and timely outpatient care at the first level of care. Results: A panel of 12 experts was formed. From the data obtained, considering the 99 diagnoses classified by ICD-10, these can be subclassified depending on whether the pathology is infectious or not, obtaining a general result of 62 pathologies in a total of 99 that can be classified as infectious, which corresponds to 62%. Discussion: From the comparison of the Uruguayan list of PSSCA that we have arrived at and the validated lists used for the initial construction of the proposed list of pathologies, we can say that the first presents a higher percentage of coincidence with the list of pathologies of Bello Horizonte . We can mention that most of the health problems identified based on the PSSCA list are sensitive to being resolved with timely and quality primary care that could prevent or significantly reduce hospitalization. Conclusions: This work describes the process of construction and validation of a list of PSSCA codes adapted to the Uruguayan context through the Delphi method. We have arrived at a list that includes a total of 99 diagnoses, grouped into a total of nineteen categories that consider the specificity of the Uruguayan context of the indicator.

Introdução: As Internações por Condições Sensíveis à Atenção Ambulatorial são um indicador que mede a utilização de serviços hospitalares para problemas de saúde que poderiam ter sido evitados no primeiro nível de atenção. O conceito refere-se aos processos em que um atendimento ambulatorial eficaz pode auxiliar na redução dos riscos de internação, em um segundo nível de atenção. O objetivo do estudo foi construir e validar uma lista uruguaia de problemas de saúde sensíveis à atenção ambulatorial (PSS-CA) segundo a CID-10. Metodologia: Para construir a lista inicial de códigos PSSCA foi realizada uma revisão das listas existentes e foi proposta uma lista inicial que foi validada através do Método Delphi. É proposta uma lista de 99 códigos de diagnóstico PSSCA adaptados ao nosso ambiente de saúde. Permitem identificar e quantificar problemas de saúde que podem levar a hospitalizações potencialmente evitáveis ​​através de cuidados ambulatórios acessíveis e oportunos no primeiro nível de cuidados. Resultados: Foi formado um painel de 12 especialistas. A partir dos dados obtidos, considerando os 99 diagnósticos classificados pela CID-10, estes podem ser subclassificados consoante a patologia seja infecciosa ou não, obtendo-se um resultado geral de 62 patologias num total de 99 que podem ser classificadas como infecciosas, o que corresponde para 62%. Discussão: A partir da comparação da lista uruguaia de PSSCA a que chegamos e das listas validadas utilizadas para a construção inicial da lista de patologias proposta, podemos dizer que a primeira apresenta um maior percentual de coincidência com a lista de patologias de Belo Horizonte. Podemos mencionar que a maioria dos problemas de saúde identificados com base na lista PSSCA são sensíveis para serem resolvidos com cuidados primários oportunos e de qualidade que possam prevenir ou reduzir significativamente a hospitalização. Conclusões: Este trabalho descreve o processo de construção e validação de uma lista de códigos PSSCA adaptados ao contexto uruguaio através do método Delphi. Chegamos a uma lista que inclui um total de 99 diagnósticos, agrupados em um total de dezenove categorias que consideram a especificidade do contexto uruguaio do indicador.

Senses and meanings of primary health care academic visions in nursing / Sentidos y significados de las visiones académicas de la atención/cuidado primaria de salud en enfermería / Sentidos e significados das visões acadêmicas da atenção básica/cuidado em enfermagem

Introduction: Primary Health Care (PHC) has acquired different meanings for different people, at specific times and places, which poses important challenges for its understanding. Objective: To analyze the meaning(s) and sense(s) of Primary/Basic Health Care in the academic views on Nursing/Health in the context of undergraduate Nursing courses offered at two public Higher Education Institutions. Materials and methods: Qualitative study with an exploratory approach. Semi-structured interviews and documentary analysis were used as data collection techniques. Results: The senses/meanings of Primary Health Care converge with the population's gateway to the health system at the first care level and with the first contact of a person with the health service. However, it is still considered as a less important service within the care network. Conclusion: Primary Health Care means a relevant possibility for Nursing/Health care through health promotion and disease prevention actions, with a commitment to respond to most of the population's health needs.

Introducción: La Atención Primaria de Salud ha adquirido diferentes significados para diversas personas, en momentos y lugares específicos, lo cual plantea importantes retos para su entendimiento. Objetivo: Analizar los significados y sentidos de la Atención Primaria de Salud desde una visión académica en Enfermería y en el contexto de cursos de pregrado en Enfermería ofrecidos en dos Instituciones Públicas de Educación Superior. Materiales y métodos: Estudio cualitativo con un enfoque exploratorio, para la recolección de datos se emplearon entrevistas semiestructuradas y análisis documental de contenidos. Resultados: Los sentidos/significados de la Atención Primaria de la Salud convergen con el ingreso de la población al sistema de salud en el primer nivel de atención y la primera experiencia de la persona con el servicio de salud. Sin embargo, dicha Atención Primaria todavía se considera un servicio de baja importancia dentro de la red asistencial. Conclusión: La Atención Primaria de Salud representa una posibilidad relevante para el cuidado de Enfermería a través de acciones de promoción de la salud y prevención de enfermedades, que debe fortalecerse para responder la mayoría de las necesidades de salud de la población.

Introdução: A Atenção Primária à Saúde tem adquirido diferentes significados para diferentes pessoas, em momentos e locais específicos, o que coloca desafios importantes para a sua compreensão. Objetivo: Analisar os sentidos e significados da Atenção Primária à Saúde na perspectiva acadêmica em Enfermagem e no contexto dos cursos de graduação em Enfermagem oferecidos em duas Instituições de Ensino Superior Públicas. Materiais e métodos: Estudo qualitativo com abordagem exploratória, utilizou-se entrevistas semiestruturadas para coleta de dados e análise de conteúdo documental. Resultados: Os sentidos/significados da Atenção Primária à Saúde convergem com a entrada da população no sistema de saúde no primeiro nível de atenção e a primeira experiência da pessoa com o serviço de saúde. Contudo, a referida Atenção Básica ainda é considerada um serviço de baixa importância dentro da rede de saúde. Conclusão: A Atenção Primária à Saúde representa uma possibilidade relevante para o cuidado de Enfermagem por meio de ações de promoção da saúde e prevenção de doenças, que devem ser fortalecidas para responder à maioria das necessidades de saúde da população.

Monitoring risk factors for dementia in middle-aged and older adults: a longitudinal study.

Given the importance of dementia syndrome and its impacts on the population, interest in studying modifiable risk factors for dementia is growing. Objective: To compare the prevalence of risk factors for dementia in middle-aged and older adults over a two-year period and to identify what variables in baseline were predictive of cognitive decline in the follow-up. Methods: Longitudinal and quantitative study, with follow-up evaluation after two years, conducted with 200 participants aged 45 years or more, registered in Primary Care Units. In the baseline (2018/2019) and follow-up (2021) assessments, sociodemographic data were collected, and cognitive performance and risk factors for dementia were evaluated (education, hearing loss, head trauma, high blood pressure, alcohol use, obesity, smoking, depressive symptoms, social isolation, physical inactivity, and diabetes mellitus). Data were compared using the McNemar's test. Individual multinomial logistic regression models were performed to identify the factors associated with cognitive decline after two years. Results: The percentages of low education, traumatic brain injury, and smoking remained the same in both assessments. There was a significant increase in the prevalence of high blood pressure (from 55.0 to 62.0%) and physical inactivity (from 58.5 to 74.5%) and a significant reduction in social isolation (from 25.0 to 18.0%). Participants with depressive symptoms in baseline had a higher risk of cognitive decline in follow-up. Conclusion: There was an increase in the prevalence of high blood pressure and physical inactivity and a reduction in social isolation after two years. Depressive symptoms predict cognitive decline.

Dada a importância da síndrome demencial e de seus impactos na população, cresce o interesse em estudar os fatores de risco modificáveis para a demência. Objetivo: Comparar a prevalência de fatores de risco para demência em adultos de meia-idade e pessoas idosas, em um período de dois anos, e identificar quais fatores de risco na avaliação de base predizem o declínio cognitivo na avaliação de acompanhamento. Métodos: Estudo longitudinal e quantitativo, com avaliação de acompanhamento após dois anos, realizado com 200 participantes com 45 anos ou mais, cadastrados na Atenção Básica. Nas avaliações de base (2018/2019) e de acompanhamento (2021) foram coletados dados sociodemográficos, foram feitas avaliação cognitiva e avaliação dos fatores de risco para demência (escolaridade, perda auditiva, traumatismo craniano, hipertensão arterial, uso de álcool, obesidade, tabagismo, sintomas depressivos, isolamento social, inatividade física, diabetes mellitus). Os dados foram comparados pelo teste de McNemar. Modelos de regressão logística multinominal individuais foram conduzidos para identificar quais fatores estavam associados ao declínio cognitivo após dois anos. Resultados: Os percentuais de baixa escolaridade, traumatismo craniano e tabagismo mantiveram-se os mesmos nas duas avaliações. Houve aumento significativo da prevalência de hipertensão arterial (de 55,0 para 62,0%) e inatividade física (de 58,5 para 74,5%), e redução significativa do isolamento social (de 25,5 para 18,0%). Participantes com sintomas depressivos na avaliação de base apresentaram maior risco de declínio cognitivo no acompanhamento. Conclusão: Houve aumento das prevalências de hipertensão arterial e inatividade física; e redução do isolamento social. Sintomas depressivos predizem declínio cognitivo.

Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial.

BACKGROUND: Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway. METHOD: From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team. RESULTS: A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance. CONCLUSION: With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

Multiple Behavioral Risk Factors As Assets for Chronic Disease Prevention: Observations From Urban Primary Care Settings in Crete, Greece.

AIM: This study aimed to assess the health profile of patient-attendees visiting primary healthcare (PHC) practice settings in the midst of the COVID-19 pandemic and to explore the relationships between multiple behavioral risk factors (MBRFs) and consultation-driven health information. Multiple behavioral risk factors involve a variety of unhealthy behaviors that are associated with an increased prevalence of non-communicable diseases (NCDs). SUBJECTS AND METHODS: The study design was based on a dataset analysis, afterward exploring the feasibility and diagnostic capacity of respiratory morbidity aspects from a study previously conducted. The study dataset contained information regarding socio-demographic characteristics, health habits, clinical information, and reported comorbidities from 183 primary care patient-attendees. A categorical regression analysis was performed, using as a numeric variable the multiple MBRFs (clustering of 0 to four factors) in order to examine relationships with the basic and clinical characteristics of the patient-attendees. RESULTS: Based on this secondary analysis, it was found that the prevalence of MBRFs is quite common among patient-attendees visiting urban PHC facilities. The prevalence of current smoking, sleep deprivation, increased body weight, and medium/high perceived stress levels were 33.9%, 52.5%, 83.1%, and 35.0%, respectively. An increased occurrence of MBRFs might be significantly predicted by the lower age of patient-attendees (b = -0.221, p = 0.05), by the absence of gray hair at an early age (b = -0.144, p = 0.042), by the physical discomfort during activities (b = 0.191, p = 0.017), or by the lower oxygen saturation (b = -0.184, p = 0.004). Diabetes mellitus (25.1%) was the most prevalent condition, followed by bronchial asthma (18.6%) and depression (15.8%). CONCLUSIONS: Lower age, absence of premature hair whitening, physical discomfort during activities, and lower oxygen saturation are linked with an increased occurrence of MBRFs, leading to a neglected way of living. Those factors could be used to alert researchers, policymakers, and PHC professionals to act accordingly in order to prevent or early diagnose NCDs.

Lifestyle Interventions in a Patient Identified as Super-Super Obese With a Body Mass Index of 90.5.

Obesity is a growing global health concern. Saudi Arabia is experiencing a higher prevalence of obesity compared to the globe. This case report focuses on a 38-year-old female with a body mass index (BMI) of 90.5 kg/m2, prediabetes, and obstructive sleep apnea who successfully underwent a lifestyle modification process resulting in remarkable weight loss. The patient's past unsuccessful attempts at weight loss had left her with a reluctance to try again initially. A multidisciplinary team collaborated to develop a management plan starting with an intensive lifestyle intervention. Lifestyle was assessed, then a structured personalized lifestyle intervention based on a plant-based diet and a gradual increase in physical activity was implemented. Over 6 months, the patient succeeded in losing 23 kg, a percent weight loss of 11.9%. An additional 5 kg was lost when liraglutide "Saxenda" was added. This case report represents the effectiveness of intensive lifestyle interventions in patients with super-super obesity for weight loss and long-term health improvement. Additional research is required to determine if the positive outcomes seen in treating a single patient can be applied to a larger population with super-super obesity. This brings up the question of whether pharmacotherapy or surgical interventions should be the primary approaches for addressing these cases, considering that surgical interventions usually involve lifestyle changes. What we already know about such cases: patients with super-super obesity often require interventions such as surgery or medication to aid in weight reduction, as they typically do not respond to lifestyle interventions alone. What this case report adds to existing knowledge: the use of lifestyle interventions proved effective in such cases as super-super obesity and delayed the need for surgical intervention even without weight reduction medications.

"To prescribe or not to prescribe, that is the question": Perspectives on opioid prescribing for chronic, cancer-related pain from clinicians who treat pain in survivorship.

BACKGROUND: Opioid pain management in cancer survivorship is a complex and understudied topic. METHODS: The authors conducted in-depth, qualitative interviews to understand clinician approaches to opioid pain management in chronic cancer pain and to generate ideas for improvement. They used a rigorous, inductive, qualitative, descriptive approach to examine clinician (n = 20) perspectives about opioid pain management in survivorship, including oncologists (n = 5), palliative care clinicians (n = 8), primary care clinicians (n = 5), and pain management specialists (n = 2). RESULTS: The findings indicated that no consistent medical home exists for chronic pain management in cancer survivors and that there are fundamental differences in how each subspecialty approaches chronic pain management in survivorship (e.g., "Do we think of this as noncancer pain or cancer pain?… This is in this limbo zone-this gray zone-because it's cancer-related pain, right?"). Simultaneously, clinicians are influenced by their peers' perceptions of their opioid prescribing decisions, sparking intraprofessional tension when disagreement occurs. In these instances, clinicians described overthinking and doubting their clinical decision-making as well as a sense of judgment, pressure, and/or shame. Finally, clinicians acknowledged a fear of consequences for opioid prescribing decisions. Specifically, participants cited conflict with patients, sometimes escalating to aggression and threats of violence, as well as potential disciplinary actions and/or legal consequences. CONCLUSIONS: Participants suggested that opportunities to improve chronic cancer pain care include developing clear, systematic guidance for chronic cancer pain management, facilitating clinician communication and consultation, creating tailored survivorship care plans in partnership with patients, and developing accessible, evidence-based, complementary pain treatments.

Willingness of healthcare providers to perform population-based cancer screening: a cross-sectional study in primary healthcare institutions in Tianjin, China.

OBJECTIVE: To evaluate the willingness of healthcare providers to perform population-based screening in primary healthcare institutions in China. METHODS: Healthcare providers of 262 primary healthcare institutions in Tianjin were invited to fill out a questionnaire consisting of demographic characteristics, workload, and knowledge of, attitude towards and willingness to perform breast, cervical and colorectal cancer screening. Willingness to screen was the primary outcome. Multilevel logistic regression models were conducted to analyse the determinants of healthcare providers' willingness to screen. ORs and 95% CIs were estimated. RESULTS: A total of 554 healthcare providers from 244 institutions answered the questionnaire. 67.2%, 72.1% and 74.3% were willing to perform breast, cervical and colorectal cancer screening, respectively. A negative attitude towards screening was associated with a low willingness for cervical (OR=0.27; 95% CI 0.08, 0.94) and colorectal (OR=0.08; 95% CI 0.02, 0.30) cancer screening, while this was not statistically significant for breast cancer screening (OR=0.30; 95% CI 0.08, 1.12). For breast, cervical and colorectal cancer screening, 70.1%, 63.8% and 59.0% of healthcare providers reported a shortage of staff dedicated to screening. A perceived reasonable manpower allocation was a determinant of increased willingness to perform breast (OR=2.86; 95% CI 1.03, 7.88) and colorectal (OR=2.70; 95% CI 1.22, 5.99) cancer screening. However, this was not significant for cervical cancer screening (OR=1.76; 95% CI 0.74, 4.18). CONCLUSIONS: In China, healthcare providers with a positive attitude towards screening have a stronger willingness to contribute to cancer screening, and therefore healthcare providers' attitude, recognition of the importance of screening and acceptable workload should be optimised to improve the uptake of cancer screening.

Qualitative study on shared decision making in cystitis management in general practice.

BACKGROUND: Cystitis are commonly treated with antibiotics, although non-antibiotic options could be considered for healthy non-pregnant women. Shared decision making (SDM) can be used in cystitis management to discuss the various treatment options but is not frequently applied in general practice. AIM: Identifying barriers and facilitators for applying SDM in cystitis management in general practice. DESIGN & SETTING: Qualitative explorative research in general practice with healthcare professionals (HCPs; general practitioners (GPs) and GP assistants) and healthy non-pregnant women with a recent history of cystitis (patients). METHOD: Individual semi-structured interviews were conducted between May and October 2022. We applied a combination of thematic and framework analysis. RESULTS: Ten GPs, seven GP assistants, and fifteen patients were interviewed. We identified three main barriers and one key facilitator: 1) applying SDM is deemed inefficient; 2) HCPs presume that patients expect antibiotic treatment and some HCPs consider non-antibiotic treatment inferior; 3) Patients are largely unaware of the various non-antibiotic treatment options for cystitis; 4) HCPs recognise some benefits of applying SDM in cystitis management, including reduced antibiotic use and improved patient empowerment, and patients appreciate involvement in treatment decisions, but preferences for SDM vary. CONCLUSION: SDM is infrequently applied in cystitis treatment in general practice due to the current efficient cystitis management, HCPs' perceptions, and patient unawareness. Nevertheless, both HCPs and patients recognise the long-term benefits of applying SDM in cystitis management. Our findings facilitate the development of tailored interventions to increase the application of SDM which should be co-created with HCPs and patients and fit into the current efficient cystitis management.

Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study.

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Acceptability of magnetic resonance imaging for prostate cancer diagnosis with patients and GPs: a qualitative interview study.

BACKGROUND: Magnetic resonance imaging (MRI) of the prostate is a new, more accurate, non-invasive test for prostate cancer diagnosis. AIM: To understand the acceptability of MRI for patients and GPs for prostate cancer diagnosis. DESIGN AND SETTING: Qualitative study of men who had undergone a prostate MRI for possible prostate cancer, and GPs who had referred at least one man for possible prostate cancer in the previous 12 months in West London and Devon. METHOD: Semi-structured interviews, conducted in person or via telephone, were audio-recorded and transcribed verbatim. Deductive thematic analysis was undertaken using Sekhon's Theoretical Framework of Acceptability, retrospectively for patients and prospectively for GPs. RESULTS: Twenty-two men (12 from Devon, age range 47-80 years), two patients' partners, and 10 GPs (6 female, age range 36-55 years) were interviewed. Prostate MRI was broadly acceptable for most patient participants, and they reported that it was not a significant undertaking to complete the scan. GPs were more varied in their views on prostate MRI, with a broad spectrum of knowledge and understanding of prostate MRI. Some GPs expressed concerns about additional clinical responsibility and local availability of MRI if direct access to prostate MRI in primary care were to be introduced. CONCLUSION: Prostate MRI appears to be acceptable to patients. Some differences were found between patients in London and Devon, mainly around burden of testing and opportunity costs. Further exploration of GPs' knowledge and understanding of prostate MRI could inform future initiatives to widen access to diagnostic testing in primary care.

Cancer Screening and Prevention in the Transgender and Gender Diverse Population: Considerations and Strategies for Advanced Practice Nurses.

OBJECTIVES: This discussion paper presents recent evidence regarding cancer screening and prevention among the transgender and gender diverse (TGD) community and highlights where and how advanced practice nurses (APNs), particularly those in primary care, can better contribute to closing the gap between healthcare disparities between TGD and cisgendered populations. METHODS: Relevant publications on the topic and professional guidelines and evidence have formed the basis for this discussion paper. RESULTS: TGD individuals are a vulnerable population with unique needs. They remain at risk of cancer and might be at greater risk of developing some cancers compared to cisgendered people but are underscreened. Barriers to gender-affirming care need to be addressed to improve access to prevention and screening services and improve the cancer care experiences and outcomes of TGD people. CONCLUSION: APNs can work in collaboration with TGD individuals and the healthcare system to improve access to culturally safe cancer screening and more effective prevention of cancer and poor cancer outcomes. IMPLICATIONS FOR NURSING PRACTICE: APNs have the potential to improve access to cancer screening for TGD people by increasing their understanding of the needs of the population, providing culturally safe care, and advocating for more preventative care and cancer screening. With greater knowledge and understanding of the needs and preferences of TGD people both broadly and in relation to cancer screening and prevention, targeted interventions and care approaches can be implemented. APNs should also aim to conduct evaluations and research into cancer prevention and screening to build the currently limited evidence base and nursing knowledge in this important field.

Baja disponibilidad de recursos y apoyo para atender a personas con diabetes e hipertensión arterial en las Unidades de Salud de la Familia de Paraguay

Introducción: Paraguay asumió el reto de lograr cobertura universal mediante redes basadas en Atención Primaria de la Salud con Unidades de Salud de la Familia (USF) en el primer nivel de atención. Un desafío es la atención integral ante enfermedades no transmisibles, principal causa de mortalidad en el país. Objetivo: analizar la capacidad de las USF para la atención de personas con hipertensión arterial y diabetes en el sistema nacional de salud. El diseño fue no experimental, cuantitativo, transversal, descriptivo con componente analítico. Metodología: Incluyó a 761 USF de 12 regiones sanitarias agrupados en 4 ejes territoriales. Se adaptó el método de evaluación SARA de la OMS con 75 variables, aplicando un cuestionario a profesionales de salud entre noviembre y diciembre de 2022. Se calculó índices de disponibilidad y preparación así como un índice que los integra. La medida continua de estos índices se categorizó en 3 grupos: suficiente >0,75 a 1; intermedio 0,5 a 0,75 y bajo <0,5. Resultados: Solo en el 38 % de las USF el índice de disponibilidad fue suficiente, en el 31,5 % para el índice de preparación y en el 31,1 % para el índice integrador SARA DM/HTA. El desempeño se asoció de forma significativa con el eje territorial no así con el área ni con la cobertura a población indígena Discusión: las USF presentaron limitaciones para la atención de personas con diabetes e hipertensión en estas regiones del país.

Introduction: Paraguay assumed the challenge of achieving universal coverage through networks based on Primary Health Care with Family Health Units (USF) at the first level of care. One challenge is comprehensive care for non-communicable diseases, the main cause of mortality in the country. Objective: to analyze the capacity of the USF to care for people with high blood pressure and diabetes in the national health system. The design was non-experimental, quantitative, cross-sectional, descriptive with an analytical component. Methods: It included 761 USF from 12 health regions grouped into 4 territorial axes. The WHO SARA evaluation method was adapted with 75 variables, applying a questionnaire to health professionals between November and December 2022. Availability and preparation indices were calculated as well as an index that integrates them. The continuous measurement of these indices was categorized into 3 groups: sufficient >0.75 to 1; intermediate 0.5 to 0.75 and low <0.5. Results: Only in 38.0% of the USF the availability index was sufficient, in 31.5% for the readiness index and in 31.1% for the SARA DM/HTA integrating index. The performance was significantly associated with the territorial axis, but not with the area or with the coverage of the indigenous population. Discussion: the USF presented limitations for the care of people with diabetes and hypertension in these regions of the country.

Family practice research in the African region 2020-2022.

BACKGROUND:  The African region produces a small proportion of all health research, including primary health care research. The SCOPUS database only lists the African Journal of Primary Health Care Family Medicine (PHCFM) and the South African Family Practice Journal (SAFP) in the field of family practice. AIM:  To review the nature of all original research (2020-2022) published in PHCFM and SAFP. SETTING:  African region. METHOD:  All 327 articles were included. Data were extracted into REDCap, using a standardised tool and exported to the Statistical Package for Social Sciences. RESULTS:  The median number of authors was 3 (interquartile range [IQR]: 2-4) and institutions and disciplines 1 (IQR: 1-2). Most authors were from South Africa (79.8%) and family medicine (45.3%) or public health (34.2%). Research focused on integrated health services (76.1%) and was mostly clinical (66.1%) or service delivery (37.9%). Clinical research addressed infectious diseases (23.4%), non-communicable diseases (24.6%) and maternal and women's health (19.4%). Service delivery research addressed the core functions of primary care (35.8%), particularly person-centredness and comprehensiveness. Research targeted adults and older adults (77.0%) as well as health promotion or disease prevention (38.5%) and treatment (30.9%). Almost all research was descriptive (73.7%), mostly surveys. CONCLUSION:  Future research should include community empowerment and multisectoral action. Within integrated health services, some areas need more attention, for example, children, palliative and rehabilitative care, continuity and coordination. Capacity building and support should enable larger, less-descriptive and more collaborative interdisciplinary studies with authors outside of South Africa.Contribution: The results highlight the strengths and weaknesses of family practice research in Africa.

Smoking Cessation Support in the Context of Other Social and Behavioral Needs in Community Health Centers.

BACKGROUND: Cigarette smoking rates remain disproportionately high among low income populations with unmet social and behavioral health needs. To address this problem, we sought to develop and evaluate the feasibility, acceptability, and preliminary effectiveness of a novel smoking cessation program for community health centers that serve these populations. METHODS: We implemented a randomized pilot trial of two smoking cessation programs in three county operated community health center (CHC) sites: (1) a systematic assessment of smoking habits and standard tools to assist with smoking cessation counseling ("Enhanced Standard Program" or ESP), and (2) another that added a structured assessment of social and behavioral barriers to smoking cessation, ("Connection to Health for Smokers" or CTHS). Clinical outcomes were evaluated between 10 to 16 weeks, supplemented with interviews of patient participants and health care team members. RESULTS: 141 adults were randomized and 123 completed the intervention (61 in ESP, 62 in CTHS). At follow-up, over half of participants reported ≥1 quit attempts (59.7% ESP and 56.5% CTHS; adjusted p = .66) while more in ESP (24.6% vs. 12.9%) were documented as not smoking in the last 7 days (adjusted p = 0.03). In addition to being in ESP, predictors of smoking cessation included higher baseline confidence in ability to quit (p = 0.02) and more quit attempts during the study (p = 0.04). Health care teams, however, generally preferred the more comprehensive approach of CTHS. CONCLUSION: Lessons learned from this pilot study may inform the development of effective smoking cessation programs for CHCs that combine elements of both interventions.

A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities.

Introduction and aim: Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services. Methods and analysis: A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices. Conclusion and knowledge contribution: PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.

Sex matters in the association between cardiovascular health and incident dementia: evidence from real world data.

BACKGROUND: Cardiovascular health has been associated with dementia onset, but little is known about the variation of such association by sex and age considering dementia subtypes. We assessed the role of sex and age in the association between cardiovascular risk and the onset of all-cause dementia, Alzheimer's disease, and vascular dementia in people aged 50-74 years. METHODS: This is a retrospective cohort study covering 922.973 Catalans who attended the primary care services of the Catalan Health Institute (Spain). Data were obtained from the System for the Development of Research in Primary Care (SIDIAP database). Exposure was the cardiovascular risk (CVR) at baseline categorized into four levels of Framingham-REGICOR score (FRS): low (FRS < 5%), low-intermediate (5% ≤ FRS < 7.5%), high-intermediate (7.5% ≤ FRS < 10%), high (FRS ≥ 10%), and one group with previous vascular disease. Cases of all-cause dementia and Alzheimer's disease were identified using validated algorithms, and cases of vascular dementia were identified by diagnostic codes. We fitted stratified Cox models using age parametrized as b-Spline. RESULTS: A total of 51,454 incident cases of all-cause dementia were recorded over a mean follow-up of 12.7 years. The hazard ratios in the low-intermediate and high FRS groups were 1.12 (95% confidence interval: 1.08-1.15) and 1.55 (1.50-1.60) for all-cause dementia; 1.07 (1.03-1.11) and 1.17 (1.11-1.24) for Alzheimer's disease; and 1.34 (1.21-1.50) and 1.90 (1.67-2.16) for vascular dementia. These associations were stronger in women and in midlife compared to later life in all dementia types. Women with a high Framingham-REGICOR score presented a similar risk of developing dementia - of any type - to women who had previous vascular disease, and at age 50-55, they showed three times higher risk of developing dementia risk compared to the lowest Framingham-REGICOR group. CONCLUSIONS: We found a dose‒response association between the Framingham-REGICOR score and the onset of all dementia types. Poor cardiovascular health in midlife increased the onset of all dementia types later in life, especially in women.

Engaging patients in designing a transmural allied health pathway: A qualitative exploration of hospital-to-home transitions.

INTRODUCTION: The transition from hospital to home is often suboptimal, resulting in patients not receiving the necessary allied healthcare after discharge. This may, in turn, lead to delayed recovery, a higher number of readmissions, more emergency department visits and an increase in mortality and healthcare costs. This study aimed to gain insight into patients' experiences, perceptions, and needs regarding hospital-to-home transition, focusing on allied healthcare as a first step towards the development of a transitional integrated allied healthcare pathway for patients with complex care needs after hospital discharge. METHODS: We conducted semistructured interviews with patients. Participants were recruited from universities and general hospitals in the Amsterdam region between May and July 2023. They were eligible if they (1) were discharged from the hospital minimally 3 and maximally 12 months after admission to an oncologic surgery department, internal medicine department, intensive care unit, or trauma centre, (2) received hospital-based care from at least one allied healthcare provider, who visited the patient at least twice during hospital admission, (3) spoke Dutch or English and (4) were 18 years or older. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis of the interview data. RESULTS: Nineteen patients were interviewed. Three themes emerged from the analysis. 'Allied healthcare support during transition' depicts patients' positive experiences when they felt supported by allied health professionals during the hospital-to-home transition. 'Patient and family involvement' illustrates how much patients value the involvement of their family members during discharge planning. 'Information recall and processing' portrays the challenges of understanding and remembering overwhelming amounts of information, sometimes unclear and provided at the wrong moment. Overall, patients' experiences of transitional care were positive when they were involved in the discharge process. Negative experiences occurred when their preferences for postdischarge communication were ignored. CONCLUSIONS: This study suggests that allied health professionals need to continuously collaborate and communicate with each other to provide patients and their families with the personalized support they need. To provide high-quality and person-centred care, it is essential to consider how, when, and what information to provide to patients and their families to allow them to contribute to their recovery actively. PATIENT OR PUBLIC CONTRIBUTION: The interview guide for this manuscript was developed with the assistance of patients, who reviewed it and provided us with feedback. Furthermore, patients provided us with their valuable lived experiences by participating in the interviews conducted for this study.

A nudge strategy to increase the uptake of colorectal cancer screening in Saudi Arabia: A pragmatic randomized trial in the Hail region.

Purpose: The purpose of this research was to examine the effectiveness of using a nudge strategy to encourage eligible clients to participate in colorectal cancer screening (CRCS) at primary care facilities. Additionally, it emphasizes the good outcomes of utilizing nudge in primary healthcare settings by reflecting on the novel experience of family physicians and nurses in the field of CRCS. Nudge is a cost-effective intervention that serves as a choice architect to assist people in making wise decisions for their lives. It is a subtly changed environment or combination of words that push individuals to make a decision without restricting their alternatives. Research Methods: This is a six-month, pragmatic trial with open-label recruitment that enrolled people with an average CRC risk from four screening healthcare zones that included 34 public primary care facilities. The study protocol is registered and can be accessed here: https://clinicaltrials.gov/ct2/show/NCT05785975. Results: An obvious increase in the proportion of the uptake of CRCS screening is higher in the two intervention sites-Al Hait General Hospital Zone (38%) and Al-Shamli General Hospital Zone (26%), than in the two control sites, Bagaa General Hospital Zone (18%) and King Khalid Hospital Zone (18%). Conclusions: Using the nudge strategy to increase CRCS uptake is valuable and effective; additionally, front-line family physicians and nurses in primary care are encouraged to use a planned, positive, and highly selective set of words when offering screening. Policymakers could make use of these research outcomes when designing new guidelines for CRCS.