Development of palliative care clinical practice guidelines and referral care pathways for primary care practitioners in Pakistan.

BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.

Conceptualizing National Advisory Boards in primary care research: application to the Two in One HIV and COVID screening and testing model.

The authors report on their development of a National Advisory Board (NAB) to guide a funded project: Two in One: HIV + COVID-19 Screening and Testing Model. This project aimed to improve primary care practitioners' capacity to routinize HIV, PrEP/PEP, and COVID-19 vaccine screenings for all their patients while relying on culturally responsive communication with their minoritized patients. To approach their monumental research and education tasks, they created a NAB, drawing from the literature on advisory boards to (a) promote board member engagement and (b) progress successfully through the six stages suggested for successful advisory boards. A midpoint survey and final focus groups with NAB members indicated mixed levels of engagement, a sense of time and work being valued, and pride in the media and academic reach of the project. The authors offer considerations for others considering forming a NAB to guide primary care research and interventions.

Patients' experiences of and roles in interprofessional collaborative practice in primary care: a constructivist grounded theory study.

AIM: This constructivist grounded theory study aimed to (1) explore patients' experiences of and roles in interprofessional collaborative practice for chronic conditions in primary care and (2) consider the relevance and alignment of an existing theoretical framework on patients' roles and based on the experiences of patient advocates. BACKGROUND: High-quality management of chronic conditions requires an interprofessional collaborative practice model of care considering an individual's mental, physical, and social health situation. Patients' experiences of this model in the primary care setting are relatively unknown. METHODS: A constructivist grounded theory approach was taken. Interview data were collected from primary care patients with chronic conditions across Australia in August 2020 - February 2022. Interviews were recorded, transcribed verbatim, and thematically analysed by (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation, and (5) theme and sub-theme development. Themes and sub-themes were mapped against an existing theoretical framework to expand and confirm the results from a previous study with a similar research aim. FINDINGS: Twenty adults with chronic conditions spanning physical disability, diabetes, heart disease, cancer, autoimmune, and mental health conditions participated. Two themes were developed: (1) Adapting to Change with two sub-themes describing how patients adapt to interprofessional team care and (2) Shifting across the spectrum of roles, with five sub-themes outlining the roles patients enact while receiving care. The findings suggest that patients' roles are highly variable and fluid in interprofessional collaborative practice, and further work is recommended to develop a resource to support greater patient engagement in interprofessional collaborative practice.

Implementation of a primary-tertiary shared care model to improve the detection of familial hypercholesterolaemia (FH): a mixed methods pre-post implementation study protocol.

INTRODUCTION: Familial hypercholesterolaemia (FH) is an autosomal dominant inherited disorder of lipid metabolism and a preventable cause of premature cardiovascular disease. Current detection rates for this highly treatable condition are low. Early detection and management of FH can significantly reduce cardiac morbidity and mortality. This study aims to implement a primary-tertiary shared care model to improve detection rates for FH. The primary objective is to evaluate the implementation of a shared care model and support package for genetic testing of FH. This protocol describes the design and methods used to evaluate the implementation of the shared care model and support package to improve the detection of FH. METHODS AND ANALYSIS: This mixed methods pre-post implementation study design will be used to evaluate increased detection rates for FH in the tertiary and primary care setting. The primary-tertiary shared care model will be implemented at NSW Health Pathology and Sydney Local Health District in NSW, Australia, over a 12-month period. Implementation of the shared care model will be evaluated using a modification of the implementation outcome taxonomy and will focus on the acceptability, evidence of delivery, appropriateness, feasibility, fidelity, implementation cost and timely initiation of the intervention. Quantitative pre-post and qualitative semistructured interview data will be collected. It is anticipated that data relating to at least 62 index patients will be collected over this period and a similar number obtained for the historical group for the quantitative data. We anticipate conducting approximately 20 interviews for the qualitative data. ETHICS AND DISSEMINATION: Ethical approval has been granted by the ethics review committee (Royal Prince Alfred Hospital Zone) of the Sydney Local Health District (Protocol ID: X23-0239). Findings will be disseminated through peer-reviewed publications, conference presentations and an end-of-study research report to stakeholders.

Opportunistic atrial fibrillation screening in primary care in Ireland: results of a pilot screening programme.

BACKGROUND: Atrial fibrillation (AF), a common, frequently asymptomatic cardiac arrhythmia, is a major risk factor for stroke. Identification of AF enables effective preventive treatment to be offered, potentially reducing stroke risk by up to two-thirds. There is international consensus that opportunistic AF screening is valuable though uncertainty remains about the optimum screening location and method. Primary care has been identified as a potential location for AF screening using one-lead ECG devices. METHODS: A pilot AF screening programme is in primary care in the south of Ireland. General practitioners (GPs) were recruited from Cork and Kerry. GPs invited patients ≥65 years to undergo AF screening. The screening comprised a one-lead ECG device, Kardia Mobile, blood pressure check and ascertainment of smoking status. Possible AF on one-lead ECG was confirmed with a 12-lead ECG. GPs also recorded information including medical history, current medication and onward referral. The Keele Decision Support tool was used to assess patients for oral anticoagulation (OAC). RESULTS: 3555 eligible patients, attending 52 GPs across 34 GP practices, agreed to undergo screening. 1720 (48%) were female, 1780 (50%) were hypertensive and 285 (8%) were current smokers. On the one-lead ECG, 3282 (92%) were in normal sinus rhythm, 101 (3%) had possible AF and among 124 (4%) the one-lead ECG was unreadable or unclassified. Of the 101 patients with possible AF, 45 (45%) had AF confirmed with 12-lead ECG, an incidence rate of AF of 1.3%. Among the 45 confirmed AF cases, 27 (60%) were commenced on OAC therapy by their GP. CONCLUSION: These findings suggest that AF screening in primary care may prove useful for early detection of AF cases that can be assessed for treatment. One-lead ECG devices may be useful in the detection of paroxysmal AF in this population and setting. Current OAC of AF may be suboptimal.

Research to Improve Clinical Care in Family Medicine: Big Data, Telehealth, Artificial Intelligence, and More.

This issue highlights changes in medical care delivery since the start of the COVID-19 pandemic and features research to advance the delivery of primary care. Several articles report on the effectiveness of telehealth, including its use for hospital follow-up, medication abortion, management of diabetes, and as a potential tool for reducing health disparities. Other articles detail innovations in clinical practice, from the use of artificial intelligence and machine learning to a validated simple risk score that can support outpatient triage decisions for patients with COVID-19. Notably one article reports the impact of a voluntary program using scribes in a large health system on physician documentation behaviors and performance. One article addresses the wage gap between early-career female and male family physicians. Several articles report on inappropriate testing for common health problems; are you following recommendations for ordering Pulmonary Function Tests, mt-sDNA for colon cancer screening, and HIV testing?

What Complexity Science Predicts About the Potential of Artificial Intelligence/Machine Learning to Improve Primary Care.

Primary care physicians are likely both excited and apprehensive at the prospects for artificial intelligence (AI) and machine learning (ML). Complexity science may provide insight into which AI/ML applications will most likely affect primary care in the future. AI/ML has successfully diagnosed some diseases from digital images, helped with administrative tasks such as writing notes in the electronic record by converting voice to text, and organized information from multiple sources within a health care system. AI/ML has less successfully recommended treatments for patients with complicated single diseases such as cancer; or improved diagnosing, patient shared decision making, and treating patients with multiple comorbidities and social determinant challenges. AI/ML has magnified disparities in health equity, and almost nothing is known of the effect of AI/ML on primary care physician-patient relationships. An intervention in Victoria, Australia showed promise where an AI/ML tool was used only as an adjunct to complex medical decision making. Putting these findings in a complex adaptive system framework, AI/ML tools will likely work when its tasks are limited in scope, have clean data that are mostly linear and deterministic, and fit well into existing workflows. AI/ML has rarely improved comprehensive care, especially in primary care settings, where data have a significant number of errors and inconsistencies. Primary care should be intimately involved in AI/ML development, and its tools carefully tested before implementation; and unlike electronic health records, not just assumed that AI/ML tools will improve primary care work life, quality, safety, and person-centered clinical decision making.

Making it "EASI" for pediatricians to determine when toddler tantrums are "more than the terrible twos": Proof-of-concept for primary care screening with the Multidimensional Assessment Profiles-Early Assessment Screener for Irritability (MAPS-EASI).

BACKGROUND: Up to 20% of youth have impairing mental health problems as early as age 3. Early identification and intervention of mental health risks in pediatric primary care could mitigate this crisis via prevention prior to disease onset. The purpose of this study was to establish the feasibility and acceptability of implementing a brief transdiagnostic screening instrument in pediatric primary care for irritability and corollary impairment. METHOD: Five pediatric clinicians in a Midwest clinic implemented the Multidimensional Assessment Profiles-Early Assessment Screener of Irritability (MAPS-EASI) for toddlers (24-30 months) and their families. MAPS-EASI (psychometrically derived from the well-validated MAPS-Scales) includes six items (scored 0-5) about symptoms (e.g., tantrums, grumpy mood), context, and frequency and two items (scored 0-3) assessed impairment. Positive screens (MAPS-EASI ≥ 5 plus impairment ≥ 2) were referred to an evidence-based parenting intervention. We assessed reach and outcomes of MAPS-EASI screening. Follow-up interviews with clinicians assessed perspectives on irritability screening and MAPS-EASI implementation. RESULTS: Of 201 eligible families, 100 (49.8%) completed the screener for a 24- or 30-month well-child visit. Mean MAPS-EASI scores were 5.8 (SD = 3.2), mean impairment scores were 0.9 (SD = 0.9), and 24 (24.0%) screened positive. Clinicians indicated that irritability screening for toddlers was aligned with their prevention-oriented, developmentally based practice. MAPS-EASI had face validity and increased clinician decision-making confidence. Finally, clinicians identified barriers and facilitators to large-scale implementation. CONCLUSIONS: MAPS-EASI proved to be feasible and acceptable in pediatric primary care. Further tailoring will be needed as the MAPS-EASI processes are scaled out to new contexts and populations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Addressing mental health, earlier in pediatric primary care: Introduction to the special section.

Leading national health organizations have declared pediatric mental health an urgent public health issue. Pediatric primary care is an ideal setting to improve mental health in young children; however, various existing barriers limit the effective identification of social-emotional risk among toddlers. This special section of Families, Systems, & Health includes four articles that identify multilevel barriers and facilitators to population-level early childhood mental health screening, identification, and referral and describe implementation strategies that may be used to improve pediatric mental health. In the first article, authors describe clinicians' concerns regarding the social-emotional screening of young children. In the second article, authors highlight the potential for a transdiagnostic screening tool for assessing toddler irritability that may support clinical decision making. In the third article, authors use information gathered from clinicians to generate a logic model that can guide the implementation of screening and referral for toddlers with elevated social-emotional risk. In the fourth article, authors explore caregivers' perceptions of other factors, such as effectiveness, demand, and cost, of the proposed intervention, that may impact their service engagement. Together, these articles outline a plan for facilitating early childhood mental health screening, identification, and referral that has the potential for reducing the prevalence of pediatric mental health diagnoses. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Identifying priority areas to support primary care engagement in breast cancer survivorship care: A Delphi study.

INTRODUCTION: Existing approaches in cancer survivorship care delivery have proven to be insufficient to engage primary care. This study aimed to identify stakeholder-informed priorities to improve primary care engagement in breast cancer survivorship care. METHODS: Experts in U.S. cancer survivorship care delivery were invited to participate in a 4-round online Delphi panel to identify and evaluate priorities for defining and fostering primary care's engagement in breast cancer survivorship. Panelists were asked to identify and then assess (ratings of 1-9) the importance and feasibility of priority items to support primary care engagement in survivorship. Panelists were asked to review the group results and reevaluate the importance and feasibility of each item, aiming to reach consensus. RESULTS: Respondent panelists (n = 23, response rate 57.5%) identified 31 priority items to support survivorship care. Panelists consistently rated three items most important (scored 9) but with uncertain feasibility (scored 5-6). These items emphasized the need to foster connections and improve communication between primary care and oncology. Panelists reached consensus on four items evaluated as important and feasible: (1) educating patients on survivorship, (2) enabling screening reminders and monitoring alerts in the electronic medical record, (3) identifying patient resources for clinicians to recommend, and (4) distributing accessible reference guides of common breast cancer drugs. CONCLUSION: Role clarity and communication between oncology and primary care were rated as most important; however, uncertainty about feasibility remains. These findings indicate that cross-disciplinary capacity building to address feasibility issues may be needed to make the most important priority items actionable in primary care.

A mixed methods analysis of the medication review intervention centered around the use of the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA) in Swiss primary care practices.

BACKGROUND: Electronic clinical decision support systems (eCDSS), such as the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) trial. METHODS: We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs (n = 21) and their patients (n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group (n = 8), and interview data were analyzed through thematic analysis. RESULTS: In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations. CONCLUSIONS: Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs' overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports). TRIAL REGISTRATION: Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018.

Family Medicine Team Perspectives on Screening for Health-Related Social Needs.

INTRODUCTION: Social drivers of health (SDH) strongly influence health outcomes and disparities. Although systemic level change is vital to address the disparities driven by SDH, it is also crucial that health care organizations develop the ability to care for patients in a manner that accounts for social factors and their influence on patient health. Although primary care is a natural fit for health-related social needs (HRSN) screening and intervention, significant barriers can impede primary care's effectiveness in this area. METHODS: We conducted 3 focus groups with family medicine clinicians, clinical staff, and social care workers in an academic medical center using a semistructured discussion guide to explore current practices, perceived benefits, barriers, and potential opportunities and approaches for integrating routine HRSN screening in primary care. RESULTS: 3 primary themes emerged from the focus groups. They included 1) the barriers to routine screening in primary care, including time, workload, emotional burden, patient factors, and team members' fear of inadequacy of resources or their own ability; 2) the importance and benefit of HRSN screening, including the opportunity to improve patient care through increased care team awareness of the patient's context, interventions to address HRSN, and improved relationships between the care team and the patient; and 3) recommendations for implementing routine screening in primary care, including opportunities to optimize workflow and technology, the importance of an electronic medical record (EMR)-integrated resource database, and the centrality of teamwork. DISCUSSION: Family medicine health care teams embrace the importance of HRSN screening and the potential for positive impact. However, there are vital barriers and considerations to address for HRSN screening to be effectively integrated into primary care visits.

Using implementation science to develop a familial hypercholesterolemia screening program in primary care: The CARE-FH study.

BACKGROUND: We designed the Collaborative Approach to Reach Everyone with Familial Hypercholesterolemia (CARE-FH) clinical trial to improve FH screening in primary care and facilitate guideline-based care. OBJECTIVE: The goal was to incorporate perspectives from end-users (healthcare system leaders, primary care clinicians, cardiologists, genetic counselors, nurses, and clinic staff) and improve translation of screening guidance into practice. METHODS: We partnered with end-users to sequentially define the current state of FH screening, assess acceptability, feasibility, and appropriateness of implementing an FH screening program, and select clinically actionable strategies at the patient-, clinician-, and system-level to be deployed as a package in the CARE-FH clinical trial. Methods informed by implementation science and human centered design included: contextual inquiries, surveys, and deliberative engagement sessions. RESULTS: Screening for FH occurred rarely in primary care, and then only after a cardiovascular event or sometimes due to a family history of high cholesterol or early heart attack. Surveys suggested FH screening in primary care was acceptable, appropriate, and feasible. Reported and observed barriers to screening include insufficient time at patient encounters to screen, cost and convenience of testing for patients, and knowledge regarding causes of dyslipidemia. Facilitators included clear guidance on screening criteria and new therapies to treat FH. These results led to the development of multilevel strategies that were presented to end-users, modified, and then pilot tested in one primary care clinic. CONCLUSIONS: A refined implementation strategy package for FH screening was created with a goal of improving FH awareness, identification, and initiation of guideline-based care. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/study/NCT05284513?id=NCT05284513&rank=1 Unique Identifier: NCT05284513.

Primary Care Providers Experiences Implementing Low-Dose Computed Tomography Recommendations for Lung Cancer Screening.

PURPOSE: Describe primary care providers' (PCPs) barriers and facilitators to implementation of lung cancer screening programs in rural settings. METHODS: We conducted qualitative interviews with PCPs practicing in rural Oregon from November 2019 to September 2020. The interview questions and analytic framework were informed by the 2009 Consolidated Framework for Implementation Research. We used inductive and deductive approaches for analysis. RESULTS: We interviewed 15 key participants from 12 distinct health care systems. We identified several Consolidated Framework for Implementation Research factors affecting lung cancer screening implementation. 1) Most PCPs did not have workflows to assist in discussing screening and relied on their memory and knowledge of the patient's history to prompt discussions. PCPs supported screening and managed the patient throughout the process. 2) PCPs reported several patient-level barriers, including geographic access to lung cancer screening scans and out-of-pocket cost concerns. 3) PCPs reported that champions are necessary to create opportunities for local practices to adopt lung cancer screening programs. CONCLUSIONS: Rural-practicing PCPs were supportive of lung cancer screening, however workflow processes, time challenges, and patient-reported barriers remain impediments to improved screening in their clinics. We identified several areas for improvement in lung cancer screening implementation in rural primary care practices, ranging from designing clinic workflows and processes to designating clinic staff to support referral, screening, and follow-up care for patients.

Implementation of Provider-Focused Education to Improve Laboratory Screening for Pediatric Patients With Elevated Body Mass Index in Primary Care: A Quality Improvement Project.

INTRODUCTION: Children with elevated body mass index (BMI) do not consistently receive recommended laboratory screenings. This project aimed to increase provider screening rates and knowledge of screening guidelines for this population. METHOD: This project utilized the Rosswurm and Larrabee evidence-based practice model. Providers completed education with pretest and posttest design. Laboratory screening rates were measured with retrospective chart reviews, and a project satisfaction survey was conducted. RESULTS: Nine (82%) of 11 providers showed an increase in knowledge of screening for children with elevated BMI. Laboratory screening increased (27% to 39%) above the preintervention median (25%) for children with obesity and was above the median (22%) for one month of the project (15% to 26%) for children with overweight. CONCLUSIONS: Project results suggest education improved knowledge and compliance with guidelines for laboratory screening of children with an elevated BMI. Asynchronous education and sharing of compliance rates are adaptable to similar quality improvement projects.

Deprescribing in primary care without deterioration of health-related outcomes: A real-life, quality improvement project.

Medication reviews focusing on deprescribing can reduce potentially inappropriate medication; however, evidence regarding effects on health-related outcomes is sparse. In a real-life quality improvement project using a newly developed chronic care model, we investigated how a general practitioner-led medication review intervention focusing on deprescribing affected health-related outcomes. We performed a before-after intervention study including care home residents and community-dwelling patients affiliated with a large Danish general practice. The primary outcomes were changes in self-reported health status, general condition and functional level from baseline to 3-4 months follow-up. Of the 105 included patients, 87 completed the follow-up. From baseline to follow-up, 255 medication changes were made, of which 83% were deprescribing. Mean self-reported health status increased (0.55 [95% CI: 0.22 to 0.87]); the proportion with general condition rated as 'average or above' was stable (0.06 [95% CI: -0.02 to 0.14]); and the proportion with functional level 'without any disability' was stable (-0.05 [95% CI: -0.09 to 0.001]). In conclusion, this general practitioner-led medication review intervention was associated with deprescribing and increased self-reported health status without the deterioration of general condition or functional level in real-life primary care patients. The results should be interpreted carefully given the small sample size and lack of control group.

Exploring the feasibility of an artificial intelligence based clinical decision support system for cutaneous melanoma detection in primary care - a mixed method study.

Objective: Skin examination to detect cutaneous melanomas is commonly performed in primary care. In recent years, clinical decision support systems (CDSS) based on artificial intelligence (AI) have been introduced within several diagnostic fields.Setting: This study employs a variety of qualitative and quantitative methodologies to investigate the feasibility of an AI-based CDSS to detect cutaneous melanoma in primary care.Subjects and Design: Fifteen primary care physicians (PCPs) underwent near-live simulations using the CDSS on a simulated patient, and subsequent individual semi-structured interviews were explored with a hybrid thematic analysis approach. Additionally, twenty-five PCPs performed a reader study (diagnostic assessment on the basis of image interpretation) of 18 dermoscopic images, both with and without help from AI, investigating the value of adding AI support to a PCPs decision. Perceived instrument usability was rated on the System Usability Scale (SUS).Results: From the interviews, the importance of trust in the CDSS emerged as a central concern. Scientific evidence supporting sufficient diagnostic accuracy of the CDSS was expressed as an important factor that could increase trust. Access to AI decision support when evaluating dermoscopic images proved valuable as it formally increased the physician's diagnostic accuracy. A mean SUS score of 84.8, corresponding to 'good' usability, was measured.Conclusion: AI-based CDSS might play an important future role in cutaneous melanoma diagnostics, provided sufficient evidence of diagnostic accuracy and usability supporting its trustworthiness among the users.

Effective primary care is important for discovering cutaneous melanoma, the deadliest and an increasingly prevalent form of skin cancer. 'Trust', 'usability and user experience', and 'the clinical context' are the qualitative themes that emerged from the qualitative analysis. These areas need to be considered for the successful adoption of AI assisted decision support tools by PCPs.The AI CDSS tool was rated by the PCPs at grade B (average 84.8) on the System Usability Scale (SUS), which is equivalent to 'good' usability.A reader study, (diagnostic assessment on the basis of image interpretation) with 25 PCPs rating dermoscopic images, showed increased value of adding an AI decision support to their clinical assessment.

Mayor uso de teleconsultas programadas y mensajería asincrónica del portal en atención primaria / Increased Use of Scheduled Teleconsultations and Asynchronous Portal Messaging in Primary Care

Introducción: durante la pandemia de COVID-19 hubo un auge sin precedentes de la telemedicina, probablemente por la forzada adopción de tecnología ante las medidas restrictivas. El presente estudio se propuso comparar la interacción y la comunicación entre médicos de cabecera (MC) y pacientes, antes y durante el período de pandemia, en términos de consultas ambulatorias programadas y mensajes del Portal de Salud. Materiales y métodos: corte transversal con muestreo consecutivo de turnos programados y mensajes, ocurridos entre las semanas epidemiológicas (SE) 10 y 23, de 2019 y 2020, respectivamente. Se incluyeron 147 médicos del Servicio de Medicina Familiar y Comunitaria, y una cápita de 73 427 pacientes afiliados al Plan de Salud del Hospital Italiano de Buenos Aires. Se realizó análisis cuantitativo y cualitativo. Resultados: hubo una reducción del 70% de las consultas presenciales (de 76 375 en 2019 a 23 200 en 2020) y un aumento concomitante de teleconsultas (de 255 en la SE13 a 1089 en la SE23). En simultáneo, los mensajes aumentaron sustancialmente (de 28 601 en 2019 a 84 916 en 2020), con un inicio abrupto al comienzo del confinamiento, y una tendencia decreciente a lo largo del tiempo. Antes de la pandemia, el contenido estuvo relacionado con órdenes electrónicas de estudios complementarios, control de resultados, recetas de medicación crónica y/o interconsultas a especialistas, mientras que los dominios más frecuentes durante la pandemia fueron necesidades informativas epidemiológicas, como medidas preventivas para COVID-19, vacuna antineumocócica, vacuna antigripal, casos o sospechas, resultados de hisopados, entre otras. Conclusión: el auge de las tecnologías de la comunicación e información durante la pandemia permitió dar continuidad a los procesos asistenciales en salud pese al distanciamiento físico. Hubo mayor utilización de mensajería por necesidades informativas de los pacientes, y la relación médico-paciente se ha modificado. (AU)

Introduction: during the COVID-19 pandemic, there was an unprecedented boom in telemedicine, probably due to the forced adoption of technology in the face of restrictive measures. This study aimed to compare the interaction and communication between general practitioners and patients before and during the pandemic based on scheduled outpatient consultations and Health Portal messages. Materials and methods: Cross-sectional study with a consecutive sampling of scheduled appointments and messages, occurring between epidemiological weeks (EW) 10 and 23 of 2019 and 2020, respectively. We included 147 physicians from the Family and Community Medicine Service and a capita of 73427 patients affiliated with the Hospital Italiano de Buenos Aires health plan. We conducted a quantitative and qualitative analysis. Results: there was a 70% reduction in face-to-face consultations (from 76375 in 2019 to 23200 in 2020) and a concomitant increase in teleconsultations (from 255 in EW13 to 1089 in EW23). Concurrently, messages increased substantially (from 28601 in 2019 to 84916 in 2020), with an abrupt onset at the beginning of confinement and a decreasing trend over time. Before the pandemic, the content involved electronic orders for complementary studies, outcome monitoring, chronic medication prescriptions, or expert consultations. The most frequent domains during the pandemic were epidemiological information needs, such as preventive measures for COVID-19, pneumococcal vaccine, influenza vaccine, cases or suspicions, and swab results, among others. Conclusion: the rise of communication and information technologies during the pandemic allowed the continuity of healthcare processes despite the physical distance. There was increased use of messaging for patients' information needs, and the doctor-patient relationship has changed. (AU)

Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study.

BACKGROUND: Advances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery. METHODS: This protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation. DISCUSSION: Study findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites. TRIAL REGISTRATION: Registered with ClinicalTrials.gov on June 2, 2022: NCT05400941.

Validated frailty measures using electronic primary care records: a review of diagnostic test accuracy.

INTRODUCTION: Identification of people who have or are at risk of frailty enables targeted interventions, and the use of tools that screen for frailty using electronic records (which we term as validated electronic frailty measures (VEFMs)) within primary care is incentivised by NHS England. We carried out a systematic review to establish the sensitivity and specificity of available primary care VEFMs when compared to a reference standard in-person assessment. METHODS: Medline, Pubmed, CENTRAL, CINHAL and Embase searches identified studies comparing a primary care VEFM with in-person assessment. Studies were quality assessed using Quality Assessment of Diagnostic Accuracy Studies revised tool. Sensitivity and specificity values were extracted or were calculated and pooled using StatsDirect. RESULTS: There were 2,245 titles screened, with 10 studies included. These described three different index tests: electronic frailty index (eFI), claims-based frailty index (cFI) and polypharmacy. Frailty Phenotype was the reference standard in each study. One study of 60 patients examined the eFI, reporting a sensitivity of 0.84 (95% CI = 0.55, 0.98) and a specificity of 0.78 (0.64, 0.89). Two studies of 7,679 patients examined cFI, with a pooled sensitivity of 0.48 (95% CI = 0.23, 0.74) and a specificity of 0.80 (0.53, 0.98). Seven studies of 34,328 patients examined a polypharmacy as a screening tool (defined as more than or equal to five medications) with a pooled sensitivity of 0.61 (95% CI = 0.50, 0.72) and a specificity of 0.66 (0.58, 0.73). CONCLUSIONS: eFI is the best-performing VEFM; however, based on our analysis of an average UK GP practice, it would return a high number of false-positive results. In conclusion, existing electronic frailty tools may not be appropriate for primary care-based population screening.