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.

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care.

BACKGROUND: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program. METHODS: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40-69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations. RESULTS: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40-69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program. CONCLUSIONS: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

The Ability of Primary Care Practices to Measure and Report on Care Quality.

BACKGROUND: Creating useful clinical quality measure (CQM) reports in a busy primary care practice is known to depend on the capability of the electronic health record (EHR). Two other domains may also contribute: supportive leadership to prioritize the work and commit the necessary resources, and individuals with the necessary health information technology (IT) skills to do so. Here we describe the results of an assessment of the above 3 domains and their associations with successful CQM reporting during an initiative to improve smaller primary care practices' cardiovascular disease CQMs. METHODS: The study took place within an AHRQ EvidenceNOW initiative of external support for smaller practices across Washington, Oregon and Idaho. Practice facilitators who provided this support completed an assessment of the 3 domains previously described for each of their assigned practices. Practices submitted 3 CQMs to the study team: appropriate aspirin prescribing, use of statins when indicated, blood pressure control, and tobacco screening/cessation. RESULTS: Practices with advanced EHR reporting capability were more likely to report 2 or more CQMs. Only one-third of practices were "advanced" in this domain, and this domain had the highest proportion of practices (39.1%) assessed as "basic." The presence of advanced leadership or advanced skills did not appreciably increase the proportion of practices that reported 2 or more CQMs. CONCLUSIONS: Our findings support previous reports of limited EHR reporting capabilities within smaller practices but extend these findings by demonstrating that practices with advanced capabilities in this domain are more likely to produce CQM reports.

Culture change and lessons learned from ten years in the VA centers of excellence in primary care education.

BACKGROUND: Team-based care is critical to achieving health care value while maximizing patient outcomes. Few descriptions exist of graduate-level team training interventions and practice models. Experience from the multisite, decade-long Veterans Affairs (VA) Centers of Excellence in Primary Care Education provides lessons for developing internal medicine training experiences in interprofessional clinical learning environments. METHODS: A review of multisite demonstration project transforming traditional silo-model training to interprofessional team-based primary care. Using iterative quality improvement approaches, sites evaluated curricula with learner, faculty and staff feedback. Learner- and patient-level outcomes and organizational culture change were examined using mixed methods, within and across sites. Participants included more than 1600 internal medicine, nurse practitioner, nursing, pharmacy, psychology, social work and physical therapy trainees. This took place in seven academic university-affiliated VA primary care clinics with patient centered medical home design RESULTS: Each site developed innovative design and curricula using common competencies of shared decision making, sustained relationships, performance improvement and interprofessional collaboration. Educational strategies included integrated didactics, workplace collaboration and reflection. Sites shared implementation best practices and outcomes. Cross-site evaluations of the impacts of these educational strategies indicated improvements in trainee clinical knowledge, team-based approaches to care and interest in primary care careers. Improved patient outcomes were seen in the quality of chronic disease management, reduction in polypharmacy, and reduced emergency department and hospitalizations. Evaluations of the culture of training environments demonstrated incorporation and persistence of interprofessional learning and collaboration. CONCLUSIONS: Aligning education and practice goals with cross-site collaboration created a robust interprofessional learning environment. Improved trainee/staff satisfaction and better patient care metrics supports use of this model to transform ambulatory care training. TRIAL REGISTRATION: This evaluation was categorized as an operation improvement activity by the Office of Academic Affairs based on Veterans Health Administration Handbook 1058.05, in which information generated is used for business operations and quality improvement (Title 38 Code of Federal Regulations Part 16 (38 CFR 16.102(l)). The overall project was subject to administrative oversight rather Human Subjects Institutional Review Board, as such informed consent was waived as part of the project implementation and evaluation.

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.

Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes.

Importance: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide. Objective: To examine whether primary care physicians' MIPS scores are associated with performance on process and outcome measures. Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. Exposures: MIPS score. Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, -7.1 percentage points [95% CI, -8.0 to -6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, -4.8 percentage points [95% CI, -5.4 to -4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, -12.2 percentage points [95% CI, -13.1 to -11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, -8.9 [95% CI, -13.7 to -4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care-sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

Guías para el abordaje de infancias y adolescencias trans en el primer nivel de atención / Guidelines for approaching trans children and adolescents at primary care level / Recomendações para lidar com pais de crianças e adolescentes trans no primeiro nível de atenção

Introducción: en muchas oportunidades el/la pediatra o médica/o de familia será la primera persona a la que consulten los niños/as y adolescentes trans a fin de plantear sus dudas y experiencias, por lo tanto es fundamental que el/la profesional aborde en la consulta esta temática sin prejuicios, con una mirada actualizada en el marco de los derechos de niñas, niños y adolescentes. Objetivo: brindar herramientas para un adecuado acompañamiento y seguimiento en la atención en salud a las infancias y adolescencias trans en el primer nivel de atención. Metodología: para la elaboración de esta guía se hizo una revisión bibliográfica en Pubmed y Scielo. Se realizó dicha búsqueda desde 2010 a la fecha con el prescriptor "infancias trans", "adolescencias trans", en inglés y en idioma español. Resultados: se elaboraron guías para el abordaje en la atención en el primer nivel de atención de niños/as y adolescentes trans aportando herramientas para la historia clínica, teniendo en cuenta la entrevista, el examen físico y el abordaje multi e interdisciplinario. Conclusiones: las experiencias trans en las infancias y adolescencias no deben ser miradas desde un enfoque patologizador sino como vivencias legítimas. El/la profesional de la salud juega un rol fundamental en la función de acompañamiento y como garante de sus derechos promoviendo la autonomía en la toma de decisiones.

Introduction: many times pediatricians or family doctors are the first people trans-children and adolescents consult and raise questions and experiences to. Therefore, it is key for doctors to have an unbiassed approach to this issue in the consultation, with an updated view of the framework of children and adolescents. Objective: provide tools for proper health care support and follow-up ifor trans children and adolescents at primary care. Methodology: for the preparation of these guidelines, we made a bibliographic review in Pubmed, Scielo. This search was carried out from 2010 to date using "trans children", "trans adolescents" prescribers, in English and in Spanish. Results: guidelines were created for primary care regarding the care of trans children and adolescents, providing tools for medical records and considering the interview, the physical examination and the multi-interdisciplinary approach. Conclusions: trans experiences in childhood and adolescence should not be viewed from a pathologizing perspective, but rather as legitimate experiences. Health professionals play a key role in accompanying and guarding the rights of children and adolescents and promoting their autonomy in decision-making instances.

Introdução: em muitas ocasiões, o pediatra ou médico de família é a primeira pessoa que as crianças e adolescentes trans consultam para compartilhar suas dúvidas e vivências, por isso é fundamental que ele aborde a consulta sobre esse assunto sem preconceitos, com uma perspectiva atualizada no marco dos direitos de crianças e adolescentes. Objetivo: fornecer ferramentas para suporte e acompanhamento adequados no atendimento da saúde de crianças e adolescentes trans no primeiro nível de atenção. Metodologia: para a elaboração deste guia, foi feita uma revisão bibliográfica no Pubmed, Scielo. A pesquisa com as palavras "crianças trans", "adolescentes trans", vem sendo realizada desde 2010 até hoje em inglês e espanhol. Resultados: foram elaboradas diretrizes para a abordagem do cuidado no primeiro nível de atenção a crianças e a adolescentes trans, fornecendo instrumentos para a história clínica, levando em consideração a entrevista, o exame físico e a abordagem multidisciplinar. Conclusões: as experiências trans na infância e adolescência não devem ser vistas a partir de uma abordagem patologizante, mas sim como experiências legítimas. O profissional de saúde tem papel fundamental na função de acompanhamento e como garantidor de seus direitos, promovendo autonomia na tomada de decisões.

Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review.

PURPOSE: South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence. METHODS: A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC. RESULTS: IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care. CONCLUSION: Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.

Interventions to Increase Colorectal Cancer Screening Uptake in Primary Care: A Systematic Review.

OBJECTIVE: We systematically reviewed and summarized previous studies that examined facilitators and barriers to implementing interventions to increase CRCS uptake in primary care practice. METHODS: We searched PubMed, Medline (EBSCO), and CINAHL databases, from the inception of these databases to April 2020. The search strategy combined a set of terms related to facilitators/barriers, intervention implementation, CRCS, and uptake/participation. A priori set inclusion and exclusion criteria were used during both title/abstract screening and full-text screening phases to identify the eligible studies. Quality of the included studies was appraised using quality assessment tools, and data were extracted using a predetermined data extraction tool. We classified facilitators and barriers according to the Consolidated Framework for Implementation Research domains and constructs and identified the common facilitators and barriers looking at how common they were across studies. RESULTS: A total of 12 studies were included in the review. Engagement of the clinic team, leadership team, and partners, clinics' motivation to improve CRCS rates, use of the EMR system, continuous monitoring and feedback system, and having a supportive environment for implementation were the most commonly reported implementation facilitators. Limited time for the clinic team to devote to a new project, challenges in getting accurate, timely data related to CRCS, limited capacity/support to use the EMR system, and disconnect between clinic team members were the most commonly reported implementation barriers. CONCLUSIONS: The synthesized findings improve our understanding of facilitators of and barriers to the implementation of interventions to increase CRCS participation in primary care practice, and inform the customized implementation strategies. Many of the included studies had limited use of rigorous implementation science frameworks to guide their implementation and evaluation, which precludes a comprehensive understanding of the implementation factors specific to CRCS interventions in primary care. Future studies assessing the CRCS intervention implementation factors would benefit from the use of implementation science frameworks.

Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: What can (and should) improve?

The article describes the temporal evolution of prenatal quality indicators in the primary health care network in Brazil and investigates regional differences. This study used data from the external evaluation of Brazil's National Program for Improving Primary Care Access and Quality (PMAQ) with health teams participating in Cycles I, II and III of the Program, carried out respectively in 2012, 2013/14 and 2017/18. The number of visits, physical examination procedures, guidelines and request for laboratory tests were investigated. There was a positive evolution for tests-HIV, syphilis, blood glucose and ultrasound, and for all tests, guidance on feeding and weight gain of the baby and examination of the oral cavity. The indicators that performed the worst were: performance of tetanus vaccine, six or more visits, receiving guidance on exclusive breastfeeding and care for the newborn, and the procedures-all, measurement of uterine height, gynecological exam and cervix cancer prevention. These changes had a varied behavior between the regions of the country.

High and Sustained Participation in a Multi-year Voluntary Performance Measurement Initiative Among Primary Care Teams.

BACKGROUND: The province of Ontario, Canada has made major investments in interdisciplinary primary care teams. There is interest in both demonstrating and improving the quality of care they provide. Challenges include lack of consensus on the definition of quality and evidence that the process of measuring quality can be counter-productive to actually achieving it. This study describes how primary care teams in Ontario voluntarily measured quality at the team level. METHODS: Data for this 4-year observational study came from electronic medical records (EMRs), patient surveys and administrative reports. Descriptive statistics were calculated for individual measures (eg, access, preventive interventions) and composite indicators of quality and healthcare system costs. Repeated measures identified patient and practice characteristics related to quality and cost outcomes. RESULTS: Teams participated in an average of 5 of 8 possible iterations of the reporting process. There was variation between teams. For example, cervical cancer screening rates ranged from 21 to 86% of eligible patients. Rural teams had significantly better performance on some indicators (eg, continuity) and worse on others (eg, cancer screening). There were some statistical but small changes in performance over time. CONCLUSION: High, sustained voluntary participation suggests that the initiative served a need for the primary care teams involved. The absence of robust data standards suggests that these standards were not crucial to achieve participation. The constant level of performance might mean that measurement has not yet led to improvement or that measures used might not accurately reflect improvement. The data reinforce the need to consider differences between rural and urban settings. They also suggest that further analysis is needed to identify characteristics that teams can change to improve the quality of care their patients experience. The study describes a practical, sustainable real-world approach to performance measurement in primary care that was attractive to interdisciplinary teams.

Screening for Unhealthy Alcohol and Drug Use in General Medicine Settings.

Unhealthy alcohol and drug use are among the top 10 causes of preventable death in the United States, but they are infrequently identified and addressed in medical settings. Guidelines recommend screening adult primary care patients for alcohol and drug use, and routine screening should be a component of high-quality clinical care. Brief, validated screening tools accurately detect unhealthy alcohol and drug use, and their thoughtful implementation can facilitate adoption and optimize the quality of screening results. Recommendations for implementation include patient self-administered screening tools, integration with electronic health records, and screening during routine primary care visits.

Physician perspectives on delays in cancer diagnosis in Alberta: a qualitative study.

BACKGROUND: Delays in cancer diagnosis have been associated with reduced survival, decreased quality of life after treatment, and suboptimal patient experience. The objective of the study was to explore the perspectives of a group of family physicians and other specialists regarding potentially avoidable delays in diagnosing cancer, and approaches that may help expedite the process. METHODS: We conducted a qualitative study using interviews with physicians practising in primary and outpatient care settings in Alberta between July and September 2019. We recruited family physicians and specialists who were in a position to discuss delays in cancer diagnosis by email via the Cancer Strategic Clinical Network and the Alberta Medical Association. We conducted semistructured interviews over the phone, and analyzed data using thematic analysis. RESULTS: Eleven family physicians and 22 other specialists (including 7 surgeons or surgical oncologists, 3 pathologists, 3 radiologists, 2 emergency physicians and 2 hematologists) participated in interviews; 22 were male (66.7%). We identified 4 main themes describing 9 factors contributing to potentially avoidable delays in diagnosis, namely the nature of primary care, initial presentation, investigation, and specialist advice and referral. We also identified 1 theme describing 3 suggestions for improvement, including system integration, standardized care pathways and a centralized advice, triage and referral support service for family physicians. INTERPRETATION: These findings suggest the need for enhanced support for family physicians, and better integration of primary and specialty care before cancer diagnosis. A multifaceted and coordinated approach to streamlining cancer diagnosis is required, with the goals of enhancing patient outcomes, reducing physician frustration and optimizing efficiency.

Enfrentamiento terapéutico del paciente adulto hipertenso en Atención Primaria de Salud: una propuesta a considerar / Therapeutic coping of hypertensive adult patients in Primary Health Care: a proposal to consider

Arterial Hypertension (HT) is one of the most widely spread chronic diseases in the world, with a suspicion in the Chilean population of 27.6%, according to the results of the 2017 National Health Survey. Reponsible for high morbidity and mortality, being, in Chile, the main risk factor related to years of life lost due to disability and premature death (DALYs). This fact has motivaded a constant publication of clinical practices guidelines and recomendations from many scientific societies in whole wide world. Hypertension represents a significant proportion of medical consultations for the primary care doctors. In fact, may be a huge challenge to get acceptable percentages of compensation in blood pressure, and mainly, to reduce morbidity and mortality in their patients. Because of this, we propose a set of questions and answers to guide the management of hypertension un primary care, based on the recommendation of the main guidelines of clinical practice.

Patient navigation programs in Alberta, Canada: an environmental scan.

BACKGROUND: Patient navigation is a complex intervention that has garnered substantial interest and investment across Canada. We conducted an environmental scan to understand the landscape of patient navigation programs within the health care system in Alberta, Canada. METHODS: We included patient navigation programs within Alberta Health Services (AHS) and Alberta's Primary Care Networks (PCNs). Key informants were asked in October 2016 to identify existing programs and their corresponding program contacts. These program contacts were invited to complete a telephone-based survey from October 2016 to July 2017, to provide program descriptions and eligibility criteria, and to identify gaps in navigation. Programs were included if they engaged patients on an individual basis, and either facilitated continuity of care or promoted patient and family empowerment. We tabulated results and calculated summary statistics for program characteristics. RESULTS: Ninety-five potentially eligible programs were identified by key informants. The response rate to the study survey was 73% (n = 69). After excluding programs not meeting inclusion criteria, we included a total of 58 programs in the study: 43 AHS programs and 15 PCN programs. Nearly all programs (93%, n = 54) delivered navigation via an individual acting as a navigator. A minority of programs also included nonnavigator components, such as Web-based resources (7%, n = 4) and process or structural changes to facilitate navigation (22%, n = 13). Certain patient subgroups were particularly well-served by patient navigation; these included patients with cancer, substance use disorders or mental health concerns, and pediatric patients. Gaps identified in navigation fell under 4 domains: awareness, resources, geographic distribution and integration. INTERPRETATION: Patient navigation programs are common and have extended beyond cancer care, from which the construct originated; however, gaps include a lack of awareness and inequitable access to the programs. These findings will be of interest to those developing and implementing patient navigation interventions in Alberta and other jurisdictions.

Redução ou cessação do uso de derivados de tabaco na APS / Reduction or cessation of tobacco use in PHC

Esta síntese rápida de evidências foi comissionada e subsidiada pelo Ministério da Saúde, no âmbito do projeto GEREB-010-FIO-20 e faz parte da Coleção "Rapid response for health promotion". PROBLEMA: O uso contínuo do tabaco, por exposição direta ou indireta, é considerado um problema global de saúde pública, responsável por oito milhões de mortes ao ano. Cerca de 80% dos usuários da substância residem em países de baixa e média renda, como o Brasil. O principal problema de saúde decorrente do uso dos derivados de tabaco é o câncer de pulmão, terceiro tipo de câncer mais comum na população e o mais letal. Neste cenário é importante que equipes e serviços de Atenção Primária à Saúde (APS) estejam preparados para fornecer ações de prevenção e controle do fumo. Opções para enfrentar o problema: De 234 registros recuperados das bases de dados, após processo de seleção e elegibilidade, treze Revisões Sistemáticas (RS) foram incluídas nesta síntese narrativa. Os resultados foram organizados em quatro opções para políticas em contextos de APS. Efeitos positivos foram relatados nas RS para uma variedade de intervenções, no entanto, algumas incertezas também foram apontadas. Com relação à qualidade metodológica, uma RS foi classificada como de confiança moderada, duas de confiança baixa e dez de confiança criticamente baixa. Opção 1. Intervenções de aconselhamento conduzidas por profissionais de saúde: Seis RS apresentaram efeitos das intervenções de aconselhamento para cessação do uso do tabaco, conduzidas por profissionais farmacêuticos, enfermeiros, profissionais com treinamento específico para lidar com o tabagismo e profissionais não especificados. Uma variedade de modalidades de aconselhamento mostrou-se efetiva na comparação com nenhuma intervenção, cuidado habitual ou intervenções menos intensivas. Incertezas foram apontadas com relação aos efeitos da entrevista motivacional e na comparação do aconselhamento com intervenções mistas. Opção 2. Intervenções comportamentais únicas ou combinadas: Duas RS relataram que intervenções comportamentais se mostraram efetivas para lidar com o tabagismo em comparação a cuidados habituais, materiais educativos e aconselhamento breve. Incertezas foram relatadas em relação ao reforço contingente e com relação ao apoio comportamental para fumantes com sofrimento psíquico e jovens em diferentes situações de risco, sendo: adolescentes grávidas, adolescentes com doença mental, adolescentes em tratamento por uso abusivo de substâncias e estudantes residentes de comunidades socioeconomicamente vulneráveis (o risco e faixa etária não foi especificado em um estudo). Opção 3. Apoio de registro médico e feedback motivacional personalizado sobre riscos biomédicos: Duas RS investigaram os efeitos do apoio de registro médico nas consultas, e o feedback dos riscos biomédicos. As evidências são escassas para afirmar se essas intervenções são ou não efetivas na cessação do tabagismo. O uso de registro médico tem como base apenas dois estudos primários, um dos quais sem grupo controle. O uso de resultados de exames mostrou-se efetivo com o feedback sobre danos relacionados ao fumo, mas não teve o mesmo efeito quando esse feedback se referia à exposição ao fumo e ao risco de doenças relacionadas ao fumo. Opção 4. Intervenções multicomponentes: Oito RS apresentaram efeitos de diversas intervenções combinadas para redução ou cessação do uso do tabaco. Algumas intervenções foram realizadas por profissionais de farmácia, enfermagem, médicos ou equipe clínica. As intervenções multicomponentes mostraram-se efetivas para a cessação do tabagismo, particularmente nos estudos em que foram comparadas a nenhuma intervenção, cuidados habituais ou intervenções mais comumente utilizadas. No entanto, é importante considerar algumas incertezas de maior magnitude apontadas nos estudos, como a adição do aconselhamento por entrevista motivacional ou apoio por telefone

This rapid synthesis of evidence was commissioned and subsidized by the Ministry of Health, under the project GEREB-010-FIO-20 and is part of the "Rapid response for health promotion" Collection. PROBLEM: The continuous use of tobacco, through direct or indirect exposure, is considered a global public health problem, responsible for eight million deaths a year. About 80% of substance users reside in low- and middle-income countries, such as Brazil. The main health problem resulting from the use of tobacco derivatives is lung cancer, the third most common type of cancer in the population and the most lethal. In this scenario, it is important that Primary Health Care (PHC) teams and services are prepared to provide tobacco prevention and control actions. Options to tackle the problem: From 234 records retrieved from the databases, after a selection and eligibility process, thirteen Systematic Reviews (SR) were included in this narrative synthesis. The results were organized into four options for policies in PHC contexts. Positive effects were reported in the SRs for a variety of interventions, however, some uncertainties were also pointed out. Regarding methodological quality, one SR was classified as moderately confident, two as low confidence and ten as critically low confidence. Option 1. Counseling interventions conducted by health professionals: Six SRs showed effects of counseling interventions for tobacco use, conducted by pharmacists, nurses, professionals with specific training to deal with tobacco and unspecified professionals. A variety of counseling modalities have been shown to be effective in comparison with no intervention, usual care, or less intensive interventions. Uncertainties were pointed out regarding the effects of motivational interviewing and the comparison of counseling with mixed interventions. Option 2. Single or Combined Behavioral Interventions: Two SRs reported that behavioral interventions were effective in dealing with smoking compared to usual care, educational materials, and brief counseling. Uncertainties were reported in relation to contingent reinforcement and in relation to behavioral support for smokers with psychological distress and young people in different risk situations, namely: pregnant adolescents, adolescents with mental illness, adolescents undergoing treatment for substance abuse and students residing in communities socioeconomically vulnerable (risk and age group were not specified in one study). Option 3. Medical record support and personalized motivational feedback on biomedical risks: Two SRs investigated the effects of medical record support on appointments, and biomedical risk feedback. Evidence is scarce to state whether or not these interventions are effective in smoking cessation. The use of medical records is based on only two primary studies, one of which without a control group. The use of test results was effective with feedback on smoking-related harm, but did not have the same effect when that feedback referred to smoking exposure and risk of smoking-related illness. Option 4. Multicomponent Interventions: Eight SRs showed effects of several combined interventions to reduce or stop tobacco use. Some interventions were performed by pharmacy, nursing, medical or clinical staff professionals. Multicomponent interventions were shown to be effective for smoking cessation, particularly in studies where they were compared to no intervention, usual care, or more commonly used interventions. However, it is important to consider some uncertainties of greater magnitude pointed out in the studies, such as the addition of motivational interviewing counseling or telephone support

United States Best Practice Guidelines for Primary Palliative Care in the Emergency Department.

The growing palliative care needs of emergency department (ED) patients in the United States have motivated the development of ED primary palliative care principles. An expert panel convened to develop best practice guidelines for ED primary palliative care to help guide frontline ED clinicians based on available evidence and consensus opinion of the panel. Results include recommendations for screening and assessment of palliative care needs, ED management of palliative care needs, goals of care conversations, ED palliative care and hospice consults, and transitions of care.