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.

Relação enfermeiro-pessoa afetada pela Tuberculose fundamentada na teoria do alcance de metas de imogene king / La relación enfermería-Persona afectada por la Tuberculosis, según la Teoría del logro de objetivos de imogene king / The nurse-tuberculosis patient relationship according to Imogene King's theory of goal achievement

Resumo Introdução: As ações desenvolvidas na Atenção Primária à Saúde são um dos pontos fortes de combate à tuberculose. Nesse nível de atenção, o contato contínuo do enfermeiro por meio da consulta de enfermagem permite manter relação com a população adoecida. Diante da relação enfermeiro-pessoa cuidada para o estabelecimento do vínculo e adesão ao tratamento contra tuberculose, compreende-se a importância do referencial teórico de Imogene King para estruturar a interação enfermeiro-pessoa cuidada e oferecer uma dinâmica para esse processo. Objetivo: Analisar a relação enfermeiro-pessoa afetada pela tuberculose fundamentada na Teoria do Alcance de Metas de Imogene King. Método: Estudo descritivo com abordagem qualitativa, com 14 enfermeiros da APS, selecionadas por conveniência. A coleta de dados ocorreu de agosto a novembro de 2018, por meio de entrevista semiestruturada, elaborada com base no Registro Meta-Orientado de Enfermagem de Imogene King. Os dados foram analisados de forme qualitativa pelo Software IRAMUTEQ. A pesquisa foi aprovada pelo Comitê de Ética. Resultados: Após a análise, emergiram quatro classes: 1) relação estabelecida com base no acolhimento; 2) relação enfermeiro-pessoa com tuberculose e o apoio de outros profissionais e familiares; 3) relação estabelecida com vistas ao cumprimento do tratamento; e 4) relação estabelecida para enfrentamento do preconceito diante da tuberculose. Conclusão: O acolhimento, a família e o vínculo entre profissional, paciente e equipe da Atenção Primária à Saúde fortalecem o enfrentamento da doença e reforçam a adesão ao tratamento medicamentoso.

Resumen Introducción: Uno de los puntos fuertes de la lucha contra la tuberculosis son las acciones desarrolladas en la atención primaria de salud. En este nivel asistencial, el contacto continuo de las enfermerías a través de la consulta de enfermería permite mantener una relación con la población enferma. Frente a la relación enfermería-persona para el establecimiento del vínculo y la adherencia al tratamiento contra la tuberculosis, se entiende la importancia del referente teórico de Imogene King para estructurar la interacción enfermería-persona y ofrecer una dinámica para este proceso. Objetivo: Análisis de la relación entre el personal de enfermería y las personas afectadas por la tuberculosis, a partir de la teoría del logro de objetivos de Imogene King. Método: Estudio descriptivo con abordaje cualitativo, con 14 enfermeras de atención primaria de salud, seleccionadas por conveniencia. La recolección de datos ocurrió de agosto a noviembre de 2018, a través de una entrevista semiestructurada, elaborada con base en el registro meta-orientado de enfermería de Imogene King. Los datos fueron analizados cualitativamente utilizando el software IRAMUTEQ. La investigación fue aprobada por el Comité de Ética. Resultados: Después del análisis, surgieron cuatro clases: 1) relación establecida con base en la recepción, 2) relación enfermería-persona con tuberculosis y apoyo de otras personas profesionales y familiares, 3) relación establecida con miras al cumplimiento del tratamiento y 4) relación establecida para combatir los prejuicios contra la tuberculosis. Conclusión: La acogida, la familia y el vínculo entre profesional, paciente y equipo de atención primaria de salud fortalecen el afrontamiento de la enfermedad y refuerzan la adherencia al tratamiento farmacológico.

Abstract Introduction: One of the main aspects in the fight against tuberculosis are the actions developed in Primary Health Care (PHC). At this level of care, the nurse's continuous contact through the nursing consultation allows them to maintain a relationship with the sick population. Regarding the nurse-patient relationship for establishing a bond and the compliance with tuberculosis treatment, we understand the importance of Imogene King's theoretical framework for structuring the nurse-patient interaction and offering a dynamic for this process. Objective: To analyze the nurse-tuberculosis patient relationship based on Imogene King's Theory of Goal Achievement. Method: A descriptive study with a qualitative approach, with 14 PHC nurses, selected by convenience. Data were collected from August to November 2018 through semi-structured interviews based on Imogene King's Meta-Oriented Nursing Record. The data were analyzed qualitatively using the IRAMUTEQ software. The research was approved by the Ethics Committee. Results: After the analysis, four classes emerged: 1) relationship established on the basis of welcoming; 2) nurse-tuberculosis patient relationship and the support of other professionals and family members; 3) relationship established towards treatment compliance; and 4) relationship established to confront prejudice associated with tuberculosis. Conclusion: The welcoming, the family, and the bond between the professional, the patient and Primary Health Care team strengthen the coping with the disease and reinforce the compliance with the pharmacological treatment.

Investigating the impact of primary care networks on continuity of care in English general practice: Analysis of interviews with patients and clinicians from a mixed methods study.

INTRODUCTION: In England, primary care networks (PCNs) offer opportunities to improve access to and sustainability of general practice through collaboration between groups of practices to provide care with a broader range of practitioner roles. However, there are concerns that these changes may undermine continuity of care. Our study investigates what the organisational shift to PCNs means for continuity of care. METHODS: The paper uses thematic analysis of qualitative data from interviews with general practitioners and other healthcare professionals (HCPs, n = 33) in 19 practices in five PCNs, and their patients (n = 35). Three patient cohorts within each participating practice were recruited, based on anticipated higher or lower needs for continuity of care: patients over 65 years with polypharmacy, patients with anxiety or depression and 'working age' adults aged between 18 and 45 years. FINDINGS: Patients and clinicians perceived changes to continuity in PCNs in our study. Larger-scale care provision in PCNs required better care coordination and information-sharing processes, aimed at improving care for 'vulnerable' patients in target groups. However, new working arrangements and ways of delivering care in PCNs undermine HCPs' ability to maintain continuity through ongoing relationships with patients. Patients experience this in terms of reduced availability of their preferred clinician, inefficiencies in care and unfamiliarity of new staff, roles and processes. CONCLUSIONS: New practitioners need to be effectively integrated to support effective team-based care. However, for patients, especially those not deemed 'vulnerable', this may not be sufficient to counter the loss of relationship with their practice. Therefore, caution is required in relation to designating patients as in need of, or not in need of continuity. Rather, continuity for all patients could be maintained through a dynamic understanding of the need for it as fluctuating and situational and by supporting clinicians to provide follow-up care. PATIENT AND PUBLIC INVOLVEMENT (PPI): A PPI group was recruited and consulted during the study for feedback on the study design, recruitment materials and interpretation of findings.

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data.

PURPOSE: Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage. METHODS: Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017. RESULTS: A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month. CONCLUSION: This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

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.

Medical Insurance Representatives Perceptions on National Health Insurance Primary Healthcare Re-Engineering in South Africa: A Qualitative Study.

The South African government is moving toward universal health coverage (UHC) with the passing of the National Health Insurance (NHI) Bill. Access to quality primary healthcare (PHC) is the cornerstone of UHC principles. The South African governmental health department have begun focusing efforts on improving the efficiency and functionality of this system; that includes the involvement of private healthcare professionals and medical insurance companies. This study sought to explore perceptions of medical insurance company personnel on PHC re-engineering as part of NHI restructuring. A qualitative research design was adopted in this study. Semi-structured interviewed were conducted on 10 participants. Their responses were audio recorded and transcribed utilizing Microsoft Word® documents. Nvivo® was used to facilitate the analysis of data. A thematical approach was used to categories codes into themes. Although participants were in agreement with the current healthcare reform in South Africa. The findings of this study have highlighted several gaps in the NHI Bill at the current point in time. In order to achieve standardized quality of care at a primary level; it is imperative that reimbursement frameworks with clearly detailed service provision and accountability guidelines are developed.

Spanish primary care in pediatric trauma (AITP) consensus: An AITP checklist. / Consenso AITP español: Una lista de verificación AITP.

INTRODUCTION: The course in Primary Care in Pediatric Trauma (ATIP in Spanish) has been taught in Spain since 1997, and there are currently 9 accredited training centers. Care of polytraumatized pediatric patients often takes place in an environment conducive to errors resulting from forgetfulness, which is why checklists - mnemonic tools widely used in industry and medicine - are particularly useful to avoid such errors. Although several checklists exist for pediatric trauma care, none have been developed within the setting of our course. MATERIALS AND METHODS: The criteria for being selected as an expert in Primary Care in Pediatric Trauma were agreed upon with the scientific polytrauma committee of the Spanish Pediatric Surgery Society. The items that make up the checklist were obtained from a review of the literature and consultation with selected experts, using the Delphi Technique. RESULTS: 10 experts representing the 9 groups or training centers in Primary Care in Pediatric Trauma were selected, and a 28-item checklist was drawn up in accordance with their design recommendations. CONCLUSIONS: With the consensus of all the groups, a checklist for the treatment of polytraumatized pediatric patients was drawn up using the Delphi Technique, an essential requirement for the dissemination of this checklist, which should be adapted and validated for use in each healthcare center.

INTRODUCCION: El curso de Asistencia Inicial al Trauma Pediátrico se imparte en España desde 1997, existiendo en la actualidad 9 centros formadores acreditados. La asistencia al paciente pediátrico politraumatizado se produce muchas veces en un ambiente proclive al error por olvido, por lo que las listas de verificación, como herramientas mnemotécnicas de amplia difusión en la industria y en medicina, serían especialmente útiles para evitarlos. Aunque existen varias listas de verificación para la asistencia al traumatismo pediátrico, ninguna se ha desarrollado en el entorno de nuestro curso. MATERIAL Y METODOS: Se acordaron los criterios para ser seleccionado como experto en Asistencia Inicial al Trauma Pediátrico con la comisión científica de politrauma de la Sociedad Española de Cirugía Pediátrica. Los ítems para formar la lista de verificación se obtuvieron a partir de una revisión bibliográfica y de la consulta a los expertos seleccionados, empleando un método Delphi. RESULTADOS: Se seleccionaron 10 expertos que representan los 9 grupos o centros formadores en Asistencia Inicial al Trauma Pediátrico y se elaboró una lista de verificación con 28 ítems, siguiendo sus recomendaciones de diseño. CONCLUSIONES: Se diseñó una lista de verificación para el manejo del paciente pediátrico politraumatizado, con el consenso de todos los grupos empleando un método Delphi, requisito fundamental para facilitar la difusión de esta lista. Sería preciso adaptar y validar dicha lista para su uso en cada centro asistencial.

A Provider-Facing Decision Support Tool for Prostate Cancer Screening in Primary Care: A Pilot Study.

OBJECTIVES: Our objective was to pilot test an electronic health record-embedded decision support tool to facilitate prostate-specific antigen (PSA) screening discussions in the primary care setting. METHODS: We pilot-tested a novel decision support tool that was used by 10 primary care physicians (PCPs) for 6 months, followed by a survey. The tool comprised (1) a risk-stratified algorithm, (2) a tool for facilitating shared decision-making (Simple Schema), (3) three best practice advisories (BPAs: <45, 45-75, and >75 years), and (4) a health maintenance module for scheduling automated reminders about PSA rescreening. RESULTS: All PCPs found the tool feasible, acceptable, and clear to use. Eight out of ten PCPs reported that the tool made PSA screening conversations somewhat or much easier. Before using the tool, 70% of PCPs felt confident in their ability to discuss PSA screening with their patient, and this improved to 100% after the tool was used by PCPs for 6 months. PCPs found the BPAs for eligible (45-75 years) and older men (>75 years) more useful than the BPA for younger men (<45 years). Among the 10 PCPs, 60% found the Simple Schema to be very useful, and 50% found the health maintenance module to be extremely or very useful. Most PCPs reported the components of the tool to be at least somewhat useful, with 10% finding them to be very burdensome. CONCLUSION: We demonstrated the feasibility and acceptability of the tool, which is notable given the marked low acceptance of existing tools. All PCPs reported that they would consider continuing to use the tool in their clinic and were likely or very likely to recommend the tool to a colleague.

Using Project Extension for Community Healthcare Outcomes to Enhance Substance Use Disorder Care in Primary Care: Mixed Methods Study.

BACKGROUND: Substance use and overdose deaths make up a substantial portion of injury-related deaths in the United States, with the state of Ohio leading the nation in rates of diagnosed substance use disorder (SUD). Ohio's growing epidemic has indicated a need to improve SUD care in a primary care setting through the engagement of multidisciplinary providers and the use of a comprehensive approach to care. OBJECTIVE: The purpose of this study was to assess the ability of the Weitzman Extension for Community Healthcare Outcomes (ECHO): Comprehensive Substance Use Disorder Care program to both address and meet 7 series learning objectives and address substances by analyzing (1) the frequency of exposure to the learning objective topics and substance types during case discussions and (2) participants' change in knowledge, self-efficacy, attitudes, and skills related to the treatment of SUDs pre- to postseries. The 7 series learning objective themes included harm reduction, team-based care, behavioral techniques, medication-assisted treatment, trauma-informed care, co-occurring conditions, and social determinants of health. METHODS: We used a mixed methods approach using a conceptual content analysis based on series learning objectives and substances and a 2-tailed paired-samples t test of participants' self-reported learner outcomes. The content analysis gauged the frequency and dose of learning objective themes and illicit and nonillicit substances mentioned in participant case presentations and discussions, and the paired-samples t test compared participants' knowledge, self-efficacy, attitudes, and skills associated with learning objectives and medication management of substances from pre- to postseries. RESULTS: The results of the content analysis indicated that 3 learning objective themes-team-based care, harm reduction, and social determinants of health-resulted in the highest frequencies and dose, appearing in 100% (n=22) of case presentations and discussions. Alcohol had the highest frequency and dose among the illicit and nonillicit substances, appearing in 81% (n=18) of case presentations and discussions. The results of the paired-samples t test indicated statistically significant increases in knowledge domain statements related to polysubstance use (P=.02), understanding the approach other disciplines use in SUD care (P=.02), and medication management strategies for nicotine (P=.03) and opioid use disorder (P=.003). Statistically significant increases were observed for 2 self-efficacy domain statements regarding medication management for nicotine (P=.002) and alcohol use disorder (P=.02). Further, 1 statistically significant increase in the skill domain was observed regarding using the stages of change theory in interventions (P=.03). CONCLUSIONS: These findings indicate that the ECHO program's content aligned with its stated learning objectives; met its learning objectives for the 3 themes where significant improvements were measured; and met its intent to address multiple substances in case presentations and discussions. These results demonstrate that Project ECHO is a potential tool to educate multidisciplinary providers in a comprehensive approach to SUD care.

[The territorial nature of the Primary Health Care of Brazil's Unified Health System (SUS): the proliferation of community medical clinics in the Metropolitan Region of Belém, State of Pará, Brazil]. / A territorialidade da Atenção Básica à Saúde do SUS: a difusão das clínicas médicas populares na Região Metropolitana de Belém, Pará, Brasil.

The scope of this article is an analysis of the proliferation of community medical clinics in the municipalities that comprise the Metropolitan Region of Belem. An investigation was conducted into the performance of the primary health care network of Brazil's Unified Health System, with a view to getting a better understanding of the reasons for, and origins of, the proactive stance of the community health sector. The discussion is based on the review of primary and secondary data, obtained via fieldwork in 119 community clinics in the Metropolitan Region of Belem, and information from Brazil's Unified Health System data center. It was revealed that the community health clinic sector has benefited extensively in recent years from the intensification of underfunding of Brazil's Unified Health System, especially the primary health care network, which is undergoing a process of fragmentation. This is directly responsible for the reduction and disruption of multiprofessional primary health care teams, in addition to the losses suffered in the supplementary health sector. The community clinics adopt an spontaneous and contradictory care model created by the private sector to meet the repressed demand of Brazil's Unified Health System.

O artigo apresenta uma análise sobre a difusão das clínicas médicas populares nos municípios que compõem a Região Metropolitana de Belém (RMB). Com o propósito de compreender as razões e as origens do avanço do setor de saúde popular, promoveu-se uma investigação sobre a atuação da rede de atenção básica à saúde (ABS) do Sistema Único de Saúde (SUS). A discussão se fundamenta na revisão de dados primários e secundários, captados via trabalho de campo nas 119 clínicas populares da RMB e via informações do DATASUS. Constatou-se que o setor das clínicas de saúde popular foi beneficiado amplamente nos últimos anos, mediante a intensificação do subfinanciamento do SUS, em particular da rede de ABS, que passa por um processo de fragmentação, responsáveis pela redução e pela desarticulação das equipes multiprofissionais de ABS, além das perdas apresentadas no setor de saúde suplementar. As clínicas populares seguem um modelo assistencial inacabado e contraditório, criado pela própria iniciativa privada para o preenchimento da demanda reprimida do SUS em razão de o acesso a essas instituições não garantir uma assistência universal e gratuita ou assegurar um tratamento continuo, motivo pelo qual uma ampla parcela destes usuários é devolvida ao SUS.

[Effects of parliamentary amendments on municipal financing of primary health care in the Brazilian Unified National Health System]. / Efeitos das emendas parlamentares no financiamento municipal da atenção primária à saúde do Sistema Único de Saúde.

This study aims to analyze the effects of the expansion of the federal transfer of parliamentary amendments for municipal financing of primary health care (PHC) in the Brazilian Unified National Health System (SUS), from 2015 to 2020. A longitudinal study was conducted using secondary data on transfers of parliamentary amendments from the Brazilian Ministry of Health and expenditure of municipalities' own resources on public health actions and services and PHC. The effect of the transfer of parliamentary amendments on municipal financing was verified in a stratified way by population size of the municipalities, using generalized estimating equation models. The transfer of parliamentary amendments for PHC showed a large discrepancy in per capita values among municipalities of different population sizes. No correlation with municipal spending on public health actions and services was observed in municipalities with more than 10,000 inhabitants, and the association with spending on PHC (p < 0.050) was inverse in all municipalities. Therefore, the increase in the transfer of parliamentary amendments by the Brazilian Ministry of Health favored a reduction in the allocation of municipal revenues to PHC, which may have been directed to other spending purposes in the SUS. These changes seem to represent priorities established for municipal budget expenditure, which have repercussions on local conditions for guaranteeing stable funding for PHC in Brazil.

O objetivo deste artigo é analisar os efeitos da ampliação do repasse federal de emendas parlamentares no financiamento municipal da atenção primária à saúde (APS) do Sistema Único de Saúde (SUS), no período de 2015 a 2020. Foi realizado estudo longitudinal com dados secundários de transferências por emendas parlamentares do Ministério da Saúde e de despesas com recursos próprios dos municípios, aplicadas em ações e serviços públicos de saúde e na APS. O efeito do repasse de emendas parlamentares no financiamento municipal foi verificado de forma estratificada por porte populacional dos municípios, por meio de modelos de equações de estimativas generalizadas. O repasse de emendas parlamentares para a APS apresentou grande discrepância de valores per capita entre os municípios de diferentes portes populacionais. Observou-se inexistência de correlação com a despesa municipal em ações e serviços públicos de saúde nos municípios com mais de 10 mil habitantes e associação inversa com a despesa em APS (p < 0,050) em todos os grupos. Conclui-se que o aumento do repasse de emendas parlamentares pelo Ministério da Saúde favoreceu a redução da alocação de receitas municipais com APS, que podem ter sido direcionados para outras finalidades de gasto no SUS. Tais mudanças parecem refletir prioridades estabelecidas para a despesa orçamentária dos municípios, que repercutem sobre as condições locais para a garantia da estabilidade do financiamento da APS no Brasil.

El artículo tiene como objetivo analizar los efectos de la ampliación de la transferencia de recursos federal de enmiendas parlamentarias sobre el financiamiento municipal de la atención primaria de salud (APS) en el Sistema Único de Salud brasileño (SUS), en el período del 2015 al 2020. Se realizó un estudio longitudinal con datos secundarios de transferencias de recursos por enmiendas parlamentarias del Ministerio de Salud y de gastos con recursos propios de los municipios, aplicados a acciones y servicios públicos de salud y a la APS. El efecto de la transferencia de recursos de enmiendas parlamentarias sobre el financiamiento municipal se verificó de forma estratificada por tamaño de población de los municipios, utilizando modelos de ecuaciones de estimaciones generalizadas. La transferencia de recursos de enmiendas parlamentarias para la APS mostró una gran discrepancia en los valores per cápita entre municipios de diferente tamaño poblacional. No hubo correlación con el gasto municipal en acciones y servicios públicos de salud en aquellos con más de 10.000 habitantes y asociación inversa con el gasto en APS (p < 0,050) en todos los grupos de municipios. Se concluye que el aumento en la transferencia de recursos de enmiendas parlamentarias por parte del Ministerio de Salud favoreció la reducción de la asignación de ingresos municipales a la APS, que pueden haber sido dirigidos a otros fines de gasto en el SUS. Tales cambios parecen reflejar prioridades establecidas para el gasto presupuestario municipal, que repercuten en las condiciones locales para garantizar la estabilidad del financiamiento de la APS en Brasil.

"It Can Be Confusing": Family Perspectives on Food Insecurity Screening in Urban Pediatric Primary Care Clinics.

Food insecurity, for which families are routinely screened at medical visits, has deleterious health consequences. This study sought to understand the lived experiences of families with lower incomes participating in food insecurity screening at two urban pediatric primary care clinics. Forty-three semi-structured interviews were performed in English and Spanish with families with public insurance after well visits where food insecurity screening was documented. Immersion-crystallization analysis was used to identify salient themes. Families reported discomfort with food insecurity screening, but nonetheless found screening acceptable when performed universally and privately. Families shared confusion about how their screening responses would be used and expected that resources would be available promptly for those who screen positive. Food insecurity screening may be improved for families through explanations of how responses will be used, allowing families to opt out, soliciting family preferences for resource referral, and offering promptly available resources for families with food insecurity.

Challenges Addressing Lung Cancer Screening for Patients With Multimorbidity in Primary Care: A Qualitative Study.

PURPOSE: Many individuals who are eligible for lung cancer screening have comorbid conditions complicating their shared decision-making conversations with physicians. The goal of our study was to better understand how primary care physicians (PCPs) factor comorbidities into their evaluation of the risks and benefits of lung cancer screening and into their shared decision-making conversations with patients. METHODS: We conducted semistructured interviews by videoconference with 15 PCPs to assess the extent of shared decision-making practices and explore their understanding of the intersection of comorbidities and lung cancer screening, and how that understanding informed their clinical approach to this population. RESULTS: We identified 3 themes. The first theme was whether to discuss or not to discuss lung cancer screening. PCPs described taking additional steps for individuals with complex comorbidities to decide whether to initiate this discussion and used subjective clinical judgment to decide whether the conversation would be productive and beneficial. PCPs made mental assessments that factored in the patient's health, life expectancy, quality of life, and access to support systems. The second theme was that shared decision making is not a simple discussion. When PCPs did initiate discussions about lung cancer screening, although some believed they could provide objective information, others struggled with personal biases. The third theme was that ultimately, the decision to be screened was up to the patient. Patients had the final say, even if their decision was discordant with the PCP's advice. CONCLUSIONS: Shared decision-making conversations about lung cancer screening differed substantially from the standard for patients with complex comorbidities. Future research should include efforts to characterize the risks and benefits of LCS in patients with comorbidities to inform guidelines and clinical application.

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.

Association between sociodemographic factors, clinic characteristics and mental health screening rates in primary care.

BACKGROUND: Screening for mental health problems has been shown to be effective to detect depression and initiate treatment in primary care. Current guidelines recommend periodic screening for depression and anxiety. This study examines the association of patient sociodemographic factors and clinic characteristics on mental health screening in primary care. DESIGN: In this retrospective cohort study, electronic medical record (EMR) data from a 14-month period from 10/15/2021 to 12/14/2022 were analyzed. Data were retrieved from 18 primary care clinics from the Corewell Health healthcare system in West Michigan. The main outcome was documentation of any Patient Health Questionnaire (PHQ-4/PHQ-9/GAD-7) screening in the EMR within the 14-month period at patient level. General linear regression models with logit link function were used to assess adjusted odds ratio (aOR) of having a documented screening. RESULTS: In total, 126,306 unique patients aged 16 years or older with a total of 291,789 encounters were included. The prevalence of 14-month screening was 79.8% (95% CI, 79.6-80.0). Regression analyses revealed higher screening odds for patients of smaller clinics (<5,000 patients, aOR 1.88; 95% CI 1.80-1.98 vs. clinics >10.000 patients), clinics in areas with mental health provider shortages (aOR 1.69; 95% CI 1.62-1.77), frequent visits (aOR 1.80; 95% CI, 1.78-1.83), and having an annual physical / well child visit encounter (aOR 1.52; 95% CI, 1.47-1.57). Smaller positive effect sizes were also found for male sex, Black or African American race, Asian race, Latinx ethnicity (ref. White/Caucasians), and having insurance through Medicaid (ref. other private insurance). DISCUSSION: The 14-month mental health screening rates have been shown to be significantly lower among patients with infrequent visits seeking care in larger clinics and available mental health resources in the community. Introducing and incentivizing mandatory mental health screening protocols in annual well visits, are viable options to increase screening rates.

Psychedelic Therapy: A Primer for Primary Care Clinicians-Ketamine.

BACKGROUND: Ketamine, an arylcyclohexylamine dissociative anesthetic agent, has evolved into a versatile therapeutic. It has a rapid-onset, well-understood cardiovascular effects and a favorable safety profile in clinical use. Its enantiomeric compound, esketamine, was approved by the Food and Drug Administration in 2019 for both treatment-resistant depression and major depressive disorder with suicidal ideation. AREAS OF UNCERTAINTY: Research indicates dose-dependent impacts on cognition, particularly affecting episodic and working memory following both acute administration and chronic use, albeit temporarily for the former and potentially persistent for the latter. Alongside acute risks to cardiovascular stability, ketamine use poses potential liver toxicity concerns, especially with prolonged or repeated exposure within short time frames. The drug's association with "ketamine cystitis," characterized by bladder inflammation, adds to its profile of physiological risks. THERAPEUTIC ADVANCES: Data demonstrate a single intravenous infusion of ketamine exhibits antidepressant effects within hours (weighted effect size averages of depression scores (N = 518) following a single 0.5 mg/kg infusion of ketamine is d = 0.96 at 24 hours). Ketamine is also effective at reducing posttraumatic stress disorder (PTSD) symptom severity following repeated infusions (Clinician-Administered PTSD Scale scores: -11.88 points compared with midazolam control). Ketamine also decreased suicidal ideation in emergency settings (Scale for Suicidal Ideation scores: -4.96 compared with midazolam control). Through its opioid-sparing effect, ketamine has revolutionized postoperative pain management by reducing analgesic consumption and enhancing recovery. LIMITATIONS: Many studies indicate that ketamine's therapeutic effects may subside within weeks. Repeated administrations, given multiple times per week, are often required to sustain decreases in suicidality and depressive symptoms. CONCLUSIONS: Ketamine's comprehensive clinical profile, combined with its robust effects on depression, suicidal ideation, PTSD, chronic pain, and other psychiatric conditions, positions it as a substantial contender for transformative therapeutic application.