L'influence des prestations des médecins à la première ligne de soins sur le système intégré de district sanitaire à Kisangani, République Démocratique du Congo: une étude qualitative.

INTRODUCTION: in the DRC, doctors, formerly absent, are increasingly being employed as primary care physicians, in particular but not exclusively in urban areas. This study describes and analyses the impact of primary care physician services on the integrated district health system in Kisangani, DRC. METHODS: in the third quarter of 2018, we conducted 40 semi-structured interviews of health district stakeholders (population, nurses, doctors, managers) selected in a reasoned way. Questions focused on doctors' motivation, their package of activities and the perceptions of other district stakeholders on their front-line services. Data were analysed using the thematic content analysis. RESULTS: the services of primary care physicians were a de facto but they were unplanned and unsupported. This derived largely from doctors' need for professional integration. This seemed to improve treatment acceptability but limited their financial accessibility. It was associated with an uncontrolled expansion of the activity packages and caused competition between first-line and second-line physicians. CONCLUSION: physician services are a challenge and an opportunity to strengthen first-line care while preserving complementarity with second-line care. A (re)definition of first-line physicians' role and activity package is then required. Hence, the need to improve the dialogue between different health system actors in order to (re)define consensually a model of first-line care adapted to match physicians' needs.

Tiotropium in asthma - perspectives for the primary care physician.

Asthma is a heterogeneous disease characterized by airway inflammation resulting from complex interactions between multiple hosts as well as environmental factors. As a chronic respiratory condition, asthma exerts a significant impact on patients and the healthcare system. Per the Global Initiative for Asthma (GINA), inhaled corticosteroids (ICS) with/without long-acting beta2-agonists (LABAs) should be used as the preferred controllers for the management of asthma. Despite a range of therapeutic options, many patients with asthma remain uncontrolled, resulting in an increased risk of hospitalization and emergency room visits and a worsened quality of life. Tiotropium (Spiriva®, Boehringer Ingelheim Pharmaceuticals, Inc; 1.25 µg, two puffs, once daily), delivered via the Respimat® inhaler (Boehringer Ingelheim Pharmaceuticals, Inc.), was the first long-acting muscarinic antagonist to be approved as an add-on maintenance treatment option for patients with asthma aged ≥6 years at GINA steps 4 and 5. By binding to the muscarinic receptors M1 and M3 in the bronchial airways, tiotropium antagonizes the action of acetylcholine, leading to smooth muscle relaxation and reduced mucus secretion.The efficacy and safety of tiotropium add-on to ICS±LABA maintenance treatment have been evaluated in randomized controlled trials (RCTs) involving patients with a range of asthma severities (mild, moderate, and severe) and across age groups (children, adolescents, and adults). Add-on tiotropium was found to be well tolerated and efficacious in all RCTs. Moreover, the findings from real-world studies complement results from RCTs, showing beneficial effects of tiotropium in reducing exacerbations, hospitalization, emergency room visits, and asthma worsening.In this review article, we discuss the pathophysiology of asthma and the role of tiotropium in the management of asthma from the perspective of a primary care physician.

Biologics for the primary care physician: Review and treatment of psoriasis.

Psoriasis is a chronic inflammatory disease that affects approximately 7.5 million people in the United States. The disease results in significant suffering, morbidity, and economic impact. Psoriasis is a multifaceted disease with a strong genetic component. Genetic data has revealed the presence of particular risk alleles in patients with psoriasis. Triggers of the disease have been elucidated and include factors such as trauma, obesity, infection, stress, and medications. At its core, psoriasis is a result of a dysfunctional immune response with T-cells at the center of immunogenesis. Clinically, psoriasis is characterized by discrete, erythematous scaly plaques. These lesions are often found on extensor surfaces, especially the elbows and knees. Although extensor surfaces are the prototypical destination of lesions, psoriasis may affect any area of the skin including the scalp, intertriginous areas, nails, palms, and soles. Location of lesions are important in assessing the impact on quality of life for patients. Diagnosis of psoriasis can typically be made clinically based on characteristic history and physical examination findings. In rare cases, biopsy may be needed to rule out other papulosquamous disease. Histologic findings of psoriasis can be non-specific and include marked epidermal hyperplasia, dilated vessels within the dermal papilla, and elongated rete ridges. Importantly, psoriasis is a systemic disease and organ systems outside of the skin must be considered. Co-morbidities of psoriasis include psoriatic arthritis, type 2 diabetes mellitus, cardiovascular disease, psychiatric disease, inflammatory bowel disease, neoplasms, and ocular disease. Management of psoriasis depends on the severity of the disease. In mild to moderate cases, topical medications are the cornerstone of treatment. Topical corticosteroids are the most commonly used and have limited systemic effects due to the localized application of medication. In moderate to severe cases of psoriasis, topical medications are ineffective and not feasible. Phototherapy and non-biologic systemic medications have been useful treatments; however, phototherapy is time consuming and non-biologic systemics have only modest response rates. In the last decade, biologic medications have become an important component of care for treating moderate to severe psoriasis. These medications target various cytokines responsible for psoriasis manifestations such as tumor necrosis factor (TNF-α), interleukin-12, interleukin-23, and interleukin-17. In the past 15 years, numerous biologic medications have been granted FDA approval, with the majority approved in the past several years. Some of the commonly used biologics include etanercept, adalimumab, infliximab, ixekizumab, secukinumab, brodalumab, guselkumab, ustekinumab, and tildrakizumab. Given the wealth of new biologics, current treatment guidelines have rapidly become outdated. This review provides summarized information of landmark trials that led to the approval of these medications.

The Role of Primary Care Physicians in Childhood Cancer Survivorship Care: Multiperspective Interviews.

BACKGROUND: Primary care physicians (PCPs) are well placed to provide holistic care to survivors of childhood cancer and may relieve growing pressures on specialist-led follow-up. We evaluated PCPs' role and confidence in providing follow-up care to survivors of childhood cancer. SUBJECTS, MATERIALS, AND METHODS: In Stage 1, survivors and parents (of young survivors) from 11 Australian and New Zealand hospitals completed interviews about their PCPs' role in their follow-up. Participants nominated their PCP for an interview for Stage 2. In Stage 2, PCPs completed interviews about their confidence and preparedness in delivering childhood cancer survivorship care. RESULTS: Stage 1: One hundred twenty survivors (36% male, mean age: 25.6 years) and parents of young survivors (58% male survivors, survivors' mean age: 12.7 years) completed interviews. Few survivors (23%) and parents (10%) visited their PCP for cancer-related care and reported similar reasons for not seeking PCP-led follow-up including low confidence in PCPs (48%), low perceived PCP cancer knowledge (38%), and difficulty finding good/regular PCPs (31%). Participants indicated feeling "disconnected" from their PCP during their cancer treatment phase. Stage 2: Fifty-one PCPs (57% male, mean years practicing: 28.3) completed interviews. Fifty percent of PCPs reported feeling confident providing care to childhood cancer survivors. PCPs had high unmet information needs relating to survivors' late effects risks (94%) and preferred a highly prescriptive approach to improve their confidence delivering survivorship care. CONCLUSION: Improved communication and greater PCP involvement during treatment/early survivorship may help overcome survivors' and parents' low confidence in PCPs. PCPs are willing but require clear guidance from tertiary providers. IMPLICATIONS FOR PRACTICE: Childhood cancer survivors and their parents have low confidence in primary care physicians' ability to manage their survivorship care. Encouraging engagement in primary care is important to promote holistic follow-up care, continuity of care, and long-term surveillance. Survivors'/parents' confidence in physicians may be improved by better involving primary care physicians throughout treatment and early survivorship, and by introducing the concept of eventual transition to adult and primary services. Although physicians are willing to deliver childhood cancer survivorship care, their confidence in doing so may be improved through better communication with tertiary services and more appropriate training.

Creating a Primary Care Workforce: Strategies for Leaders, Clinicians, and Nurses.

Many primary care clinics struggle with rapid implementation and systematic expansion of primary care behavioral health (PCBH) services. Often, an uneven course of program development is due to lack of attention to preparing clinic leadership, addressing operational factors, and training primary care providers (PCPs) and nurses. This article offers competency tools for clinic leaders, PCPs, and nurses to use in assessing their status and setting change targets. These tools were developed by researchers working to disseminate evidence-based interventions in primary care clinics that included fully integrated behavioral health consultants and were then used by early adaptors of the PCBH model. By deploying these strategies, both practicing and teaching clinics will take a big step forward in developing the primary care workforce needed for primary care teams, where the behavioral health needs of a patient of any age can be addressed at the time of need.

Who is Responsible for What Happens Before, During, and After Colonoscopy? Results of a National Survey of Primary Care Physicians.

BACKGROUND AND AIMS: Primary care providers (PCPs) play a critical role in colon cancer screening by initiating referrals to gastroenterologists for colonoscopy, but little is known about their role in pre-colonoscopy bowel preparation selection and pre-colonoscopy follow-up care. This study aimed to better understand coordination of care between PCPs and gastroenterologists as well as the current availability of "open-access" screening colonoscopy. METHODS: A multiple-choice survey was developed to assess PCPs' experiences with open-access colonoscopy, their involvement in the pre-colonoscopy process, and follow-up after colonoscopy. The survey was distributed electronically to a nationally representative sample of PCPs, via the American College of Physicians (ACP) Research Center's Internal Medicine Insider Research Panel. RESULTS: Of 442 PCPs invited to participate, 210 responded (response rate, 210/442, 48%), and 29 were ineligible (spent <25% of their time on clinical care or placed no referrals to colonoscopy), yielding 181 completed surveys. A total of 39% reported that open access was "rarely" or "never" available in their practice setting. The majority reported that pre-colonoscopy care was coordinated by gastroenterologists rather than PCPs. For example, 93% reported that gastroenterologists were responsible for bowel preparation selection in their practice setting. Post-colonoscopy, 54% of PCPs reported that they were responsible for ordering subsequent colonoscopies. CONCLUSIONS: PCPs frequently coordinate follow-up care postprocedure but play a relatively minor role in the pre-colonoscopy bowel preparation process. Open access availability for screening colonoscopy remains limited in this national sample of PCPs.

A coordinated PCP-Cardiologist Telemedicine Model (PCTM) in China's community hypertension care: study protocol for a randomized controlled trial.

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease, and its control rate has remained low worldwide. Studies have found that telemonitoring blood pressure (BP) helped control hypertension in randomized controlled trials. However, little is known about its effect in a structured primary care model in which primary care physicians (PCPs) are partnering with cardiology specialists in electronic healthcare data sharing and medical interventions. This study aims to identify the effects of a coordinated PCP-cardiologist model that applies telemedicine tools to facilitate community hypertension control in China. METHODS/DESIGN: Patients with hypertension receiving care at four community healthcare centers that are academically affiliated to Shanghai Chest Hospital, Shanghai JiaoTong University are eligible if they have had uncontrolled BP in the previous 3 months and access to mobile Internet. Study subjects are randomly assigned to three interventional groups: (1) usual care; (2) home-based BP telemonitor with embedded Global System for Mobile Communications (GSM) module and unlimited data plan, an app to access personal healthcare record and receive personalized lifestyle coaching contents, and proficiency training of their use; or (3) this plus coordinated PCP-cardiologist care in which PCPs and cardiologists share data via a secure CareLinker website to determine interventional approaches. The primary outcome is mean change in systolic blood pressure over a 12-month period. Secondary outcomes are changes of diastolic blood pressure, HbA1C, blood lipids, and medication adherence measured by the eight-item Morisky Medication Adherence Scale. DISCUSSION: This study will determine whether a coordinated PCP-Cardiologist Telemedicine Model that incorporates the latest telemedicine technologies will improve hypertension care. Success of the model would help streamline the present community healthcare processes and impact a greater number of patients with uncontrolled hypertension. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02919033 . Registered on 23 September 2016.

[Primary care in Ireland]. / La atención primaria en Irlanda.

Spanish doctors are still leaving the country to look for quality work. Ireland is not a country with many Spanish professionals but it is interesting to know its particular Health care system. Ireland is one of the countries with a national health care system, although it has a mixture of private health care insurance schemes. People have a right to health care if they have been living in Ireland at least for a year. Access to the primary care health system depends on age and income: free of charge for Category 1 and co-payments for the rest. This division generates great inequalities among the population. Primary Care doctors are self-employed, and they work independently. However, since 2001 they have tended to work in multidisciplinary teams in order to strengthen the Primary Care practice. Salary is gained from a combination of public and private incomes which are not differentiated. The role of the General Practitioner consists in the treatment of acute and chronic diseases, minor surgery, child care, etc. There is no coordination between Primary and Secondary care. Access to specialised medicine is regulated by the price of consultation. Primary Care doctors are not gatekeepers. To be able to work here, doctors must have three years of training after medical school. After that, Continuing Medical Education is compulsory, and the college of general practitioners monitors it annually. The Irish health care system does not fit into the European model. Lack of a clear separation between public and private health care generates great inequalities. The non-existence of coordination between primary and specialised care leads to inefficiencies, which Ireland cannot allow itself after a decade of economic crisis.

Congenital Heart Disease and Reproductive Risk: An Overview for Obstetricians, Cardiologists, and Primary Care Providers.

Patients with congenital heart disease have improved survival rates, and most patients are now expected to survive into adulthood. This improved survival has resulted in increasing numbers of women with congenital heart disease who are of childbearing age. This patient population requires specialized advice on contraception and pregnancy risk. Understanding the unique challenges this population presents is key to providing appropriate care.

[Integrated care delivery system for mental illness: A case study of Intermountain Healthcare (USA)]. / Prise en charge intégrée des maladies mentales: l'exemple d'Intermountain Healthcare (USA).

BACKGROUND: Mental health is a public health priority among chronic diseases in France and the United States. Although there is room for progress in France, the experience of Intermountain Healthcare (IH), Utah, in the United States can provide convincing experimental data. AIM: To identify the lessons learned from IH clinical integration of mental health specialists in primary care practices called "Mental Health Integration" (MHI) which might be useful in France. METHODS: This research is based on qualitative analysis of data derived from collaborative work with IH experts, literature searches, and item queries on the 3 objectives of the Triple Aim of the Institute for Healthcare Improvement (IHI). RESULTS: The MHI programme was developed to achieve IHI T riple AIM: improving user satisfaction; improving access of care and the health of the population; reducing health care costs per capita. By integrating mental health specialists within a multidisciplinary team headed by primary care physicians and working under the same roof with care managers and support staff, the MHI model enhances the process of the Chronic Care Model. Furthermore MHI has become the foundation for team-based care centered on the patient and theirfamily over the continuum of care by offering a global and structured evidenced-based care process. Prevention and integration of specialized care have been developed. Users and their families are co-responsible for their health. Discussion: Evaluation is systematic and based on specific indicators. The efficiency and clinical and organizational effectiveness created generate savings for health insurance as well as improved access to care and health equality.

Establishing an integrated gastroenterology service between a medical center and the community.

AIM: To combine community and hospital services in order to enable improvements in patient management, an integrated gastroenterology service (IGS) was established. METHODS: Referral patterns to specialist clinics were optimized; open access route for endoscopic procedures (including esophago-gastro-duodenoscopy, sigmoidoscopy and colonoscopy) was established; family physicians' knowledge and confidence were enhanced; direct communication lines between experts and primary care physicians were opened. Continuing education, guidelines and agreed instructions for referral were promoted by the IGS. Six quality indicators were developed by the Delphi method, rigorously designed and regularly monitored. Improvement was assessed by comparing 2010, 2011 and 2012 indicators. RESULTS: An integrated delivery system in a specific medical field may provide a solution to a fragmented healthcare system impaired by a lack of coordination. In this paper we describe a new integrated gastroenterology service established in April 2010. Waiting time for procedures decreased: 3 mo in April 30th 2010 to 3 wk in April 30th 2011 and stayed between 1-3 wk till December 30th 2012. Average cost for patient's visit decreased from 691 to 638 NIS (a decrease of 7.6%). Six health indicators were improved significantly comparing 2010 to 2012, 2.5% to 67.5%: Bone densitometry for patients with inflammatory bowel disease, preventive medications for high risk patients on aspirin/NSAIDs, colonoscopy following positive fecal occult blood test, gastroscopy in Barrett's esophagus, documentation of family history of colorectal cancer, and colonoscopy in patients with a family history of colorectal cancer. CONCLUSION: Establishment of an IGS was found to effectively improve quality of care, while being cost-effective.

Osteopathic physicians and international medical graduates in the rural primary care physician workforce.

BACKGROUND AND OBJECTIVES: Primary care physician (PCP) shortages are a longstanding problem in the rural United States. This study describes the 2005 supply of two important components of the rural PCP workforce: rural osteopathic (DO) and international medical graduate (IMG) PCPs. METHODS: American Medical Association (AMA) and American Osteopathic Association (AOA) 2005 Masterfiles were combined to identify clinically active, non-resident, non-federal physicians aged 70 or younger. Rural-Urban Commuting Area codes were used to categorize practice locations as urban, large rural, small rural, or isolated small rural. National- and state-level analyses were performed. PCPs included family physicians, general internists, and general pediatricians. RESULTS: DOs comprised 4.9% and IMGs 22.2% of the total clinically active workforce. However, they contributed 10.4% and 19.3%, respectively, to the rural PCP workforce, although their relative representation varied geographically. DO PCPs were more likely than allopathic PCPs to practice in rural places (20.5% versus 14.9%, respectively). IMG PCPs were more likely than other PCPs to practice in rural persistent poverty locations (12.4% versus 9.1%). The proportion of rural PCP workforce represented by DOs increased with increasing rurality and that of IMGs decreased. CONCLUSIONS: DO and IMG PCPs constitute a vital portion of the rural health care workforce. Their ongoing participation is necessary in addressing existing rural PCP shortages and handling the influx of newly insured residents as the Patient Protection and Affordable Care Act (ACA) comes into effect. The impact on rural DO and IMG PCP supply of ACA measures intended to increase their numbers remains to be seen.

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

BACKGROUND: Although misdiagnosis in the outpatient setting leads to significant patient harm and wasted resources, it is not well studied. The authors surveyed primary care physicians (PCPs) about barriers to timely diagnosis in the outpatient setting and assessed their perceptions of diagnostic difficulty. METHODS: Surveys of PCPs practicing in an integrated health system across 10 geographically dispersed states in 2005. The survey elicited information on key cognitive failures (including in clinical knowledge or judgement) for a specific case, and solicited strategies for reducing diagnostic delays. Content analysis was used to categorise cognitive failures and strategies for improvement. The authors examined the extent and predictors of diagnostic difficulty, defined as reporting >5% patients difficult to diagnose. RESULTS: Of 1817 physicians surveyed, 1054 (58%) responded; 848 (80%) respondents primarily practiced in outpatient settings and had an assigned patient panel (inclusion sample). Inadequate knowledge (19.9%) was the most commonly reported cognitive factor. Half reported >5% of their patients were difficult to diagnose; more experienced physicians reported less diagnostic difficulty. In adjusted analyses, problems with information processing (information availability and time to review it) and the referral process were associated with greater diagnostic difficulty. Strategies for improvement most commonly involved workload issues (panel size, non-visit tasks). CONCLUSIONS: PCPs report a variety of reasons for diagnostic difficulties in primary care practice. In this study, knowledge gaps appear to be a prominent concern. Interventions that address these gaps as well as practice level issues such as time to process diagnostic information and better subspecialty input may reduce diagnostic difficulties in primary care.

Naturopathy and the primary care practice.

Naturopathy is a distinct type of primary care medicine that blends age-old healing traditions with scientific advances and current research. Naturopathy is guided by a unique set of principles that recognize the body's innate healing capacity, emphasize disease prevention, and encourage individual responsibility to obtain optimal health. Naturopathic treatment modalities include diet and clinical nutrition, behavioral change, hydrotherapy, homeopathy, botanical medicine, physical medicine, pharmaceuticals, and minor surgery. Naturopathic physicians (NDs) are trained as primary care physicians in 4-year, accredited doctoral-level naturopathic medical schools. At present, there are 15 US states, 2 US territories, and several provinces in Canada, Australia, and New Zealand that recognize licensure for NDs.

Integrating sustainability and health care.

Unsustainable development around the world has contributed to ecological degradation and human suffering while compromising the ability of ecosystems and social institutions to support human life. The United States health care system and its institutions are significant contributors to unsustainable development, but leaders of change are emerging from the health care arena. Health professionals, including primary care providers, are poised to serve as models for sustainability and to facilitate the necessary transformation toward more sustainable practices. Health professionals must, within a practical framework, embrace an objective definition of sustainability and then act to achieve it.