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.

Being Vulnerable: A Qualitative Inquiry of Physician Touch in Medical Education.

PURPOSE: Effective nonverbal communication is associated with empathic behavior and improved patient outcomes. Touch, as a form of nonverbal communication, is relatively unexplored in medical education. This study sought to gain in-depth insights into physicians' experiences communicating with touch and to examine how these insights could inform communication skills curricula. METHOD: Collaborative inquiry, a form of action research, was used. Six experienced physician-educators from the University of Calgary met 8 times between 2015 and 2018 to critically reflect on their experiences of touch in clinical practice, teaching, and learning. Data comprised meeting transcripts, individual narrative accounts, and digital recordings of role-plays. Interpretative phenomenology, the study of lived experience, guided analysis. RESULTS: Two themes were identified-touch as presence and touch as risk. Participants used touch to demonstrate presence and a shared humanity with patients, to express "being with" a patient. Risk was not associated with the physical experience of touch but, rather, with its social meaning, interpreted through gender, culture, relationships, and context. Individual experiences were open to many interpretations. Participants expressed tension between their personal experience communicating with touch to express empathy and formal curricular structures. Reflection, role-modeling, and clinical debriefs were suggested as ways to encourage situational awareness and sensitive use of touch. CONCLUSIONS: Touch is a powerful means to communicate with patients but is highly subjective. Rather than avoiding touch for fear of misinterpretation, encouraging dialogue about its complexity could promote a more balanced understanding of touch and its potential to convey empathy and help physicians more effectively manage risk when using touch.

Effectiveness of Pharmacist Interventions on Cardiovascular Risk in Patients With CKD: A Subgroup Analysis of the Randomized Controlled RxEACH Trial.

BACKGROUND: Affecting a substantial proportion of adults, chronic kidney disease (CKD) is considered a major risk factor for cardiovascular (CV) events. It has been reported that patients with CKD are underserved when it comes to CV risk reduction efforts. STUDY DESIGN: Prespecified subgroup analysis of a randomized controlled trial. SETTING & PARTICIPANTS: Adults with CKD and at least 1 uncontrolled CV risk factor were enrolled from 56 pharmacies across Alberta, Canada. INTERVENTION: Patient, laboratory, and individualized CV risk assessments; treatment recommendations; prescription adaptation(s) and/or initiation as necessary; and regular monthly follow-up for 3 months. OUTCOMES: The primary outcome was change in estimated CV risk from baseline to 3 months after randomization. Secondary outcomes were change between baseline and 3 months after randomization in individual CV risk factors (ie, low-density lipoprotein cholesterol, blood pressure, and hemoglobin A1c), risk for developing end-stage renal disease, and medication use and dosage; tobacco cessation 3 months after randomization for those who used tobacco at baseline; and the impact of rural versus urban residence on the difference in change in estimated CV risk. MEASUREMENTS: CV risk was estimated using the Framingham, UK Prospective Diabetes Study, and international risk assessment equations depending on the patients' comorbid conditions. RESULTS: 290 of the 723 participants enrolled in RxEACH had CKD. After adjusting for baseline values, the difference in change in CV risk was 20% (P<0.001). Changes of 0.2mmol/L in low-density lipoprotein cholesterol concentration (P=0.004), 10.5mmHg in systolic blood pressure (P<0.001), 0.7% in hemoglobin A1c concentration (P<0.001), and 19.6% in smoking cessation (P=0.04) were observed when comparing the intervention and control groups. There was a larger reduction in CV risk in patients living in rural locations versus those living in urban areas. LIMITATIONS: The 3-month follow-up period can be considered relatively short. It is possible that larger reduction in CV risk could have been observed with a longer follow up period. CONCLUSIONS: This subgroup analysis demonstrated that a community pharmacy-based intervention program reduced CV risk and improved control of individual CV risk factors. This represents a promising approach to identifying and managing patients with CKD that could have important public health implications.

Patient, family physician and community pharmacist perspectives on expanded pharmacy scope of practice: a qualitative study.

BACKGROUND: The RxEACH trial was a randomized trial to evaluate the efficacy of community pharmacy-based case finding and intervention in patients at high risk for cardiovascular (CV) events. Community-dwelling patients with poorly controlled risk factors were identified and their CV risk reduced through patient education, prescribing and follow-up by their pharmacist. Perspectives of patients, family physicians and community pharmacists were obtained regarding pharmacists' identification and management of patients at high risk for CV events, to identify strategies to facilitate implementation of the pharmacist's expanded role in routine patient care. METHODS: We used a qualitative methodology (individual semistructured interviews) with conventional qualitative content analysis to describe perceptions about community pharmacists' care of patients at high risk for CV events. Perceptions were categorized into macro (structure), meso (institution) and micro (practice) health system levels, based on a conceptual framework of care for optimizing scopes of practice. RESULTS: We interviewed 48 participants (14 patients, 13 family physicians and 21 community pharmacists). Patients were supportive of the expanded scope of practice of pharmacists. All participant groups emphasized the importance of communication, ability to share patient information, trust and better understanding of the roles, responsibilities, accountabilities and liabilities of the pharmacist within their expanded role. INTERPRETATION: Despite support from patients and changes to delivery of care in primary care settings, ongoing efforts are needed to understand how to best harmonize family physician and community pharmacist roles across the health system. This will require collaboration and input from professional associations, regulatory bodies, pharmacists, family physicians and patients.

Adverse Childhood Experiences: Survey of Resident Practice, Knowledge, and Attitude.

BACKGROUND AND OBJECTIVES: Adverse childhood experiences (ACEs) affect 20%-50% of adults and are associated with considerable adult chronic disease, unhealthy behavior, and early mortality. Physicians seldom identify this history although identification can improve health. Low screening rates are attributed to poor physician knowledge of ACEs and barriers to screening, including a lack of confidence to screen and insufficient training. Female physicians and physicians with personal ACE histories report more confidence to screen and fewer time barriers. Our aims were to identify resident screening practices, ACE knowledge, attitudes, and personal ACE histories and to determine preferred ways to learn more, if required. METHODS: Family medicine residents were surveyed, using a previously published survey. Items included ACE screening practices, ACE knowledge, attitudes, and personal ACE histories. RESULTS: The response rate was 97% (112/115), and 58% were female. Two percent of residents screened females and males at the first visit, thereafter residents screened women (6.3%) more than men (0.9%). One third of residents identified the correct prevalence of ACE in women and one tenth male prevalence. Unhealthy behaviors or physical chronic disease were not associated with ACE histories. Sixty-five percent of residents were not confident to screen. Twenty-nine percent of residents reported a trauma history. Eighty percent believed it was their role to screen. Formal medical training to screen was received by 45.5%; only five residents recalled training during residency. CONCLUSIONS: Resident ACE screening rates were extremely low. Physician educational initiatives are recommended to increase confidence to screen and actual screening prior to graduation.