Strategies to reduce low-value care - An applied behavior analysis using a single-case design.

Introduction: Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach? Materials and methods: In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data. Results: Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies. Conclusion: The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

The knowledge, attitudes, and perceptions toward the Oxford AstraZeneca COVID-19 vaccine amongst Primary Health care workers in North-Central Trinidad.

Aim: To determine the effects of knowledge, attitudes, and perceptions of primary care health workers toward receiving the Oxford AstraZeneca vaccine in North Central, Trinidad. Methods: A pretested de novo questionnaire containing forty-eight (48) closed ended questions and one (1) open ended question was used to gather data. Descriptive and inferential statistics were used to analyze the data obtained from the questionnaire. These included percentages, means and standard deviations for the descriptive aspect and the Chi-Square test to examine any significant associations. Analysis of Variance (ANOVA) was used to assess any significant differences in means among several categories and the independent samples t-test for assessing any significant difference in means between two categories. Results: 273 respondents completed the questionnaire. Most of the participants (72.2%) were female and within the age range 25-36 (56.0%). The mean knowledge score about the AstraZeneca vaccine was 16.28 (SD = 2.28) out of 19 with an overall correct response rate of 79%. 30.4% of participants had a good attitude score and 59.7% had a positive perception toward the AstraZeneca vaccine. There were significant associations between knowledge and marital status (p = 0.001), income level (p = 0.001), education level (p < 0.001), and length of employment (p = 0.041); attitudes and sex (p = 0.01), age (p = 0.04), marital status (p = 0.009), income level (p < 0.001), education level (p = 0.005) and category of staff (p < 0.001); perception and sex (p = 0.002), marital status (p = 0.027), income level (p < 0.001), and category of staff (p < 0.001). Conclusions: The main contributors to vaccine hesitancy were inadequate duration of clinical trials and fear of adverse side effects. A significant number of participants (17%) were unwilling to get the vaccine due to lack of information.

Invariance-based causal prediction to identify the direct causes of suicidal behavior.

Despite decades of research, the direct causes of suicide remain unknown. Some researchers have proposed that suicide is sufficiently complex that no single variable or set of variables can be determined causal. The invariance-based causal prediction (ICP) is a contemporary data analytic method developed to identify the direct causal relationships, but the method has not yet been applied to suicide. In this study, we used ICP to identify the variables that were most directly related to the emergence of suicidal behavior in a prospective sample of 2,744 primary care patients. Fifty-eight (2.1%) participants reported suicidal behavior during the following year. Of 18 predictors tested, shame was most likely to be directly causal only under the least restrictive conditions. No single variable or set of variables was identified. Results support the indeterminacy hypothesis that suicide is caused by many combinations of factors, none of which are necessary for suicide to occur.

Training student volunteers as community resource navigators to address patients' social needs: A curriculum toolkit.

Introduction: Few resources are available to train students to provide patients assistance for obtaining needed community-based services. This toolkit outlines a curriculum to train student volunteers to become "community resource navigators" to serve patients via telephone at partner health sites. Methods: University students co-designed the Help Desk navigator program and training for volunteer navigators as part of an academic-community partnership with a local Federally Qualified Health Center (FQHC). The multi-modal curricula consisted of five components: didactic instruction on social determinants of health and program logistics, mock patient calls and documentation, observation of experienced navigator interaction with patients, supervised calls with real patients, and homework assignments. In 2020, training materials were adapted for virtual delivery due to the COVID-19 pandemic. Trainees completed a survey after completion to provide qualitative feedback on the training and preparedness. Results: The training was offered for the first cohort of 11 student volunteer navigators in 2019, revised and then offered for 13 undergraduate and nursing students over 6 weeks in 2020. In the training evaluation, trainees described the new knowledge and skills gained from the training, the long-term benefits toward their educational and professional career goals, and helpful interactive delivery of the training. Trainees also highlighted areas for improvement, including more time learning about community resources and practicing challenging patient conversations. Conclusions: Our peer-to-peer, multi-modal training prepares student volunteers to become community resource navigators. Student, eager for meaningful clinical experiences, are an untapped resource that can help patients with their social needs.

Estimating the Impact of COVID-19 Pandemic Related Lockdown on Utilization of Maternal and Perinatal Health Services in an Urban Neighborhood in Delhi, India.

Objective: To estimate utilization of maternal, perinatal healthcare services after the lockdown was implemented in response to the COVID-19 pandemic compared to the period before. Methods: This study conducted in Dakshinpuri, an urban neighborhood in Delhi, reports data over a 13-month period which includes the period "before lockdown" i.e., October 1, 2019 to March 21, 2020 and "after lockdown" i.e., March 22 to November 5, 2020. The period "after lockdown" included the lockdown phase (March 22 to May 31, 2020) and unlock phase (June 1 to November 5, 2020). Mothers delivered during this period in the study area were interviewed using semi-structured questionnaires. In-depth interviews (IDIs) were conducted in a subsample to understand the experiences, challenges, and factors for underutilization of healthcare services. Findings: The survey covered a total population of 21,025 in 4,762 households; 199 eligible mothers (mean age 27.4 years) were interviewed. In women who delivered after lockdown against before lockdown, adjusted odds of having >2 antenatal care visits in the third trimester was 80% lower (aOR 0.2, 95% CI 0.1-0.5); proportion of institutional deliveries was lower (93 vs. 97%); exclusive breastfeeding during first 6 months of birth (64.5 vs. 75.7%) and health worker home visitation within 6 weeks of birth (median, 1 vs. 3 visits) were substantially lower. Fear of contracting COVID-19, poor quality of services, lack of transportation and financial constraints were key issues faced by mothers in accessing health care. More than three-fourth (81%) of the mothers reported feeling down, depressed or hopeless after lockdown. The major factors for stress during lockdown was financial reasons (70%), followed by health-related concerns. Conclusion: COVID-19 pandemic-related lockdown substantially affected maternal and perinatal healthcare utilization and service delivery.

Online Consultations Between General Practitioners and Psychiatrists in the Netherlands: A Qualitative Study.

Objective: To examine the nature and scope of questions about psychiatric patient cases submitted by general practitioners (GPs) to an established online consultation platform and to determine if they could have been answered by consulting existing clinical guidelines. Methods: All anonymized psychiatric cases submitted by GPs to the online electronic Prisma platform between September 2018 and November 2019 were examined in a mixed-methods study. Descriptive statistics and qualitative thematic analysis were used, followed by axial coding to arrive at overarching themes to characterize cases. Results: Of the 136 included cases, 44.1% concerned female patients and about half concerned patients aged 31-60 years. Common psychiatric disorders were depression, attention deficit hyperactivity disorder, sleeping problems, sexual disorders, and eating disorders. The first response was usually given within 2 h (interquartile range, 0-14.3 h), with 86% answered within 24 h and 95% within 48 h. Qualitative analysis revealed four themes, namely "type of question," "cases in relation to current clinical guidelines," "case complexity" and "the doctor being pressured." Type of question comprised diagnostic, therapeutic, and referral questions. Notably, for 44.1% of questions no current clinical guidelines was present and 46.3% of cases were deemed complex in nature. GPs were willing to share their experiences of coping with being pressured by patients. Conclusion: The findings of this study support the potential for an online electronic consultation platform to facilitate feasible and useful interprofessional consultation between GPs and psychiatrists for a broad range mental illnesses and questions of varying complexity.

Loneliness and Healthcare Use in Older Adults: Evidence From a Nationally Representative Cohort in Northern Ireland-A Cross-Sectional Replication Study.

Background: Few have explored associations between loneliness and healthcare use independent of health and health behaviors. Recent indication of gender effects also requires validation across health service and cultural settings. We investigated the associations among loneliness, health and healthcare use (HCU) in older adults including stratification to investigate whether associations differed by gender. Methods: Secondary analysis of a nationally representative sample of 8,309 community-dwelling adults aged 50 and over from the Northern Ireland Cohort for the Longitudinal Study of Aging. Primary outcomes were: self-reported General Practice (GP) and emergency department (ED) visits in past year. Negative binomial and logistic regression analysis were used to investigate associations between loneliness and HCU, later adjusting for potential confounders (health and health behaviors). Results: Loneliness was consistently positively associated with both GP and ED visits (with IRRs ranging from 1.10 to 1.49 for GP visits, 1.16 to 1.98 for ED visits and ORs ranging from 1.13 to 1.51 for reporting at least one ED visit). With addition of health and health behaviors, all associations between loneliness and HCU became non-significant, excepting a small independent association between UCLA score and GP visits [IRR 1.03 (95% CI 1.01-1.05)]. Stratification of models revealed no gender effects. Conclusion: All but one association between loneliness and HCU became non-significant when health and health behaviors were included. The remaining association was small but implications remain for health service resources at population level. No gender effects were present in contrast to recent findings in the Republic of Ireland. Further studies on gender, loneliness and healthcare use needed.

Who Suffers From Pharmaceutical Poverty and What Are Their Needs? Evidence From a Spanish Region.

Background: Pharmaceutical poverty occurs when a patient cannot afford the cost of prescribed medication and/or medical products. Nonprofit organizations are covering the cost of medication to those patients in some contexts. The aim of the study was to describe the population of beneficiaries of the PB, a nongovernmental organization based on the primary healthcare system, which provides free-of-charge access to medicines and their utilization pattern of medicines and healthcare products. Methods: This was an observational study using PB beneficiary data collected between November 2017 and December 2018 in Catalonia. The Catalan Health Service provided information from the general population. A descriptive analysis of the beneficiaries' characteristics was conducted and compared to the general population. Results: The beneficiaries (N = 1,206) were mainly adults with a low level of education, unemployed, with functional disability, and with ≥1 child. Compared with the general population, the beneficiaries were older, had a lower level of education, showed a higher prevalence of functional disability, were less likely to be Spanish, and were more likely to be divorced and unemployed. The beneficiaries were polymedicated, and most were using medication related to the nervous (79%), musculoskeletal (68%), and cardiovascular system (56%) and alimentary tract and metabolism (68%). Almost 19% of beneficiaries used healthcare products. Female beneficiaries were older and more likely to be divorced or widowed, employed, and with children. Compared to men, women were more likely to use medicines for pain and mental disorders. The pediatric group used medications for severe, chronic conditions (heart diseases, autoimmune diseases, conduct disorders, and attention deficit hyperactivity disorder). Conclusion: Patients with severe, chronic, and disabling conditions are affected by pharmaceutical poverty. While the system of copayment remains unchanged, family physicians and pediatricians should explore economic barriers to treatment and direct their patients to resources that help to cover the cost of treatment.

ICD-10-Coding of Medically Unexplained Physical Symptoms and Somatoform Disorders-A Survey With German GPs.

Background: General practitioners (GPs) are reluctant to use codes that correspond to somatization syndromes. Aim: To quantify GPs' views on coding of medically unexplained physical symptoms (MUPS), somatoform disorders, and associated factors. Design and Setting: Survey with German GPs. Methods: We developed six survey items [response options "does not apply at all (1)"-"does fully apply (6)"], invited a random sample of 12.004 GPs to participate in the self-administered cross-sectional survey and analysed data using descriptive statistics and logistic regression analyses. Results: Response rate was 15.2% with N = 1,731 valid responses (54.3% female). Participants considered themselves familiar with ICD-10 criteria for somatoform disorders (M = 4.52; SD =.036) and considered adequate coding as essential prerequisite for treatment (M = 5.02; SD = 1.21). All other item means were close to the scale mean: preference for symptom or functional codes (M = 3.40; SD = 1.21), consideration of the possibility of stigmatisation (M = 3.30; SD = 1.35) and other disadvantages (M = 3.28; SD = 1.30) and coding only if psychotherapy is intended (M = 3.39; SD = 1.46). Exposure, guideline knowledge, and experience were most strongly associated with GPs' self-reported coding behaviour. Conclusions: Subjective exposure, guideline knowledge, and experience as a GP, but no sociodemographic variable being associated with GPs' subjective coding behaviour could indicate that GPs offer a relatively homogeneous approach to coding and handling of MUPS and somatoform disorders. Strengthening guideline knowledge and implementation, and practise with simulated patients could increase the subjective competence to cope with the challenge that patients with MUPS and somatoform disorders present.

REFOCUS-PULSAR Recovery-Oriented Practice Training in Adult Primary Mental Health Care: Exploratory Findings Including From a Pretest-Posttest Evaluation.

Objectives: Australian general practitioners (GPs) are pivotal in mental health care. The REFOCUS-PULSAR (Principles Unite Local Services Assisting Recovery) primary care study aimed to improve personal recovery outcomes in adults with mental health problems consulting GPs. Design: Modified from an intended stepped-wedge cluster study, an exploratory (pre- and post-intervention) design employed cross-sectional surveys of patients consulting GPs. Setting: Eighteen primary care sites (clusters) in Victoria, Australia in 2013-2017. Participants: From 30 GPs recruited, 23 participated (76%), with 235 patient surveys returned from adults aged <75 years receiving mental health care. Intervention: A co-delivered face-to-face training intervention for GPs in recovery-oriented practice (ROP), with personal recovery a key focus, used multimedia, mnemonics, and targeted interview schedules to encourage ROP-with availability of support sessions for 1 year. Outcome Measures: Primary: the Questionnaire about the Process of Recovery full-scale score (outcome). Secondary: INSPIRE (experience), Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and Kessler Psychological Distress Scale (K10) (outcomes). Other: General-practice-Users Perceived-need Inventory (experience). Results: Small positive significant effects indicated primary-outcome post-intervention improvements [t-test (233) = -2.23, p = 0.01], also improvement in two secondary outcomes (WEMWBS t(233) = -2.12, p = 0.02 and K10 t(233) = 2.44, p = 0.01). More patients post-intervention reported "no need" for further help from their GP; but in those reporting needs, there was greater unmet need for counseling. Conclusions: ROP implementation, internationally influential in specialist mental health care, here is explored in primary care where it has had less attention. These exploratory findings suggest better patient outcomes followed introducing GPs to ROP in routine practice conditions. Higher unmet need for counseling post-intervention reported by patients might be a sign of limited supply despite ROP facilitating better identification of needs. Challenges in project implementation means that these findings carry risks of bias and flag the importance establishing research infrastructure in primary care. Clinical Trial Registration: www.clinicaltrials.gov/, The Australian and New Zealand Clinical Trial Registry Identifier: ACTRN12614001312639.

Does the Conservative Non-pharmacological Management of Knee Osteoarthritis in Switzerland Reflect the Clinical Guidelines? A Survey Among General Practitioners, Rheumatologists, and Orthopaedic Surgeons.

Introduction: The International Guidelines recommend exercise, education and weight management (if appropriate) as the first-line conservative treatment for patients with knee osteoarthritis (OA) to enhance their self-management. The aim of this study was to investigate the current state of conservative non-pharmacological management of patients with knee OA in Switzerland and to explore the perceived barriers and facilitators to the application of the guideline recommendations. Materials and methods: Eleven semi-structured interviews with selected general practitioners (GPs), rheumatologists and orthopaedic surgeons were performed. Based on these results, an online survey was developed and sent to the members of three scientific medical societies. Questions addressed the frequency of diagnostic measures, treatment options, reasons for referral to exercise and also barriers and facilitators. Results: A total of 234 members responded. They indicated that patients normally present due to pain (n = 222, 98.2%) and functional limitations of the knee (n = 151, 66.8%). In addition to clinical assessment, X-ray (n = 214, 95.5%) and MRI (n = 70, 31.3%) were the most frequently used diagnostic measures. Treatment options usually involved patient education for diagnosis (n = 223, 98.6%) and suitable activities (n = 217, 96%), pharmacological treatment (n = 203, 89.8%) and referral to physiotherapy (n = 188, 83.2%). The participants estimated that they had referred 54% of their patients with knee OA for a specific exercise. The referral to exercise was driven by "patient expectation/high level of suffering" (n = 73, 37.1%) and their "own clinical experience" (n = 49, 24.9%). The specialists rated the most important barriers to referral to exercise as "disinterest of patient" (n = 88, 46.3%) and "physically active patient" (n = 59, 31.1%). As the most important facilitators, they rated "importance to mention exercise despite the short time of consultation" (n = 170, 89.4%) and "insufficiently physically active patient" (n = 165, 86.9%). Discussion: A substantial evidence-performance gap in the management of patients with knee OA appears to exist in Switzerland. For the systematic referral to exercise as the first-line intervention, it might be useful for medical doctors to suggest a structured exercise programme to patients with knee OA, rather than just advising general exercise.

Impact of Contextual Factors on the Attendance and Role in the Evidence-Based Chronic Disease Prevention Programs Among Primary Care Practitioners in Shanghai, China.

BACKGROUND: The implementation of evidence-based approaches by general practitioners (GPs) is new in the primary care setting, and few quantitative studies have evaluated the impact of contextual factors on the attendance of these approaches. METHODS: In total, 892 GPs from 75 community healthcare centers (CHCs) in Shanghai completed our survey. We used logistic regression to analyze factors affecting the number of evidence-based chronic disease programs attended by GPs and whether they had held the lead position in such a program. RESULTS: A total of 346 (38.8%) of the practitioners had never participated in any evidence-based chronic disease prevention (EBCDP) program. The EBCDP interventions in which the GPs had participated were predominantly related to hypertension, diabetes, and cardiovascular disease. However, the proportion of GPs in the lead role was relatively low, between 0.8% (programs involving prevention and control of asthma) and 5.0% (diabetes). Organizational factors and areas were significantly associated with evidence-based practices (EBPs) of the GP, while monthly income and department were the most significantly related to GPs who have the lead role in a program. The results indicated that GPs who had taken the lead position had higher scores for policy and economic impeding factors. GPs who were men, had a higher income, and worked in prevention and healthcare departments and urban areas were more likely to take the lead position. CONCLUSION: Evidence-based programs for chronic diseases should be extended to different types of diseases. Personal, organizational, political, and economic factors and the factors of female sex, lower income, department type, and suburban area environment should be considered to facilitate the translation of evidence to practice.

Levels of Adherence of an Exercise Referral Scheme in Primary Health Care: Effects on Clinical and Anthropometric Variables and Depressive Symptoms of Hypertensive Patients.

Among the modifiable health behaviors, physical activity (PA) promotion has been one of the challenges in primary care, particularly how to translate the results of proven interventions and implement them in the real world. This study was aimed to compare whether two programs designed for hypertensive patients achieve changes in clinical and anthropometric variables, quality of life, and depressive symptoms; and if higher levels of adherence to one of the interventions using an exercise referral (ER) approach achieved better health outcomes. Pragmatic cluster randomized trials were carried out in four Primary Health Care Units (PHCUs). Physicians in the PHCUs identified hypertensive patients and assessed whether they were eligible to be part of this trial. Each center was randomized to a brief PA counseling (BC, n = 2) or an exercise referral (ER, n = 2) intervention to conducted PA programs among hypertensive patients aged 35-70 years, self-reported as physically inactive. Outcome variables included changes in blood pressure levels, triglycerides, HDL cholesterol, fasting glucose, body mass index, waist/hip ratio, abdominal obesity, and metabolic syndrome risk score, health-related quality of life, and depressive symptoms. Longitudinal multilevel analyses assessed the effects of the BC and ER programs and the level of adherence of the ER on clinical, anthropometric, and mental health variables, models were linear for continuous variables, and logistic for dichotomous variables. Differences were observed in triglycerides, BMI, metabolic risk scores variables, and depressive symptoms among ER and BC programs. In addition, differences in the ER group were observed according to the level of adherence in blood pressure levels, waist circumference and waist/hip ratio, depressive symptoms, and the mental health component of health-related quality of life. An ER program in comparison to a BC intervention is promoting changes in some specific health indicators of hypertensive patients, showing the usefulness of these PA programs in primary health care facilities.

Protocol for a Nested Randomized Controlled Trial to Evaluate the Feasibility and Preliminary Efficacy of the Mindfulness Based Health Promotion Program on the Quality of Life of Older Adults Assisted in Primary Care-"The MBHP-Elderly Study".

Introduction: Population aging is a global phenomenon that has grown rapidly and progressively all over the world. Interventions that promote health must be studied and implemented to make the aging process be with quality of life. Depression and anxiety are the most common mental health conditions that compromise the quality of life on the elderly and it can cause damage to the autonomy and activities of daily life. Mindfulness training has been shown to improve psychological health and quality of life on adults. Studies involving Mindfulness-Based Interventions (MBIs) with older people are scarce in the literature, but they have been increasing in recent years showing promising results for healthy aging. This trial will investigate the feasibility and preliminary efficacy of an MBI on the quality of life of elderly assisted in the Primary Care. Materials and Methods: A cohort-nested randomized controlled trial with 3 assessment points (baseline, post-intervention and 1-year follow up) will be conducted to compare a MBI program (Mindfulness-Based Health Promotion) to a cognitive stimulation control-group in a Primary Care facility. One-hundred and two older adults will be recruited from a cohort of this facility and they will be randomized and allocated into an intervention group (N = 76) and the control group (N = 76). The primary outcome evaluated will be the improvement of quality of life assessed by the WHOQOL-BREF and WHOQOL-OLD. The secondary outcomes will be cognitive function, psychological health, sleep quality, self-compassion, and religiosity. Qualitative data will be assessed by focus group and the word free evocation technique. The feasibility of the program will also be evaluated by adherence and unwanted effects questionnaires. Discussion: This cohort-nested clinical trial will be the first mixed-methods study with 3 assessment points which will study the feasibility and preliminary efficacy of a mindfulness-based program for older people in Latin America population. If the findings of this study confirm the effectiveness of this program in this population it will be possible to consider it as intervention that might be implemented as public policy addressed to older people in healthcare systems. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03048708. Registered retrospectively on October 11th 2018.