RÉSUMÉ
Biologic treatments can alleviate severe asthma symptoms and reduce health service use. However, service capacity limits and low referral rates from primary care indicate unmet patient need. We report a mixed-methods evaluation of an enhanced severe asthma pathway implemented in Staffordshire and Stoke-on-Trent, UK which aimed to optimise primary care referrals through training/education, and increased capacity in specialist clinics. Quantitative analysis assessed patient wait times between pathway stages, prescribing changes, exacerbations, hospital admissions and asthma control. Interviews with 12 stakeholders evaluated perceptions of the enhanced pathway across settings. In 12 months, 564 patients from 28 general practices were reviewed for biologics eligibility, of whom 125 (22.2%) were referred for specialist assessment. Wait times were significantly lower under the enhanced pathway when compared against historic patients following the standard pathway, and reduced overall from a mean of 76.4 to 26.7 weeks between referral and biologics initiation (p < 0.001). Patients commencing biologics (n = 46) showed significantly reduced reliever inhaler prescribing rates (p = 0.037), 60% lower oral steroid use (p < 0.001), significantly reduced exacerbation rates (p < 0.001) and fewer hospital admissions (p < 0.001) compared with the 12 months pre-treatment. Mean asthma control scores reduced from 3.13 pre-initiation to 1.89 post-initiation (p < 0.001) - a clinically significant improvement. Interviewees viewed the enhanced pathway positively, although ongoing issues related to difficulties engaging primary care amid concerns around increased workloads and pathway capacity. The large number of referrals generated from a comparatively small number of general practices confirms substantial unmet need that an enhanced severe asthma pathway could help address if implemented routinely.
Sujet(s)
Asthme , Produits biologiques , Programme clinique , Orientation vers un spécialiste , Humains , Asthme/traitement médicamenteux , Asthme/thérapie , Produits biologiques/usage thérapeutique , Mâle , Royaume-Uni , Femelle , Adulte d'âge moyen , Adulte , Antiasthmatiques/usage thérapeutique , Soins de santé primaires/méthodes , Hospitalisation/statistiques et données numériquesRÉSUMÉ
BACKGROUND: Depression and anxiety are common mental disorders among older adults, but they are frequently underdiagnosed. Attitudes towards seeking professional mental health care is one of the barriers to access to treatment. This study was aimed at assessing the attitudes towards seeking psychological help among older adults who are enrolled in primary care in Chile, and to determine the associated factors. METHODS: This cross-sectional study recruited 233 primary care users aged 65 or more years. The Attitudes Towards Seeking Professional Psychological Help was used. Reliability and factor analysis of this scale were carried out. The average scores of the scale and factors were calculated and compared, by selected variables. Multivariate linear regression was estimated to determine factors associated with attitudes towards seeking psychological help. RESULTS: Three factors were identified in the attitudes towards seeking psychological help: confidence in psychologists, coping alone with emotional problems, and predisposition to seek psychological help. On average, participants had a favorable attitude towards seeking psychological help, compared with previous research. Lower level of education, and risk of social isolation were inversely associated with these attitudes. CONCLUSION: Strategies to improve mental health literacy and social connection among older adults, could have an impact on factors that mediate the access to mental health care, such as attitudes towards seeking psychological help, among people who have a lower level of education or are at risk of social isolation.
Sujet(s)
Vie autonome , Acceptation des soins par les patients , Soins de santé primaires , Humains , Mâle , Sujet âgé , Femelle , Chili/épidémiologie , Soins de santé primaires/méthodes , Études transversales , Acceptation des soins par les patients/psychologie , Vie autonome/psychologie , Sujet âgé de 80 ans ou plus , Attitude envers la santéRÉSUMÉ
BACKGROUND: To evaluate the effectiveness of delivering feedback reports to increase completion of LST notes among VA Home Based Primary Care (HBPC) teams. The Life Sustaining Treatment Decisions Initiative (LSTDI) was implemented throughout the Veterans Health Administration (VHA) in the United States in 2017 to ensure that seriously ill Veterans have care goals and LST decisions elicited and documented. METHODS: We distributed monthly feedback reports summarizing LST template completion rates to 13 HBPC intervention sites between October 2018 and February 2020 as the sole implementation strategy. We used principal component analyses to match intervention to 26 comparison sites and used interrupted time series/segmented regression analyses to evaluate the differences in LST template completion rates between intervention and comparison sites. Data were extracted from national databases for VA HBPC in addition to interviews and surveys in a mixed methods process evaluation. RESULTS: LST template completion rose from 6.3 to 41.9% across both intervention and comparison HBPC teams between March 1, 2018, and February 26, 2020. There were no statistically significant differences for intervention sites that received feedback reports. CONCLUSIONS: Feedback reports did not increase documentation of LST preferences for Veterans at intervention compared with comparison sites. Observed increases in completion rates across intervention and comparison sites can likely be attributed to implementation strategies used nationally as part of the national roll-out of the LSTDI. Our results suggest that feedback reports alone were not an effective implementation strategy to augment national implementation strategies in HBPC teams.
Sujet(s)
Services de soins à domicile , Soins de santé primaires , Department of Veterans Affairs (USA) , Anciens combattants , Humains , Soins de santé primaires/méthodes , Soins de santé primaires/normes , États-Unis , Anciens combattants/psychologie , Services de soins à domicile/normes , Mâle , Femelle , Sujet âgé , Rétroaction , Documentation/méthodes , Documentation/normes , Préférence des patientsRÉSUMÉ
BACKGROUND: Despite a large burden of life-limitingillness, there exists a dearth of services of palliative care in Pakistan. International guidelines have questionable applicability in Pakistan due to the socioeconomic differences. We generated a protocol describing the process of developing comprehensive palliative care guidelines and palliative care referral pathways for primary care practitioners to adopt in Pakistan. METHODS: A GRADE-ADOLOPMENT approach with modification has been employed to create guidelines for a Pakistani context. The "National Comprehensive Cancer Network Guidelines Insights: Palliative Care, Version 2.2021" was used as the source guideline. Recommendations from the source guideline were reviewed by two local palliative care specialists to either "Adopt," "Adapt" or "Exclude". The finalized recommendations were incorporated into the local palliative care guideline. Clinical diagnosis and referral pathways were made from the finalized guideline. Any gaps in management found in the pathways were filled by taking existing recommendations from other credible guidelines. RESULTS: Twenty-seven recommendations were adopted without modification. No recommendations were deemed to be adapted and 15 were excluded. The referral care pathways created were reflective of the local guideline and included elements of initial assessment, preliminary management, reassessment, and referral. 6 additional recommendations were made. CONCLUSION: The described clinical practice guidelines and primary care clinical referral pathways will aid to standardize palliative care provision in Pakistan. These can be used by other resource constrained settings to develop guidelines within their own local context.
Sujet(s)
Soins palliatifs , Soins de santé primaires , Orientation vers un spécialiste , Humains , Pakistan , Soins palliatifs/normes , Soins palliatifs/méthodes , Orientation vers un spécialiste/normes , Soins de santé primaires/méthodes , Soins de santé primaires/normes , Guides de bonnes pratiques cliniques comme sujetRÉSUMÉ
OBJECTIVE: The objective of this pilot study was to explore the impact of interpreter format (virtual vs in person) on clinical outcomes in patients with non-English language preference (NELP) and type 2 diabetes mellitus (T2DM) in a primary care setting. We hypothesized that NELP patients utilizing in person interpreters would have improved HbA1c values, better follow-up rate, and more complex care plans compared to patients utilizing virtual interpreters. METHODS: We completed a retrospective chart review of 137 NELP patients with T2DM who required a medical interpreter (February to June 2021). We calculated univariate and bivariate statistics to characterize the sample and assess the extent to which measures of continuity (follow-up visit rate and time to follow-up visit), quality (change in HbA1c), and complexity (medication intervention complexity) were associated with interpreter type. RESULTS: There was no statistically significant difference in follow-up rate or average days to follow-up visit for NELP patients with in person as opposed to virtual interpreters. Patients with virtual interpreters demonstrated a non-statistically significant decrease in HbA1c compared to those with in person interpreters. Finally, there was no statistically significant association between interpreter format and intervention complexity. CONCLUSIONS: Quality medical interpretation contributes to optimal health outcomes in NELP patients with diabetes. Our study suggests that both in person and virtual interpreters can be effective in providing care for NELP patients, especially for chronic disease management in the context of a primary care relationship. It also highlights the importance of pursuing additional qualitative and mixed method studies to better understand the benefits of various interpreter formats across different visit types.
Sujet(s)
Diabète de type 2 , Traduction , Humains , Projets pilotes , Diabète de type 2/thérapie , Femelle , Mâle , Adulte d'âge moyen , Études rétrospectives , Sujet âgé , Barrières de communication , Hémoglobine glyquée/analyse , Langage , Adulte , Soins de santé primaires/méthodesRÉSUMÉ
BACKGROUND: As digital health services are increasingly developing and becoming more interactive in Serbia, a comprehensive instrument for measuring eHealth literacy (EHL) is needed. OBJECTIVE: This study aimed to translate, culturally adapt, and investigate the psychometric properties of the Serbian version of the eHealth Literacy Questionnaire (eHLQ); to evaluate EHL in the population of primary health care (PHC) users in Serbia; and to explore factors associated with their EHL. METHODS: The validation study was conducted in 8 PHC centers in the territory of the Macva district in Western Serbia. A stratified sampling method was used to obtain a representative sample. The Translation Integrity Procedure was followed to adapt the questionnaire to the Serbian language. The psychometric properties of the Serbian version of the eHLQ were analyzed through the examination of factorial structure, internal consistency, and test-retest reliability. Descriptive statistics were calculated to determine participant characteristics. Differences between groups were tested by the 2-tailed Students t test and ANOVA. Univariable and multivariable linear regression analyses were used to determine factors related to EHL. RESULTS: A total of 475 PHC users were enrolled. The mean age was 51.0 (SD 17.3; range 19-94) years, and most participants were female (328/475, 69.1%). Confirmatory factor analysis validated the 7-factor structure of the questionnaire. Values for incremental fit index (0.96) and comparative fit index (0.95) were above the cutoff of ≥0.95. The root mean square error of approximation value of 0.05 was below the suggested value of ≤0.06. Cronbach α of the entire scale was 0.95, indicating excellent scale reliability, with Cronbach α ranging from 0.81 to 0.90 for domains. The intraclass correlation coefficient ranged from 0.63 to 0.82, indicating moderate to good test-retest reliability. The highest EHL mean scores were obtained for the understanding of health concepts and language (mean 2.86, SD 0.32) and feel safe and in control (mean 2.89, SD 0.33) domains. Statistically significant differences (all P<.05) for all 7 eHLQ scores were observed for age, education, perceived material status, perceived health status, searching for health information on the internet, and occupation (except domain 4). In multivariable regression models, searching for health information on the internet and being aged younger than 65 years were associated with higher values of all domain scores except the domain feel safe and in control for variable age. CONCLUSIONS: This study demonstrates that the Serbian version of the eHLQ can be a useful tool in the measurement of EHL and in the planning of digital health interventions at the population and individual level due to its strong psychometric properties in the Serbian context.
Sujet(s)
Soins de santé primaires , Télémédecine , Humains , Serbie , Soins de santé primaires/méthodes , Soins de santé primaires/statistiques et données numériques , Adulte , Femelle , Adulte d'âge moyen , Enquêtes et questionnaires/normes , Mâle , Télémédecine/méthodes , Télémédecine/statistiques et données numériques , Traductions , Jeune adulte , Sujet âgé , Compétence informationnelle en santé/statistiques et données numériques , Psychométrie/méthodes , Reproductibilité des résultatsRÉSUMÉ
BACKGROUND: Benzodiazepines and other sedative hypnotic drugs (BSHs) are frequently prescribed for sleep problems, but cause substantial adverse effects, particularly in older adults. Improving knowledge on barriers, facilitators and needs of primary care providers (PCPs) to BSH deprescribing could help reduce BSH use and thus negative effects. METHODS: We conducted a mixed methods study (February-May 2023) including a survey, semi-structured interviews and focus groups with PCPs in Switzerland. We assessed barriers, facilitators and needs of PCPs to BSH deprescribing. Quantitative data were analyzed descriptively, qualitative data deductively and inductively using the Theoretical Domain Framework (TDF). Quantitative and qualitative data were integrated using meta-interferences. RESULTS: The survey was completed by 126 PCPs (53% female) and 16 PCPs participated to a focus group or individual interview. The main barriers to BSH deprescribing included patient and PCP lack of knowledge on BSH effects and side effects, lack of PCP education on treatment of sleep problems and BSH deprescribing, patient lack of motivation, PCP lack of time, limited access to cognitive behavioral therapy for insomnia and absence of public dialogue on BSHs. Facilitators included informing on side effects to motivate patients to discontinue BSHs and start of deprescribing during a hospitalization. Main PCP needs were practical recommendations for pharmacological and non-pharmacological treatment of sleep problems and deprescribing schemes. Patient brochures were wished by 69% of PCPs. PCPs suggested the brochures to contain explanations about risks and benefits of BSHs, sleep hygiene and sleep physiology, alternative treatments, discontinuation process and tapering schemes. CONCLUSION: The barriers and facilitators as well as PCP needs and opinions on patient material we identified can be used to develop PCP training and material on BSH deprescribing, which could help reduce the inappropriate use of BSHs for sleep problems.
Sujet(s)
Benzodiazépines , Déprescriptions , Hypnotiques et sédatifs , Humains , Femelle , Mâle , Hypnotiques et sédatifs/usage thérapeutique , Sujet âgé , Benzodiazépines/usage thérapeutique , Adulte d'âge moyen , Suisse , Soins de santé primaires/méthodes , Attitude du personnel soignant , Adulte , Groupes de discussion/méthodes , Enquêtes et questionnaires , Médecins de premier recoursRÉSUMÉ
The authors report on their development of a National Advisory Board (NAB) to guide a funded project: Two in One: HIV + COVID-19 Screening and Testing Model. This project aimed to improve primary care practitioners' capacity to routinize HIV, PrEP/PEP, and COVID-19 vaccine screenings for all their patients while relying on culturally responsive communication with their minoritized patients. To approach their monumental research and education tasks, they created a NAB, drawing from the literature on advisory boards to (a) promote board member engagement and (b) progress successfully through the six stages suggested for successful advisory boards. A midpoint survey and final focus groups with NAB members indicated mixed levels of engagement, a sense of time and work being valued, and pride in the media and academic reach of the project. The authors offer considerations for others considering forming a NAB to guide primary care research and interventions.
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Comités consultatifs , COVID-19 , Infections à VIH , Soins de santé primaires , Humains , Soins de santé primaires/méthodes , COVID-19/diagnostic , Infections à VIH/diagnostic , Dépistage de masse/méthodes , Dépistage de la COVID-19/méthodes , SARS-CoV-2 , Groupes de discussion , Recherche sur les services de santé , MâleRÉSUMÉ
AIM: This constructivist grounded theory study aimed to (1) explore patients' experiences of and roles in interprofessional collaborative practice for chronic conditions in primary care and (2) consider the relevance and alignment of an existing theoretical framework on patients' roles and based on the experiences of patient advocates. BACKGROUND: High-quality management of chronic conditions requires an interprofessional collaborative practice model of care considering an individual's mental, physical, and social health situation. Patients' experiences of this model in the primary care setting are relatively unknown. METHODS: A constructivist grounded theory approach was taken. Interview data were collected from primary care patients with chronic conditions across Australia in August 2020 - February 2022. Interviews were recorded, transcribed verbatim, and thematically analysed by (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation, and (5) theme and sub-theme development. Themes and sub-themes were mapped against an existing theoretical framework to expand and confirm the results from a previous study with a similar research aim. FINDINGS: Twenty adults with chronic conditions spanning physical disability, diabetes, heart disease, cancer, autoimmune, and mental health conditions participated. Two themes were developed: (1) Adapting to Change with two sub-themes describing how patients adapt to interprofessional team care and (2) Shifting across the spectrum of roles, with five sub-themes outlining the roles patients enact while receiving care. The findings suggest that patients' roles are highly variable and fluid in interprofessional collaborative practice, and further work is recommended to develop a resource to support greater patient engagement in interprofessional collaborative practice.
Sujet(s)
Comportement coopératif , Théorie ancrée , Relations interprofessionnelles , Soins de santé primaires , Humains , Soins de santé primaires/méthodes , Femelle , Mâle , Adulte d'âge moyen , Maladie chronique/thérapie , Sujet âgé , Australie , Adulte , Recherche qualitative , Équipe soignante , Entretiens comme sujet , Participation des patientsRÉSUMÉ
OBJECTIVES: This qualitative study aimed to explore opportunities to strengthen tuberculosis (TB) health service delivery from the perspectives of health workers providing TB care in Shigatse prefecture of Tibet Autonomous Region, China. DESIGN: Qualitative research, semi-structured in-depth interviews. SETTING: The TB care ecosystem in Shigatse, including primary and community care. PARTICIPANTS: Participants: 37 semi-structured interviews were conducted with village doctors (14), township doctors and nurses (14), county hospital doctors (7) and Shigatse Centre for Disease Control staff (2). RESULTS: The three main themes reported include (1) the importance of training primary and community health workers to identify people with symptoms of TB, ensure TB is diagnosed and link people with TB to further care; (2) the need to engage community health workers to ensure retention in care and adherence to TB medications; and (3) the opportunity for innovative technologies to support coordinated care, retention in care and adherence to medication in Shigatse. CONCLUSIONS: The quality of TB care could be improved across the care cascade in Tibet and other high-burden, remote settings by strengthening primary care through ongoing training, greater support and inclusion of community health workers and by leveraging technology to create a circle of care. Future formative and implementation research should include the perspectives of health workers at all levels to improve care organisation and delivery.
Sujet(s)
Agents de santé communautaire , Recherche qualitative , Services de santé ruraux , Tuberculose , Humains , Tibet , Tuberculose/thérapie , Tuberculose/prévention et contrôle , Services de santé ruraux/organisation et administration , Agents de santé communautaire/enseignement et éducation , Femelle , Mâle , Entretiens comme sujet , Adulte , Personnel de santé/enseignement et éducation , Prestations des soins de santé/organisation et administration , Soins de santé primaires/organisation et administration , Soins de santé primaires/méthodes , Adulte d'âge moyenRÉSUMÉ
Importance: Finding effective and scalable solutions to address diagnostic delays and disparities in autism is a public health imperative. Approaches that integrate eye-tracking biomarkers into tiered community-based models of autism evaluation hold promise for addressing this problem. Objective: To determine whether a battery of eye-tracking biomarkers can reliably differentiate young children with and without autism in a community-referred sample collected during clinical evaluation in the primary care setting and to evaluate whether combining eye-tracking biomarkers with primary care practitioner (PCP) diagnosis and diagnostic certainty is associated with diagnostic outcome. Design, Setting, and Participants: Early Autism Evaluation (EAE) Hub system PCPs referred a consecutive sample of children to this prospective diagnostic study for blinded eye-tracking index test and follow-up expert evaluation from June 7, 2019, to September 23, 2022. Participants included 146 children (aged 14-48 months) consecutively referred by 7 EAE Hubs. Of 154 children enrolled, 146 provided usable data for at least 1 eye-tracking measure. Main Outcomes and Measures: The primary outcomes were sensitivity and specificity of a composite eye-tracking (ie, index) test, which was a consolidated measure based on significant eye-tracking indices, compared with reference standard expert clinical autism diagnosis. Secondary outcome measures were sensitivity and specificity of an integrated approach using an index test and PCP diagnosis and certainty. Results: Among 146 children (mean [SD] age, 2.6 [0.6] years; 104 [71%] male; 21 [14%] Hispanic or Latine and 96 [66%] non-Latine White; 102 [70%] with a reference standard autism diagnosis), 113 (77%) had concordant autism outcomes between the index (composite biomarker) and reference outcomes, with 77.5% sensitivity (95% CI, 68.4%-84.5%) and 77.3% specificity (95% CI, 63.0%-87.2%). When index diagnosis was based on the combination of a composite biomarker, PCP diagnosis, and diagnostic certainty, outcomes were concordant with reference standard for 114 of 127 cases (90%) with a sensitivity of 90.7% (95% CI, 83.3%-95.0%) and a specificity of 86.7% (95% CI, 70.3%-94.7%). Conclusions and Relevance: In this prospective diagnostic study, a composite eye-tracking biomarker was associated with a best-estimate clinical diagnosis of autism, and an integrated diagnostic model including PCP diagnosis and diagnostic certainty demonstrated improved sensitivity and specificity. These findings suggest that equipping PCPs with a multimethod diagnostic approach has the potential to substantially improve access to timely, accurate diagnosis in local communities.
Sujet(s)
Trouble autistique , Marqueurs biologiques , Technologie d'oculométrie , Soins de santé primaires , Humains , Mâle , Femelle , Enfant d'âge préscolaire , Soins de santé primaires/méthodes , Études prospectives , Nourrisson , Marqueurs biologiques/sang , Marqueurs biologiques/analyse , Trouble autistique/diagnostic , Sensibilité et spécificitéRÉSUMÉ
INTRODUCTION: Familial hypercholesterolaemia (FH) is an autosomal dominant inherited disorder of lipid metabolism and a preventable cause of premature cardiovascular disease. Current detection rates for this highly treatable condition are low. Early detection and management of FH can significantly reduce cardiac morbidity and mortality. This study aims to implement a primary-tertiary shared care model to improve detection rates for FH. The primary objective is to evaluate the implementation of a shared care model and support package for genetic testing of FH. This protocol describes the design and methods used to evaluate the implementation of the shared care model and support package to improve the detection of FH. METHODS AND ANALYSIS: This mixed methods pre-post implementation study design will be used to evaluate increased detection rates for FH in the tertiary and primary care setting. The primary-tertiary shared care model will be implemented at NSW Health Pathology and Sydney Local Health District in NSW, Australia, over a 12-month period. Implementation of the shared care model will be evaluated using a modification of the implementation outcome taxonomy and will focus on the acceptability, evidence of delivery, appropriateness, feasibility, fidelity, implementation cost and timely initiation of the intervention. Quantitative pre-post and qualitative semistructured interview data will be collected. It is anticipated that data relating to at least 62 index patients will be collected over this period and a similar number obtained for the historical group for the quantitative data. We anticipate conducting approximately 20 interviews for the qualitative data. ETHICS AND DISSEMINATION: Ethical approval has been granted by the ethics review committee (Royal Prince Alfred Hospital Zone) of the Sydney Local Health District (Protocol ID: X23-0239). Findings will be disseminated through peer-reviewed publications, conference presentations and an end-of-study research report to stakeholders.
Sujet(s)
Hyperlipoprotéinémie de type II , Soins de santé primaires , Humains , Hyperlipoprotéinémie de type II/diagnostic , Hyperlipoprotéinémie de type II/thérapie , Hyperlipoprotéinémie de type II/génétique , Soins de santé primaires/méthodes , Dépistage génétique/méthodes , Plan de recherche , Nouvelle-Galles du Sud , Diagnostic précoceRÉSUMÉ
INTRODUCTION: We hypothesized that multidisciplinary, proactive electronic consultation (MPE) could overcome barriers to prescribing guideline-directed medical therapies (GDMTs) for patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS: We conducted an efficacy-implementation pilot study of MPE for T2D and CKD for primary care provider (PCP)-patient dyads at an academic health system. MPE included (1) a dashboard to identify patients without a prescription for sodium-glucose cotransporter-2 inhibitors (SGLT2i) and without a maximum dose prescription for renin-angiotensin-aldosterone system inhibitors (RAASi), (2) a multidisciplinary team of specialists to provide recommendations using e-consult templates, and (3) a workflow to deliver timely e-consult recommendations to PCPs. In-depth interviews were conducted with PCPs and specialists to assess feasibility, acceptability, and appropriateness of MPE and were analyzed using an iterative qualitative analysis approach to identify major themes. Prescription data were extracted from the electronic health record to assess preliminary effectiveness to increase GDMT. RESULTS: 20 PCPs agreed to participate, 18 PCPs received MPEs for one of their patients with T2D and CKD, and 16 PCPs and 2 specialists were interviewed. Major themes were as follows: appropriateness of prioritization of GDMT for T2D and CKD, acceptability of the content of the recommendations, PCP characteristics impact experience with MPE, acceptability and appropriateness of multidisciplinary collaboration, feasibility of MPE to overcome patient-specific barriers to GDMT, and appropriateness of workflow. At 6 months postbaseline, 7/18 (39%) patients were newly prescribed an SGLT2i, and 7/18 (39%) patients were either newly prescribed or had increased dose of RAASi. CONCLUSIONS: MPE was an acceptable and appropriate health system strategy to identify and address gaps in GDMT among patients with T2D and CKD. Adopting MPE could enhance GDMT, though PCPs raised feasibility concerns which could be improved with program enhancements, including follow-up e-consults for reinforcement, and administrative support for navigating system-level barriers.
Sujet(s)
Diabète de type 2 , Orientation vers un spécialiste , Insuffisance rénale chronique , Humains , Insuffisance rénale chronique/traitement médicamenteux , Diabète de type 2/traitement médicamenteux , Projets pilotes , Mâle , Femelle , Adulte d'âge moyen , Guides de bonnes pratiques cliniques comme sujet/normes , Soins de santé primaires/méthodes , Soins de santé primaires/normes , Inhibiteurs du cotransporteur sodium-glucose de type 2/usage thérapeutique , Sujet âgé , Adhésion aux directives/statistiques et données numériques , Équipe soignante , Études de suivi , Types de pratiques des médecins/normes , PronosticRÉSUMÉ
In primary care medicine for adult or pediatric populations, phone calls from patients or parents are common. The variety of questions is broad, going from simple administrative requests to life-threatening emergencies. The safety of the patient is the main priority when answering these calls. In opposition to emergency departments in hospitals where numerous well-defined triage systems (for example, Swiss Emergency Triage Scale), including clinical exam with vital signs, have been used, it is difficult to find practical guidelines for a safe and efficient phone triage in medical practices. Swiss pediatricians already use a triage book to help them assess the need for emergency care for their young patients. A similar type of resource would be helpful for a safe management of calls in adult medicine.
En cabinet de médecine de famille, adulte ou pédiatrique, les appels téléphoniques de patients ou de leurs proches sont nombreux. Leurs questions sont variées, allant de la simple requête administrative à l'urgence vitale. La sécurité du patient reste la priorité principale dans les réponses apportées lors de ces appels. Contrairement aux systèmes d'urgences hospitalières utilisant de multiples échelles de tri comprenant un examen clinique de base avec signes vitaux (par exemple, Échelle suisse de tri), il existe peu de stratégies pour un triage efficace et sûr en médecine de cabinet. Les pédiatres suisses utilisent actuellement un guide au triage téléphonique visant à cibler correctement les besoins urgents de soins pour leurs jeunes patients. Un équivalent pour la médecine adulte serait une aide supplémentaire pour une prise en charge en toute sécurité.
Sujet(s)
Soins de santé primaires , Téléphone , Triage , Triage/méthodes , Triage/normes , Triage/organisation et administration , Humains , Soins de santé primaires/méthodes , Soins de santé primaires/organisation et administration , Soins de santé primaires/normes , Suisse , Adulte , Enfant , Services des urgences médicales/méthodes , Services des urgences médicales/normes , Services des urgences médicales/organisation et administrationRÉSUMÉ
INTRODUCTION: Providing abortion in primary care expands access and alleviates delays. The 2020 COVID-19 public health emergency (PHE) led to the expansion of telehealth, including medication abortion (MAB). This study evaluates the accessibility of novel telehealth MAB (teleMAB) initiated during the PHE, with the lifting of mifepristone restrictions, compared with traditional in-clinic MAB offered before the PHE at a Massachusetts safety-net primary care organization. METHODS: We conducted a retrospective electronic medical record review of 267 MABs. We describe sociodemographic, care access, and complete abortion characteristics and compare differences between teleMAB and in-clinic MABs using Chi-squared test, fisher's exact test, independent t test, and Wilcoxon rank sum. We conducted logistic regression to examine differences in time to care (6 days or less vs 7 days or more). RESULTS: 184 MABs were eligible for analysis (137 in-clinic, 47 teleMAB). Patients were not significantly more likely to receive teleMAB versus in-clinic MAB based on race, ethnicity, language, or payment. Completed abortion did not significantly differ between groups (P = .187). Patients received care more quickly when accessing teleMAB compared with usual in-clinic MAB (median 3 days, range 0 to 20 vs median 6 days, range 0 to 32; P < . 001). TeleMAB patients had 2.29 times the odds of having their abortion appointment within 6 days compared with in-clinic (95% CI: 1.13, 4.86). CONCLUSION: TeleMAB in primary care is as effective, timelier, and potentially more accessible than in-clinic MAB when in-person mifepristone regulations were enforced. TeleMAB is feasible and can promote patient-centered and timely access to abortion care.
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Avortement provoqué , COVID-19 , Accessibilité des services de santé , Soins de santé primaires , Télémédecine , Humains , Femelle , Télémédecine/statistiques et données numériques , Télémédecine/organisation et administration , Télémédecine/méthodes , Avortement provoqué/méthodes , Avortement provoqué/statistiques et données numériques , Études rétrospectives , Adulte , Soins de santé primaires/organisation et administration , Soins de santé primaires/méthodes , Grossesse , Massachusetts , Accessibilité des services de santé/statistiques et données numériques , SARS-CoV-2 , Jeune adulte , Mifépristone/administration et posologie , Mifépristone/usage thérapeutique , Abortifs/administration et posologieRÉSUMÉ
Primary care physicians are likely both excited and apprehensive at the prospects for artificial intelligence (AI) and machine learning (ML). Complexity science may provide insight into which AI/ML applications will most likely affect primary care in the future. AI/ML has successfully diagnosed some diseases from digital images, helped with administrative tasks such as writing notes in the electronic record by converting voice to text, and organized information from multiple sources within a health care system. AI/ML has less successfully recommended treatments for patients with complicated single diseases such as cancer; or improved diagnosing, patient shared decision making, and treating patients with multiple comorbidities and social determinant challenges. AI/ML has magnified disparities in health equity, and almost nothing is known of the effect of AI/ML on primary care physician-patient relationships. An intervention in Victoria, Australia showed promise where an AI/ML tool was used only as an adjunct to complex medical decision making. Putting these findings in a complex adaptive system framework, AI/ML tools will likely work when its tasks are limited in scope, have clean data that are mostly linear and deterministic, and fit well into existing workflows. AI/ML has rarely improved comprehensive care, especially in primary care settings, where data have a significant number of errors and inconsistencies. Primary care should be intimately involved in AI/ML development, and its tools carefully tested before implementation; and unlike electronic health records, not just assumed that AI/ML tools will improve primary care work life, quality, safety, and person-centered clinical decision making.
Sujet(s)
Intelligence artificielle , Apprentissage machine , Soins de santé primaires , Humains , Soins de santé primaires/méthodes , Relations médecin-patient , Dossiers médicaux électroniques , Amélioration de la qualitéRÉSUMÉ
Despite its importance for clinical care and outcomes among older adults, functional status-the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)-is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.
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Activités de la vie quotidienne , Soins de santé primaires , Humains , Sujet âgé , Soins de santé primaires/méthodes , Projets pilotes , Femelle , Mâle , Sujet âgé de 80 ans ou plus , État fonctionnel , Évaluation gériatrique/méthodes , COVID-19/épidémiologie , États-UnisRÉSUMÉ
BACKGROUND: Atrial fibrillation (AF), a common, frequently asymptomatic cardiac arrhythmia, is a major risk factor for stroke. Identification of AF enables effective preventive treatment to be offered, potentially reducing stroke risk by up to two-thirds. There is international consensus that opportunistic AF screening is valuable though uncertainty remains about the optimum screening location and method. Primary care has been identified as a potential location for AF screening using one-lead ECG devices. METHODS: A pilot AF screening programme is in primary care in the south of Ireland. General practitioners (GPs) were recruited from Cork and Kerry. GPs invited patients ≥65 years to undergo AF screening. The screening comprised a one-lead ECG device, Kardia Mobile, blood pressure check and ascertainment of smoking status. Possible AF on one-lead ECG was confirmed with a 12-lead ECG. GPs also recorded information including medical history, current medication and onward referral. The Keele Decision Support tool was used to assess patients for oral anticoagulation (OAC). RESULTS: 3555 eligible patients, attending 52 GPs across 34 GP practices, agreed to undergo screening. 1720 (48%) were female, 1780 (50%) were hypertensive and 285 (8%) were current smokers. On the one-lead ECG, 3282 (92%) were in normal sinus rhythm, 101 (3%) had possible AF and among 124 (4%) the one-lead ECG was unreadable or unclassified. Of the 101 patients with possible AF, 45 (45%) had AF confirmed with 12-lead ECG, an incidence rate of AF of 1.3%. Among the 45 confirmed AF cases, 27 (60%) were commenced on OAC therapy by their GP. CONCLUSION: These findings suggest that AF screening in primary care may prove useful for early detection of AF cases that can be assessed for treatment. One-lead ECG devices may be useful in the detection of paroxysmal AF in this population and setting. Current OAC of AF may be suboptimal.
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Fibrillation auriculaire , Électrocardiographie , Dépistage de masse , Soins de santé primaires , Humains , Fibrillation auriculaire/diagnostic , Fibrillation auriculaire/épidémiologie , Femelle , Mâle , Irlande/épidémiologie , Projets pilotes , Soins de santé primaires/méthodes , Sujet âgé , Dépistage de masse/méthodes , Facteurs de risque , Incidence , Sujet âgé de 80 ans ou plus , Accident vasculaire cérébral/prévention et contrôle , Accident vasculaire cérébral/épidémiologie , Accident vasculaire cérébral/étiologie , Valeur prédictive des testsRÉSUMÉ
OBJECTIVES: Sixty-three percent of Latinos/as/x in Alabama, speak English "not well" or "not at all." Effective provider-patient communication is the foundation of successful clinical interactions. Medical interpretation is important to the healthcare provision for patients with limited English proficiency (LEP). We examined Alabama providers' perceptions of working with medical interpreters to identify strategies to improve healthcare provision for LEP patients. METHODS: We conducted nine semistructured qualitative interviews with primary healthcare providers in western Alabama. We used NVivo to conduct thematic coding and content analysis. RESULTS: Of the nine providers, one self-identified as Latina and the others identified as White. Four participants worked in community clinics and five worked at university-based clinics. Four themes emerged: preference for in-person interpreters over technology-based interpretation; providers' perceptions and expectations of the roles of professional interpreters; challenges in the communication process; and use of family members or other ad hoc interpreters. CONCLUSIONS: To meet the needs of Latino/a/x communities, clinical settings should invest in adequate staffing of in-person interpreters, infrastructure and workflow improvements, and the hiring and training of polylingual providers. Capacity-building opportunities to establish team building between interpreters and providers could be useful tools in improving healthcare provision for LEP patients.