Invisibilização e preconceitos velados: barreiras para o acesso aos serviços de atenção básica pela população trans / Invisibilization and veiled prejudices: barriers to access to primary care services for the transgender population / Invisibilización y prejuicios velados: barreras para el acceso de la población trans a los servicios de atención primaria

Introdução: No processo de edificação da Política Nacional de Saúde Integral LGBT+, a Atenção Básica ganha importante destaque, pois deveria funcionar como o contato preferencial dos usuários transgênero (trans). Objetivo: Investigar quais as percepções dos profissionais da Atenção Básica quanto às situações de vulnerabilidade enfrentadas pelas pessoas trans, bem como pesquisar os impedimentos que eles consideram existir na busca dessa população por acesso a esses serviços. Métodos: Utilizou-se uma abordagem qualitativa por meio de entrevistas semiestruturadas com 38 profissionais de saúde atuantes das Estratégias Saúde da Família de dois municípios do interior do estado de São Paulo. O material obtido foi submetido à análise de conteúdo de Bardin. Resultados: Os resultados apontaram para o desconhecimento quanto aos reais empecilhos que dificultam o acesso e seguimento de pessoas trans nos serviços de saúde. Observou-se ainda a manutenção de preconceitos e ideias que reforçam estereótipos ligados ao tema e que se estendem ao exercício da profissão. Isso se relaciona diretamente com a falta da abordagem de assuntos relacionados à sexualidade humana na graduação desses profissionais, além da falta de atualização quanto ao tema, o que impacta a qualidade do serviço que é ofertado à população em estudo. Conclusões: As normativas e portarias já existentes precisam ser efetivamente postas em prática, fazendo-se imperativas a ampliação e difusão do conhecimento a respeito da temática trans no contexto dos serviços públicos de saúde, o que pode servir como base para subsidiar a formação dos profissionais que atuam nesse setor, bem como políticas públicas efetivas.

Introduction: In the process of creating the National LGBT+ Comprehensive Health Policy, primary care has important prominence as it must work as the preferential contact of transgender (trans) users. Objective: To investigate the perceptions of primary care professionals about the vulnerability situations faced by trans persons and also hindrances they consider existing in this population's search for access to these services. Methods: A qualitative approach was used through semi-structured interviews with 38 health care professionals working in the Family Health Strategy of two cities in the countryside of the state of São Paulo. The material obtained was submitted to analysis of Bardin content. Results: The results pointed to a lack of knowledge about real hindrances that obstruct the access to and follow-up by health services for trans persons. It was also observed the maintenance of prejudices and ideas that reinforce stereotypes connected to the matter and extend to the practice of professionals. It is directly related to the lack of approach of issues related to human sexuality in the education of those professionals, in addition to lack of update about it, which impacts the quality of service offered to the population under study. Conclusions: The standards and ordinances already existing need to be effectively practiced, being crucial the extension and spread of knowledge about trans matters in the context of public health services. It can be the basis for subsidizing the education of professionals who work in this field, as well as effective public policies.

Introducción: En el proceso de edificación de la Política Nacional de Salud Integral LGBT+, la Atención Básica tiene importante destaque, pues debería funcionar como contacto preferente de los usuarios transgénero (trans). Objetivo: Investigar las percepciones de los profesionales de Atención Básica sobre las situaciones de vulnerabilidad que enfrentan las personas trans, así como investigar los impedimentos que consideran que existe en la búsqueda de esta población por el acceso a estos servicios. Métodos: Se utilizó un abordaje cualitativo por medio de entrevistas semiestructuradas con 38 profesionales de salud actuantes de las Estrategias de Salud de la Familia de dos municipios del interior del estado de São Paulo. El material obtenido fue sometido a análisis de contenido de Bardin. Resultados: Los resultados apuntaron al desconocimiento sobre los reales obstáculos que dificultan el acceso de personas trans a los servicios, además del segmento de los cuidados en las unidades. Se observó además que se mantienen los prejuicios e ideas que refuerzan estereotipos vinculados al tema y que se extienden al ejercicio de la profesión. Esto se relaciona directamente a la falta da abordaje de asuntos relacionados a la sexualidad humana en la graduación de estos profesionales, además de la falta de actualización sobre el tema, lo que impacta en la calidad del servicio que se ofrece a la población en estudio. Conclusiones: Las normas y ordenanzas ya existentes deben ser efectivamente puestas en práctica, por lo que es imperativo ampliar y difundir el conocimiento sobre la temática trans en el contexto de los servicios públicos de salud, que pueda servir de base para apoyar la formación de profesionales que actúan en este sector, así como políticas públicas efectivas.

Association between socioeconomic deprivation, ethnicity and health outcomes in preschool children with recurrent wheeze in England: a retrospective cohort study.

BACKGROUND: Preschool-aged children have among the highest burden of acute wheeze. We investigated differences in healthcare use, treatment and outcomes for recurrent wheeze/asthma in preschoolers from different ethno-socioeconomic backgrounds. METHODS: Retrospective cohort study using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics in England. We reported number of acute presentations and hospitalisations stratified by index of multiple deprivation (IMD) and ethnicity; and factors associated with treatment non-escalation, and hospitalisation rates using multivariable logistic and Poisson regression models. RESULTS: 194 291 preschool children were included. In children not trialled on asthma preventer medications, children from the most deprived IMD quintile (adjusted OR 1.67; 95% CI 1.53 to 1.83) and South Asian (1.77; 1.64 to 1.91) children were more likely to have high reliever usage and where specialist referral had not occurred, the odds of referral being indicated was higher in the most deprived quintile (1.39; 1.28 to 1.52) and South Asian (1.86; 1.72 to 2.01) children compared with the least deprived quintile and white children, respectively.Hospitalisation rates for wheeze/asthma were significantly higher in children from the most deprived quintile (adjusted IRR 1.20; 95% CI 1.13 to 1.27) compared with the least, and in South Asian (1.57; 1.44 to 1.70) and black (1.32; 1.22 to 1.42) compared with white children. CONCLUSIONS: We identified inequalities in wheeze/asthma treatment and morbidity in preschool children from more deprived, and non-white backgrounds. A multifaceted approach to tackle health inequality at both the national and local levels, which includes a more integrated and standardised approach to treatment, is needed to improve health outcomes in children with preschool wheeze/asthma.

Applying a Trauma-Informed Lens to Challenging Adolescent Encounters: A Faculty Development Session for Pediatricians.

Introduction: Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure. Methods: Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics. Results: In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery. Discussion: We demonstrate that a brief session can create improvement in pediatric providers' perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour.

BACKGROUND: Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs' experiences diagnosing and managing pOUD in their chronic pain patients. METHODS: This qualitative research used semi-structured interviews and a case study to investigate GPs' experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual's perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed. RESULTS: Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions. CONCLUSIONS: Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

Beyond 'Screen & Refer': Understanding Families' Use of Resources for Health-related Social Needs Identified via Primary Care.

OBJECTIVE: As health-related social needs (HRSN) screening increases, attention to families' resource preferences lags. This study of a pediatric primary care intervention (DULCE) with reliable HRSN screening and resource connection explored whether resources adequately addressed families' needs and, when HRSN persisted, families' reasons for declining resources. METHODS: This retrospective cohort, mixed-methods study analyzed data from 989 families that received care at seven pediatric clinics implementing DULCE in three states. DULCE screens for seven HRSN around the 1-month and 4-month well-child visits; we calculated the percent of initial and ongoing positive screens. For positive rescreens, we calculated the percent that had all eligible or wanted resources and that were interested in further resources. We also analyzed case notes, which elicited families' resource preferences, and explored demographic characteristics associated with ongoing HRSN. RESULTS: Half of enrolled families (508 of 989) initially screened positive for HRSN; 124 families had positive rescreens; 26 expressed interest in further assistance. Most families with ongoing concrete supports needs accessed all eligible resources (60-100%); 20-58% had everything they wanted. Fewer families with ongoing maternal depression and intimate partner violence accessed all eligible resources (48% and 18%, respectively); most reported having all wanted resources (76% and 90%, respectively). Families declined resources due to lack of perceived need, the HRSN resolving, or families addressed HRSN themselves. White families were more likely to rescreen positive. CONCLUSIONS: Pediatric medical homes must honor family-centered decision-making while empowering families to accept beneficial resources. Healthcare systems should advocate for resources that families need and want.

General practitioners' perspectives on diagnostic testing in children with persistent non-specific symptoms.

BACKGROUND: Diagnostic testing is prevalent among children with persistent non-specific symptoms (PNS), and both undertesting and overtesting have negative consequences for child and society. Research in adults with PNS has shown that general practitioners (GPs) use diagnostic testing for reasons other than diagnosis, but comparable research has not been conducted in children. Understanding GPs' perspectives of testing decisions in children could provide insights into mechanisms of undertesting and overtesting. AIM: To investigate GPs' perspectives of conducting or refraining from diagnostic testing in children with PNS, and differences with motives in adults. DESIGN AND SETTING: Qualitative study using semi-structured interviews with Dutch GPs. METHOD: We purposively sampled GPs until data saturation. Reasons for conducting or refraining from diagnostic tests were explored using two real-life cases from daily practice. Online video interviews were transcribed verbatim. Data were collected and analyzed concurrently by thematic content analysis. FINDINGS: Twelve GPs participated. Their decision-making involved a complex trade-off among four themes: medical (e.g., alarm symptoms), psychosocial (e.g., doctor-patient relationship), consultation management (e.g., 'quick fix'), and efficient resource utilization (e.g., sustainability). Compared to adults, GPs were more hesitant to conduct diagnostic testing in children due to their higher vulnerability to fearing invasive procedures, lower probability of organic disease, and reduced autonomy. CONCLUSION: As in adults, GPs' decisions to conduct diagnostic tests in children were motivated by reasons beyond diagnostic uncertainty. Educational programs, interventions, and guidelines that aim to change the testing behaviors of GPs in children with PNS should target these reasons as well.

Preconception indicators and associations with health outcomes reported in UK routine primary care data: a systematic review.

BACKGROUND: Routine primary care data may be a valuable resource for preconception health research and informing provision of preconception care. AIM: To review how primary care data could provide information on the prevalence of preconception indicators and examine associations with maternal and offspring health outcomes. DESIGN AND SETTING: Systematic review of observational studies using UK routine primary care data. METHOD: Literature searches were conducted in five databases (March 2023) to identify observational studies that used national primary care data from individuals aged 15-49 years. Preconception indicators were defined as medical, behavioural and social factors that may impact future pregnancies. Health outcomes included those that may occur during and after pregnancy. Screening, data extraction and quality assessment were conducted by two reviewers. RESULTS: From 5,259 records screened, 42 articles were included. The prevalence of 30 preconception indicators was described for female patients, ranging from 0.01% for sickle cell disease to >20% for each of advanced maternal age, previous caesarean section (among those with a recorded pregnancy), overweight, obesity, smoking, depression and anxiety (irrespective of pregnancy). Few studies reported indicators for male patients (n=3) or associations with outcomes (n=5). Most studies had low risk of bias, but missing data may limit generalisability. CONCLUSION: Findings demonstrate that routinely collected UK primary care data can be used to identify patients preconception care needs. Linking primary care data with health outcomes collected in other datasets is underutilised but could help quantify how optimising preconception health and care can reduce adverse outcomes for mothers and children.

Pharmacists' current and potential prescribing roles in primary care in the Netherlands: a case study.

In some countries, pharmacists have obtained prescribing rights to improve quality and accessibility of care and reduce physician workload. This case study explored pharmacists' current roles in and potential for prescribing in primary care in the Netherlands, where prescribing rights for pharmacists do not exist. Participatory observations of pharmacists working in either general practice or community pharmacy were conducted, as were semi-structured interviews about current and potential practice. The latter were extended to patients and other healthcare professionals, mainly general practitioners, resulting in 34 interviews in total. Thematic analyses revealed that pharmacists, in all cases, wrote prescriptions that were then authorized by a physician before dispensing. General practice-based pharmacists often prescribed medications during patient consultations. Community pharmacists mainly influenced prescribing through (a) medication reviews where the physician and/or practice nurse often were consulted to make treatment decisions, and (b) collaborative agreements with physicians to start or substitute medications in specific situations. These findings imply that the pharmacists' current roles in prescribing in the Netherlands resemble collaborative prescribing practices in other countries. We also identified several issues that should be addressed before formally introducing pharmacist prescribing, such as definitions of tasks and responsibilities and prescribing-specific training for pharmacists.

Consistency, completeness and external validity of ethnicity recording in NHS primary care records: a cohort study in 25 million patients' records at source using OpenSAFELY.

BACKGROUND: Ethnicity is known to be an important correlate of health outcomes, particularly during the COVID-19 pandemic, where some ethnic groups were shown to be at higher risk of infection and adverse outcomes. The recording of patients' ethnic groups in primary care can support research and efforts to achieve equity in service provision and outcomes; however, the coding of ethnicity is known to present complex challenges. We therefore set out to describe ethnicity coding in detail with a view to supporting the use of this data in a wide range of settings, as part of wider efforts to robustly describe and define methods of using administrative data. METHODS: We describe the completeness and consistency of primary care ethnicity recording in the OpenSAFELY-TPP database, containing linked primary care and hospital records in > 25 million patients in England. We also compared the ethnic breakdown in OpenSAFELY-TPP with that of the 2021 UK census. RESULTS: 78.2% of patients registered in OpenSAFELY-TPP on 1 January 2022 had their ethnicity recorded in primary care records, rising to 92.5% when supplemented with hospital data. The completeness of ethnicity recording was higher for women than for men. The rate of primary care ethnicity recording ranged from 77% in the South East of England to 82.2% in the West Midlands. Ethnicity recording rates were higher in patients with chronic or other serious health conditions. For each of the five broad ethnicity groups, primary care recorded ethnicity was within 2.9 percentage points of the population rate as recorded in the 2021 Census for England as a whole. For patients with multiple ethnicity records, 98.7% of the latest recorded ethnicities matched the most frequently coded ethnicity. Patients whose latest recorded ethnicity was categorised as Other were most likely to have a discordant ethnicity recording (32.2%). CONCLUSIONS: Primary care ethnicity data in OpenSAFELY is present for over three quarters of all patients, and combined with data from other sources can achieve a high level of completeness. The overall distribution of ethnicities across all English OpenSAFELY-TPP practices was similar to the 2021 Census, with some regional variation. This report identifies the best available codelist for use in OpenSAFELY and similar electronic health record data.

[Systematic review of the primary care quality assessment instruments used in the last 10 years]. / Revisión sistemática de los instrumentos de evaluación de la calidad de Atención Primaria utilizados en los últimos 10 años.

OBJECTIVE: There are numerous instruments in the scientific literature for the evaluation of the quality of Primary Care (PC) and to know which of them are the most used and in which countries provides more information to make a well-founded decision. The aim is to determine which, between 2013 and 2023, have been the instruments used to assess the international quality of PC, its evolution and geographical distribution. DESIGN: Systematic review. DATA SOURCES: PubMed and Embase. From March to December 2023. INCLUSION CRITERIA: 1) Validation studies of specific assessment instruments to measure the quality of PC and/or the satisfaction of patients, providers or managers. 2) carried out in the field of PC and 3) published between 1/01/2013 and 01/02/2023. 83 full-text articles were included. DATA EXTRACTION: From each publication, an instrument used to evaluate the quality of the PC, attributes of the PC it evaluates, recipient of the evaluation, user, provider or manager, year, and country. RESULTS: Fifteen PC assessment instruments were found. The most widely used is the Primary Care Assessing Tool (PCAT), with wide geographical distribution, versions in several languages, is more limited in Europe, except in Spain, and is mostly used in the Primary Care Assessing Tool (PCAT). CONCLUSIONS: The PCAT, due to its cultural adaptability, availability in several languages, its ability to evaluate the fundamental principles of PC enunciated by the World Health Organization and to contemplate the perspectives of all health agents, is a complete, versatile, and consistent questionnaire for the evaluation of the quality of PC.

Primary Care Telemedicine and Care Continuity: Implications for Timeliness and Short-term Follow-up Healthcare.

BACKGROUND: The effectiveness of telemedicine by a patient's own primary care provider (PCP) versus another available PCP is understudied. OBJECTIVE: Examine the association between primary care visit modality with timeliness and follow-up in-person healthcare, including variation by visits with the patient's own PCP versus another PCP. DESIGN AND PARTICIPANTS: Cohort study including primary care visits in a large, integrated delivery system in 2022. MEASURES: Outcomes included timeliness (visit completed within 7 days of scheduling) and in-person follow-up (PCP visits, emergency department (ED) visits, hospitalizations) within 7 days of the index PCP visit. Logistic regression measured the association between visit modality (in-person, video, and audio-only telemedicine) with the patient's own PCP or another PCP and outcomes, adjusting for characteristics. KEY RESULTS: Among 4,817,317 primary care visits, 59% were in-person, 27% audio-only, and 14% video telemedicine. Most (71.3%) were with the patient's own PCP. Telemedicine visits were timelier, with modality having a larger association for visits with patient's own PCP versus another PCP (P < 0.001). For visits with patient's own PCPs, return office visit rates were 1.2% for in-person, 5.3% for video, and 6.1% for audio-only. For another PCP, rates were 2.2% for in-person, 7.3% for video, and 8.1% for audio. Follow-up ED visits ranged from 1.4% (in-person) to 1.6% (audio-only) with own PCP, compared to 1.9% (in-person) to 2.3% (audio-only) with another PCP. Differences in return office and ED visits between in-person and telemedicine were larger for visits with another PCP compared to their own PCP (P < 0.001). Follow-up hospitalizations were rare, ranging from 0.19% (in-person with own PCP) to 0.32% (video with another PCP). CONCLUSION: Differences in return office and ED visits between in-person and telemedicine were larger when patients saw a less familiar PCP compared to their own PCP, reinforcing the importance of care continuity.

[Diabetes and frailty in the elderly: a cross-sectional study of an outpatient population]. / Diabète et fragilité chez la personne âgée, étude transversale d'une population ambulatoire.

Screening for frailty syndrome, a marker of mortality risk, dependence, and institutionalization, is currently recommended in primary care to prevent its consequences effectively. Elderly diabetic individuals represent a significant and growing proportion of general practitioners' patient population, but their frailty status compared to the non-diabetic population is poorly understood. To study the relationship between diabetes and frailty in individuals aged 75 and older in general medicine. A total of 309 patients were included, among them 64 were diabetic patients, with a male/female ratio of 0.72. The proportion of frail elderly people was comparable between diabetics (24 %) and non-diabetics (27.6 %), as was the mean Fried score (1.78 vs. 1.56; not significant). Subgroup analysis revealed a significant difference in the risk of frailty, which was multiplied by 2.14 in diabetics without complications compared with non-diabetics, [95 % CI=2.03 to 2.25, p<2e(-16)]. Larger-scale studies at multiple outpatient sites should be conducted in general medicine among subjects aged over 75. Frailty management should be continued and carried out in patients whether they are diabetic or not.

Comorbidities and use of health services in people with diabetes mellitus according to risk levels by adjusted morbidity groups.

BACKGROUND: People with diabetes mellitus frequently have other comorbidities and involve greater use of primary and hospital care services. The aim of this study was to describe the comorbidities and use of primary and hospital care services of people with diabetes according to their risk level by adjusted morbidity groups (AMG) and to analyse the factors associated with the utilisation of these services. METHODS: Cross-sectional study. People with diabetes were identified within the population of patients with chronic conditions of an urban health care centre by the AMG stratification tool integrated into the primary health care electronic clinical record of the Community of Madrid. Sociodemographic, functional, clinical characteristics and annual health care services utilisation variables were collected. Univariate, bivariate and Poisson regression analyses were performed. RESULTS: A total of 1,063 people with diabetes were identified, representing 10.8% of patients with chronic conditions within the health centre. A total of 51.4% were female, the mean age was 70 years, 94.4% had multimorbidity. According to their risk level, 17.8% were high-risk, 40.6% were medium-risk and 41.6% were low-risk. The most prevalent comorbidities were hypertension (70%), dyslipidaemia (67%) and obesity (32.4%). Almost 50% were polymedicated. Regarding health services utilisation, 94% were users of primary care, and 59.3% were users of hospital care. Among the main factors associated with the utilisation of both primary and hospital care services were AMG risk level and complexity index. In primary care, utilisation was also associated with the need for primary caregivers, palliative care and comorbidities such as chronic heart failure and polymedication, while in hospital care, utilisation was also associated with comorbidities such as cancer, chronic obstructive pulmonary disease or depression. CONCLUSIONS: People with diabetes were older, with important needs for care, many associated comorbidities and polypharmacy that increased in parallel with the patient's risk level and complexity. The utilisation of primary and hospital care services was very high, being more frequent in primary care. Health services utilization were principally associated with functional factors related to the need of care and with clinical factors such as AMG medium and high-risk level, more complexity index, some serious comorbidities and polymedication.

Evaluating the Effectiveness of the COPD Assessment Test (CAT) in Screening for Chronic Obstructive Pulmonary Disease.

Background: Chronic obstructive pulmonary disease (COPD) is a major public health problem that remains largely under-diagnosed, mainly due to the under-use of spirometry to establish the diagnosis. The aim of this study is to evaluate the effectiveness of the Moroccan Arabic dialect version of the COPD Assessment Test (CAT) in screening for COPD. Methods: This was a cross-sectional study carried out in primary care facilities in Morocco, involving participants aged 40 and over. The performance of CAT in detecting cases of COPD was measured with reference to the results of spirometry, considered to be the gold Standard. Results: A total of 477 participants were included in the study. The prevalence of COPD was 6.7%. Internal consistency of the Moroccan Arabic dialect version of the CAT was high, with a Cronbach's alpha of 0.89. The total score of the CAT and of each item was significantly higher in subjects with COPD than in those without (P=0.000). Significantly negative correlations were found between CAT total score and FEV1 (r = -0.33, p=0.000), CAT and FVC (r = -0.22, p=0.000), CAT and FEV1/FVC ratio (r = -0.22, p=0.000). The receiver operating characteristic curve showed an area under the curve of 0.93. A CAT score of 10 was the optimal cut-off value for COPD screening, with a sensitivity, specificity, positive predictive value, and negative predictive value of 78.1%, 93.9%, 48.1% and 98.4%, respectively. Conclusion: The results of the present study showed that the CAT could be used as a screening tool for COPD. The use of this tool by healthcare professionals in primary care settings will improve and promote early diagnosis of this chronic disease.

Enhancing LGBT + primary healthcare in Slovenia: A national qualitative study of experiences and expectations of LGBT + people and family doctors.

BACKGROUND: Despite growing acceptance of LGBT + individuals, an underlying stigma persists even in healthcare, resulting in substandard care and worse healthcare outcomes for LGBT + individuals. OBJECTIVES: To examine and compare the experiences and expectations regarding primary healthcare among LGBT + individuals and general practitioners (GPs) in Slovenia. METHODS: We conducted an online national qualitative study using open-ended questions. To reach LGBT + population snowball method of recruitment was employed by sharing the questionnaire through LGBT + organisations, while GPs were invited by email of Association of family doctors in Slovenia. Anonymous data was collected from October to December 2021 and the questionnaires of 25 GPs and 90 LGBT + individuals of various ages, backgrounds, gender identities and sexual orientations were reviewed using thematic analysis. RESULTS: Both LGBT + participants and GPs expressed a desire for equal treatment. However, while all GPs claimed to treat all patients equally, LGBT + participants reported more varied experiences. Specific knowledge, especially on LGBT + terminology and healthcare, was perceived as lacking among GPs, leading LGBT + individuals to seek advice from specialists or community counselling. Systemic barriers, including societal stigmatisation and limited formal education on LGBT + issues, were identified, highlighting the need for designated safe spaces and improved GP training. Safety emerged as a central theme, crucial for fostering trust and disclosure between patients and healthcare providers. CONCLUSION: The study underscores the significance of a sense of safety in the patient-doctor relationship and highlights the need for improved training and attitudes to provide inclusive and affirming healthcare for LGBT + individuals.

Primary care settings must prioritise creating safe and non-judgmental environments for better LGBT + healthcare.Addressing formal GP education on LGBT + terminology, identities, and healthcare needs is crucial to provide inclusive care.Overcoming systemic barriers, such as societal prejudice and homophobia, requires creating visible safe space signals in primary care settings.

A multifaceted risk management program to improve the reporting rate of patient safety incidents in primary care: a cluster-randomised controlled trial.

BACKGROUND: While patient safety incident reporting is of key importance for patient safety in primary care, the reporting rate by healthcare professionals remains low. This study aimed to assess the effectiveness of a risk management program in increasing the reporting rate within multiprofessional primary care facilities. METHODS: A nation-wide cluster-randomised controlled trial was performed in France, with each cluster defined as a primary care facility. The intervention included professional e-learning training, identification of a risk management advisor, and multidisciplinary meetings to address incident analysis. In the first observational period, a patient safety incident reporting system for professionals was implemented in all facilities. Then, facilities were randomised, and the program was implemented. Incidents were reported over the 15-month study period. Quasi-Poisson models were used to compare reporting rates. RESULTS: Thirty-five facilities (intervention, n = 17; control, n = 18) were included, with 169 and 232 healthcare professionals, respectively, involved. Overall, 7 out of 17 facilities carried out the entire program (41.2%), while 6 did not hold meetings (35.3%); 48.5% of professionals logged on to the e-learning website. The relative rate of incidents reported was 2.7 (95% CI = [0.84-11.0]; p = 0.12). However, a statistically significant decrease in the incident rate between the pre-intervention and post-intervention periods was observed for the control arm (HR = 0.2; 95% CI = [0.05-0.54]; p = 0.02), but not for the intervention arm (HR = 0.54; 95% CI = [0.2-1.54]; p = 0.23). CONCLUSION: This program didn't lead to a significant improvement in the patient safety incident reporting rate by professionals but seemed to sustain reporting over time. Considering that the program was fully implemented in only 41% of facilities, this highlights the difficulty of implementing such multidisciplinary programs in primary care despite its adaptation to the setting. A better understanding of how risk management is currently organized in these multiprofessional facilities is of key importance to improve patient safety in primary care. TRIAL REGISTRATIONS: The study has been registered at clinicaltrials.gov (NCT02403388) on 30 March 2015.

Effects of the COVID-19 Pandemic on the Implementation of NCD Care at the Primary Care Level in the Philippines: A Qualitative Inquiry.

Background and Objective: The focusing of resources to COVID-19 response hampered and disadvantaged primary care services including that for Non-Communicable Diseases (NCDs), compromising continuity of care and hence, patients' disease status. However, studies from low- and middle-income countries (LMICs) remain sparse; therefore, evidence generation on how the pandemic impacted the provision of these primary care services in LMICs will help further understand how policies can be reframed, and programs be made more efficient and effective despite similar crises. To bridge this gap, the study investigated how the pandemic affected the implementation of NCD care at the primary care level in the Philippines. Methods: Thirty-one online focus group discussions via Zoom Meetings were conducted among 113 consenting physicians, nurses, midwives, and community health workers from various facilities - community health centers and stations, free-standing clinics, infirmaries, and level 1 hospitals - located within two provinces in the Philippines. All interviews were video-recorded upon participants' consent and transcribed verbatim. Inductive thematic analysis was employed through NViVo 12® to generate themes, identify categories, and describe codes. Results: The impact of COVID-19 on NCD care at the primary care level revolved around heightened impediments to service delivery, alongside worsening of pre-existing challenges experienced by the healthcare workforce; subsequently compelling the public to resort to unhealthy practices. These detriments to the primary healthcare system involved resource constraints, discontinued programs, referral difficulties, infection, overburden among workers, and interrupted training activities. Citizens were also observed to adopt poor healthcare seeking behavior, thereby discontinuing treatment regimen. Conclusion: Healthcare workers asserted that disadvantages caused by the pandemic in their NCD services at the primary care level possibly threaten patients' health status. Besides the necessity to address such detriments, this also emphasizes the need for quantitative studies that will aid in drawing inferences and evaluating the effect of health crises like the pandemic on such services to bridge gaps in improving quality of care.

Development and validation of 10-year risk prediction models of cardiovascular disease in Chinese type 2 diabetes mellitus patients in primary care using interpretable machine learning-based methods.

AIM: To develop 10-year cardiovascular disease (CVD) risk prediction models in Chinese patients with type 2 diabetes mellitus (T2DM) managed in primary care using machine learning (ML) methods. METHODS: In this 10-year population-based retrospective cohort study, 141 516 Chinese T2DM patients aged 18 years or above, without history of CVD or end-stage renal disease and managed in public primary care clinics in 2008, were included and followed up until December 2017. Two-thirds of the patients were randomly selected to develop sex-specific CVD risk prediction models. The remaining one-third of patients were used as the validation sample to evaluate the discrimination and calibration of the models. ML-based methods were applied to missing data imputation, predictor selection, risk prediction modelling, model interpretation, and model evaluation. Cox regression was used to develop the statistical models in parallel for comparison. RESULTS: During a median follow-up of 9.75 years, 32 445 patients (22.9%) developed CVD. Age, T2DM duration, urine albumin-to-creatinine ratio (ACR), estimated glomerular filtration rate (eGFR), systolic blood pressure variability and glycated haemoglobin (HbA1c) variability were the most important predictors. ML models also identified nonlinear effects of several predictors, particularly the U-shaped effects of eGFR and body mass index. The ML models showed a Harrell's C statistic of >0.80 and good calibration. The ML models performed significantly better than the Cox regression models in CVD risk prediction and achieved better risk stratification for individual patients. CONCLUSION: Using routinely available predictors and ML-based algorithms, this study established 10-year CVD risk prediction models for Chinese T2DM patients in primary care. The findings highlight the importance of renal function indicators, and variability in both blood pressure and HbA1c as CVD predictors, which deserve more clinical attention. The derived risk prediction tools have the potential to support clinical decision making and encourage patients towards self-care, subject to further research confirming the models' feasibility, acceptability and applicability at the point of care.

Comparing Two Training Modalities Supporting the Adoption of the SEEK Approach in Pediatric Primary Care 6/30/24.

OBJECTIVE: To compare the impact of two common continuing medical education training modalities - independent online training (IND) and a Maintenance of Certification-4 activity (MOC) - on primary care professionals' (PCPs') thinking and practice behavior regarding the Safe Environment for Every Kid (SEEK) approach. This was part of an implementation science study scaling up the evidence-based practice, SEEK. METHODS: This is a longitudinal, multi-site, mixed methods, cluster randomized controlled trial comparing 21 pediatric primary care practices across the U.S. randomized to one of two training modalities. Two hundred and ten PCPs completed surveys up to 4 times over a two-year period to assess their thinking and practice regarding SEEK; a subset was interviewed up to 3 times. RESULTS: Training led to significant and sustained improvements in PCPs' thinking and behavior related to SEEK, with no significant differences between the IND and MOC groups. PCPs mostly viewed their training positively, but several described shortcomings. PCP characteristics, such as age and sex, did not moderate the impact of the training, nor did the presence of a behavioral health professional. CONCLUSIONS: The lack of significant differences between the training modalities favors the simpler IND modality. This was despite the MOC training employing key principles of adult education. Of note, MOC-4 credits are required for pediatric board certification. More research is needed to optimize continuing medical education and to tailor approaches for different learners.

Evaluation of the first 5 years of the Next Generation GP leadership programme: balancing autonomy and accountability.

BACKGROUND: In 2017, a group of trainee general practitioners (GPs) came together to design and deliver a six-session leadership development programme for their peer trainee and early career GPs: the Next Generation GP programme. Over 2500 GPs took part in Next Generation GP between 2017 and 2022. AIM: To evaluate the origins and development of the Next Generation GP programme, its early impact on individuals and general practice, and what it reveals about GPs' needs for career and leadership development at a time of major workforce and demand pressures. METHODS: A rapid review of evidence on general practice workforce and career trends informed the design of qualitative research interviews (n=28) with a purposive sample of programme participants, primary care leaders and educational experts. This was supplemented by analysis of secondary data from participant evaluations of programme workshops. RESULTS: Many programme participants reported: improved competence in leadership skills, increased understanding of the health system, having new support networks and more energy for their GP role. Respondents pointed out the strengths of the programme, also highlighting ways in which it could be adapted to enable a transition to a more sustainable position within broader clinical and leadership career development. CONCLUSIONS: Next Generation GP has to date largely fulfilled its programme objectives. It now needs more tangible, longer-term objectives against which to assess outcomes. This evaluation has contributed to evidence about primary care leadership needing more policy attention, for the balance of autonomy and accountability within GP leadership needs careful and sustained support.