What AHRQ Learned While Working to Transform Primary Care.

Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.

A mixed methods analysis of the medication review intervention centered around the use of the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA) in Swiss primary care practices.

BACKGROUND: Electronic clinical decision support systems (eCDSS), such as the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) trial. METHODS: We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs (n = 21) and their patients (n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group (n = 8), and interview data were analyzed through thematic analysis. RESULTS: In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations. CONCLUSIONS: Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs' overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports). TRIAL REGISTRATION: Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018.

A pilot study of implementing an adapted model for integration of interventions for people with alcohol use disorders in Tanzanian primary healthcare facilities.

BACKGROUND: Ensuring that evidence-based interventions for people with alcohol use disorders (AUD) are acceptable, effective, and feasible in different socio-cultural and health system contexts is essential. We previously adapted a model of integration of AUD interventions for the Tanzanian primary healthcare system. This pilot study aimed to assess the impact on AUD detection and the acceptability and feasibility of the facility-based components of this model from the perspective of healthcare providers (HCPs). METHODS: This mixed-methods study comprised a pre-post quasi-experimental study and a qualitative study. The integrated model included training HCPs in managing AUD, introducing systematic screening for AUD, documentation of AUD service utilization, and supportive supervision. We collected information on the number of people identified for AUD three months before and after piloting the service model. A non-parametric trend test, a distribution-free cumulative sum test, was used to identify a change in the identification rate of AUD beyond that observed due to secular trends or, by chance, three months before and after implementing the integrated AUD facility-based interventions. The Mann-Kendal test was used to assess the statistical significance of the trend. We conducted three focus group discussions exploring the experience of HCPs and their perspectives on facilitators, barriers, and strategies to overcome them. The focus group discussions were analyzed using thematic analysis. RESULTS: During the pre-implementation phase of the facility-based interventions of the adapted AUD model, HCPs assessed 322 people for AUD over three months, ranging from a minimum of 99 to a maximum of 122 per month. Of these, 77 were identified as having AUD. Moreover, HCPs screened 2058 people for AUD during implementation; a minimum of 528 to a maximum of 843 people were screened for AUD per month for the three months. Of these, 514 screened positive for AUD (AUDIT ≥ 8). However, this change in screening for AUD was not statistically significant (p-value = 0.06). HCPs reported that knowledge and skills from the training helped them identify and support people they would not usually consider having problematic alcohol use. Perceived barriers to implementation included insufficient health personnel compared to needs and inconvenient health management information systems. HCPs proposed strategies to overcome these factors and recommended multisectoral engagement beyond the health system. CONCLUSIONS: Although the change in the trend in the number of people screened for AUD by HCPs post-implementation was not statistically significant, it is still feasible to implement the facility-based components of the adapted integrated AUD model while addressing the identified bottlenecks and strategies for implementation. Therefore, a large-scale, adequately powered implementation feasibility study is needed. Findings from this study will be used to finalize the adapted model for integrating AUD interventions for future implementation and larger-scale evaluation.

Exploring treatment burden in people with type 2 diabetes mellitus: a thematic analysis in china's primary care settings.

BACKGROUND: Understanding treatment burden is a critical element to the effective management of Type 2 Diabetes Mellitus (T2DM). The current study aims to address the knowledge gap surrounding treatment burden of T2DM from the patient's perspective in China's primary care settings. METHODS: A narrative review informed the creation of an a priori coding structure to identify aspects of T2DM treatment burden. Focus groups were conducted, employing a maximum variation sampling strategy to select participants from diverse sociodemographic backgrounds across urban, suburban, rural, and remote areas in China. Participants included adults with T2DM care in primary care settings for over a year and a Treatment Burden Questionnaire score of 25 or higher. Deductive thematic analysis, guided by the coding structure, facilitated a comprehensive exploration and further development of the conceptual framework of T2DM treatment burden. RESULTS: Four focus groups, each comprising five participants from diverse areas, were conducted. Utilising the Cumulative Complexity Model and Normalisation Process Theory as theoretical underpinnings, the thematic analysis refined the conceptual framework based on the coding structure from the narrative review. Five key themes were refined, encompassing medical information, medication, administration, healthcare system, and lifestyle. Additionally, the financial and time/travel themes merged into a new theme termed "personal resources", illustrating their overlapping within the framework. Participants in these focus groups highlighted challenges in managing medical information, an aspect often underrepresented in prior treatment burden research. The thematic analysis culminated in a finalised conceptual framework, offering a comprehensive understanding of the treatment burden experiences of people with T2DM in China's primary care settings. This framework includes six key constructs, delineating T2DM treatment burden and associated factors, such as antecedents and consequences. CONCLUSIONS: This study provides insights into the treatment burden of T2DM. A conceptual framework was finalised to deepen the understanding of the multifaceted constructs and the nature of treatment burden in people with T2DM. Furthermore, it emphasises the need to tailor T2DM treatment to individual capacities, considering their personal resource allocation and treatment utilisation.

Primary Care Interventions to Prevent Child Maltreatment: US Preventive Services Task Force Recommendation Statement.

Importance: Child maltreatment, which includes child abuse and neglect, can have profound effects on health, development, survival, and well-being throughout childhood and adulthood. The prevalence of child maltreatment in the US is uncertain and likely underestimated. In 2021, an estimated 600 000 children were identified by Child Protective Services as experiencing abuse or neglect and an estimated 1820 children died of abuse and neglect. Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate benefits and harms of primary care-feasible or referable behavioral counseling interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of maltreatment. Population: Children and adolescents younger than 18 years who do not have signs or symptoms of or known exposure to maltreatment. Evidence Assessment: The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of or known exposure to maltreatment. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective: To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection: English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results: Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

El pediatra de Atención Primaria y la anafilaxia / The primary care pediatrician and anaphylaxis

La anafilaxia es una reacción alérgica grave de instauración rápida y potencialmente mortal. El diagnóstico de anafilaxia es clínico y debe realizarse de manera precoz. Aparece en las 2 primeras horas tras exposición al alérgeno, en los primeros 30 minutos en alergia alimentaria y más precozmente con medicamentos intravenosos o picaduras de himenópteros. Los síntomas cutáneos suelen ser los primeros en manifestarse y están presentes en la mayoría de los casos, más de un 80%. Pueden ser leves o transitorios e incluso no estar presentes en un 18% de los casos. Si se afecta el sistema cardiocirculatorio estaríamos ante un shock anafiláctico. La causa más frecuente en Pediatría son los alimentos. Existen cofactores cuya presencia aumenta la probabilidad de anafilaxia; los más importantes son: el ejercicio, los fármacos, la fiebre y el estrés. El tratamiento de elección es la adrenalina intramuscular. Tanto los padres como los niños deben saber identificar los signos y/o síntomas del inicio de la anafilaxia para instaurar el tratamiento pautado en el plan de acción escrito.

Anaphylaxis is a severe, rapid and potentially fatal allergic reaction. The diagnosis of anaphylaxis is clinical and must be early. It appears in the first 2 hours after exposure to the allergen, in the first 30 minutes in food allergy and earlier with intravenous drugs or hymenoptera stings. Cutaneous symptoms are generally the first to appear and are present in most cases, more than 80%. They may be mild or transitory, or absent in 18% of cases. If the cardio-circulatory system is affected, an anaphylactic shock occurs. The most frequent cause in pediatrics is nutrition. There are several cofactors whose presence increases the likelihood of anaphylaxis; the most important are: exercise, medication, fever and stress. The treatment of choice is intramuscular adrenaline. Parents and children should be able to identify the signs and/or symptoms of anaphylaxis in order to implement the treatment prescribed in the written action plan. (AU)

Participación ciudadana, imprescindible en procesos comunitarios: experiencia en la realización del diagnóstico de salud de Santpedor / Citizen participation, essential in community processes: experience in the Santpedor health diagnosis

Introducción. En este artículo se quiere plasmar la grata experiencia de hacer un diagnóstico de salud en la población de Santpedor. El diagnóstico se llevó a cabo con acción participativa desde el primer momento y durante todo el proceso. Se hizo con un grupo motor, donde solo dos de las 15 personas que lo representan eran agentes sanitarios. Estos agentes legitimaron el proceso comunitario, coordinaron el grupo motor y lo guiaron. Sin embargo, eran una pieza más del puzle comunitario, siendo los otros 13 agentes comunitarios no sanitarios los auténticos protagonistas al posibilitar llegar a la población y completar el puzle comunitario. Objetivo. Realizar el diagnóstico de salud de Santpedor con acción participativa. Métodos. Se utilizó una metodología mixta secuencial y explicativa, con una parte cuantitativa (descriptivo transversal) y una parte cualitativa (acción participativa). En este artículo se explica la metodología que se utilizó para hacer el diagnóstico de salud de Santpedor y se describen las estrategias participativas para llegar a la población y favorecer la pertinencia en el proceso comunitario, así como las técnicas empleadas para la detección de las necesidades y su priorización. Las técnicas cualitativas utilizadas para la detección de los activos fueron el mapping party y la marcha de activos. Las técnicas empleadas para identificar las necesidades fueron la encuesta y las entrevistas grupales (grupos focales, grupo nominal y entrevistas individuales). Resultados. Se identificaron 604 activos de Santpedor. En el análisis cuantitativo se observó que Santpedor presentaba un gran relevo generacional y un tejido económico diversificado. En el análisis cualitativo, se logró una gran cantidad de información con la que, una vez analizada y trabajada con todo el grupo motor, se confeccionó un listado con 17 necesidades que había que cubrir para mejorar la salud de la población. ... (AU)

Introduction. In this paper we seek to capture the pleasant experience in making a health diagnosis in the Santpedor population. The diagnosis was made with participation from the very first moment and during the entire process. It was made with a driving group where only two of the 15 people representing it were health agents. These agents legitimized the community process, coordinated the driving group and guided it. However, they were just one more piece of the community puzzle, the other 13 non-health community agents being the real protagonists to reach the population and complete the community puzzle. Aim. To make a health diagnosis in Santpedor with the population taking part. Methods. A mixed explanatory sequential methodology was used. Comprised of a quantitative part (cross-sectional descriptive) and a qualitative part (participation). This paper explains the methodology used to made this. It reports the participation used to reach the population and favour relevance in the community process; as well as the techniques used to detect needs and their prioritization. The qualitative techniques used to detect assets were: mapping party, asset march. The techniques used to detect needs were by means of a survey ("bustiada") and group interviews (focus groups, nominal group and individual interviews). Results. A total of 604 Santpedor assets were identified. In the quantitative analysis, it was observed that Santpedor had a major generational change and a diversified economic fabric. In the qualitative analysis, a large amount of information was obtained which, once analyzed and worked on with the entire driving group, led to a list of 17 needs to improve the health of the population. These needs were prioritized by means of a simple vote, where a large citizen participation was attained with 754 votes from the citizens. The first need detected was "housing needs", followed by "public transportation needs", and "work needs". ... (AU)

Accuracy of urgency allocation in patients with shortness of breath calling out-of-hours primary care: a cross-sectional study.

BACKGROUND: In out-of-hours primary care (OHS-PC), semi-automatic decision support tools are often used during telephone triage. In the Netherlands, the Netherlands Triage Standard (NTS) is used. The NTS is mainly expert-based and evidence on the diagnostic accuracy of the NTS' urgency allocation against clinically relevant outcomes for patients calling with shortness of breath (SOB) is lacking. METHODS: We included data from adults (≥18 years) who contacted two large Dutch OHS-PC centres for SOB between 1 September 2020 and 31 August 2021 and whose follow-up data about final diagnosis could be retrieved from their own general practitioner (GP). The diagnostic accuracy (sensitivity and specificity with corresponding 95% confidence intervals (CI)) of the NTS' urgency levels (high (U1/U2) versus low (U3/U4/U5) and 'final' urgency levels (including overruling of the urgency by triage nurses or supervising general practitioners (GPs)) was determined with life-threatening events (LTEs) as the reference. LTEs included, amongst others, acute coronary syndrome, pulmonary embolism, acute heart failure and severe pneumonia. RESULTS: Out of 2012 eligible triage calls, we could include 1833 adults with SOB who called the OHS-PC, mean age 53.3 (SD 21.5) years, 55.5% female, and 16.6% showed to have had a LTE. Most often severe COVID-19 infection (6.0%), acute heart failure (2.6%), severe COPD exacerbation (2.1%) or severe pneumonia (1.9%). The NTS urgency level had a sensitivity of 0.56 (95% CI 0.50-0.61) and specificity of 0.61 (95% CI 0.58-0.63). Overruling of the NTS' urgency allocation by triage nurses and/or supervising GPs did not impact sensitivity (0.56 vs. 0.54, p = 0.458) but slightly improved specificity (0.61 vs. 0.65, p < 0.001). CONCLUSIONS: The semi-automatic decision support tool NTS performs poorly with respect to safety (sensitivity) and efficiency (specificity) of urgency allocation in adults calling Dutch OHS-PC with SOB. There is room for improvement of telephone triage in patients calling OHS-PC with SOB. TRIAL REGISTRATION: The Netherlands Trial Register, number: NL9682 .

Virtual quality improvement collaborative with primary care practices during COVID-19: a case study within a clinically integrated network.

INTRODUCTION: Quality improvement collaboratives (QICs) are a common approach to facilitate practice change and improve care delivery. Attention to QIC implementation processes and outcomes can inform best practices for designing and delivering collaborative content. In partnership with a clinically integrated network, we evaluated implementation outcomes for a virtual QIC with independent primary care practices delivered during COVID-19. METHODS: We conducted a longitudinal case study evaluation of a virtual QIC in which practices participated in bimonthly online meetings and monthly tailored QI coaching sessions from July 2020 to June 2021. Implementation outcomes included: (1) level of engagement (meeting attendance and poll questions), (2) QI capacity (assessments completed by QI coaches), (3) use of QI tools (plan-do-check-act (PDCA) cycles started and completed) and (4) participant perceptions of acceptability (interviews and surveys). RESULTS: Seven clinics from five primary care practices participated in the virtual QIC. Of the seven sites, five were community health centres, three were in rural counties and clinic size ranged from 1 to 7 physicians. For engagement, all practices had at least one member attend all online QIC meetings and most (9/11 (82%)) poll respondents reported meeting with their QI coach at least once per month. For QI capacity, practice-level scores showed improvements in foundational, intermediate and advanced QI work. For QI tools used, 26 PDCA cycles were initiated with 9 completed. Most (10/11 (91%)) survey respondents were satisfied with their virtual QIC experience. Twelve interviews revealed additional themes such as challenges in obtaining real-time data and working with multiple electronic medical record systems. DISCUSSION: A virtual QIC conducted with independent primary care practices during COVID-19 resulted in high participation and satisfaction. QI capacity and use of QI tools increased over 1 year. These implementation outcomes suggest that virtual QICs may be an attractive alternative to engage independent practices in QI work.

Evaluation of an automated feedback intervention to improve antibiotic prescribing among primary care physicians (OPEN Stewardship): a multinational controlled interrupted time-series study.

Tools to advance antimicrobial stewardship in the primary health care setting, where most antimicrobials are prescribed, are urgently needed. The aim of this study was to evaluate OPEN Stewarship (Online Platform for Expanding aNtibiotic Stewardship), an automated feedback intervention, among a cohort of primary care physicians. We performed a controlled, interrupted time-series study of 32 intervention and 725 control participants, consisting of primary care physicians from Ontario, Canada and Southern Israel, from October 2020 to December 2021. Intervention participants received three personalized feedback reports targeting several aspects of antibiotic prescribing. Study outcomes (overall prescribing rate, prescribing rate for viral respiratory conditions, prescribing rate for acute sinusitis, and mean duration of therapy) were evaluated using multilevel regression models. We observed a decrease in the mean duration of antibiotic therapy (IRR = 0.94; 95% CI: 0.90, 0.99) in intervention participants during the intervention period. We did not observe a significant decline in overall antibiotic prescribing (OR = 1.01; 95% CI: 0.94, 1.07), prescribing for viral respiratory conditions (OR = 0.87; 95% CI: 0.73, 1.03), or prescribing for acute sinusitis (OR = 0.85; 95% CI: 0.67, 1.07). In this antimicrobial stewardship intervention among primary care physicians, we observed shorter durations of therapy per antibiotic prescription during the intervention period. The COVID-19 pandemic may have hampered recruitment; a dramatic reduction in antibiotic prescribing rates in the months before our intervention may have made physicians less amenable to further reductions in prescribing, limiting the generalizability of the estimates obtained.IMPORTANCEAntibiotic overprescribing contributes to antibiotic resistance, a major threat to our ability to treat infections. We developed the OPEN Stewardship (Online Platform for Expanding aNtibiotic Stewardship) platform to provide automated feedback on antibiotic prescribing in primary care, where most antibiotics for human use are prescribed but where the resources to improve antibiotic prescribing are limited. We evaluated the platform among a cohort of primary care physicians from Ontario, Canada and Southern Israel from October 2020 to December 2021. The results showed that physicians who received personalized feedback reports prescribed shorter courses of antibiotics compared to controls, although they did not write fewer antibiotic prescriptions. While the COVID-19 pandemic presented logistical and analytical challenges, our study suggests that our intervention meaningfully improved an important aspect of antibiotic prescribing. The OPEN Stewardship platform stands as an automated, scalable intervention for improving antibiotic prescribing in primary care, where needs are diverse and technical capacity is limited.

Safety-Net Primary Care and Endocrinology Clinicians' Knowledge and Perspectives on Screening for Nonalcoholic Fatty Liver Disease: A Mixed-Methods Evaluation.

OBJECTIVE: Clinical guidelines have expanded the indications for nonalcoholic fatty liver disease (NAFLD) screening to type 2 diabetes mellitus and obesity, which are conditions common in populations who receive care in urban safety-net settings. This study aimed to evaluate safety-net primary care and endocrinology clinicians' knowledge of NAFLD, determine barriers and facilitators to screening, and examine perspectives on the use of electronic health record tools for risk assessment. METHODS: Sequential explanatory mixed methods using survey and qualitative interviews with primary care, primary care subspecialty, and endocrinology clinicians in an urban safety-net health care system. RESULTS: A total of 109 participants completed the survey (36.5% response rate), and 13 participated in interviews. Most respondents underestimated or did not know the prevalence of NAFLD (68%), did not use the recommended noninvasive tests for risk stratification (65%), and few were comfortable with screening for (27%) or managing (17%) NAFLD. Endocrinologists had greater knowledge of risk factors but lower rates of comfort and more often felt that screening was not their responsibility. The qualitative themes included the following: (1) lack of knowledge about screening, (2) concern for underdiagnosing NAFLD, (3) perception of severity impacts beliefs about screening, (4) screening should occur in primary care but is not normative practice, (5) concerns exist about benefit, (6) competing demands with a complex population hinder screening, and (7) a need for easier ways to integrate screening into practice. CONCLUSION: Knowledge gaps may hamper uptake of new guidelines for NAFLD screening in primary care and endocrinology clinics in an urban safety-net health care system. Implementation strategies focused on training and educating clinicians and informed by behavioral economics may increase screening.

Barriers to and facilitators of successful implementation of a palliative approach to care in primary care practices: a mixed methods study.

OBJECTIVE: Integrating a palliative approach to care into primary care is an emerging evidence-based practice. Despite the evidence, this type of care has not been widely adopted into primary care settings. The objective of this study was to examine the barriers to and facilitators of successful implementation of a palliative approach to care in primary care practices by applying an implementation science framework. DESIGN: This convergent mixed methods study analysed semistructured interviews and expression of interest forms to evaluate the implementation of a protocol, linked to implementation strategies, for a palliative approach to care called Early Palliation through Integrated Care (EPIC) in three primary care practices. This study assessed barriers to and facilitators of implementation of EPIC and was guided by the Consolidated Framework for Implementation Research (CFIR). A framework analysis approach was used during the study to determine the applicability of CFIR constructs and domains. SETTING: Primary care practices in Canada. Interviews were conducted between September 2020 and November 2021. PARTICIPANTS: 10 individuals were interviewed, who were involved in implementing EPIC. Three individuals from each practice were reinterviewed to clarify emerging themes. RESULTS: Overall, there were implementation barriers at multiple levels that caused some practices to struggle. However, barriers were mitigated when practices had the following facilitators: (1) a high level of intra-practice collaboration, (2) established practices with organisational structures that enhanced communications, (3) effective leveraging of EPIC project supports to transition care, (4) perceptions that EPIC was an opportunity to make a long-term change in their approach to care as opposed to a limited term project and (5) strong practice champions. CONCLUSIONS: Future implementation work should consider assessing facilitators identified in our results to better gauge primary care pre-implementation readiness. In addition, providing primary care practices with support to help offset the additional work of implementing innovations and networking opportunities where they can share strategies may improve implementation success.

Profiles of met and unmet care needs in the oldest-old primary care patients with depression - results of the AgeMooDe study.

BACKGROUND: Unmet care needs have been associated with an increased risk of depression in old age. Currently, the identification of profiles of met and unmet care needs associated with depressive symptoms is pending. Therefore, this exploratory study aimed to identify profiles of care needs and analyze associated factors in oldest-old patients with and without depression. METHODS: The sample of 1092 GP patients aged 75+ years is based on the multicenter study "Late-life depression in primary care: needs, health care utilization and costs (AgeMooDe)". Depression (i.e. clinically meaningful depressive symptoms) was determined using the Geriatric Depression Scale (GDS) (cutoff score ≥ 4). Needs of patients were assessed using the Camberwell Assessment of Need for the Elderly (CANE). Associated sociodemographic and clinical factors were examined, and latent class analysis identified the need profiles. RESULTS: The main result of the study indicates three need profiles: 'no needs', 'met physical needs', and 'unmet social needs'. Members of the 'met physical needs' (OR = 3.5, 95 %-CI: 2.5-4.9) and 'unmet social needs' (OR = 17.4, 95 %-CI: 7.7-39.7) profiles were significantly more likely to have depression compared to members of the 'no needs' profile. LIMITATIONS: Based on the cross-sectional design, no conclusions can be drawn about the causality or direction of the relationships between the variables. CONCLUSIONS: The study results provide important insights for the establishment of needs-based interventions for GPs. Particular attention should be paid to the presence of unmet social needs in the oldest-old GP patients with underlying depressive symptoms.

The impact on primary care of a large waterborne campylobacter outbreak in Norway: a controlled observational study.

OBJECTIVE: Document the impact of an outbreak of gastroenteritis on local primary health care services, compared to a control period. DESIGN: Controlled observational study with data from the outbreak and a control period. Data obtained from electronic medical records (EMR) of general practitioners (GPs) and the out-of-hours (OOH) service. Telephone data from the OOH service's telephone records. SETTING: Campylobacteriosis outbreak in Askøy municipality, Norway in 2019. Over 2000 individuals were infected. SUBJECTS: Patients in contact with GPs and the OOH service during the outbreak and a control period. MAIN OUTCOME MEASURES: Patient contacts with GPs and the OOH service during the outbreak and a control period. RESULTS: There was a 36% increase in contacts during the outbreak compared to the control period (4798 vs. 3528), with the OOH service handling 78% of outbreak-related contacts. Telephone advice was the dominant method for managing the increase in contacts to primary care, both in OOH services and daytime general practice (OR 3.73 CI: [3.24-4.28]). Children aged 0-4 years had increased use of primary care during the outbreak (OR 1.51 CI: [1.28-1.78]). GPs referred 25% and OOH services referred 75% of 70 hospitalized cases. CONCLUSION: The OOH service handled most of the patients during the outbreak, with support from daytime general practice. The outbreak caused a shift towards telephone advice as a means of providing care. Young children significantly increased their use of primary care during the outbreak.

What do primary care providers want to know when caring for patients living with frailty? An analysis of eConsult communications between primary care providers and specialists.

BACKGROUND: Frailty is a complex condition that primary care providers (PCPs) are managing in increasing numbers, yet there is no clear guidance or training for frailty care. OBJECTIVES: The present study examined eConsult questions PCPs asked specialists about patients with frailty, the specialists' responses, and the impact of eConsult on the care of these patients. DESIGN: Cross-sectional observational study. SETTING: ChamplainBASE™ eConsult located in Eastern Ontario, Canada. PARTICIPANTS: Sixty one eConsult cases closed by PCPs in 2019 that use the terms "frail" or "frailty" to describe patients 65 years of age or older. MEASUREMENTS: The Taxonomy of Generic Clinical Questions (TGCQ) was used to classify PCP questions and the International Classification for Primary Care 3 (ICPC-3) was used to classify the clinical content of each eConsult. The impact of eConsult on patient care was measured by PCP responses to a mandatory survey. RESULTS: PCPs most frequently directed their questions to cardiology (n = 7; 11%), gastroenterology (n = 7; 11%), and endocrinology (n = 6; 10%). Specialist answers most often pertained to medications (n = 63, 46%), recommendations for clinical investigation (n = 24, 17%), and diagnoses (n = 22, 16%). Specialist responses resulted in PCPs avoiding referral in 57% (n = 35) of cases whereas referrals were still required in 15% (n = 9) of cases. Specialists responded to eConsults in a median 1.11 days (IQR = 0.3-4.7), and 95% (n = 58) of cases received a response within 7 days. Specialists recorded a median of 15 min to respond (IQR = 10-20), with a median cost of $50.00 CAD (IQR = 33.33 - 66.66) per eConsult. CONCLUSIONS: Through the analysis of questions and responses submitted to eConsult, this study provides novel information on PCP knowledge gaps and approaches to care for patients living with frailty. Furthermore, these analyses provide evidence that eConsult is a feasible and valuable tool for improving care for patients with frailty in primary care settings.

Are remote health clinics primary health care focused? Validation of the Primary Health Care Engagement (PHCE) Scale for the Australian remote primary health care setting.

AIM: To test and validate a measure of primary health care (PHC) engagement in the Australian remote health context. BACKGROUND: PHC principles include quality improvement, community participation and orientation of health care, patient-centred continuity of care, accessibility, and interdisciplinary collaboration. Measuring the alignment of services with the principles of PHC provides a method of evaluating the quality of care in community settings. METHODS: A two-stage design of initial content and face validity evaluation by a panel of experts and then pilot-testing the instrument via survey methods was conducted. Twelve experts from clinical, education, management and research roles within the remote health setting evaluated each item in the original instrument. Panel members evaluated the representativeness and clarity of each item for face and content validity. Qualitative responses were also collected and included suggestions for changes to item wording. The modified tool was pilot-tested with 47 remote area nurses. Internal consistency reliability of the Australian Primary Health Care Engagement scale was evaluated using Cronbach's alpha. Construct validity of the Australian scale was evaluated using exploratory factor analysis and principal component analysis. FINDINGS: Modifications to suit the Australian context were made to 8 of the 28 original items. This modified instrument was pilot-tested with 47 complete responses. Overall, the scale showed high internal consistency reliability. The subscale constructs 'Quality improvement', 'Accessibility-availability' and 'population orientation' showed low levels of internal consistency reliability. However, the mean inter-item correlation was 0.31, 0.26 and 0.31, respectively, which are in the recommended range of 0.15 to 0.50 and indicate that the items are correlated and are measuring the same construct. The Australian PHCE scale is recommended as a tool for the evaluation of health services. Further testing on a larger sample may provide clarity over some items which may be open to interpretation.

Reasons for Provider-to-Provider Synchronous Teleconsultations Between Nurses in Primary Care: A Cross-Sectional Study of TelessaúdeRS-UFRGS Service.

Introduction: Nurses have proven to be fundamental for the expansion and consolidation of primary health care (PHC), as well as the development of digital health strategies. We explored the results of a synchronous telephone teleconsultations service between professionals for nurses in Brazil. Methods: This is a cross-sectional study. We retrieved data from teleconsultations registry. All teleconsultations answered by the team of nurses between September 2018 and July 2021 were analyzed regarding the reasons (according to International Classification of Primary Care, 2nd edition-ICPC-2) and decisions of the teleconsultation. Results: There were 9,273 phone teleconsultations registered in the period, requested by 3,125 nurses from all states throughout the country, of which 56.9% called once and 15.9% used the teleconsultations at least 4 times. We found 362 different reasons for solicitations, which were classified according to the ICPC-2 chapters. The most frequent codes were respiratory (25.9%), general and unspecified (21.2%), and skin (21.2%), which corresponded to 68% of the total sample. Most teleconsultations (66.9%) had as outcome the maintenance of the case at PHC. Conclusion: Teleconsultations are widely used and address a broad number of situations. This service may improve the quality of Brazilian PHC and promote the development of clinical reasoning and critical thinking by nurses.

How do primary care providers and autistic adults want to improve their primary care? A Delphi-study.

LAY ABSTRACT: Autistic adults often encounter different types of healthcare barriers. Because autistic adults also have an increased risk for health problems, the aim of this study was to evaluate barriers and to explore how primary care providers and autistic adults want to improve their primary healthcare. In this co-created study, semi-structured interviews with three autistic adults, two parents of autistic children and six care providers were performed to evaluate barriers in Dutch healthcare. Next, in the survey-study (using the Delphi-method including controlled feedback in three consecutive questionnaires), 21 autistic adults and 20 primary care providers rated the impact of barriers and the usefulness and feasibility of recommendations to improve primary healthcare. In the interviews, 20 barriers in Dutch healthcare for autistic people were found. In the survey-study, the primary care providers rated the negative impact of most barriers lower than the autistic adults. This survey-study resulted in 22 recommendations to improve primary healthcare focused on: primary care providers (including education in collaboration with autistic people), autistic adults (including improvement of preparation for general practitioner-appointments) and organization of general practice (including improvement of continuity in care). In conclusion, primary care providers seem to view healthcare barriers as less impactful than autistic adults. In this co-created study, recommendations to improve primary healthcare for autistic adults were identified, based on the needs of autistic adults and primary care providers. These recommendations provide a basis for primary care providers, autistic adults and their support network to start conversations about, for example, strategies to improve primary care providers' knowledge, autistic adults' preparation for a general practitioner-appointment and organization of primary care.

Implementation of Provider-Focused Education to Improve Laboratory Screening for Pediatric Patients With Elevated Body Mass Index in Primary Care: A Quality Improvement Project.

INTRODUCTION: Children with elevated body mass index (BMI) do not consistently receive recommended laboratory screenings. This project aimed to increase provider screening rates and knowledge of screening guidelines for this population. METHOD: This project utilized the Rosswurm and Larrabee evidence-based practice model. Providers completed education with pretest and posttest design. Laboratory screening rates were measured with retrospective chart reviews, and a project satisfaction survey was conducted. RESULTS: Nine (82%) of 11 providers showed an increase in knowledge of screening for children with elevated BMI. Laboratory screening increased (27% to 39%) above the preintervention median (25%) for children with obesity and was above the median (22%) for one month of the project (15% to 26%) for children with overweight. CONCLUSIONS: Project results suggest education improved knowledge and compliance with guidelines for laboratory screening of children with an elevated BMI. Asynchronous education and sharing of compliance rates are adaptable to similar quality improvement projects.