Construct Validity Testing of the Provider Co-Management Index to Measure Shared Care in Provider Dyads.

BACKGROUND: Co-management encompasses the dyadic process between two healthcare providers. The Provider Co-Management Index (PCMI) was initially developed as a 20-item instrument across three theory-informed subscales. OBJECTIVE: This study aimed to establish construct validity of the PCMI with a sample of primary care providers through exploratory and confirmatory factor analyses. METHODS: We conducted a cross-sectional survey of primary care physicians, nurse practitioners, and physician assistants randomly selected from the IQVIA database across New York State. Mail surveys were used to acquire a minimum of 300 responses for split sample factor analyses. The first subsample (derivation sample) was used to explore factorial structure by conducting an exploratory factor analysis. A second (validation) sample was used to confirm the emerged factorial structure using confirmatory factor analysis. We performed iterative analysis and calculated good fit indices to determine the best-fit model. RESULTS: There were 333 responses included in the analysis. Cronbach's alpha was high for a three-item per dimension scale within a one-factor model. The instrument was named PCMI-9 to indicate the shorter version length. DISCUSSION: This study established the construct validity of an instrument that scales the co-management of patients by two providers. The final instrument includes nine items on a single factor using a 4-point, Likert-type scale. Additional research is needed to establish discriminant validity.

Presència dels familiars al box de crítics dels serveis d’urgències / Presencia de los familiares en el box de críticos de los servicios de urgencias / Family presence in the resuscitation room of pediatric emergency departments

Fonament. La presència dels familiars és cada cop més habitual als serveis d’urgències pediàtriques (SUP), on participen activament en la presa de decisions, els tractamentsi les cures del pacient.Objectiu. 1) Conèixer la proporció de SUP catalans en quèla presència dels familiars és habitual als boxs de crítics ien quines condicions. 2) Descriure els problemes que se’nderiven.Mètode. Estudi descriptiu multicèntric. Se sol·licita als responsables dels SUP que complimentin una enquesta sobrela presència de familiars als boxs de crítics (protocol, ubicació, acompanyament dels familiars, problemes derivats).Resultats. S’envien divuit enquestes, i s’obtenen setze respostes (taxa de resposta 88,8%) d’hospitals de mitjana(12/16) i alta (4/16) complexitat. Tots els SUP disposen debox de crítics i en 15/16 s’ofereix als familiars ser-hi presents durant l’atenció de l’infant; en un SUP no s’ofereixaquesta opció perquè l’espai és reduït, malgrat que la troben necessària. Dos SUP disposen de protocol. Durantl’atenció al pacient greu, els familiars estan acompanyatsper algun sanitari (11/16), però intermitentment (7/16). Espermeten un o dos familiars, sempre que ho desitgin(13/16) o després de l’estabilització inicial (2/16). Dos responsables manifesten problemes derivats, com el nerviosisme i l’agressivitat familiar.Conclusions. La presència de familiars als boxs de crítics éshabitual als SUP enquestats, sense problemes destacables.No obstant això, s’han detectat alguns aspectes millorables(elaboració de protocols i acompanyament dels familiars). (AU)

Fundamento. La presencia de familiares es cada vez más habitualen los servicios de urgencias pediátricas (SUP), colaborando en latoma de decisiones, tratamientos y cuidados del paciente. Objetivo. 1) Conocer la proporción de SUP catalanes en los que lapresencia de familiares es habitual en el box de críticos y en quécondiciones. 2) Describir problemas derivados.Método. Estudio descriptivo multicéntrico. Se solicita a los responsables de los SUP cumplimentar una encuesta sobre la presenciade familiares en el box de críticos (protocolo, ubicación, acompañamiento de los familiares, problemas derivados).Resultados. Se envían 18 encuestas y se obtienen 16 respuestas(tasa de respuesta (88,8%) de hospitales de mediana (12/16) yalta (4/16) complejidad. Todos los SUP disponen de box de críticos y en 15/16 se ofrece la presencia de familiares durante laatención del paciente crítico, en uno de ellos no está permitida porespacio reducido, pero la consideran necesaria. Dos SUP disponende protocolo. Los familiares están acompañados por algún profesional sanitario (11/16), pero de manera intermitente (7/16). Sepermiten 1 o 2 familiares, siempre que lo deseen (13/16) o después de la estabilización inicial (2/16). Dos responsables notificanproblemas puntuales (nerviosismo y agresividad familiar).Conclusiones. La presencia de familiares en los boxes de críticoses habitual en los SUP participantes, sin problemas destacables.Se han detectado algunos aspectos de mejora (elaboración de protocolos y acompañamiento de los familiares). (AU)

Background. Family presence is common in pediatric emergencydepartments (PED), and relatives actively collaborate in decisionmaking, treatment, and patient care.Objective. 1) To identify the proportion of Catalan PED where family presence is allowed in the resuscitation room and to describethe characteristics of family presence. 2) To describe the problemsthat arise from the presence of family members.Method. A multicenter descriptive study was designed. Chiefphysicians of PED were asked to participate via email in a surveyasking about the PED characteristics and the family presence inthe resuscitation room (protocol, location, relatives’ companion,problems).Results. 18 surveys were sent, obtaining 16 responses (responserate 88.8%) from middle (12/16) and high (4/16) complexity hospitals. All the PED have a resuscitation room, and family presence is offered in 15 of them (in one hospital family presence is notallowed because of limited space). 2 PEDs have a written protocolabout family presence in the resuscitation room. Family membersare accompanied by a healthcare worker (11/16), but not continuously (7/16). One or two relatives are usually allowed to be present in the resuscitation room, for as long as they desire (13/16)or after initial stabilization (2/16). Two chief physicians reportedoccasional problems (family anxiety and aggressivity).Conclusions. Family presence in the resuscitation room is commonin Catalan PED, without significant related problems. However,some aspects should be improved, particularly related to writtenprotocols and accompaniment of family members. (AU)

Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

Testing Practices, Interpretation, and Diagnostic Evaluation of Iron Deficiency Anemia by US Primary Care Physicians.

Importance: Recognition of iron deficiency anemia (IDA) is important to initiate timely evaluation for gastrointestinal tract cancer. Retrospective studies have reported delays in diagnostic evaluation of IDA as a common factor associated with delayed diagnosis of colorectal cancer. Objective: To assess how US primary care physicians (PCPs) approach testing for anemia, interpret iron laboratory studies, and refer patients with IDA for gastrointestinal endoscopy. Design, Setting, and Participants: This survey study, conducted in August 2019, included members of the American College of Physicians Internal Medicine Insiders Panel, a nationally representative group of American College of Physicians membership, who self-identified as PCPs. Participants completed a vignette-based survey to assess practices related to screening for anemia, interpretation of laboratory-based iron studies, and appropriate diagnostic evaluation of IDA. Main Outcomes and Measures: Descriptive statistics based on survey responses were evaluated for frequency of anemia screening, correct interpretation of iron laboratory studies, and proportion of patients with new-onset IDA referred for gastrointestinal tract evaluation. Results: Of 631 PCPs who received an invitation to participate in the survey, 356 (56.4%) responded and 31 (4.9%) were excluded, for an adjusted eligible sample size of 600, yielding 325 completed surveys (response rate, 54.2%). Of the 325 participants who completed surveys, 180 (55.4%) were men; age of participants was not assessed. The mean (SD) duration of clinical experience was 19.8 (11.2) years (range, 1.0-45.0 years). A total of 250 participants (76.9%) screened at least some patients for anemia. Interpretation of iron studies was least accurate in a scenario of a borderline low ferritin level (40 ng/mL) with low transferrin saturation (2%); 86 participants (26.5%) incorrectly responded that this scenario did not indicate IDA, and 239 (73.5%) correctly identified this scenario as IDA. Of 312 participants, 170 (54.5%) recommended bidirectional endoscopy (upper endoscopy and colonoscopy) for new IDA for women aged 65 years; of 305 respondents, 168 (55.1%) recommended bidirectional endoscopy for men aged 65 years. Conclusions and Relevance: In this survey study, US PCPs' self-reported testing practices for anemia suggest overuse of screening laboratory tests, misinterpretation of iron studies, and underuse of bidirectional endoscopy for evaluation of new-onset IDA. Both misinterpretation of iron studies and underuse of bidirectional endoscopy can lead to delayed diagnosis of gastrointestinal tract cancers and warrant additional interventions.

Childhood chronic cough made easy: a simplified approach for the primary care setting.

Cough is a defense mechanism, but when it becomes persistent and troublesome, it must be carefully assessed. Chronic cough, that is, cough persisting for more than 4 weeks, has a proven negative impact on a child's quality of life; it interferes with daily activities, sleep, and schooling and may involve frequent health care visits and long-lasting treatments. Currently, there is a plethora of algorithms in the literature aiming to assist in the assessment of chronic cough in children; however, referring to complex flowcharts may be impractical for the usually busy primary care physician. Herein, we provide a simplified tool for the assessment of children with chronic cough in the primary care setting, presenting a basic approach to the most common causes along with hints to avoid common pitfalls in everyday practice. Finally, the most common clinical scenarios are analyzed, aiming to assist primary care physicians in providing the appropriate care to these patients.

Rational use of shoulder MRI in the private setting: specialist-ordered MRIs influence clinical management significantly more often than primary care physicians.

PURPOSE: The aim of this study was to determine the difference in proportion of shoulder MRIs that influence the management plan of shoulder patients based on whether MRI was ordered by a shoulder specialist, orthopaedic surgeon or primary care provider prior to referral to a specialist. METHODS: This observational analytical study was conducted in a private practice setting. Data were obtained from 153 MRIs performed on 151 patients. Seventy-seven MRIs were ordered by a specialist shoulder surgeon and 76 by a primary care provider (general practitioner, non-operative sports medicine physician or physiotherapist). RESULTS: Specialist-ordered MRIs influenced patient management significantly more often than primary care-ordered MRIs (82% vs. 22%, p < 0.001). Fifty-four percent of referral letters from primary care providers to the specialist did not have documentation of a physical examination, yet an MRI had been ordered. The most common diagnoses for primary care-ordered MRIs which did not have influence on patient management were subacromial bursitis and adhesive capsulitis. CONCLUSION: With less than 25% of primary care-ordered shoulder MRIs influencing clinical management, questions must be raised about the indications for MRI. Greater than 50% of referrals contained no documented physical examination, suggesting that MRI is being relied upon for assessment. If access to private MRI was to be rationalized, perhaps shoulder specialist-ordered CT and X-ray could be covered by insurance providers. Currently, they are not covered in our system, yet are more likely to influence clinical management than primary care-ordered MRIs, which are currently covered by insurance without restriction on indications.

Assessment of and Interventions for Women at High Risk for Breast or Ovarian Cancer: A Survey of Primary Care Physicians.

As clinical guidelines for cancer prevention refer individuals to primary care physicians (PCP) for risk assessment and clinical management, PCPs may be expected to play an increasing role in cancer prevention. It is crucial that PCPs are adequately supported to assess an individual's cancer risk and make appropriate recommendations. The objective of this study is to assess use, familiarity, attitude, and behaviors of PCPs regarding breast and ovarian cancer risk and prevention, to better understand the factors that influence their prescribing behaviors. We conducted a cross-sectional, web-based survey of PCPs in the United States, recruited from an opt-in healthcare provider panel. Invitations were sent in batches until the target sample size of 750 respondents (250 each for obstetrics/gynecology, internal medicine, and family medicine) was met. Self-reported use of breast/ovarian cancer risk assessments was low (34.7%-59.2%) compared with discussion of cancer family history (96.9%), breast exams (87.1%), and mammograms (92.8%). Although most respondents (48.0%-66.8%) were familiar with cancer prevention interventions, respondents who reported to be less familiar were more likely to report cautious attitudes. When presented with hypothetical cases depicting patients at different breast/ovarian cancer risks, up to 34.0% of respondents did not select any of the clinically recommended course(s) of action. This survey suggests that PCP use of breast/ovarian cancer risk assessment tools and ability to translate the perceived risks to clinical actions is variable. Improving implementation of cancer risk assessment and clinical management guidelines within primary care may be necessary to improve the appropriate prescribing of cancer prevention interventions.Prevention Relevance: Primary care physicians are becoming more involved in cancer prevention management, so it is important that cancer risk assessment and medical society guideline recommendations for cancer prevention are better integrated into primary care to improve appropriate prescribing of cancer prevention interventions and help reduce cancer risk.

Healthcare Provider Perspectives on Lowering Colorectal Cancer Screening Initiation Age to 45 Years: Results From a Survey of Clinicians in the U.S.

We conducted a survey of primary care clinicians and gastroenterologists (n = 938) between 11/06/19-12/06/19 to assess knowledge and attitudes regarding colorectal cancer screening. We assessed clinicians' attitudes toward lowering the colorectal cancer screening initiation age to 45 years, a topic of current debate. We also evaluated provider and practice characteristics associated with agreement. Only 38.1% of primary care clinicians endorsed colorectal cancer screening initiation at age 45 years, compared to 75.5% of gastroenterologists (p < .0001). Gastroenterologists were over 5 times more likely than primary care clinicians to endorse lowering the screening initiation age (OR = 5.30, 3.54-7.93). Other factors found to be independently associated with agreement with colorectal cancer screening initiation at age 45 years included seeing more than 25 patients per day (vs. fewer) and suburban (vs. urban) location. Results emphasize the need for collaboration between primary care clinicians and gastroenterologists to ensure that patients receive consistent messaging and evidence-based care.

Primary care physicians comprehensively manage acute pulmonary embolism without higher-level-of-care transfer: A report of two cases.

RATIONALE: The evidence for outpatient pulmonary embolism (PE) management apart from hospitalization is expanding. The availability and ease of direct oral anticoagulants have facilitated this transition. The literature, however, is sparse on the topic of comprehensive management of pulmonary embolism in the primary care clinic setting. As such, the role of the primary care physician in the complete diagnosis, risk stratification for outpatient eligibility, and initiation of treatment is unclear. CASE PRESENTATIONS: Case 1: A 33-year-old man with known heterozygous Factor V Leiden mutation and a remote history of deep vein thrombosis presented to his primary care physician's office with 2 days of mild pleuritic chest pain and a dry cough after a recent transcontinental flight. Case 2: A 48-year-old man with a complex medical history including recent transverse myelitis presented to his primary care family physician with dyspnea and pleuritic chest pain for 6 days. DIAGNOSIS: Case 1: Computed tomographic pulmonary angiography that same afternoon showed multiple bilateral segmental and subsegmental emboli as well as several small pulmonary infarcts. Case 2: The patient's D-dimer was elevated at 1148 ng/mL. His physician ordered a computed tomographic pulmonary angiography, performed that evening, which showed segmental and subsegmental PE. INTERVENTIONS: Both patients were contacted by their respective physicians shortly after their diagnoses and, in shared decision-making, opted for treatment at home with 5 days of enoxaparin followed by dabigatran. OUTCOMES: Neither patient developed recurrence nor complications in the subsequent 3 months. LESSONS: These cases, stratified as low risk using the American College of Chest Physicians criteria and the PE Severity Index, are among the first in the literature to illustrate comprehensive primary care-based outpatient PE management. Care was provided within an integrated delivery system with ready, timely access to laboratory, advanced radiology, and allied health services. This report sets the stage for investigating the public health implications of comprehensive primary care-based PE management, including cost-savings as well as enhanced patient follow-up and patient satisfaction.

Patient and caregiver perspectives on early identification for advance care planning in primary healthcare settings.

BACKGROUND: As part of a broader study to improve the capacity for advance care planning (ACP) in primary healthcare settings, the research team set out to develop and validate a computerized algorithm to help primary care physicians identify individuals at risk of death, and also carried out focus groups and interviews with relevant stakeholder groups. Interviews with patients and family caregivers were carried out in parallel to algorithm development and validation to examine (1) views on early identification of individuals at risk of deteriorating health or dying; (2) views on the use of a computerized algorithm for early identification; and (3) preferences and challenges for ACP. METHODS: Fourteen participants were recruited from two Canadian provinces. Participants included individuals aged 65 and older with declining health and self-identified caregivers of individuals aged 65 and older with declining health. Semi-structured interviews were conducted via telephone. A qualitative descriptive analytic approach was employed, which focused on summarizing and describing the informational contents of the data. RESULTS: Participants supported the early identification of patients at risk of deteriorating health or dying. Early identification was viewed as conducive to planning not only for death, but for the remainder of life. Participants were also supportive of the use of a computerized algorithm to assist with early identification, although limitations were recognized. While participants felt that having family physicians assume responsibility for early identification and ACP was appropriate, questions arose around feasibility, including whether family physicians have sufficient time for ACP. Preferences related to the content of and approach to ACP discussions were highly individualized. Required supports during ACP include informational and emotional supports. CONCLUSIONS: This work supports the role of primary care providers in the early identification of individuals at risk of deteriorating health or death and the process of ACP. To improve ACP capacity in primary healthcare settings, compensation systems for primary care providers should be adjusted to ensure appropriate compensation and to accommodate longer ACP appointments. Additional resources and more established links to community organizations and services will also be required to facilitate referrals to relevant community services as part of the ACP process.

Primary Care Provider Involvement in Thyroid Cancer Survivorship Care.

CONTEXT: While prior research has examined how primary care providers (PCPs) can care for breast and colon cancer survivors, little is known about their role in thyroid cancer survivorship. OBJECTIVE: To understand PCP involvement and confidence in thyroid cancer survivorship care. DESIGN/SETTING/PARTICIPANTS: We surveyed PCPs identified by thyroid cancer patients from the Georgia and LA SEER registries (n = 162, response rate 56%). PCPs reported their involvement in long-term surveillance and confidence in handling survivorship care (role of random thyroglobulin levels and neck ultrasound, and when to end long-term surveillance and refer back to the specialist). We examined: 1) PCP-reported factors associated with involvement using multivariable analyses; and 2) bivariate associations between involvement and confidence in handling survivorship care. MAIN OUTCOME MEASURES: PCP involvement (involved vs not involved) and confidence (high vs low). RESULTS: Many PCPs (76%) reported being involved in long-term surveillance. Involvement was greater among PCPs who noted clinical guidelines as the most influential source in guiding treatment (OR 4.29; 95% CI, 1.56-11.82). PCPs reporting high confidence in handling survivorship varied by aspects of care: refer patient to specialist (39%), role of neck ultrasound (36%) and random thyroglobulin levels (27%), and end long-term surveillance (14%). PCPs reporting involvement were more likely to report high confidence in discussing the role of random thyroglobulin levels (33.3% vs 7.9% not involved; P < 0.01). CONCLUSIONS: While PCPs reported being involved in long-term surveillance, gaps remain in their confidence in handling survivorship care. Thyroid cancer survivorship guidelines that delineate PCP roles present one opportunity to increase confidence about their participation.

Assessment of Physician Priorities in Delivery of Preventive Care.

Importance: Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services. Objective: To understand primary care physicians' prioritization of preventive services. Design, Setting, and Participants: This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019. Exposures: A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services. Main Outcomes and Measures: Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model. Results: Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model. Conclusions and Relevance: In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

Diabetes care knowledge and practice among primary care physicians in Southeast Nigeria: a cross-sectional study.

BACKGROUND: Due to the perennial shortage of diabetes specialists, primary care physicians (PCPs) constitute the largest diabetes care manpower in Nigeria. However, the competence of the PCPs to undertake this task is not known. This study was aimed at evaluating diabetes care knowledge and practice among PCPs in Southeastern part of Nigeria. METHODS: This was a cross-sectional study among PCPs in Southeastern Nigeria. Diabetes care knowledge and practices were evaluated using a structured self administered questionnaire. RESULTS: A total of 64 PCPs with mean duration of practice of 17.3 ± 11.6 years completed the study. 65.6% were in private practice and 50% attended to between 11 and 20 persons living with diabetes (PLWD) weekly. Majority (78.1%) had not participated in any diabetes training since graduation from medical school and 79.9% were not aware of any diabetes clinical practice guideline. The PCPs had adequate knowledge of classical symptoms of diabetes. However, they had very poor knowledge of glycemic thresholds for diagnosis of diabetes which was 26.6, 45.3 and 10.9% for fasting blood glucose (FBG), random blood glucose (RBG) and glycated hemoglobin (A1c) respectively. We observed serious gaps in diabetes care practice such that only 18.8% of the respondents performed foot examination on newly diagnosed PLWD while 28.1 and 39.1% provided counseling on foot care and hypoglycemia respectively. Annual comprehensive foot examination was conducted by only 12.5%, none of the physicians ever screened for microalbuminuria and only 21.9% conducted annual dilated eye examination. Majority (57.8%) rated their confidence in prescribing insulin as "low" and only 23.4% had ever prescribed outpatient insulin for type 2 diabetes in their practice. Glycemic monitoring was largely limited to FBG and only 17.2% monitored A1c. Duration of practice more than 10 years (OR 10.1; P 0.034) and non participation in diabetes training (OR 6.5; P 0.027) were significant predictors of poor diabetes care knowledge. CONCLUSION: Diabetes care knowledge and practice were poor among PCPs in Southeast Nigeria. There is an urgent need to improve their capacity to provide diabetes care through periodic training.

Person-centred and efficient care delivery for high-need, high-cost patients: primary care professionals' experiences.

BACKGROUND: High-need, high-cost (HNHC) patients, who typically have complex and long-term care demands, contribute considerably to the high work pressure of primary care professionals (PCPs). To improve patient as well as provider experiences, it is crucial to take into account the PCPs' perspective in designing health care strategies for HNHC patients. Therefore, this study aimed to create insight into PCPs' experienced barriers and possible solutions with regards to person-centred, efficient care delivery to HNHC patients. METHODS: We conducted a qualitative study using focus group interviews with PCPs at a Dutch primary care group. A semi-structured interview guide was developed for the interviews. Qualitative content analysis was employed deductively by means of a categorisation matrix. The matrix was based on the components retrieved from the SELFIE framework for integrated care for multi-morbidity. RESULTS: Forty-two PCPs participated in five focus group interviews. Discussed barriers and solutions were related to the core of the SELFIE framework (i.e. the individual and environment), and particularly four of the six health system components in the framework: service delivery, leadership & governance, workforce, and technologies & medical products. Many discussed barriers revolved around the complex biopsychosocial needs of HNHC patients: PCPs reported a lack of time (service delivery), insufficiently skilled PCPs (workforce), and inefficient patient information retrieval and sharing (technologies & medical products) as barriers to adequately meet the biopsychosocial needs of HNHC patients. CONCLUSIONS: This qualitative study suggests that primary care is currently insufficiently equipped to accommodate the complex biopsychosocial needs of HNHC patients. Therefore, it is firstly important to strengthen primary care internally, taking into account the experienced lack of time, the insufficient number of equipped PCPs and lack of inter-professional information retrieval and sharing. Secondly, PCPs should be supported in cooperating and communicating more efficiently with health services outside primary care to adequately deliver person-centred, efficient care. As a prerequisite, it is crucial to direct policy efforts at the design of a strong system of social and community services. In terms of future research, it is important to assess the feasibility and effects of re-designing primary care based on the provided recommendations.

Do Polish primary care physicians meet the expectations of their patients? An analysis of Polish QUALICOPC data.

BACKGROUND: Meeting the expectations of patients is one of the most crucial criteria when assessing the quality of a healthcare system. This study aimed to compare the expectations and experiences of patients of primary care in Poland and to identify key patient characteristics affecting these outlooks. METHODS: The study was performed within the framework of the international Quality and Costs of Primary Care in Europe (QUALICOPC) cross-sectional, questionnaire-based study. In Poland, a nationally representative sample of 2218 patients were recruited to take part in the study. As a study tool, we used data from two of four QUALICOPC questionnaires: "Patient Experience" and "Patient Values". RESULTS: Patients' expectations were fulfilled in all study areas: accessibility, continuity, quality of care, and equity. We observed that the highest-met expectations indexes were in the area of quality of care, while the lowest, but still with a positive value, were in the area of accessibility. Patient-doctor communication was the aspect most valued by study participants. Elements of the patient's own level of engagement during the consultation were ranked as less essential. CONCLUSIONS: Comparing patient experiences to their values allows us to identify areas for improvement that are prioritized by patients. Accessibility is recognized as the most important area by Polish patients, simultaneously showing the highest level of patient-perceived improvement potential. Interpersonal care is another domain, in which the needs of patients are satisfied but are also relatively high. Strong clinician-patient relationships seem to be a priority in patients' expectations. The continuous efforts in interpersonal communication skills training for primary care physicians should be upgraded.

Quality of primary health care in China: challenges and recommendations.

China has substantially increased financial investment and introduced favourable policies for strengthening its primary health care system with core responsibilities in preventing and managing chronic diseases such as hypertension and emerging infectious diseases such as coronavirus disease 2019 (COVID-19). However, widespread gaps in the quality of primary health care still exist. In this Review, we aim to identify the causes for this poor quality, and provide policy recommendations. System challenges include: the suboptimal education and training of primary health-care practitioners, a fee-for-service payment system that incentivises testing and treatments over prevention, fragmentation of clinical care and public health service, and insufficient continuity of care throughout the entire health-care system. The following recommendations merit consideration: (1) enhancement of the quality of training for primary health-care physicians, (2) establishment of performance accountability to incentivise high-quality and high-value care; (3) integration of clinical care with the basic public health services, and (4) strengthening of the coordination between primary health-care institutions and hospitals. Additionally, China should consider modernising its primary health-care system through the establishment of a learning health system built on digital data and innovative technologies.

[INR and vitamin K antagonists management by the primary care physicians in Normandy]. / Gestion de l'INR et des antivitamines K par les médecins généralistes de Normandie.

The main objective of our study was to carry out a statement of the knowledge and the management of the VKA by the General Practitioners (GPs) of Normandy and to evaluate their experience of the use of DOA with a questionnaire; 471 of the 1951 GPs requested responded. When the INR was stable in a patient affected with atrial fibrillation, the GPs participating dosed it again 4 weeks later, modified the dosage when the INR was below 1.9 or upper 3.2. The risk of stroke was overestimated to 6.2% per year with fluindione and to 31.5% without curative anticoagulation. The mean TTR was overstated to 84%. When the INR was at 4.4, the risk of serious cerebral bleeding was overestimated at 12.4%. 80.26% of the GPs skipped the next dose and 11.25% controlled the INR the day after. So, few GPs used the HAS protocol. After the INR decreased to 3.6, the GPs diminished the dose of 14.62%. 70% of the GPs, responded using only their experience for AVK management. Fluindione was the most to use VKA by 52.7% of them although 24.42% thought it was the most effective. The majority of GPs thought the DOA were a least as effective than the VKA, without being responsible of more bleeding (77.92%) and improved the quality of life of the patients (88.54%). Although the DOA's prescriptions increase, the improvement of the VKA management have to stay a concern for the GPs.

Primary health care physicians' knowledge and adherence regarding hypertension management guidelines in southwest of Saudi Arabia.

To measure Primary Health Care physicians' knowledge of and adherence to the Saudi Hypertension Management Guidelines (SHMGs) in Southwest of Saudi Arabia.This study was a cross-sectional investigation where data was collected via a self-administered questionnaire. The demographics of the physicians, data related to the source of the guidelines for hypertension management, knowledge about the SHMGs and physicians' adherence to the SHMG were collected. Student's t test was used to assess the presence of any statistical difference between the level of knowledge and adherence according to the study's measured variables.A total of 316 physicians participated in this investigation, representing 65% of all the PHC physicians in the Jazan region. The number of correct answers measuring knowledge about various topics varied between 18% and 94% with a mean overall score of 7.9/16. The number of reported practices adherent to the guidelines varied between 2% and 97%, and the mean overall score was 7.2/11. Receiving hypertension management guidelines from the Directory of Health was statistically associated with a higher level of knowledge (P value < .05). Undergoing clinical training for hypertension management and seeing fewer numbers of patients on a daily basis was associated with a statistically higher level of adherence to the guidelines (P value < .05).Improper distribution of guidelines, lack of continuous clinical training, negative attitude of physicians toward guidelines and large number of patients seen by physicians are likely to hinder translating guidelines to actual clinical practice.

Virginity testing: recommendations for primary care physicians in Europe and North America.

Virginity testing is a complex, culturally mediated practice that is poorly understood by Western clinicians. While advocating for global elimination of the practice of virginity testing as a human rights violation, clinical practice is often more complicated and ethically nuanced, and the clinician must act in the best interest of her patient. Upholding human rights does not have to be incompatible with providing a needed service to a patient, which should never include an invasive exam if not medically necessary, but should include education and safety assessments.