A descriptive study of pain treatment and its follow-up in primary care of elderly patients after orthopaedic care

Objective Primary care plays a central role in diagnosing dementia and coordinating and providing care. This study explores how older people with dementia and their family caregivers experience the process from diagnosis to follow-up in primary care, what support is needed, what works well and what could be improved. Design Semi-structured interviews were conducted with four people with dementia and 11 family caregivers in Stockholm, Sweden. Data were analyzed with inductive thematic analysis. Results Four themes were identified: Seamless assessment – from primary care to memory clinic, describes the transition from primary care to memory clinics, where empathy and professionalism are crucial to prevent feelings of failure. After diagnosis – a no man’s land, highlights a communication gap between memory clinics and primary care that leaves informants feeling abandoned and causes emotional distress and isolation. Follow-up in a deficient primary care, underscores the importance of having ‘a single point of entry’ for coordinated support and a primary care provider with expertise in dementia. Embracing life with the diagnosis, emphasizes the need for guidance from a dedicated dementia team to manage progression. Conclusion People with dementia and their caregivers felt that primary care often failed to meet their needs due to limited accessibility, poor coordination, and a lack of dementia-specific expertise. Strengthening the role of general practitioners, introducing liaison nurses, and enhancing collaboration with municipal services could improve continuity, navigation, and support. These findings underscore the need for Swedish health care policy to promote sustainable, person-centered dementia care models within primary care.

Background: An unprecedented rise in the prevalence of low-risk well-differentiated thyroid cancer (TC) has been reported in several countries, which is partly due to an increased utility of sensitive imaging techniques. The outcome of these cancers has generally remained excellent and the overall 5-year survival is almost 100%. However, the extended follow-up strategy for these patients remains unclear and while the initial management is done in specialist centres some experts opt to follow them on a long-term basis while others discharge them to primary care after the initial management. The effectiveness of one strategy versus the other has not been studied. Methods: We conducted a real-world comparison to assess the outcome of low-risk TC (AJCC stage I) with undetectable thyroglobulin (TG) 2 years after radio­iodine (I-131) therapy. The outcome from Halifax (NS, Canada) and London (ON, Canada), where all TC patients are routinely followed by the tertiary care team, was compared with that from Edmonton (AB, Canada), where patients are routinely discharged to primary care. Results: All patients were diagnosed between January 1, 2006, and December 31, 2011. The mean follow-up in primary care after discharge was 62.2 months and in tertiary care it was 64.6 months (p = 0.43). Rates of recurrence were similar in both groups, i.e., 1.1% in primary care and 1.3% in tertiary care (p = 0.69). Ultrasound surveillance was conducted in 56.5% of the patients in primary care and 52.6% of the tertiary care group (p = 0.26). The rate of annual unstimulated TG testing per patient was 0.58 (range 0–14) in primary care and 0.96 (range 0–6) in tertiary care (p = 0.06). More patients in primary care (86%) than in tertiary care (29.9%) consistently had thyroid-stimulating hormone levels within the target range (p < 0.001). The mean healthcare cost, based on a single follow-up visit with a blood test and ultrasound in the primary care group was CAD 118.01 and in the tertiary care group it was CAD 164.12. Conclusion: Our study shows that extended follow-up of low-risk TC patients is perfectly feasible in primary care and provides significant economic benefit for the healthcare system.

Objective Gestational diabetes mellitus (GDM) is an established risk factor for developing type 2 diabetes mellitus (T2DM) that is possible to prevent by systematic follow-up and preventive measures. The aim of this study was to examine whether women with previous GDM were offered follow-up in primary care, according to Swedish national guidelines. Design Retrospective review of electronic medical records. Setting Primary care in southern Sweden, Skåne county. Subjects Women who received a GDM diagnosis in 2018 at the Endocrinology department, Skåne University Hospital in Lund. The study population consisted of a total number of 161 patients, whereof 83 patients were included. Main outcome measures Whether primary care offered follow-up for T2DM after GDM and if any communication took place between secondary and primary care. Furthermore, it was examined whether the quality of the follow-up was in accordance with the national guidelines. Results Of the study population, a total of 29% (n = 24) had been followed-up by primary care. In 55% (n = 46) of the cases, there was no communication between secondary and primary care. Plasma glucose was checked in all (n = 20) cases where follow-up could be evaluated. Conversations about lifestyle habits took place in 70% (n = 14) of the cases. Weight and risk factors for cardiovascular disease were controlled in less than half (n = 9) of the patients. Lifestyle advice was offered in two cases and in 24% (n = 20) of the cases an annual check-up was planned. Conclusions The follow-up of women with previous GDM in primary care in southern Sweden was lacking in seven out of 10 cases and showed great potential for improvement. Key Points Gestational diabetes is an established risk factor for developing type 2 diabetes. Earlier research has recognized that risk reduction is possible by systematic follow-up and preventive measures, but the extent of follow-up in primary care in southern Sweden remains unknown. This study demonstrates a lack of follow-up according to national guidelines for women with previous gestational diabetes in primary care in southern Sweden. There is great potential to improve the care of these patients with relatively simple means.

Background and Aims Previous studies indicate that 40% of patients with advanced chronic kidney disease (CKD), a proportion that increases with age, are managed in primary care despite meeting referral criteria. Older patients are more likely to have stable kidney function or may find hospital visits burdensome. We aimed to describe the proportion of older patients with advanced CKD receiving guideline-adherent care in primary and nephrology care, and describe how clinical characteristics and social determinants of health are associated with guideline adherence. Ultimately, we aim to assess whether primary care can be a suitable setting for managing subgroups of older CKD patients and adequately addressing their needs. Method This dynamic, population-based cohort study, used routine health care data of general practitioner (GP) practices and hospitals within the Extramural Leiden University Medical Center Academic Network (ELAN), linked to individual-level registry data from Statistics Netherlands. We included adults aged ≥65 years with incident or prevalent CKD (eGFR ≤30 ml/min/1.73 m2, confirmed by two measurements taken ≥90 days apart) between 2015 and 2023. Follow-up continued until death, kidney replacement therapy initiation, end of study (01-01-2023) or deregistration from a participating GP. Patients were categorized as managed in primary or nephrology care based on diagnosis-treatment combinations. We used descriptive statistics to assess the proportion of patients in each care setting and adherence to CKD guidelines, stratified by clinical characteristics and social determinants of health. Results We enrolled 1647 patients, with a median follow-up of 2.25 years; 1194 were managed exclusively in primary care and 453 (part of) follow-up in nephrology care. The mean age was 82 ± 9 years (83 ± 9 in primary care vs 79 ± 8 in nephrology care), with a median eGFR of 26 [22; 28] ml/min/1.73 m2. Of these, 973 patients had at least 15 months of follow-up in primary or nephrology care, allowing for guideline-adherence assessment. Patients with shorter follow-up were more likely to be female (55% vs 46%), older (83 ± 9 vs 81 ± 8 years), and classified as frail (30% vs 21%). Differences in adherence to quality indicators were observed between the care settings (see Fig. 1), with nephrology care showing higher adherence to kidney function monitoring (≥2 measurements per year: 68% vs 83%), annual testing of albuminuria (45% vs 65%), hemoglobin (74% vs 87%), LDL (49% vs 60%), and HbA1c (50% vs 65%), as well as higher prescription rates of renin-angiotensin-aldosterone system inhibitor (RAASi) (72% vs 77%). Annual blood pressure measurement and avoidance of NSAIDs were similar across care settings (60% vs 57% and 94% vs 94%, respectively). In both care settings, we observed lower guideline adherence for women across all indicators and a decrease in adherence with age, except for eGFR monitoring in nephrology care and blood pressure monitoring in both care settings. In primary care, patients with diabetes mellitus were more likely to receive guideline-adherent care compared to those without diabetes, with a similar trend observed for patients with hypertension, albeit to a lesser extent. No differences were found between ethnic and socioeconomic groups, or in relation to eGFR and frailty. Conclusion The majority of older patients with advanced CKD are managed in primary care, where guideline adherence is generally acceptable, but less strictly followed than in nephrology care. Among patients with diabetes or hypertension, who are treated in structured care pathways, adherence is higher, suggesting that similar proactive and structured approaches could enhance CKD care. Given the life expectancy and treatment goals of older patients, CKD management should prioritize individual needs and quality of life over strict guideline adherence. Future research should explore whether outcomes, including CKD progression, quality of life and healthcare costs, differ between patients managed in primary and nephrology care.

Factors Associated With Primary Care Clinicians' Choice of a Watchful Waiting Approach to Managing Depression

Ischaemic heart disease is the commonest cause of mortality in the United Kingdom. The objective of this study was to assess the management of patients with ischaemic heart disease in primary care, focusing particularly on the management of hypercholesterolaemia. A cross-sectional survey was carried out of the clinical records of patients aged 25-74 years with confirmed ischaemic heart disease in six general practices (total list size 56 600). Recording of risk factors varied from 97 per cent for blood pressure to 73 per cent for cholesterol measurement. Seventy-two per cent of the patients had adequate blood pressure control, based on their last recorded blood pressure. Sixty-one per cent (267) were known to be taking aspirin daily and 29 per cent (125) had undergone revascularization treatment. Sixty-eight per cent (296) of the patients had pre-treatment cholesterol levels of 5.5 mmol/l or greater and 34 per cent (147) were currently taking lipid lowering drugs. Statins were the most commonly used cholesterol lowering agents and were being taken by 30 per cent (131) of the patients. Patients who had undergone revascularization treatment had levels of recording of risk factors similar to other patients with ischaemic heart disease but were more likely to be taking daily aspirin (71 per cent versus 57 per cent, relative risk 1.24, 95 per cent confidence intervals (CI) 1.07-1.44). The mean pre-treatment cholesterol was 6.49mmol/l and the mean post-treatment cholesterol 5.80 mmol/l (difference 0.69 mmol/l, 95 per cent CI 0.55-0.84 mmol/l). Systematic searches of computerized and paper medical records can identify subgroups of patients who will benefit from continuing follow-up in primary care. The results of this study suggest that ischaemic heart disease remains an area where there is scope to improve the management of patients in primary care. Considerable effort will be required from the members of the primary health care team to achieve this objective, particularly in the areas of computerized data collection and in the identification and recall of patients.

BackgroundWomen with gestational diabetes mellitus (GDM) have a tenfold increased risk of developing diabetes, and a high risk of recurrent GDM. Endorsing the life-course approach, aiming to prevent disease and promote health across generations, the Norwegian GDM guideline recommends follow-up in primary care after delivery, with information on the increased risks, lifestyle counselling, and annual diabetes screening. Few reports exist on Norwegian women’s experiences of GDM follow-up.AimTo elucidate women’s experiences with follow-up of GDM in pregnancy and after delivery, and to explore their attitudes to diabetes risk and motivation for lifestyle changes.Design & settingQualitative study in primary care in the region of Stavanger, Norway.MethodSemi-structured in-depth interviews were conducted 24–30 months after delivery with 14 women aged 28–44 years, with a history of GDM. Data were analysed thematically.ResultsMost women were satisfied with the follow-up during pregnancy; however, only two women were followed-up according to the guideline after delivery. In most encounters with GPs after delivery, GDM was not mentioned. To continue the healthy lifestyle adopted in pregnancy, awareness of future risk was a motivational factor, and the women asked for tailored information on individual risk and improved support. The main themes emerging from the analysis were as follows: stigma and shame; uncertainty; gaining control and finding balance; and a need for support to sustain change.ConclusionWomen experienced a lack of support for GDM in Norwegian primary care after delivery. To maintain a healthy lifestyle, women suggested being given tailored information and improved support.

<h3>Objective</h3> To examine whether early follow-up with primary care or neurology is associated with lower all-cause readmissions within 30 and 90 days after acute ischemic stroke admission. <h3>Methods</h3> We performed a retrospective cohort study of patients who were discharged home after acute ischemic stroke, identified by ICD-9 and ICD-10 codes, using PharMetrics, a nationally representative claims database of insured Americans from 2009 to 2015. The primary predictor was outpatient primary care or neurology follow-up within 30 and 90 days of discharge, and the primary outcome was all-cause 30- and 90-day readmissions. Multivariable Cox models were used with primary care and neurology visits specified as time-dependent covariates, with adjustment for patient demographics, comorbid conditions, and stroke severity measures. <h3>Results</h3> The cohort included 14,630 patients. Readmissions within 30 days occurred in 7.3% of patients, and readmissions within 90 days occurred in 13.7% of patients. By 30 days, 59.3% had a primary care visit, and 24.4% had a neurology visit. Primary care follow-up was associated with reduced 30-day readmissions (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.72–0.98). Primary care follow-up before 90 days did not reach significance (HR 0.92, 95% CI 0.83–1.03). Neurology follow-up was not associated with reduced readmissions within 30 or 90 days (HR 1.05, 95% CI; HR 1.00, 95% CI, respectively). <h3>Conclusion</h3> Early outpatient follow-up with primary care is associated with a reduction in 30-day hospital readmissions. Early outpatient follow-up may represent an important opportunity for intervention after acute stroke admissions.

To examine whether early follow-up with primary care or neurology is associated with lower all-cause readmissions within 30 and 90 days after acute ischemic stroke admission. We performed a retrospective cohort study of patients who were discharged home after acute ischemic stroke, identified by ICD-9 and ICD-10 codes, using PharMetrics, a nationally representative claims database of insured Americans from 2009 to 2015. The primary predictor was outpatient primary care or neurology follow-up within 30 and 90 days of discharge, and the primary outcome was all-cause 30- and 90-day readmissions. Multivariable Cox models were used with primary care and neurology visits specified as time-dependent covariates, with adjustment for patient demographics, comorbid conditions, and stroke severity measures. The cohort included 14,630 patients. Readmissions within 30 days occurred in 7.3% of patients, and readmissions within 90 days occurred in 13.7% of patients. By 30 days, 59.3% had a primary care visit, and 24.4% had a neurology visit. Primary care follow-up was associated with reduced 30-day readmissions (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.72-0.98). Primary care follow-up before 90 days did not reach significance (HR 0.92, 95% CI 0.83-1.03). Neurology follow-up was not associated with reduced readmissions within 30 or 90 days (HR 1.05, 95% CI; HR 1.00, 95% CI, respectively). Early outpatient follow-up with primary care is associated with a reduction in 30-day hospital readmissions. Early outpatient follow-up may represent an important opportunity for intervention after acute stroke admissions.

Referral of Discharged Emergency Department Patients to Primary and Specialty Care Follow-up

This study investigated thyroid cancer (TC) survivors' perceived satisfaction with and perceptions of survivorship care follow-up options. Well-differentiated TC (WDTC) patients receiving follow-up care at an academic cancer centre completed a questionnaire assessing perceived satisfaction with follow-up care involving different clinicians and mediated by the Internet (email or videoconference) and their perceptions of these follow-up options. We examined associations between patient characteristics and perceived satisfaction with follow-up care options. Qualitative responses were analysed using conventional content analysis. Two hundred and two respondents completed the questionnaire (80 % response rate). The majority strongly agreed or agreed that they would be satisfied with specialist (surgeon, oncologist, or endocrinologist) follow-up (90.6 %) or a shared-care model that integrates specialists with primary care (67.5 %). One third (32 %) would be satisfied with video-based and 26 % with email-based specialist follow-up, 15 % with primary care alone. Longer time since diagnosis and health-related Internet use were associated with higher perceived satisfaction with Internet-based follow-up. Younger age was associated with higher perceived satisfaction with primary care follow-up. Qualitative responses (n = 145) revealed that survivors need reassurance they are receiving adequate care, regardless of the model or medium. Enablers to primary care and Internet-based follow-up are discussed. WDTC survivors want specialists involved in their follow-up. A specialist/primary care shared-care approach appears to be a suitable alternative to specialist-led follow-up for TC survivors. Internet-based visits could address some aspects of follow-up care for some WDTC survivors. Future work should examine patient and provider requirements for shared, multi-modal survivorship care.

Ictus isquémico y factores de riesgo vascular en el adulto joven y el adulto mayor. Estudio retrospectivo de base comunitaria (2011-2020)

BackgroundSouth Asians with asthma experience much higher morbidity than whites with asthma in the UK. They also experience worse follow-up in primary care after hospitalisation compared to the white population....

Improving Quality of Asthma Care After Emergency Department Discharge: Evidence Before Action

Little or no knowledge is available about which service is offered to patients with heart failure in primary care. To describe nurse-led follow-up of patients with heart failure in primary care in Sweden. A questionnaire was sent to all primary health care centres in Sweden and 610 of 939 centres returned the questionnaire. Special nurses had designated time for follow-up of heart failure patients at 18% (n=111) of the centres, compared to 93% and 78% for diabetes and obstructive lung disease. Centres with nurse-led follow-up of heart failure patients more frequently provided heart failure information (p<0.001), had more doctors interested in heart failure (p<0.001), more often had special care programmes (p<0.001) and had more co-operation with the hospitals around patients with heart failure (p<0.01), compared to centres without such follow-up (n=499). In primary care in Sweden, nurse-led follow-up is uncommon for patients with heart failure, despite being common for patients with diabetes and obstructive pulmonary disease. To improve this situation in primary care, an increased number of specially trained nurses is needed, together with further research to ensure a high quality follow-up in primary care.