Orthopedic Hip Injuries Encountered in the Primary Care Setting

Using the PHQ-9 for Depression Screening and Treatment Monitoring for Chinese Americans in Primary Care

Emotions and medicine. What do patients expect from their physicians?

Organization of Diabetes Care

Depression is a major public health problem, which is predicted to be second only to cardiovascular disease as the leading cause of disease-related disability worldwide by 2020.[1][1] It is already the leading cause of disease-related disability among women, and in most countries, the prevalence of

Conservative management of adults with stage 5 CKD (eGFR<15 ml/min per 1.73 m2) is increasingly being provided in the primary care setting. We aimed to examine perceived barriers and facilitators for conservative management of older adults by primary care physicians. In 2015, we conducted a cross-sectional, population-based survey of all primary care physicians in Alberta, Canada. Eligible participants had experience caring for adults ages ≥75 years old with stage 5 CKD not planning on initiating dialysis. Questionnaire items were on the basis of a qualitative descriptive study informed by the Behavior Change Wheel and tested for face and content validity. Physicians were contacted via postal mail and/or fax on the basis of a modified Dillman method. Four hundred nine eligible primary care physicians completed the questionnaire (9.6% response rate). The majority of respondents were men (61.6%), were ages 40-60 years old (62.6%), and practiced in a large/medium population center (68.0%). The most common barrier to providing conservative care in the primary care setting was the inability to access support to maintain patients in the home setting (39.1% of respondents; 95% confidence interval, 34.6% to 43.6%). The second most common barrier was working with nonphysician providers with limited kidney-specific clinical expertise (32.3%; 95% confidence interval, 28.0% to 36.7%). Primary care physicians indicated that the two most common strategies that would enhance their ability to provide conservative management would be the ability to use the telephone to contact a nephrologist or clinical staff from the conservative care clinic (86.9%; 95% confidence interval, 83.7% to 90.0% and 85.6%; 95% confidence interval, 82.4% to 88.9%, respectively). We identified important areas to inform clinical programs to reduce barriers and enhance facilitators to improve primary care physicians' provision of conservative kidney care. In particular, primary care physicians require additional resources for maintaining patients in their home and telephone access to nephrologists and conservative care specialists.

Skin cancer control in the primary care setting: are we making any progress?

Introduction:Transition of care from hospital to primary care has been associated with increased medication errors. This review article aims to examine the existing evidence on interventions to reduce medication discrepancies or errors in primary or ambulatory care setting during care transition from hospital to primary care.Methods:We systematically reviewed the articles in primary or ambulatory care setting on patients with care transition that involved medication safety, discrepancy, or error as outcome assessment. Primary research articles were selected. Interventions in nursing homes or long-term care facilities were excluded from the review.Results:We found 6 articles that met the inclusion criteria and 4 are prospective cohort study. The key players were pharmacists, nurse, and primary care physician. The interventions included care communication, medication reconciliation or review, and clarifying medication-related problems.Conclusion:There is evidence that interventions in primary care setting reduce medication discrepancies on patients with the transition of care from hospital to primary care setting. Only one randomized trial involving pharmacist-led medication reconciliation was done in an outpatient setting. More good-quality randomized controlled trials should be carried out to confirm the evidence.

This article reports on the outcome of an expert consensus meeting in August 2005 sponsored by the National Institute of Mental Health, which assembled 15 senior researchers with a background in treatment and services research with the Hispanic population. The purpose of the workshop was to identify research issues most pertinent for improving quality and effectiveness of treatment for Hispanics experiencing persistent mental disorders, defined as psychiatric syndromes that are of sufficient severity and duration to cause long-term impairment in social and occupational functioning and significant disability. The spectrum of ideas and recommendations advanced at the one-day meeting was wide and overlapping; therefore, the rich body of material was subsequently organized into five topics: diagnosis, quality of care and culturally appropriate services, psychosocial intervention development, psychopharmacologic interventions, and access to care. Although the authors recognize that the review was broad and the agenda presented is ambitious and in many instances generalizes to priority areas in overall mental health services and treatment research, the recommendations are intended to stimulate research for addressing the unique problems and research deficits that affect Hispanics with persistent mental disorders.

Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper

The World Health Organization (WHO) is revising the ICD-10 classification of mental and behavioural disorders, under the leadership of the Department of Mental Health and Substance Abuse and within the framework of the overall revision framework as directed by the World Health Assembly. This article describes WHO's perspective and priorities for mental and behavioural disorders classification in ICD-11, based on the recommendations of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders. The WHO considers that the classification should be developed in consultation with stakeholders, which include WHO member countries, multidisciplinary health professionals, and users of mental health services and their families. Attention to the cultural framework must be a key element in defining future classification concepts. Uses of the ICD that must be considered include clinical applications, research, teaching and training, health statistics, and public health. The Advisory Group has determined that the current revision represents a particular opportunity to improve the classification's clinical utility, particularly in global primary care settings where there is the greatest opportunity to identify people who need mental health treatment. Based on WHO's mission and constitution, the usefulness of the classification in helping WHO member countries, particularly low- and middle-income countries, to reduce the disease burden associated with mental disorders is among the highest priorities for the revision. This article describes the foundation provided by the recommendations of the Advisory Group for the current phase of work.

In spite of public education campaigns, patients with transient ischemic attack still present to primary care where accurate recognition of transient ischemic attack is essential so that specialist referral can be expedited to reduce stroke risk. The complex task of diagnosing transient ischemic attack is challenging in time-limited settings in primary care yet the potential for a transient ischemic attack recognition tool to improve diagnosis has not been determined. We set out to examine the potential utility in primary care of the only existing transient ischemic attack recognition tool. All primary care referrals with suspected transient ischemic attack from a total population of 91,000 people were analyzed over a four-year period from 2002 to 2006. Clinical and research records from the transient ischemic attack clinic and consultation notes and referral letters from primary care physicians were used to populate the Dawson recognition score. Of 513 referrals, 209 (47%) had a clinic confirmed diagnosis of transient ischemic attack. Agreement between primary care assessments and specialist assessments was greater for speech disturbance (kappa 0·68) than for unilateral facial weakness (0·58) and unilateral limb weakness (0·51). The Dawson score had greater accuracy in diagnosing all transient ischemic attack in specialist assessments than in primary care assessments (c statistics 0·80 vs. 0·70, P < 0·0001) and performed particularly poorly in primary care for detecting posterior circulation territory transient ischemic attack with a c statistic (95% confidence interval) of 0·52 (0·43-0·61). The Dawson transient ischemic attack recognition score is less accurate in primary care than in its derivation setting of specialist care. Improving the recognition of transient ischemic attack by providers of first contact health care requires derivation of rules in the clinical setting in which they are to be used.

This study examined the association between provider specialty and guideline-concordant care after the initiation of antidepressant treatment. Medical and prescription claims were analyzed from adults newly diagnosed as having major depressive disorder who initiated antidepressant treatment. Follow-up visits during the first 90 days after the index prescription were identified, and an indicator for receipt of guideline-concordant care (three or more visits) was created. Logistic regression models were used, and propensity score matching techniques were applied. Sensitivity analyses were conducted to investigate how results differed by varying the approach to identify follow-up visits. The study included 4,102 patients, and only 31% received guideline-concordant follow-up visits. Patients receiving their initial prescription from psychiatrists were nearly five times as likely as patients receiving their initial prescription from primary care providers to receive guideline-concordant follow-up care (odds ratio=4.6, 95% confidence interval=3.9-5.4). Routine care for antidepressant management falls short of guideline recommendations, especially in primary care.

Changes in medicine domestically and globally are transforming primary care in the United States. Many have suggested that primary care is in crisis or at least at a crossroads in the United States. The Annals of Internal Medicine recently devoted much of one issue to this topic.1 Primary care for children and adolescents, however, was not addressed specifically. This article focuses on pediatrics and identifies potential roles and new models for primary care pediatrics. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 Starfield3 has defined 4 attributes of primary care including first-contact care, longitudinality, comprehensiveness, and coordination. September 11, 2001, the anthrax scare, and emerging threats such as severe acute respiratory syndrome (SARS) have brought a new focus on the importance of individual-level contacts in addressing population-level threats. Before these world events, however, primary care pediatrics was already grappling with its identity and responding to significant changes in medical systems, science, and family needs. The pace and scope of these changes are such that primary care pediatricians of the future will not be performing the same role as today. Historically, American medicine has tended to be reactive rather than proactive in defining its roles in society. However, dynamic change demands collective reflection; it is time to be proactive in assessing the needs of patients, exploring potential roles as health care providers, and developing the mechanisms to redefine the primary care pediatrician of the future. Projecting future trends requires reflection on the history of the profession of preventive pediatrics. In the 1800s, few physicians in the United States routinely … Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University Department of Pediatrics, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu

A Path Toward Improving Nonalcoholic Fatty Liver Disease Care Among Non-hepatologists

Opioid use disorder (OUD) is commonly treated in specialized care settings with long-acting opioid agonists, also known as opioid agonist therapy, or OAT. Despite the rise in opioid use globally and evidence for a 50% reduction in mortality when OAT is employed, the proportion of people with OUD receiving OAT remains small. One initiative to improve the access and uptake of OAT could be to offer OAT in a primary care setting; primary care clinics are more numerous, might reduce the visibility and potential stigma of receiving treatment for OUD, and may facilitate the care of other medical conditions that are unrelated to OUD. However, it is unknown how effective treating OUD in primary care would be. To assess the benefits and harms of using opioid agonist therapy (OAT) to treat people with opioid use disorder (OUD) in a primary care setting, as compared to a traditional specialty care setting. We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, three other databases, and two trials registers in March 2025. We did not restrict searches by language or publication date. Eligible studies were parallel randomized controlled trials (RCTs) and cluster-randomized trials comparing OAT for OUD treatment in primary care versus specialty care settings. Participants were community-dwelling adults with OUD, as identified and defined by trial-specific inclusion criteria. We excluded trials if they included only pregnant women, or those who were incarcerated, but accepted all other comorbidity requirements (e.g. being HIV positive). Primary outcomes included treatment retention, abstinence from non-prescribed opioids, major adverse events, and withdrawals due to adverse events. Secondary outcomes were other patient-oriented outcomes, including quality of life, patient satisfaction, all-cause mortality, opioid-related mortality, all-cause hospitalization or emergency room visit, all-cause incarceration, and minor adverse events. Two review authors independently extracted data using a predesigned RCT template in Covidence. We assessed risk of bias using the Cochrane RoB 1 tool, and certainty of evidence using GRADE. We analyzed outcomes using Review Manager and a random-effects model to account for variability in care models and populations. We included seven RCTs involving 1992 participants. The studies were completed in France (1 study), Ukraine (1 study), and the US (5 studies), and enrolled predominantly males (75%) with a mean age of 38 years. Risk of bias in individual trials was typically low or unclear in all domains except for blinding, where it was high, given participants and providers could not realistically be blinded to setting. One trial was at high risk of bias related to random sequence generation and another for incomplete outcome data. The evidence is very uncertain whether there was a difference in treatment retention in a primary care setting (risk ratio (RR) 1.15, 95% confidence interval (CI) 0.98 to 1.34; 7 studies, 1952 participants; very low-certainty evidence). Abstinence from non-prescribed opioids at the end of follow-up may have been higher in participants managed in primary care (RR 1.59, 95% CI 1.03 to 2.46; 5 studies, 428 participants; low-certainty evidence). Major adverse events were infrequently reported. Only one trial reported all-cause death (one in primary care versus four in specialty care), but these numbers were too small to be meaningful (very low-certainty evidence). Although data from three studies regarding patient satisfaction could not be combined, patients in primary care may have had greater satisfaction. We downgraded certainty in the evidence twice for indirectness for all outcomes given the studies excluded high-risk patients (e.g. those who were pregnant, had co-dependence on alcohol or benzodiazepines, had psychiatric illness, or were homeless) and primary care providers were often atypical of primary care in general (with connections to, or proximity with, OUD-specialized clinics). We downgraded treatment retention an additional level for inconsistency due to high heterogeneity (I2 = 69%). For lower-risk people with OUD who were stable on OAT, managing their OAT in primary care, as compared to specialty care, the evidence is very uncertain for treatment retention and may have resulted in better abstinence from non-prescribed opioids and better patient satisfaction. Further trials in primary care clinics that have less experience with, or connection to, OUD specialty clinics is warranted.