Behaviour In Primary Care Research Articles

Client's perception toward services of smoking cessation clinics in Riyadh, Saudi Arabia.

In Saudi Arabia, approximately 70,000 deaths yearly occur from diseases caused by smoking. Assessing patients' smoking behavior in primary care has apparent benefits. Assisting patients with smoking cessation is one of the essential roles of primary care. This study evaluated the quality of smoking cessation clinic counseling in Riyadh, Saudi Arabia, based on customer opinions of such services. This research employed a cross-sectional approach involving individuals attending smoking cessation clinics located within primary health care centers in Riyadh city. The participants were chosen through random selection. They were informed about the study's objectives, and those who consented to take part were contacted and provided with an online questionnaire to complete. A total of 340 subjects participated (95.6%) of them were males, and 41.2% were in the age group of 25 to 35 years old. The common modality of tobacco use was cigarettes (82.6%), and 87.9% reported consuming tobacco daily. The mean (±SD) total score of the Fagerstrom Test of Nicotine Dependence was 5.03 (±2.36), and the highest percentage (44.4%) of the participants had a moderate level of nicotine dependence. The vast majority (93.8%) of the participants had former quitting experiences. Half (50.9%) of the participants showed complete satisfaction with the cessation clinics, while 13.2% and 9.1% of them were not satisfied or slightly satisfied, respectively. The majority of smoking cessation clinic visitors were satisfied with the services provided, exceeding three-quarters of them, with half totally satisfied.

Financial incentives and prescribing behavior in primary care.

Many healthcare systems prohibit primary care physicians from dispensing the drugs they prescribe due to concerns that this encourages excessive, ineffective or unnecessarily costly prescribing. Using data from the English National Health Service for 2011-2018, we estimate the impact of physician dispensing rights on prescribing behavior at the extensive margin (comparing practices that dispense and those that do not) and the intensive margin (comparing practices with different proportions of patients to whom they dispense). We control for practices selecting into dispensing based on observable (OLS, entropy balancing) and unobservable practice characteristics (2SLS). We find that physician dispensing increases drug costs per patient by 3.1%, due to more, and more expensive, drugs being prescribed. Reimbursement is partly based on a fixed fee per package dispensed and we find that dispensing practices prescribe smaller packages. As the proportion of the practice population for whom they can dispense increases, dispensing practices behave more like non-dispensing practices.

Impact of vertical integration in a referral-based healthcare system

Vertical integration has been growing steadily in healthcare and several studies have explored the impact of this phenomenon on prices, consumers, etc. In this work, motivated by changes in healthcare systems in China, we provide an operational perspective by investigating how vertical integration influences the referral behavior in primary care and the corresponding service provision at hospitals or specialists. We present an optimization model to explore the effect of different levels of vertical integration on generalists and specialists. We find that the healthcare system efficiency can indeed be improved with a moderate level of integration. However, when the level of integration increases beyond a certain threshold, healthcare costs may actually increase with more integration especially when generalists or primary care providers are inadequately trained and specialists are highly utilized. We find that full integration is not optimal. Moreover, aiming for a moderate level of integration is especially appropriate if the generalist’s ability to treat complex patients is limited and/or timely access to treatment is important. Our work also shows that physicians get higher payment without necessarily improving service quality when the integration level is higher. We discuss the implications of our results in the context of the Chinese healthcare system, although some insights may apply more broadly.

Depression rates and health-seeking behavior in primary care: Andersen model of health- care utilization

ABSTRACT Depression imposes a tremendous burden on the health-care systems. Many patients prefer informal (family & friends) over formal mental health services (MHS) provided by professionals. We aimed to investigate the prevalence of depression among primary care patients and to examine the factors predicting seeking MHS using the Andersen Health Care Utilization Model. We interviewed 300 primary care patients in Jordan. The mean age was 39.85 ± 14.45, and 80% were women. 35.7% had depression, and 28.7% had significant depression impairing daily function. The most commonly reported source of help was family members and less than one-third had the intention to seek formal MHS. The predisposing-factors domain was the only predictive of seeking MHS in depression and suicide, whereas the ‘enabling’ and ‘need’ domains were not. Knowledge, stigma and life satisfaction were predictive of seeking formal MHS. Raising awareness and empowering doctors to screen for depression is needed as less than a third would seek formal MHS.

Nudging as a Support for Behavioral Change in Lifestyle Medicine.

The practice of lifestyle medicine and its emphasis on behavioral change continues to grow around the world. Yet much of the burden of disease weighing on healthcare systems from chronic, modifiable conditions remains stubbornly present. From a behavior change perspective, efforts to date have primarily focused on public health messaging and public health campaigns (global approaches) to interventions such as health coaching (individual approaches). There exists an opportunity to consider contextual elements which support behavioral change. The practice of "nudging" behavior in primary care and allied health settings is proposed as a means of responding to these contextual opportunities. Nudging does not assure change; however, it can invite curiosity about change and small behavioral efforts in the direction of a desired change. Furthermore, its nature conserves autonomy and patient choice while inviting a health-creating behavior. As such, when considered and applied in the context of public health and individual treatment options, it creates a consistent milieu in which behavior change is facilitated.

Help-seeking behaviour in primary care of men and women with a history of abuse: A Dutch cohort study

Background Previous studies show an association between a history of abuse and higher care demand. However, studies in general practice regarding help-seeking behaviour by patients (mainly male patients) with a history of abuse are scarce. Objectives To analyse help-seeking behaviour in general practice of men and women with a history of abuse. Methods A cohort study using data from a Dutch primary care registration network from 2015 to 2019. We included all patients aged ≥ 18 years who indicated on a questionnaire that they did or did not have a history of abuse. We analysed differences in contact frequency, types of contact, reason for encounter and diagnoses between men and women with or without a history of abuse. Results The questionnaire had a response rate of 59% and resulted in 11,140 patients, of which 1271 indicated a history of abuse. Men and women with a history of abuse contact the general practitioner (GP) 1.5 times (95% CI 1.42–1.60) more often than men and women without a history of abuse, especially for psychological (rate ratio 1.97, 95% CI 1.79–2.17) and social (rate ratio 1.93, 95% CI 1.68–2.22) problems. Moreover, when diagnosed with a psychological or social problem, patients with a history of abuse contact the GP twice more often for these problems. Conclusion Compared to men and women without a history of abuse, men and women with a history of abuse visit their GP more often, particularly for psychological and social problems.

Development of a new hospital medication adherence scale in cardiovascular disorders: The Mascard

Non-adherence to prescribed cardiovascular drugs may leads to complications in both secondary and primary prevention. Thus, cardiovascular diseases lead to regular monitoring, which may require hospitalizations, making the hospital a place to re-evaluate both the patient's health and the medication adherence behavior in primary care. The objective of this study was to develop a new scale to assess medication adherence in patients with cardiovascular diseases usable during hospitalization. A cohort of 219 high-risk cardiovascular patients was included for this study. Data on reasons for non-adherence were collected using the newly developed Medication Adherence Scale in Cardiovascular disorders (Mascard) and compared with physician assessment and the control of their cardiovascular risk factors. The Mascard consists of 5 items concerning attitudes toward medication intake. It has good psychometric properties (alpha Cronbach: 0,49) and validity [positive predictive value (PPV): 0.96 and negative predictive value (NVP): 0.5] and correlated with physician assessment (Somers D = 0.34, P < 10 −4 ) and control of cardiovascular risk factors. This new free to use scale is rapid, easy to use and may be useful for health care practitioners to assess cardiovascular medication adherence in inpatients.

Short screener for suicidal behaviour in primary care - a systematic review

We summarize the available studies reporting diagnostic accuracy of brief instruments for suicidal behaviour in primary care. Databases MEDLINE, EMBASE, PsychINFO, PSYNDEX, and Cochrane Library were searched without any time constraints. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool. The certainty of evidence was rated via GRADEpro. We included studies on primary care patients or participants from the general population. Suicidal behaviour was the defined target condition. With respect to the applicability in a primary care setting we included only studies assessing brief screening instruments; a brief instrument was defined as having no more than 12 items. We assessed sensitivity, specificity, and positive and negative predictive value. A total of 12,460 studies were identified; of those, n = 7 fulfilled all strong criteria and were included. The range of sensitivity was 0.26-1.00, specificity was 0.64-0.99, positive predictive value 0.06-0.91, negative predictive value 0.83-1.00. Risk of bias was rated moderate and concerns regarding applicability acceptable. A required sensitivity of at least 0.80 and specificity of 0.50 with a moderate to high GRADE rating was achieved by 8 of 11 index tests. Brief screening instruments can support ruling-out suicidality, but are less suitable for ruling-in. They may support general practitioners in an initial assessment, but in case of a positive test result, a valid diagnostic assessment should be done by a structured clinical interview.

Encouraging rational antibiotic prescribing behaviour in primary care – prescribing practice among children aged 0–4 years 2016–2018: an observational study

Objective To study antibiotic prescriptions among 0- to 4-year-old children before and after implementing a quality project on prudent prescribing of antibiotics in primary healthcare in the capital region of Iceland. Design An observational, descriptive, retrospective study using quantitative methodology. Setting Primary healthcare in the Reykjavik area with a total population of approximately 220,000. Subjects A total of 6420 children 0–4 years of age presenting at the primary healthcare centres in the metropolitan area over three years from 2016 to 2018. Main outcome measures Reduction of antibiotic prescriptions and change in antibiotic profile. Data on antibiotic prescriptions for children 0–4 years of age was obtained from the medical records. Out-of-hours prescriptions were not included in the database. Results The number of prescriptions during the study period ranged from 263.6 to 289.6 prescriptions/1000 inhabitants/year. A reduction of 9% in the total number of prescriptions between 2017–2018 was observed. More than half of all prescriptions were for otitis media, followed by pneumonia and skin infections. Amoxicillin accounted for over half of all prescriptions, increasing between 2016 and 2018 by 51.3%. During this period, the prescribing of co-amoxiclav and macrolides decreased by 52.3% and 40.7%, respectively. These changes were significant in all cases, p < 0.0001. Conclusion The results show an overall decrease in antibiotic prescribing concurrent with a change in the choice of antibiotics prescribed and in line with the recommendations presented in the prescribing guidelines implemented by the Primary Healthcare of the Capital Area, and consistent with the project’s goals. Key points A substantial proportion of antibiotic prescribing can be considered inappropriate and the antibiotic prescription rate is highest in Iceland of the Nordic countries. After implementing guidance on the treatment of common infections together with feedback on antibiotic prescribing, a decrease in the total number of prescriptions accompanied by a shift in the antibiotic profile was observed.

A Systematic Review of Short Screening Instruments for Suicidal Behaviour in Primary Care

Background: Due to strict time management General Practitioners (GPs) prefer short instruments when identifying suicidal behaviour in their patients. We summarize the available studies reporting diagnostic accuracy of brief instruments for suicidal behaviour in primary care. Method: Databases MEDLINE, EMBASE, PsychINFO, PSYNDEX, and Cochrane Library were searched without any time constraints. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool. The certainty of evidence was rated via GRADEpro. We included studies on primary care patients or participants from the general population. Suicidal behaviour was the defined target condition. With respect to the applicability in a primary care setting we included only studies assessing brief screening instruments; a brief instrument was defined as having no more than twelve items. We assessed sensitivity, specificity, and positive and negative predictive value. Results: A total of 9,969 studies was identified; of those, six fulfilled all strong criteria and were included. The range of sensitivity was 0.26-1.00, specificity was 0.64-0.99, positive predictive value 0.06-0.91, negative predictive value 0.86-1.00. Risk of bias was rated moderate and concerns regarding applicability acceptable. A required sensitivity of at least 0.80 and specificity of 0.50 with a moderate to high GRADE rating was achieved by six of nine index tests. Conclusions: Brief screening instruments can support ruling-out suicidality, but are less suitable for ruling-in. They may support GPs in an initial assessment, but in case of a positive test result, a valid diagnostic assessment should be done by a structured clinical interview.

Does diagnostic uncertainty increase antibiotic prescribing in primary care?

This study aimed to determine the association between factors relevant to diagnostic uncertainty and physicians’ antibiotic-prescribing behaviour in primary care. A questionnaire survey was conducted on 327 physicians that measured their diagnostic ability, perceived frequency of diagnostic uncertainty, tolerance, and perceived patient tolerance of uncertainty. Physician antibiotic-prescribing behaviours were assessed based on their prescriptions (n = 207,804) of three conditions: upper respiratory tract infections (URTIs, antibiotics not recommended), acute tonsillitis (cautious use of antibiotics), and pneumonia (antibiotics recommended). A two-level logistic regression model determined the association between diagnostic uncertainty factors and physician antibiotic prescribing. Physicians perceived a higher frequency of diagnostic uncertainty resulting in higher antibiotic use for URTIs and less antibiotic use for pneumonia. Higher antibiotic use for acute tonsillitis was related to a low tolerance of uncertainty of physicians and patients. This study suggests that reducing diagnostic uncertainty and improving physician and patient uncertainty management could reduce antibiotic use.

Meanings of suicidal behavior from the perspective of primary care professionals.

To explore the meaning of suicidal behavior from the perspective of family health professionals. A qualitative study developed during 2017-2018 with 18 primary care professionals from a Brazilian municipality. Grounded theory was used as the methodological framework. Semi-oriented interviews were conducted, transcribed, and analyzed by open, axial, and selective coding. The professionals perceived themselves as unprepared, emotionally affected, and fearful to work in suicide prevention, prioritizing the referral of people to specialized services regardless of the severity of the situation. Suicide was represented as both a choice and a condition of vulnerability, being more reprehensible when associated with individual choice. We identified beliefs related to suicidal behavior that could affect the care of people at risk. Our findings reinforce the need for education and training in the prevention of suicidal behavior in primary care.

Association between Physicians' Perception of Shared Decision Making with Antibiotic Prescribing Behavior in Primary Care in Hubei, China: A Cross-Sectional Study.

Shared decision-making (SDM) has been advocated as one effective strategy for improving physician–patient relationships and optimizing clinical outcomes. Our study aimed to measure physicians’ perception of SDM and establish the relationship between physicians’ perception of SDM and prescribing behavior in patients with upper respiratory tract infections. One cross-sectional study was conducted in Hubei Province from December 2019 to January 2020. The SDM questionnaire and prescription data of 2018 from electronic health records data were matched for each physician in this study. Multilevel modeling was applied to explore the relationship between physicians’ perception of SDM and antibiotic prescribing in primary care. Analyses were statistically controlled for demographic characteristics of the physicians and patients. Physicians’ positive perception of SDM had small but statistically significant effects on lower prescribing of antibiotics in the patient group aged over 40 years (odds ratio (OR) < 1; p < 0.05). Moreover, female physicians (OR = 0.71; p = 0.007) with higher educational levels (bachelor’s degree and above; OR = 0.71; p = 0.024) were significantly associated with the prescribing of less antibiotics (p < 0.05). A more positive perception of SDM was demonstrated as one significant predictor of less prescribing of antibiotics in the patient group over 40 years. There may be a promising focus of implementing SDM strategies targeting physician–patient communication in primary care.

The effect of a mystery shopper scheme on prescribing behavior in primary care: Results from a field experiment

BackgroundHealth care systems in many countries are characterized by limited availability of provider performance data that can be used to design and implement welfare improving reforms in the health sector. We question whether a simple mystery shopper scheme can be an effective measure to improve primary care quality in such settings.MethodsUsing a randomized treatment-control design, we conducted a field experiment in primary care clinics in a Chinese city. We investigate whether informing physicians of a forthcoming mystery shopper audit influences their prescribing behavior. The intervention effects are estimated using conditional fixed-effects logistic regression. The estimated coefficients are interpreted as marginal utilities in a choice model.ResultsOur findings suggest that the mystery shopper intervention reduced the probability of prescribing overall. Moreover, the intervention had heterogeneous effects on different types of drugs.ConclusionsThis study provides new evidence suggesting that announced performance auditing of primary care providers could directly affect physician behavior even when it is not combined with pay-for-performance, or measures such as reminders, feedback or educational interventions.

RELATO DE EXPERIÊNCIA SOBRE AÇÕES DE PREVENÇÃO AO NOVO CORONAVÍRUS (COVID-19) POR UMA EQUIPE DE SAÚDE DA FAMÍLIA NO RIO GRANDE DO NORTE

Em janeiro de 2020, o novo coronavirus se espalhou para outros países da Ásia e Europa, onde a Organização Mundial da Saúde (OMS) declarou emergência em saúde pública de interesse internacional. Em março de 2020, a OMS classificou a doença causada pelo novo coronavirus como pandemia. O presente trabalho tem como objetivo relatar experiência vivenciada por parte de uma equipe de saúde da família do município de Equador no Estado do Rio Grande do Norte em ações de prevenção e combate a COVID-19. O processo de trabalho da equipe, observando o comportamento do novo coronavírus, fez pensar em estratégias que evitassem a contaminação tanto pelos profissionais quanto pela população. Além do mais, está gerando um novo modelo de atendimento e comportamento dos usuários na atenção básica.

Health-related quality of life and physical activity level after a behavior change program at Norwegian healthy life centers: a 15-month follow-up

PurposeThe long-term impact of primary care behavior change programs on health-related quality of life (HRQoL) and physical activity (PA) level is unknown. The aim of this study was to investigate changes in HRQoL and PA among participants after a 3-month behavior change intervention at Norwegian healthy life center (HLCs) and at a 15-month follow-up. Furthermore, we aimed to study associations between changes in PA and HRQoL.MethodsWe followed 524 adult participants (18–83 years), recruited from 32 HLCs in August 2016–January 2018, who provided data on HRQoL (SF-36) and PA (ActiGraph accelerometers) 12 months after a 3-month behavior change intervention. Changes in HRQoL and PA between baseline, 3-month and 15-month follow-ups, and associations between changes in PA and HRQoL were analyzed by linear mixed models.ResultsAll HRQoL dimensions improved from baseline to 3-month follow-up, and the improvements maintained at 15-month follow-up (mean 3.1–13.1 points, p < 0.001). PA increased from baseline to 3 months (mean 418 steps/day, p < 0.001), but declined from 3 to 15 months (mean − 371 steps/day, p < 0.001). We observed positive associations between changes in PA and HRQoL (0.84–3.23 points per 1000 steps/day, p < 0.023).ConclusionsTwelve months after completing a 3-month HLC intervention we found improved HRQoL, but not PA level. Still, there were positive associations between PA and HRQoL over this period, indicating that participants increasing their PA were more likely to improve their HRQoL.

Modifying Provider Vitamin D Screening Behavior in Primary Care.

Clinical evidence shows minimal benefit to vitamin D screening and subsequent treatment in the general population. This study aims to assess the effectiveness of 2 light-touch interventions on reducing vitamin D test orders. The outcomes were weekly average vitamin D rates, computed from adult primary care encounters (preventive or nonpreventive) with a family medicine (FM) or internal medicine (IM) provider from June 14, 2018 through December 12, 2018. We conducted an interrupted time series analysis and estimated the cost impact of the interventions. The interventions consisted of an educational memo (August 9, 2018) distributed to providers and removal of the vitamin D test (FM: August 15, 2018; IM: October 17, 2018) from the providers' quick order screen in the electronic health record. Change in order rates were analyzed among physicians (MDs and DOs), physician assistants (PAs), and nurse practitioners (NPs). There were 587,506 primary care encounters (FM = 367,947; IM = 219,559). Vitamin D order rates decreased from 6.9% (FM = 5.1%; IM = 9.9%) to 5.2% (FM = 4% [P < .01], IM = 7.9% [P < .01]). For FM, the vitamin D test order rate continued to fall at a 0.08% per week rate after the interventions (end of study: 2.73%). The education intervention showed a relative decrease in each provider type (FM-physician = 16% [P < .01], FM-PA = 47% [P < .01], FM-NP = 20% [P = .01], IM-physician = 14% [P = .02], IM-PA = 52% [P < .01], IM-NP = 34% [P = .04]). Annualized savings was approximately 1 million dollars. Emailed evidence-based provider education may be an effective tool for modifying providers' vitamin D test ordering behavior. The lack of the effectiveness of the vitamin D test removal from the quick order screen found for IM highlights the challenges facing simple electronic health record interventions when multiple alternate ordering pathways exist.

How do point-of-care diagnostic tests for acute respiratory infection affect antibiotic prescribing behavior in primary care?

How do point-of-care diagnostic tests for acute respiratory infection affect antibiotic prescribing behavior in primary care?

Effectiveness of an intervention to improve antibiotic-prescribing behaviour in primary care: a controlled, interrupted time-series study.

High rates of antibiotic misprescribing in primary care, with alarming clinical and economic consequences, highlight the urgent need for interventions to improve antibiotic prescribing in this setting. To assess the effectiveness on antibiotic prescribing quality indicators of a multifaceted intervention targeting health professionals' and patients' behaviour regarding antibiotic use. We conducted a pragmatic cluster-randomized controlled trial in the catchment area covered by Portugal's Central Regional Health Administration. The intervention consisted of a multidisciplinary, multifaceted programme involving physicians, pharmacists and patients, and comprising outreach visits for physicians and pharmacists, and educational materials for health professionals and patients. The following were assessed: relative ratios of prescription of penicillins sensitive to β-lactamase, penicillin combinations including β-lactamase inhibitors, third- and fourth-generation cephalosporins and fluoroquinolones; and the ratio of broad- to narrow-spectrum antibiotics. An interrupted time-series analysis for multiple-group comparisons was performed. The study protocol was registered on Clinical.trials.gov (NCT02173509). The participation rate in the educational intervention was 64% (197/309 GPs) in a total of 25 counties. Statistically significant improvements were obtained, not only in the relative prescription of penicillins sensitive to β-lactamase (overall relative change of +896%) and penicillin combinations including β-lactamase inhibitors (-161%), but also in the ratio of broad- to narrow-spectrum antibiotics (-200%). Statistically significant results were also obtained for third- and fourth-generation cephalosporins, though only in the immediate term. This study showed that quality indicators of antibiotic prescribing can be improved by tackling influences on behaviour including knowledge and attitudes surrounding physicians' clinical practice. Accordingly, these determinants must be considered when implementing interventions aimed at improving antibiotic prescribing.

Patients' and GPs' expectations regarding healthcare-seeking behaviour: a Norwegian comparative study.

BackgroundGPs are Norwegian patients' first contact point with the healthcare system for most medical problems. However, little is known regarding GPs' expectations towards their patients' healthcare-seeking behaviour, or whether doctors and patients have coinciding expectations of what GPs can do for their patients.AimTo investigate patients' and GPs’ expectations regarding patients’ healthcare-seeking behaviour in primary care, and to make comparisons between the two.Design & settingNorwegian data from the Quality and Costs of Primary Care in Europe (QUALICOPC) questionnaire study, with information from GPs and their patients.MethodBinary logistic regression was used to investigate associations between expectations, sex and age of GPs and patients, list size, and geographical location of practice. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Expectation differences between GPs and patients were analysed using generalised estimating equations (GEEs). Due to multiple testing, Bonferroni correction was used to define significance level at P≤0.002.ResultsIn total, 198 GPs (39.1% female) and 1529 patients (61.9% female) responded. No associations with sex or age were found for the GPs' expectations regarding patients' healthcare-seeking behaviour. Among patients, fewer males than females expected that most people would see their GP for sprained ankle (OR 0.7, 95% CI = 0.5 to 0.9), finger cut (OR 0.6, 95% CI = 0.4 to 0.7), smoking cessation (OR 0.6, 95% CI = 0.5 to 0.8), or anxiety (OR 0.4, 95% CI = 0.3 to 0.6). Older patients (aged >65 years) found it more important than younger patients to see a doctor in the presence of medical symptoms. GPs had higher expectations than their patients that people in general would see them for deteriorated vision (OR 4.2, 95% CI = 2.5 to 6.9), sexual problems (OR 1.8, 95% CI =1.3 to 2.6), and anxiety (OR 3.0, 95% CI =1.5 to 6.0).ConclusionFor several common health problems, males are less likely than females to believe that people will see their GP. GPs may overestimate to what degree their patients will see them for a number of common medical problems.