Challenge For Primary Care Research Articles

How general practitioners perceive the aging trajectory of oldest-old - A qualitative study

BackgroundA new population of older people is growing: the oldest-old. The care of the oldest-old (individuals aged 90 and over) is a new challenge in primary care. This study aimed to analyze the perception of General Practitioners (GP) on (1) the aging process of their patients up to a very advanced age, (2) how to adapt their practice to the care of these patients.MethodsWe conducted a qualitative study using focus group (face to face) and individual (video call) interviews of GPs in southwest France. The sampling was purposive. We analyzed the interviews using an inductive approach based on the phases of thematic analysis. We used researchers’ triangulation during the process. Collection was concluded when saturation was reached.ResultsThree focus groups and one individual interview were conducted with a total of seventeen general practitioners. GP perception concerning aging and very advanced age were based on their personal experience and their daily clinical practice. Aging was perceived as an individual, unconscious, unpredictable and irreversible phenomenon. The shift towards “very old age” appeared inevitable. It could be a physical or psychological shift, or patients neglecting themselves or lacking a project. The care of the oldest-old became more specific and individual, adapted to the wishes of the patient. Those adaptations involve medical disengagement to focus on the most essential outcomes. The objectives of health care needed to be less strict with limited invasive practices. Prevention needed to focus mainly on prevention of falls and limitation of functional decline.ConclusionGPs identified an inevitable and unpredictable shift from old age to very old age. The adaption of the theory of disengagement allowed us to identify a medical disengagement of the GPs in the care of their oldest patients.

Primary Care's Challenges and Responses in the Face of the COVID-19 Pandemic: Insights From AHRQ's Learning Community.

The COVID-19 pandemic dramatically disrupted health care systems and delivery in the United States. Despite emotional, psychological, logistical, and financial stress, primary care clinicians responded to the challenges that COVID-19 presented and continued to provide essential health services to their communities. As the lead federal agency for primary care research, the Agency for Healthcare Research and Quality (AHRQ) identified a need to engage and support primary care in responding to COVID-19. AHRQ initiated a learning community from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. The learning community provided a forum for participants to share learning and peer support, better understand the stressors and challenges confronting practices, ascertain needs, and identify promising solutions in response to the pandemic. We identified challenges, responses, and innovations that emerged through learning community engagement, information sharing, and dialog. We categorized these across 5 domains that reflect core areas integral to primary care delivery: patient-centeredness, clinician and practice, systems and infrastructure, and community and public health; health equity was crosscutting across all domains. The engagement of the community to identify real-time response and innovation in the context of a global pandemic has provided valuable insights to inform future research and policy, improve primary care delivery, and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.

Summary Community Health Centers in Belgium: thinking health out of the box

The federation of community health centersa includes 130 practices in French-speaking Belgium. They are organized as self-managed practices, which enables a certain equality between the workers in the team in terms of shared decision. Moreover, these care structures are organized as multidisciplinary teams and most of the time choose a capitation-fee payment for their services. This method of remuneration makes it possible to increase proactivity and improve prevention and health promotion, which are at the heart of the challenges for primary care. The center in Trooz illustrates this organization around the concept of community health. The active participation of patients in the project is at the center of the concerns to achieve patient-centered care.

The Challenges for Primary Care in Korea in the Context of Rapid Aging and COVID-19 Pandemic

The Challenges for Primary Care in Korea in the Context of Rapid Aging and COVID-19 Pandemic

Development of a shared decision-making intervention to improve drug safety and to reduce polypharmacy in frail elderly patients living at home.

For patients with geriatric frailty, reducing inappropriate medication is an important goal to improve patient safety in primary care. GP-side barriers include knowledge gaps, legal concerns, and lack of communication between the actors involved. The aim was to develop a multi-faceted intervention to facilitate deprescribing and shared prioritisation among frail elderlies with polypharmacy living at home. Mixed methods study including: 1) scoping review on family conferences, expert panels; 2) group discussions with GPs, mapping of needs and challenges in Primary Care; 3) workshops and expert interviews with GPs, patient advocates, researchers as a basis for a theoretical intervention model; 4) piloting. A major challenge for GPs is to conduct a productive discussion with patients and family cares on deprescribing and drug safety. A guideline for a structured family conference with a medication check and geriatric assessment was developed and proved to be feasible in the pilot study. The intervention developed to facilitate deprescribing and shared prioritisation of drug therapy based on family conferences seems suitable to be tested in a subsequent cRCT. Adapting family conferences to primary care for frail patients with polypharmacy.

Principles and challenges of quality management in primary care

The provision of care is fragmented in the complex field of health care. In order to fulfil the needs of all groups in healthcare, quality can serve as a common paradigm. For lowering adverse events, enhancing efficiency, and improving patient satisfaction, the evaluation of quality in medical settings is becoming more and more critical. The objective of the healthcare system is to give a specific patient the best care possible from a certified practitioner in the right environment. Quality management in healthcare is the management of system designs, policies, and procedures that reduce, if not completely eradicate, harm while enhancing patient care and outcomes. Quality improvement must be ongoing in order to improve efficiency, patient safety, the delivery of evidence-based healthcare, and health outcomes. Hospitals were early adopters of quality improvement but adopting evidence-based interventions is still difficult in many primary care settings. The purpose of this research is to review the available information about principles and challenges of quality management in primary care. Relationship management, customer focus, effective leadership, employee engagement, process approach, and improvement are few of the principles of quality management. Various challenges including severely departmentalized, bureaucratic, and hierarchical structure, professional autonomy, conflicts between managers and professionals among several others are faced in primary care. Research in future can effectively contribute to addressing challenges and developing guidelines for overcoming these challenges in primary care to ensure best quality healthcare services.

Pharmacist care in hypertension management: systematic review of randomized controlled trials

Abstract Background Hypertension management remains a major public health challenge in primary care. Recent hypertension guidelines recommend the involvement of pharmacists for team-based care management of hypertension. Our objective is to systematically review the evidence of the impact of pharmacist care alone, or in collaboration, on BP amongst hypertensive outpatients compared with usual care. One major focus is to assess the heterogeneity in the effects of these interventions to identify which ones work best in a given healthcare setting. Methods In collaboration with a medical librarian, a systematic literature search was conducted for any article published up to 22.10.2021 in MEDLINE, EMBASE, CENTRAL, CINAHL, Web of Science, and Trip databases. Randomized controlled trials assessing the effect of pharmacist interventions on BP among outpatients were included. The outcomes are the change in BP, BP at follow-up, or BP control. Results will be synthesized descriptively and, if appropriate, will be pooled across studies to perform meta-analysis. We published the study protocol in BMJ Open. Results A total of 1768 study records were identified by electronic database searching and loaded to the systematic review management software Covidence. After removal of duplicates, 1744 were independently screened based on title and abstract by two authors (VG, ST), and 242 full texts were evaluated. A total of 72 studies with 32641 patients are currently included for data extraction. These studies were published between 1973 and 2021 and conducted in different regions (North America: n = 34, Europe: n = 13, other: n = 25). The data extraction and analysis are ongoing. Results will be presented at the congress. Conclusions This systematic review provides updated evidence on the effect of pharmacist intervention on BP management. Heterogeneity in the effect of interventions will be carefully evaluated which will help the implementation of effective interventions in various healthcare settings. Key messages • Recent hypertension guidelines recommend the involvement of pharmacists for team-based care management of hypertension. • This systematic review provides updated evidence on the effect of pharmacist intervention on blood pressure management.

Addressing Challenges in Primary Care—Lessons to Guide Innovation

Addressing Challenges in Primary Care—Lessons to Guide Innovation

More than signposting: Findings from an evaluation of a social prescribing service.

This paper presents findings from an evaluation of a social prescribing service, undertaken between January 2019 and December 2020. Data was collected through interviews and focus groups with a range of groups including social prescribing managers, link workers (LWs), referrers (GPs and social work practitioners), clients, Voluntary and Community Sector (VCS) agencies and groups. Thematic analysis of data was undertaken, and findings were presented in respect of clients' journeys into social prescribing; the support received from LWs; their onward journeys to VCS support. The findings highlight the challenges for individuals in contacting new agencies/groups and the importance of practitioner referral into and onwards from social prescribing, as well as buddying to support clients on initial agency visits. The depth of the LW role is highlighted, as well as the complexity of client circumstances, highlighting a need for 'more than signposting', and challenging the notion of self-referral as an indicator of motivation. Social prescribing has been positioned as amongst the solutions to the challenges of primary care. However, referrals from GPs were low and significantly outnumbered by those from social workers; this suggests a need to explore in greater depth the use of social prescribing by social workers, who have, to date, been absent from social prescribing research.

A letter from Ukraine: challenges for primary care.

A letter from Ukraine: challenges for primary care.

Use of direct oral anticoagulants in primary care: a qualitative study integrating patient and practitioner perspectives.

Older patients with atrial fibrillation (AF) are increasingly offered direct oral anticoagulants (DOACs) to reduce the risk of catastrophic stroke, but clinical follow-up and compliance checks are still required to maintain patient safety. Although a recent qualitative meta-analysis has explored up-to-date research in this area, little is known qualitatively about clinicians' or patients' views and experiences of DOAC use in primary care in the UK. To understand the experiences of healthcare practitioners and patients in relation to DOAC use in UK primary care. Semi-structured interviews were undertaken. Sixteen older patients with AF taking DOACs, 10 pharmacists, and six GPs were interviewed in Sheffield, England in 2018. Interview questions were developed following a systematic literature review. Interviews were audio-recorded, transcribed, and analysed using six-stage thematic analysis. The integrated perspectives show that all three participant groups preferred DOACs over warfarin, a preference driven mainly by the safety profile compared with warfarin. GPs valued pharmacists' input in anticoagulant care, and pharmacists discussed patient safety in the context of anticoagulant audits, and highlighted the need for continuous patient education and counselling. Medication reviews by pharmacists were seen as a positive contribution to medicines optimisation. Patients had an overriding trust in their doctors. GPs valued a collaborative approach with other clinicians, and community pharmacists appeared to highlight operational challenges in primary care that may limit the effectiveness of interventions.

0382 Optimizing Obstructive Sleep Apnea Screening and Education in Underserved Community

Abstract Introduction Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. There are many conditions associated with OSA, including obesity hypoventilation syndrome, congestive heart failure, atrial fibrillation, pulmonary hypertension and pulmonary diseases. Majority of patients endorse daytime sleepiness, but family often report snoring and apneas. There are multiple screening tools, including the STOP-BANG. Scores 5 or above are high risk for OSA. Untreated OSA worsens comorbidities and increases risk of myocardial infarction and stroke. We provided physicians with this screening tool to help risk stratify, thus providing better patient education and treatment. Methods Physicians educated on OSA, STOP-BANG and documentation in didactic sessions. Patients ages 18 and older provided with questionnaire. Physicians measured neck circumference and BMI. Questionnaire reviewed with patient and education given. If high risk, sleep medicine referral recommended. Physicians documented in charts about discussion, risk category and referral status. Results Total of 407 patients completed the questionnaire, but 67 patients were excluded for no neck circumference. Remaining 340 patients stratified by STOP-BANG scores: 128 Low, 142 Intermediate, 70 High Risk. From High Risk category, 20 patients referred to Sleep Medicine. Only 18 charts from the 50 not referred explained why, which included patient declining, already on CPAP, referral already in, and because outpatient sleep study was ordered instead. Data stratified for age, gender, BMI and neck circumference. Age range from the 340 total was 19-87-years-old. From High Risk, 39 were male and 31 female. BMI range for total was 17-61, while High Risk was 22-61. Neck circumference range for total was 12-21 inches, while High Risk was 12.5-17.5 inches. Conclusion The goal was not only to provide a validated screening tool, but also provide better OSA education for physicians and patients. Results indicate many patients were intermediate or high risk. Majority of patients had multiple comorbidities, including obesity, hypertension and diabetes. This study highlights the prevalence of OSA in an inner-city primary care clinic and challenges involved in screening all at risk patients. Further investigations could include the effect of more education, continued screening and effect of lifestyle changes in this vulnerable population. Support (If Any)

Pharmacist interventions to improve hypertension management: protocol for a systematic review of randomised controlled trials

IntroductionHypertension management remains a major public health challenge in primary care. Innovative interventions to improve blood pressure (BP) control are needed. One approach is through community-based models of care with...

Direct access mammography pathway for breast pain

Introduction: Breast pain management remains not only a capacity challenge for both primary and secondary care, is also a recurring source of anxiety for patients. We implemented a Direct Access Mammography (DAM) pathway for patients with breast pain, with the aim of providing GPs access to a mammogram screen, reassurance for patients and reduced use of the one-stop clinic. Pathway Description Requests from primary care for DAM placed electronically (ICETM) were accepted provided the following clinical criteria were met; Patient age > 40 Confirmation of pain and no clinical signs, last mammogram > 12 months, no history of breast cancer.

Extracts of Eucalyptus alba Promote Diabetic Wound Healing by Inhibiting α-Glucosidase and Stimulating Cell Proliferation.

Treatment of diabetic wounds has always been a challenge for primary and acute health care. Eucalyptus alba has been reported to be used for the treatment of wounds and oxidative stress. Effects of using different temperatures and solvents for the extraction of Eucalyptus alba leaves were investigated in terms of diabetic wound healing activity. Leaves of E. alba were dried at 10°C, 30°C, 50°C, and 100°C, and dissolved in ethanol, methanol, and acetone to obtain a total of 12 extracts. All the extracts have remarkable antidiabetic, antioxidant, and cell proliferation activities. Among the tested extracts, highest activities were observed with leaves dried at 10°C and 30°C, whereas drying at 100°C resulted in the lowest activities. Ethanol-based extracts exhibited significantly increased cell proliferation compared with methanol- and acetone-based extract. The present study suggests that leaves of E. alba should be dried at temperature not more than 30°C and extracted in ethanol for optimum results. However, further studies should focus on the identification of specific bioactive compounds in E. alba leaves.

Diagnostic challenges in primary care: Identifying and avoiding cognitive bias.

These 4 cases demonstrate how cognitive bias can impede the diagnostic process.

The theatre of depression: a role for physical therapy

ABSTRACT Introduction The world’s population is experiencing an increasing prevalence of depressive disorders. A comprehensive literature review identifies a schism between current medical interventions and the increasing prevalence. Current treatment paradigms warrant analysis. Objective This manuscript theorizes an interdisciplinary team inclusive of physiotherapy as a standard would reverse the increasing prevalence. Physiotherapists’ musculoskeletal expertise and biopsychosocial approach play a valuable role in mental health. Methods A clinical narrative review of depression, including parallels with chronic pain, is provided as a substantive foundation. The review includes challenges in primary care as the gateway to mental health. Depression’s underlying mechanisms, standard interventions, current theories, and future paradigms are explored. Results A theoretical construct was formulated. This construct identified compromised emotion-regulation and self-efficacy as common dysfunctions that enables and perpetuates depression. Physical activity with cognitive reappraisals positively influences these common dysfunctions and improves general intervention outcomes. The psychologically informed physiotherapist is defined. Physiotherapists can provide functional interventions and cognitive reappraisals that address biopsychosocial needs and build resilience. Conclusion Individualized physical and functional activity that facilitate therapeutic alliance, functional improvements, cognitive reappraisals, emotion-regulation and self-efficacy delivered by a physiotherapist provide sustainable behavioral change and completes the interdisciplinary mental health team.

A qualitative study of challenges affecting the primary care system performance: Learning from Iran's experience.

Background and AimsPrimary care and the use of a referral system are essential components of any health system. The aim of this study was to investigate and identify the challenges affecting the performance of the primary health‐care system in Iran.MethodsThis qualitative study was carried out consisting of 14 interviews with experts and those familiar with the primary care system and its function. Purposive and snowball sampling was used to identify the samples. The recorded files were transcribed and entered into the MAXQDA‐11 software to be analyzed. The conventional content analysis approach was used for data analysis.ResultsThe findings of this study included 72 initial codes classified into 7 main themes and 18 subthemes. Seven main themes consist of governance, manpower, resources, financial management, services delivery, trans‐sectional, and social and cultural. The greatest challenges for Iran's primary health care (PHC) system are governance and human resources problems.ConclusionVarious dimensions of Iran's primary care system especially governance and human resources are facing several challenges that threaten its performance and efficiency. Policymakers and planners must address challenges fundamentally and do not get satisfied with superficial reforms that have short‐term and soothing effects. In this regard, enhancing governance functioning can profoundly solve numerous challenges of Iran's primary care system. We also suggest the strengthening of intersectoral collaboration.

The Pain Academy: An Evaluation of a Primary Care Brief Psychoeducational Program for Persistent Pain

Persistent pain affects 20% of adults and can impair one’s daily functioning and well-being. Psychoeducational group interventions can be effective in aiding pain management and coping strategies, however the time commitment for most evidence-based programs (10-20 hours) leads to access barriers and delivery challenges in primary care. A mixedmethods, program evaluation was conducted on a low intensity, three-session, manualized group pilot psychoeducational intervention in a primary care practice, emphasizing pain education, behavioral strategies, and pain-alleviating activities. Eighty-two percent of the clinic’s panel of individuals with persistent pain and being prescribed opioid pain medication (N=128) attended at least one class (N=105). Attendees experienced significant pre-post improvements in self-reported pain functioning and favorable satisfaction ratings by patients and medical staff. However only 51% attended all three groups, despite frequent class offerings and heavily encourage by the patient’s medical providers. This study reviews the potential promise and limitations of a low-intensity, limited session pain group to aid pain-related functioning. Additional investigation is warranted to optimize participant attendance, group format and frequency, and outcome assessment.

Challenges and Strategies for Improving COPD Primary Care Services in Quebec: Results of the Experience of the COMPAS+ Quality Improvement Collaborative.

IntroductionManagement of chronic obstructive pulmonary disease (COPD) remains a challenge in primary care and multiple barriers can limit implementation of COPD guidelines. Since 2016, a quality improvement (QI) collaborative, called COMPAS+, has been implemented across the province of Quebec (Canada) to support improvement of chronic disease management in primary care. The aim of this study was to describe the main COPD quality problems reported by participating teams and the strategies they proposed and implemented to improve COPD primary care services in Quebec.MethodsSixteen sites in four different regions of Quebec were engaged in the COMPAS+ intervention to improve primary care services delivered to people living with COPD. A total of 14 workshop reports, 31 QI action plans and 4 regional final reports underwent content analysis. Key COPD quality problems were first identified and, for each of them, root causes were classified according to the domains and constructs of the Consolidated Framework for Implementation Research. Proposed strategies were organized according to the intervention function types described in the Behavior Change Wheel.ResultsFour key COPD quality problems were identified: 1) lack of organization/coordination of COPD services, 2) lack of screening services coordination, 3) lack of interprofessional communication and collaboration and 4) lack of treatment adherence. Main root causes explaining these quality gaps were 1) lack of awareness of COPD, 2) lack of professional knowledge, 3) lack of definition of professional roles, 4) lack of resources and tools for COPD prevention, diagnosis, and follow-up, 5) lack of communication tools, 6) lack of integration of the patient-as-partner approach, and 7) lack of adaptation of patient education to their specific needs. Multiple strategies were proposed to improve healthcare professionals’ education and interprofessional collaboration and communication.ConclusionQI collaborative activities can support achieving understanding of QI challenges healthcare organizations face to improve COPD services.