Chronic Diseases In Primary Care Research Articles

Harmonization of clinical practice guidelines for primary prevention and screening: actionable recommendations and resources for primary care

BackgroundClinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program.MethodsA review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40–69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations.ResultsWe identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40–69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program.ConclusionsComprehensive care requires the ability to address a person’s overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care.

Impact effects of COVID-19 pandemic on chronic disease patients: A longitudinal prospective study.

To assess the effects of COVID-19 pandemic on clinical variables as part of the routine clinical monitoring of patients with chronic diseases in primary care. A prospective longitudinal study was conducted in primary care centres of the Andalusian Health Service. Data were recorded before the pandemic (T1), during the declaration of the state of emergency (T2) and in the transition phase (T3). The Barthel index and the Short Portable Mental Status Questionnaire (SPMSQ) were used to analyse functional and cognitive changes at the three time points. HbA1c, systolic and diastolic blood pressure, heart rate, BMI and lipid levels were assessed as clinical variables. Descriptive statistics and non-parametric chi-square test were used for analysis. STROBE checklist was used for the preparation of this paper. A total fo148 patients with chronic conditions were included in the analysis. Data analysis revealed in T2 only significant reductions in BMI, total levels of cholesterol and HDL during the onset of the pandemic. Barthel Index, SPMSQ, blood pressure and triglycerides and LDL levels worsened in T2, and the negative effects were maintained in T3. Compared to pre-pandemic values, HbA1c levels improved in T3, but HDL levels worsened. COVID-19 has drastically disrupted several functional, cognitive and biological variables. These results may be useful in identifying clinical parameters that deserve closer attention in the case of a new health crisis. Further studies are needed to assess the potential impacts of each specific chronic condition. Cognitive and functional status, blood pressure and triglycerides and LDL levels worsen in short term, maintaining the negative effects in medium-term.

Utilisation of Chronic Disease and Mental Health Management Services and Cardioprotective Medication Prescriptions in Primary Care for Patients With Cardiovascular Diseases and Cancer: A Cross-Sectional Study

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among cancer survivors. Mental health is considered an important risk factor affecting the treatment of cardiovascular disease. However, little is known about the use of secondary prevention strategies for CVD in patients with both cancer and CVD. This study aimed to compare the utilisation of primary care chronic disease management plans, mental health care and guideline-indicated cardioprotective medications among CVD patients with and without cancer. Retrospective cross-sectional study utilising clinical data of patients with CVD from 50 Australian primary care practices. Outcomes included the use of chronic disease management plans, mental health care, guideline-indicated cardioprotective medications and influenza vaccination. Logistic regression, accounting for demographic and clinical covariates and clustering effects by practices, was used to compare the two groups. Of the 15,040 patients with CVD, 1,486 patients (9.9%) concurrently had cancer. Patients with cancer, compared to those without, were older (77.6 vs 71.8 years, p<0.001), more likely to drink alcohol (62.6% vs 55.7%, p<0.001), have lower systolic (130.3±17.8 vs 132.5±21.1 mmHg, p<0.001) and diastolic (72.2±11 vs 75.3±34 mmHg, p<0.001) blood pressure. Although suboptimal for both groups, patients with cancer were significantly more likely to have general practice management plans (GPMPs) (51.4% vs 43.2%, p<0.001), coordination of team care arrangements (TCAs) (46.2% vs 37.0%, p<0.001), have a review of either GPMP or TCA (42.8% vs 34.7%, p<0.001), have a mental health treatment consultation (15.4% vs 10.5%, p=0.004) and be prescribed blood pressure-lowering medications (70.1% vs 66.0%, p=0.002). However, there were no statistical differences in the prescription of lipid-lowering or antiplatelet medications. After adjustments for covariates and multiple testing, patients with cancer did not show a difference in GPMPs, TCAs, and a review of either, but were more likely to receive mental health treatment consultations than those without cancer (odds ratio 1.76; 95% confidence interval 1.42-2.19). Less than half of patients with CVD had a GPMP, TCA or review of either. Although those patients with cancer were more likely to receive these interventions, still around half the patients did not. Medicare-funded GPMPs, TCAs and a review of either GPMP or TCA were underutilised, and future studies should seek to identify ways of improving access to these services.

Opportunities to improve quality of care for cancer survivors in primary care: findings from the BETTER WISE study

PurposeThe BETTER WISE (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care for Wellness of Cancer Survivors and Patients) intervention is an evidence-based approach to prevention and screening for cancers and chronic diseases in primary care that also includes comprehensive follow-up for breast, prostate and colorectal cancer survivors. We describe the process of harmonizing cancer survivorship guidelines to create a BETTER WISE cancer surveillance algorithm and describe both the quantitative and qualitative findings for BETTER WISE participants who were breast, prostate or colorectal cancer survivors. We describe the results in the context of the COVID-19 pandemic.MethodsWe reviewed high-quality survivorship guidelines to create a cancer surveillance algorithm. We conducted a cluster randomized trial in three Canadian provinces with two composite index outcome measured 12 months after baseline, and also collected qualitative feedback on the intervention.ResultsThere were 80 cancer survivors for whom we had baseline and follow-up data. Differences between the composite indices in the two study arms were not statistically significant, although a post hoc analysis suggested the COVID-19 pandemic was a key factor in these results. Qualitative finding suggested that participants and stakeholders generally viewed BETTER WISE positively and emphasized the effects of the pandemic.Conclusions and implications for cancer survivorsBETTER WISE shows promise for providing an evidence-based, patient-centred, comprehensive approach to prevention, screening and cancer surveillance for cancer survivors in the primary care setting.Trial registrationISRCTN21333761. Registered on December 19, 2016, http://www.isrctn.com/ISRCTN21333761.

Diyabet ve hipertansiyon hastalarında kronik hastalığa bağlı stigma düzeyinin değerlendirilmesi

Introduction and Aim: The two most common chronic diseases in primary care chronic disease follow-up are diabetes (DM) and hypertension (HT). The aim of this study is to evaluate the level of chronic disease stigma, perceived social support and depression in DM and HT patients, and to examine their effects on treatment regulation. Materials and Methods: A single-center, descriptive study was conducted with randomly selected 50 DM and 50 HT patients who applied to a Family Health Center between September and December 2020. Patients with DM were divided into regulated and non-regulated groups according to HbA1c level, and HT patients according to target cytolic/diastolic arterial pressure.The level of stigmatization with the Expected Stigma Scale in Chronic Diseases (CIASS), psychological health status with the Patient Health Questionnaire-9 Scale (PHQ-9), and perceived social support status with the Multidimensional Scale of Perceived Social Support (MSPSS) were questioned face-to-face. SPSS program was used in the analysis of the data. Results: One hundred patients with a mean age of 56.4±11.4 years and a diagnosis period of 10.4±7.2 years were included in the study. Stigma levels of patients with unregulated DM (38.0%) and unregulated HT (14%) were compared. DM patients had higher total expected stigma score of chronic diseases (p=0.001), related to work life (p&lt;0.001) and healthcare workers (p=0.007). In the linear regression analysis, it was determined that the current depression level of the patient is the determinant of the level of stigma in chronic diseases in both HT patients (F = 4.073, p=0.012, R² = 0.21) and DM patients (F = 3.154, p =0.012, R² = 0.30). Discussion and conclusion: The level of chronic disease stigma was found to be higher in DM patients than in HT patients, and the rate of treatment regulation was lower. The role of depression level, expected stigma level from work environment and healthcare professionals were pointed out in the regulation of DM.

Care coordinator application to manage chronic disease in primary care

Care coordinator application to manage chronic disease in primary care

Quality Indicators for Chronic Diseases in Primary Care

Quality indicators is defined as nominal, ordinal or quantitative measures of health care quality in order to provide effective, safe and human-centered health care. They are the most important tools in monitoring quality. Quality indicators are widely used in many countries, including Türkiye, to evaluate and improve the quality of care in the health system. Quality indicators in primary care in Türkiye started to be implemented in 2017 by the Ministry of Health with the Organization for Economic Cooperation and Development Health Care Quality Indicators Turkey project. According to this project Turkey includes 9 categories. These are Primary Health Care (preventable hospital admissions), Primary Care (prescribing), Acute Care, Mental Health Services, Patient Safety, Patient Experiences, Cancer Care, Infectious Disease Care, Dementia Health Services. The Category of Primary care has seven quality indicators. Although it was introduced in 2017 it is not widely used in primary care. Primary care plays an important role in the promotion of health care. Therefore, using quality indicators will be helpful in this process. Keywords: chronic disease, family physician, quality ındicators, health care

Patient advocates' views of patient roles in interprofessional collaborative practice in primary care: A constructivist grounded theory study.

Interprofessional collaborative practice has been shown to be an appropriate model of care for chronic disease management in primary care. However, how patients play a role in this model is relatively unknown. The aim of this constructivist grounded theory focus group study was to explore the perceptions of patient advocates regarding the role of patients in interprofessional collaborative practice for chronic conditions in primary care. Primary data were collected from patient advocates, from public and private Australian organisations and who represent patients with chronic disease in primary care, through focus groups in July-August 2020. Videoconference focus groups were recorded, transcribed verbatim and inductively, thematically analysed using the five-step approach by Charmaz: (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation and (5) theme and sub-theme development. Three focus groups comprising 17 patient advocates with diverse cultural and professional backgrounds participated. Two themes and five sub-themes relating to interprofessional collaborative practice teams were constructed from the data. In theme 1, patients 'shifted across the spectrum of roles' from 'relinquishing control to the team', 'joining the team' to 'disengaging from the team'. The second theme was the need for 'juggling roles' by 'integrating patient role with life roles', and 'learning about the patient role'. The diversity and variability of patient roles as described by patient advocates highlight the challenges of working with people with chronic conditions. The diverse patient roles described by advocates are an important finding that may better inform communication between patients and health professionals when managing chronic conditions. From the health professional perspective, identification of the role of a patient may be challenging. Therefore, future research should explore the development of a tool to assist both patients and health professionals to identify patient roles as they move across the spectrum, with the support of policy makers. This tool should aim to identify and promote patient engagement in interprofessional collaborative practice in primary care settings.

Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study

IntroductionPeople with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care...

The Normative Cost of Twenty Most Prominent Diseases in Yogyakarta, Indonesia: A Delphi Consensus Study

Objective: To formulate a convergent and consensus expert panel to calculate normative drug cost in the top twenty diseases in primary care. Method: In the first round, the expert panel define a list of consensus statements based on data derived from non-systematic reviews of treatment standard for the top twenty disease in primary care. In the second round, experienced doctors in treatment at primary care were involved to express individual consent to the statements using questionnaire. Face-to-face meeting were held simultaneously with filling questionnaire. Consensus was defined as 75% agreement. Result: Delphi process at the first round, the expert panel consisting of 11 doctors in primary care defined a list of 60 statements from 20 diseases on the treatment standard calculated the normative cost of acute and chronic disease in primary care. The second round involved 11 doctors who are experienced in primary care with more than 6 years’ experience in doing treatment in primary care. Conclusion: The identified consensus statement can help doctors to apply the normative cost calculation results on the top 20 diseases in primary care as evidence based policy study material for calculating the percentage of drug cost in the capitation system in Indonesia. Bangladesh Journal of Medical Science Vol. 21 No. 02 April’22 Page : 291-301

Traditional and complementary medicine (TCM) usage and its association with Patient Assessment of Chronic Illness Care (PACIC) among individuals with metabolic syndrome in primary care

BackgroundTraditional and Complementary Medicine (TCM) is widely used particularly among patients with chronic diseases in primary care. However, evidence is lacking regarding TCM use among patients with Metabolic Syndrome (MetS) and its association with patients’ experience on chronic disease conventional care that they receive. Therefore, this study aims to determine the prevalence and pattern of TCM use, compare the patients’ experience of chronic disease care using the Patient Assessment of Chronic Illness Care - Malay version (PACIC-M) questionnaire between TCM users and non-users and determine the factors associated with TCM use among patients with MetS in primary care.MethodologyA cross-sectional study was conducted at a university primary care clinic. Patients aged 18 to 80 years old with MetS were recruited. Socio-demographic characteristic, clinical characteristics and information on TCM use and its pattern were recorded in a proforma. Patient’s experience of chronic disease conventional care was measured using PACIC-M questionnaire. The comparison of PACIC-M mean score between TCM users and non-users was measured using independent t-test. The factors associated with TCM use were determined by simple logistic regression (SLogR), followed by multiple logistic regression (MLogR).ResultsOut of 394 participants, 381 (96.7%) were included in the final analysis. Of the 381 participants, 255 (66.9%) were TCM users (95% CI 62.7, 71.7). Only 36.9% of users disclosed about TCM use to their health care providers (HCP). The overall mean PACIC-M score was 2.91 (SD ± 0.04). TCM users had significantly higher mean PACIC-M score compared to non-users (2.98 ± 0.74 vs 2.75 ± 0.72, p = 0.01). The independent factors associated with TCM use were being female (Adj. OR 2.50, 95% CI 1.55, 4.06), having high education level (Adj. OR 2.16, 95% CI 1.37, 3.41) and having high overall PACIC-M mean score (Adj. OR 1.49, 95% CI 1.10, 2.03).ConclusionTCM use was highly prevalent in this primary care clinic. However, the disclosure rate of TCM use to HCP was low. Females, those with high education and high PACIC-M mean score were more likely to use TCM. Further research should explore the reasons for their TCM use, despite having good experience in conventional chronic disease care.

Increasing exercise adherence among elderly patients with chronic disease in primary care: a prospective cohort study

BackgroundCurrently, the evidence for exercise in maintaining health, well-being, and physical functioning is overwhelming. Despite these benefits, more than 50% of the population fails to meet the recommended exercise requirements for age and health status. In our study, we sought to provide a method to increase exercise adherence that was both effective and time-efficient for physicians and their patients.MethodsThe primary objective of this research study was to evaluate the effectiveness of a graded exercise protocol and biweekly monitoring on increasing the duration of aerobic exercise to 150 min per week in a population of elderly individuals with chronic disease. Secondarily, we evaluated for improvement in resting heart rate, blood pressure, body mass index (BMI), and cardiorespiratory fitness. The overall study design was a randomized, prospective cohort study with assessor blinding. Forty-five patients aged ≥60 years with multiple comorbidities were recruited from the Internal Medicine Clinic at Wright-Patterson AFB. Participants were randomized into a treatment or control arm and observed over a period of 34 weeks. Those in the treatment arm were given a graded walking protocol and received biweekly phone calls to evaluate compliance. Those in the control arm did not receive an intervention or biweekly monitoring. Measurements of heart rate, blood pressure, and BMI were taken quarterly in both groups. At the beginning and conclusion of the study, each participant completed a modified Balke treadmill test and Physical Activity Scale for the Elderly (PASE). Continuous variables were evaluated with the independent samples t-test, whereas categorical variables were evaluated with the chi-squared test.ResultsA greater percentage of the treatment group achieved the primary outcome (41.6% vs. 0%; p = 0.003). Those in the treatment group also had favorable improvements in heart rate response (− 2.4 beats/min vs. + 5.3 beats/min; p = 0.038) and PASE (+ 66 vs.-20; p < 0.001). No significant differences were observed between groups for mean change in heart rate, blood pressure, or BMI.ConclusionGuided, independent exercise and surveillance can be an effective tool in primary care practice to help patients reach the recommended levels of exercise for both age and health status.

Cost-effectiveness analysis of a multiple health behaviour change intervention in people aged between 45 and 75\u2009years: a cluster randomized controlled trial in primary care (EIRA study)

BackgroundMultiple health behaviour change (MHBC) interventions that promote healthy lifestyles may be an efficient approach in the prevention or treatment of chronic diseases in primary care. This study aims to evaluate the cost-utility and cost-effectiveness of the health promotion EIRA intervention in terms of MHBC and cardiovascular reduction.MethodsAn economic evaluation alongside a 12-month cluster-randomised (1:1) controlled trial conducted between 2017 and 2018 in 25 primary healthcare centres from seven Spanish regions. The study took societal and healthcare provider perspectives. Patients included were between 45 and 75 years old and had any two of these three behaviours: smoking, insufficient physical activity or low adherence to Mediterranean dietary pattern. Intervention duration was 12 months and combined three action levels (individual, group and community). MHBC, defined as a change in at least two health risk behaviours, and cardiovascular risk (expressed in % points) were the outcomes used to calculate incremental cost-effectiveness ratios (ICER). Quality-adjusted life-years (QALYs) were estimated and used to calculate incremental cost-utility ratios (ICUR). Missing data was imputed and bootstrapping with 1000 replications was used to handle uncertainty in the modelling results.ResultsThe study included 3062 participants. Intervention costs were €295 higher than usual care costs. Five per-cent additional patients in the intervention group did a MHBC compared to usual care patients. Differences in QALYS or cardiovascular risk between-group were close to 0 (− 0.01 and 0.04 respectively). The ICER was €5598 per extra health behaviour change in one patient and €6926 per one-point reduction in cardiovascular risk from a societal perspective. The cost-utility analysis showed that the intervention increased costs and has no effect, in terms of QALYs, compared to usual care from a societal perspective. Cost-utility planes showed high uncertainty surrounding the ICUR. Sensitivity analysis showed results in line with the main analysis.ConclusionThe efficiency of EIRA intervention cannot be fully established and its recommendation should be conditioned by results on medium-long term effects.Trial registrationClinicaltrials.gov NCT03136211. Registered 02 May 2017 – Retrospectively registered

Community Health Workers as Healthcare Navigators in Primary Care Chronic Disease Management: a Systematic Review

This review was carried out to synthesize the evidence of the effectiveness of community health worker (CHW) navigation in primary care chronic disease management. We searched the English language literature between January 1990 and March 2020 in Medline, Embase, Emcare, PubMed, Psych Info, CINAHL, Scopus, and Medline Epub ahead of print. Data extraction, quality rating, and assessment of the reporting of interventions were performed by two reviewers independently and the findings were synthesized narratively. Twenty-nine articles met the inclusion criteria. All but two were carried out in the USA and half were randomized controlled trials. Six of the 29 studies were of strong methodological quality while 12 were moderate and 11 weak. Overall, CHW navigation interventions were effective in increasing adherence to cancer screening and improving use of primary care for chronic disease management. There was insufficient evidence that they improved clinical outcomes or risk factors and reduced use of secondary or tertiary care or that they were cost-effective. However, criteria for recruitment, duration, and mode of training and supervision arrangements varied greatly between studies. CHW navigation interventions improved aspects of chronic disease management. However, there is insufficient evidence of the impact on patient experience, clinical outcomes, or cost-effectiveness of the interventions. Future research should focus on standardizing organizational components of the CHW navigation interventions and evaluating their cost-effectiveness. The review protocol was published in PROSPERO (CRD42020153921).

Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Development of a Tool by Adapted Delphi Procedure.

BackgroundLong-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists.ObjectiveThe aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR.MethodsWe used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators’ utility in practice and summarized them into a user-friendly layout.ResultsThis multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs.ConclusionsOur generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.

How Primary Care Physicians Elicit Sensitive Health Information From Patients: Describing Access to Psychosocial Information

Multiple communication models describe factors that influence disclosure of sensitive health information. However, these models do not address the receiver's perspective of health-related information, nor do they address how the receiver promotes disclosure. In the primary care chronic disease visit, the patient (sender) must disclose sensitive health-related psychosocial information to the primary care physician (PCP) (receiver) for the PCP to understand potential barriers to care (e.g., financial strain) and make treatment decisions (e.g., referral to social work). A vital gap exists in understanding how PCPs perceive that patients disclose. We conducted individual, semi-structured interviews (n = 17) to understand PCPs' perceptions of patient disclosure of sensitive, psychosocial information in the clinical visit. PCPs facilitate patient disclosure by (a) building and maintaining rapport and (b) nurturing the patient-provider relationship. This article describes PCPs' perceptions of how they access psychosocial information which is vital to inform clinical decisions that facilitate personalized care.

Evaluating implementation and impact of a provincial quality improvement collaborative for the management of chronic diseases in primary care: the COMPAS+ study protocol

BackgroundChronic conditions such as diabetes and chronic obstructive pulmonary disease (COPD) are common and burdensome diseases primarily managed in primary care. Yet, evidence points to suboptimal quality of care for these conditions in primary care settings. Quality improvement collaboratives (QICs) are organized, multifaceted interventions that can be effective in improving chronic disease care processes and outcomes. In Quebec, Canada, the Institut national d’excellence en santé et en services sociaux (INESSS) has developed a large-scale QIC province-wide program called COMPAS+ that aims to improve the prevention and management of chronic diseases in primary care. This paper describes the protocol for our study, which aims to evaluate implementation and impact of COMPAS+ QICs on the prevention and management of targeted chronic diseases like diabetes and COPD.MethodsThis is a mixed-methods, integrated knowledge translation study. The quantitative component involves a controlled interrupted time series involving nine large integrated health centres in the province. Study sites will receive one of two interventions: the multifaceted COMPAS+ intervention (experimental condition) or a feedback only intervention (control condition). For the qualitative component, a multiple case study approach will be used to achieve an in-depth understanding of individual, team, organizational and contextual factors influencing implementation and effectiveness of the COMPAS+ QICs.DiscussionCOMPAS+ is a QI program that is unique in Canada due to its integration within the governance of the Quebec healthcare system and its capacity to reach many primary care providers and people living with chronic diseases across the province. We anticipate that this study will address several important gaps in knowledge related to large-scale QIC projects and generate strong and useful evidence (e.g., on leadership, organizational capacity, patient involvement, and implementation) having the potential to influence the design and optimisation of future QICs in Canada and internationally.

Vitamin D Levels in Chronic Diseases in Primary Care

Vitamin D Levels in Chronic Diseases in Primary Care

Erratum - Frailty syndrome in the elderly in elderly with chronic diseases in Primary Care.

[This corrects the article doi: 10.1590/S1980-220X2018002603449].

Managing chronic disease in primary care: a review

Managing chronic disease in primary care: a review