Primary Care Environment Research Articles

Use of professional-mode flash glucose monitoring, at 3-month intervals, in adults with type 2 diabetes in general practice (GP-OSMOTIC): a pragmatic, open-label, 12-month, randomised controlled trial

Continuous glucose monitoring, either real-time (personal) or retrospective (professional mode), can identify day-to-day glucose profiles to guide management decisions for people with type 2 diabetes. We aimed to examine the effects of professional-mode flash glucose monitoring, done at 3-month intervals, in adults with type 2 diabetes in general practice. We did a pragmatic, two-arm, open label, 12-month, individually randomised controlled trial (GP-OSMOTIC) in 25 general practices in Victoria, Australia. Eligible participants were adults aged 18-80 years, with type 2 diabetes diagnosed for at least 1 year and HbA1c at least 5·5 mmol/mol (0·5%) above their target in the past month despite being prescribed at least two non-insulin glucose-lowering drugs, insulin, or both (with therapy stable for at least 4 months). We randomly assigned participants (1:1) to either use of a professional-mode flash glucose monitoring system or usual clinical care (control). All participants wore the flash glucose monitoring sensor at baseline, and electronic randomisation (using permuted block sizes of four and six, and stratified by clinic) was done after the sensor was attached. Masking of participants and treating clinicians to group allocation was not possible, but the study statistician was masked to allocation when analysing the data. At baseline, and 3, 6, 9, and 12 months, participants in the flash glucose monitoring group wore the professional-mode flash glucose monitoring sensor for 5-14 days before their general practice visit. The sensor recorded interstitial glucose concentrations every 15 min, but the glucose data were not available to the participant until their general practice visit, where the sensor output would be uploaded to a computer by the health professional and discussed. Control group participants wore the sensor at baseline and at 12 months for data analysis only, and had usual care visits every 3 months. The primary outcome was the between-group difference in mean HbA1c at 12 months. Secondary outcomes were the between-group differences in: mean percentage time in target glucose range (4-10 mmol/L), based on ambulatory glucose profile data at 12 months; mean diabetes-specific distress (assessed with the Problem Areas In Diabetes [PAID] scale) at 12 months; and mean HbA1c at 6 months. Analysis was done by intention to treat. This trial is registered at the Australian and New Zealand Clinical Trials Registry, ACTRN12616001372471. Between Oct 4, 2016, and Nov 17, 2017, we randomly assigned 299 adults: 149 to flash glucose monitoring and 150 to usual care. At 6 months, HbA1c was lower in the flash glucose monitoring group than in the usual care group (difference -0·5%, 95% CI -0·8% to -0·3%; p=0·0001). However, at 12 months (primary outcome), there was no significant between-group difference in estimated mean HbA1c (8·2% [95% CI 8·0 to 8·4] for flash glucose monitoring vs 8·5% [8·3 to 8·7] for usual care; between-group difference -0·3%, 95% CI -0·5 to 0·01; [66 mmol/mol, 95% CI 64 to 68 vs 69 mmol/mol, 67 to 72; between-group difference -3·0, 95% CI -5·0 to 0·1]; p=0·059). Mean percentage time spent in target glucose range at 12 months was 7·9% (95% CI 2·3 to 13·5) higher in the flash glucose monitoring group than in the usual care group (p=0·0060). Diabetes-specific distress PAID scores were unchanged at 12 months (between-group difference -0·7, 95% CI -3·3 to 1·9; p=0·61). No episodes of severe hypoglycaemia or treatment-related deaths were reported. One participant died during the study from causes unrelated to the intervention (following complications post-myocardial infarction with multiple comorbidities). Professional-mode flash glucose monitoring in adults with type 2 diabetes in general practice did not improve the primary outcome of HbA1c at 12 months or diabetes-specific distress compared with usual care, but did improve time in target glucose range at 12 months and HbA1c at 6 months. Our findings suggest that professional-mode flash glucose monitoring can be implemented in a pragmatic primary care environment. Although there was no change in HbA1c at 12 months, the improved time in target range might reflect the potential of the technology to support personalised clinical care by providing insights into glycaemic profiles for some people with type 2 diabetes. National Health and Medical Research Council of Australia, Sanofi Australia, and Abbott Diabetes Care.

Accessing primary health care services for transition-aged young adults with cerebral palsy; perspectives of young adults, parents, and physicians

AbstractBackgroundYoung adults with childhood-onset disabilities experience challenges with accessing age appropriate primary health care services as they transition from pediatric to adult health care services. They often experience a negative impact on their health with associated long-term health and social concerns, disease complications and increased use of emergency services once transitioned to adult services. This is particularly challenging for youth with cerebral palsy (CP) due the complexity of their medical needs. The aim of this study was to explore experiences with accessing or providing primary care services for transitioned-aged young adults with CP from young adult, parent, pediatrician and primary care physician perspectives.MethodsA qualitative descriptive design was conducted to identify the challenges and facilitators for transitioned aged young adults with accessing primary, adult care services. Semi-structured interviews were conducted with 16 participants within the circle of care (4 adults with CP, 4 parents, 4 pediatricians and 4 primary healthcare physicians) for individuals with CP in Toronto, Canada. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis guided both the data collection and the data analysis processes.ResultsData analysis revealed that all participant groups reported transition challenges with respect to accessibility, the suitability of some primary care environments for caring for individuals with complex care needs, gaps in seamless care, and limited time and funding when receiving or providing primary care services to young adults with CP.DiscussionThere is a greater demand for adult healthcare providers now to deliver services for adults with childhood onset disabilities. Transition-aged young adults with CP and complex medical needs have increased challenges with accessing primary care services. Considering the following would improve primary care services transition for this population with complex medical needs: ongoing partnering between pediatric and adult health care streams to promote seamless care; connection to team-based primary care services where family physicians, subspecialties and interprofessional practitioners work together to provide joint care planning; salary compensation for increased service needs due to medical complexity; accessible sites; and development of guidelines for transitioning youth/young adults with complex care needs.

Musculoskeletal (MSK) practitioners in primary care: an evaluation of a MSK core capabilities framework and review process

ABSTRACTThe General Practice Contract 2019/20 established first contact musculoskeletal (MSK) physiotherapists in primary care. This paper describes an evaluation exploring the feasibility of using the MSK Core Capabilities Framework and a peer review process to evidence capability. It discusses how this process may be developed to ensure MSK practitioners are able to evidence the level of practice required within the complex environment of primary care. MSK practitioners were supported to evidence their capabilities against the MSK Framework. Twenty-two participants took part in the evaluation of this intervention via semi-structured interviews. A robust and iterative process of qualitative data analysis was undertaken. The findings are framed in terms of Davis’ Technology Acceptance Model of evaluation (i.e. user perceptions).There were a range of perceived benefits of the Framework including as a means of quality assurance, career progression, the promotion of knowledge consolidation and reflective practice. There were however, a number of ‘translation into practice’ issues. Given the newness of the MSK Framework, it is perhaps not surprising there is a need for refinement. This evaluation highlights key enablers for reviewing capabilities of MSK practitioners: a curriculum; educational supervision; and accreditation. Learning also applies more widely to other emerging role opportunities.

A systematic review and meta-analysis of community and primary-care-based hepatitis C testing and treatment services that employ direct acting antiviral drug treatments

BackgroundDirect Acting Antiviral (DAAs) drugs have a much lower burden of treatment and monitoring requirements than regimens containing interferon and ribavirin, and a much higher efficacy in treating hepatitis C (HCV). These characteristics mean that initiating treatment and obtaining a virological cure (Sustained Viral response, SVR) on completion of treatment, in non-specialist environments should be feasible. We investigated the English-language literature evaluating community and primary care-based pathways using DAAs to treat HCV infection.MethodsDatabases (Cinahl; Embase; Medline; PsycINFO; PubMed) were searched for studies of treatment with DAAs in non-specialist settings to achieve SVR. Relevant studies were identified including those containing a comparison between a community and specialist services where available. A narrative synthesis and linked meta-analysis were performed on suitable studies with a strength of evidence assessment (GRADE).ResultsSeventeen studies fulfilled the inclusion criteria: five from Australia; two from Canada; two from UK and eight from USA. Seven studies demonstrated use of DAAs in primary care environments; four studies evaluated integrated systems linking specialists with primary care providers; three studies evaluated services in locations providing care to people who inject drugs; two studies evaluated delivery in pharmacies; and one evaluated delivery through telemedicine. Sixteen studies recorded treatment uptake. Patient numbers varied from around 60 participants with pathway studies to several thousand in two large database studies. Most studies recruited less than 500 patients. Five studies reported reduced SVR rates from an intention-to-treat analysis perspective because of loss to follow-up before the final confirmatory SVR test. GRADE assessments were made for uptake of HCV treatment (medium); completion of HCV treatment (low) and achievement of SVR at 12 weeks (medium).ConclusionServices sited in community settings are feasible and can deliver increased uptake of treatment. Such clinics are able to demonstrate similar SVR rates to published studies and real-world clinics in secondary care. Stronger study designs are needed to confirm the precision of effect size seen in current studies. Prospero: CRD42017069873.

133 A Quick Pediatric Early Warning Scores is Predicitive of Adverse Outcome in a Out-of-Hospital Cohort of Unselected Ambulance Patients

Pediatric Early Warning Scores (PEWS) for hospital inpatients can recognise deteriorating children hours before a critical event. We have previously published data validating the use of PEWS in the out-of-hospital environment. 1. Which specific physiological parameters of the PEWS were most predictive of the primary outcome; specifically, ICU admission within 48 hours or death within 30 days 2. Is a quick PEWS (qPEWS), using less parameters, valid in the out-of-hospital environment. All patients aged < 16 years old conveyed by the Scottish Ambulance Service (SAS) to hospital from 2011 to 2015. A stepwise approach was used by including the eight individual PEWS components with significance level thresholds of 5% and 10% respectively for entry to and remaining in the model. 102,993 patients were available for analysis. All eight components of the PEWS were independent predictors of the primary outcome; however, the AUC increased little after the first 4 entered components - GCS, heart rate, O2 saturation and systolic BP - derived as the qPEWS. There were a total of 67265 patients with at least one record of all 4 components of a qPEWS score. Using the qPEWS score as the explanatory variable showed an area under the curve (AUC) for the primary outcome of 0.782 (95% CI 0.763 to 0.801, p<0.001). qPEWS using four components is predictive of adverse outcome in an unselected paediatric out-of-hospital population. Capture of the four data points required for qPEWS is much better - three times as many patients had the data available compared to PEWS (67265 vs 21202). All 4 of the parameters required for qPEWS can be captured with a saturation probe, making this a practical scoring tool to use in primary care, out-of-hospital and austere environments. This simplified score is not at the expense of diagnostic accuracy.

MANAGEMENT OF NON-COMMUNICABLE DISEASE PREVENTION AT DISTRICT LEVEL IN MALAYSIA

Background: The Non –Communicable Disease (NCD) unit in Malaysia has had much focus in recent years as its country undergoes a major epidemiologic transition with the rise in the four largest contributors of NCD deaths namely cardiovascular disease, cancer, diabetes and chronic respiratory disease. In line with reducing the burden of NCD both for the patient and healthcare, the district health office plays a vital role in managing disease prevention through adequate planning, focusing on the implementation of primary, secondary and tertiary prevention and monitoring the health of the population. Materials and Methods: A literature review was conducted through online database search such as Google Scholar and PubMed to identify articles that were related to the current management of non-communicable disease prevention. Initial keywords used were district health management, non-communicable disease, prevention and Malaysia. The reference list was also reviewed for related articles including some that were handpicked. Result: Healthcare system in Malaysia is performed as a top down exercise whereby most of the national planning is conducted at federal level by the Ministry of Health. However, at the ground level, the district health office needs to conduct situational analysis to identify the needs and challenges of the local community within their jurisdiction. The management of NCD prevention is focusing on the implementation of actions through primary, secondary and tertiary prevention levels that fall within the role of health professionals and health care providers in primary care, hospitals and community services environment. Conclusion: Community empowerment and health education are important components in primary prevention of NCD. Early diagnosis and prompt treatment for NCD provided at the district level will stop the progression of the disease, leading to a better prognosis. Tertiary prevention in the form of rehabilitation at district level reduces and limits the disability and impairment related to NCD. Keywords: Non-communicable disease, prevention, district level, NCD program, community empowerment

Occupational Therapy in Primary Care: Positioned and Prepared to Be a Vital Part of the Team.

Reilly's (1962) now deeply cherished statement that "man, through the use of his hands, as they are energized by mind and will, can influence the state of his own health" (p. 1) was followed a few years later with a question to current and future occupational therapy practitioners. In 1966, Reilly asked how the profession would respond to the challenges of an expanding knowledge base, accelerating health care costs, and escalating regulatory burden. Visionary Wilma West, a contemporary of Reilly's, expanded on these themes by focusing on ways occupational therapy practitioners could leverage the breadth and depth of their practice to confront these challenges. These issues are now paramount in the primary care arena. An expanding body of literature, including the articles in a special section in this issue of the American Journal of Occupational Therapy, supports occupational therapy's role as a vital part of the solution to contemporary health care challenges. Occupational therapy practitioners are educationally prepared and successfully poised through policy to engage in evidence-based practice in the primary care environment.

Perception of the professional nursing environment in Primary Care in the Valencian Community, in departments with public and private management

Nursing practice environments (NPE) improve the quality of care, satisfaction and heath results; there are no studies that compare the Primary Health Care (PHC) environments according to their management model. Our aim is to estimate and compare the perception of the quality of the NPE in the PHC in Health Departments (HD) of the Valencian Community (Spain) with management model public or indirect-private (Administrative concession). Transversal study on PHC nurses from three HD, one with direct public management and two with indirect-private management. The Practice Environment Scale-Nursing Work Index questionnaire, validated in Spain, was administered. Sociodemographic and professional variables were recorded. Variables related to test score were analyzed by multiple linear regression. Two hundred and sixty-nine answers (80.3%). All HD perceived NPE quality in a positive way, both globally and for the different dimensions (except D4). Indirect private management model HD obtained higher global scores, the same tendency was observed for D1 and D2, and the opposite for D4. Global score was related to age, professional experience, being a coordinator and management model; only the age of the nurses and being a coordinator showed a significant relationship with the score in the multivariate regression model. The NPE of the PHC of the Valencian Community are of good quality, without significant differences according to different management models of the HD. Being a coordinator and, particularly, the age of the nurses are variables that are independently related to the global score obtained.

Malnutrition Across the Continuum of Care

To determine the impact identifying malnutrition in Veterans has on clinically related outcomes. Hypothesis: Identification of malnutrition in primary care settings will lead to clinical improvements. Malnutrition is of utmost concern as it contributes to the worsening of disease states and increased medical costs associated with malnutrition. In 2015, the Veterans Affairs (VA) developed the nationwide Nutrition and Food Service Strategic Planning Goals to address the identification and treatment of malnutrition. Consequently, employees extensively trained using the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (Academy/ASPEN) criteria, which led to a significant increase in malnutrition identification. Since this new standard of practice was initiated, there have been no quality improvement studies conducted to determine the clinical benefits of identification and treatment of malnutrition in the primary care setting. This retrospective study measured the impact of registered dietitian nutritionist (RDN) identification of malnutrition on clinical outcomes in a veteran ambulatory setting. The outcomes studied included: Malnutrition clinical characteristics (MCCs), number of dehydration-related emergency room visits, osmolality, number of hospital admissions, length of stay (LOS), Morse fall risk, number of falls, and Zaritt caregiver burden. Data was collected by electronic chart review of 98 patients identified with malnutrition (excluded individuals with active oncology or spinal cord injury treatment, hospice admission, or death within study timeframe) in the home-based primary care (HBPC) or outpatient setting between March 2016 and March 2018. Outcomes in the HBPC and outpatient settings, individually and combined, provided an overall view of the primary care environment. RDN-identification was associated with statistically significant improvements (p<0.025) in hospital LOS, admissions, and MCCs. No other variables reached statistical significance. There were 43 total hospital admissions before malnutrition identification and 23 admissions afterward. Hospital days reduced from 284 pre-identification to 170 days post-identification. The RDN identified malnutrition by the following characteristics: loss of muscle mass (96%), loss of subcutaneous fat (87%), inadequate energy intake (82%), weight loss (67%), diminished functional status (44%), and fluid accumulation (6%). Interventions utilized in outpatient and HBPC, respectively, was as follows: oral nutrition supplementation, 98%, 93%; education, 100%, 90%; counseling, 76%, 5%; and coordination of care, 51%, 70%. In addition, the percent of MCCs improved for outpatient and HBPC patients. RDNs have a unique skillset to identify malnutrition and implement interventions based on patients’ individual needs. Early identification in primary care may decrease malnutrition morbidity by treating the problem in the ambulatory setting before resolution becomes more difficult in an acute admission. Furthermore, RDN interventions may support quality improvement scores pertaining to LOS and admissions. Future studies with larger sample sizes are needed to determine whether RDN intervention intensity, type and duration between visits has an impact on clinical outcomes.

Strengthening primary care: the role of e-learning

ABSTRACTHealth systems strengthening has been defined as ‘any array of initiatives and strategies that improves one or more of the functions of the health system and leads to better health through improvements in access, coverage, quality, or efficiency’. Health systems strengthening depends on human resources. These can only be developed through the provision of healthcare professional education at undergraduate, postgraduate and continuing professional development levels. E-learning is being increasingly used in healthcare professional education. There is a growing evidence that e-learning produces broadly similar outcomes as face-to-face education. However, there is burgeoning interest in how healthcare professionals learn online and how they transfer their learning into clinical practice. This paper examines concepts that are important in the delivery of high-quality e-learning in the primary care environment. If we are to leverage e-learning to the maximum effect, it must enable transfer to clinical practice and be accessible and sustainable from a financial and environmental perspective. Ideally it should be adaptive and relevant to the core activities of primary care professionals.

DREEM in primary care: students’ perspectives on educational environment of family medicine internship in primary care centres: experiences at Akdeniz University Faculty of Medicine in Turkey

ABSTRACTObjective: In many countries, medical education programmes are expanding, and educational environments are starting to change from hospitals to primary health care centres. International organizations for medical education highlight that medical students should also be educated at primary and secondary care centres in addition to third-step health care. In this study, the evaluation of sixth-year (final year) medical students’ perspectives on the educational environment of family medicine internship in primary care is presented, using the Dundee Ready Educational Environment Measurement (DREEM)Material and methods: This descriptive cross-sectional study was conducted with sixth-year medical students. Starting in the 2017–2018 academic year, sixth-year medical students started to enrol in educational courses in primary care. A total of 223 students completed internships in primary care for a two-week period, during which we applied the Dundee Ready Educational Environment Measure (DREEM) to evaluate the educational environment at the end of the internship. The collected questionnaires were analysed by using IBM-SPSS version 23 for Mac OS. Student’s t-test and Mann-Whitney U Test were used for comparisons.Results: Of the 223 students, 192 (86%) completed the questionnaire. The total DREEM score was 138.62/200 (%63.5). The students rated the learning environment as positive. The mean score for students’ perceptions of teaching, students’ perceptions of teachers, students’ academic self-perceptions, students’ perceptions of the atmosphere and students’ social self-perceptions were 31.65/48, 30.45/44, 23.46/32, 34.20/48 and were 18.56/28, respectively. The total mean score and subscale scores were not significantly different between males and females.Conclusion: This study suggests that students’ perception of the global learning environment in primary care was more positive than negative. The lowest scores were recorded for Students’ Perceptions of Learning and Students’ Social Self-Perceptions, and the highest score was recorded for Students’ Academic Self-Perceptions.

Simulation Training for Operational Medicine Providers (STOMP): Impact of a Comprehensive Skills-Based Curriculum for Military General Medical Officers.

A standardized training curriculum designed for general medical officers (GMO) titled Simulation Training for Operational Medicine Providers (STOMP) was recently developed to educate and improve GMOs' procedural skills through directed feedback prior to assuming duties in an operational environment. This study aimed to determine the impact this novel curriculum had on GMOs'confidence levels in 21 core privileges covering eight different subspecialties while stationed at Naval Medical Center Portsmouth (NMCP). A cohort study from 2015 to 2017 was designed to address our specific aim to examine if the implementation of the STOMP curriculum increased GMOs' confidence levels. Fifty-seven participants enrolled in the study. The GMO case group completed the STOMP curriculum (n = 22), while the control or GMO self-study group (n = 35) did not complete the curriculum. Six months after starting clinical practice at NMCP, both groups completed an online survey that assessed their confidence level in performing each core privilege using a 5-point Likert scale. Scores were analyzed using a Wilcoxon Mann-Whitney test. Research data were derived from an approved Naval Medical Center, Portsmouth, Virginia IRB, protocol number: NMCP.2016.0010. Participants demonstrated a statistically significant increase in self-rated confidence scores (p < 0.05) in nine core privilege skills: punch biopsy, shave biopsy, excisional biopsy, removal of otic foreign body, removal of nasal foreign body, removal of ocular foreign body, tonometry, incision and drainage of a thrombosed hemorrhoid, and reduction of simple closed fractures and dislocations. These findings suggest that a novel and recently developed standardized simulation training curriculum entitled STOMP improves the confidence levels of early career physicians' in several primary care procedural skills and is an ideal adjunct to traditional lecture-based teaching prior to independent practice in a primary care environment.

Mixed-methods feasibility study of blood pressure self-screening for hypertension detection

ObjectiveTo assess the feasibility of using a blood pressure (BP) self-measurement kiosk—a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records— to improve hypertension...

An approach to acute pulmonary embolism in the primary emergency care environment

Pulmonary embolism (PE) is a common emergency presenting among high risk patients. It is important to have a structured approach to clinical assessment, diagnosis and management of this potentially life-threatening emergency. Clinical and management pathways have improved over the last 10 years as clear guidelines have emerged. Newer diagnostic modalities have become available and will hopefully improve the pick-up rate of PE and reduce the morbidity and mortality. High level evidence presented by the American Society of Haematology and the European Society of Cardiology forms the basis for this review.

Smart capnometry: Personalising the diagnosis and management of respiratory disease

To develop a connected, portable, point-of-care medical device (capnometer) for the diagnosis, monitoring and management of acute and chronic cardiorespiratory diseases at home and in primary and secondary care environments, facilitating timely, evidence-based treatment interventions and

Raising tuberculosis awareness in the primary care environment

While tuberculosis may no longer be a leading cause of death in the UK, it is still a global health concern. Sue Silvester, Gail Beckett and Sharwend Supermanian describe how it is investigated, diagnosed and treated and its implications in primary care Tuberculosis (TB) is an infection that can cause disease in any part of the body; it is infectious when there is pulmonary involvement. World TB Day is on 24 March every year – it is a day to raise awareness and focus our minds on the ultimate aim of TB eradication. To achieve this aim it is essential for all health professionals to understand the disease processes – how TB is acquired, transmitted, diagnosed and treated (in order to execute effective prevention and control strategies) – as well as their role in supporting specialist TB teams.

Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11).

Chronic pain is a major source of suffering. It interferes with daily functioning and often is accompanied by distress. Yet, in the International Classification of Diseases, chronic pain diagnoses are not represented systematically. The lack of appropriate codes renders accurate epidemiological investigations difficult and impedes health policy decisions regarding chronic pain such as adequate financing of access to multimodal pain management. In cooperation with the WHO, an IASP Working Group has developed a classification system that is applicable in a wide range of contexts, including pain medicine, primary care, and low-resource environments. Chronic pain is defined as pain that persists or recurs for more than 3 months. In chronic pain syndromes, pain can be the sole or a leading complaint and requires special treatment and care. In conditions such as fibromyalgia or nonspecific low-back pain, chronic pain may be conceived as a disease in its own right; in our proposal, we call this subgroup "chronic primary pain." In 6 other subgroups, pain is secondary to an underlying disease: chronic cancer-related pain, chronic neuropathic pain, chronic secondary visceral pain, chronic posttraumatic and postsurgical pain, chronic secondary headache and orofacial pain, and chronic secondary musculoskeletal pain. These conditions are summarized as "chronic secondary pain" where pain may at least initially be conceived as a symptom. Implementation of these codes in the upcoming 11th edition of International Classification of Diseases will lead to improved classification and diagnostic coding, thereby advancing the recognition of chronic pain as a health condition in its own right.

Prediction of Long-Term Incidence of Chronic Cardiovascular and Cardiopulmonary Diseases in Primary Care Patients for Population Health Monitoring: The Intermountain Chronic Disease Model (ICHRON)

ObjectiveTo apply the practical parsimonious modeling method of the Intermountain Mortality Risk Score in a primary care environment to predict chronic disease (ChrD) onset. Patients and MethodsPrimary care patients free of ChrD (women: n=98,711; men: n=45,543) were evaluated to develop (70% [n=95,882] of patients) and validate (the other 30% [n=48,372]) the sex-specific Intermountain Chronic Disease Risk Score (ICHRON) if seen initially between January 1, 2003, and December 31, 2005. The sex-specific ICHRON was composed of comprehensive metabolic profile and complete blood count components and age. The primary outcome was the first diagnosis of coronary artery disease, myocardial infarction, heart failure, atrial fibrillation, stroke, diabetes, renal failure, chronic obstructive pulmonary disease, peripheral vascular disease, or dementia within 3 years of baseline. ResultsAt 3 years, 9.0% of men (mean age, 44±16 years) and 6.6% of women (mean age, 42±16 years) received a diagnosis of ChrD. In the derivation population, C-statistics were 0.783 (95% CI, 0.774-0.791) for men and 0.774 (95% CI, 0.767-0.781) for women. In the validation population, C-statistics were 0.774 (95% CI, 0.762-0.786) for men and 0.762 (95% CI, 0.752-0.772) for women. Evaluation of 10-year outcomes for ICHRON and analysis of its association with each outcome individually at 3 years revealed similar predictive ability. ConclusionAn augmented intelligence clinical decision tool for primary care, ICHRON, is developed using common laboratory parameters, which provides good discrimination of ChrD risk at 3 and 10 years.

Preparing the future workforce to address the health needs of small rural Australian towns through non-traditional allied health student placements

Introduction: The health care needs of underserved rural and remote communities are often not addressed due to a lack of clinicians. In some rural communities’ preschool and primary school children are showing signs of mental health disorders including emotional, social and behavioural problems. These children often have lower levels of literacy compared to state levels. Short description of practice change implemented: Occupational therapy (OT) and speech pathology (SP) students from various Australian universities are placed in preschool and primary schools throughout the year. Each of the students are given a case load of up to 20 children. The students provide ongoing support and feedback to teachers and parents. The practice changes are: 1) provision of continuous early intervention and therapy 2) traditionally these children would not have had access to allied health (AH) services 3) low intensity supervision 4) student immersion into disadvantaged rural populations 5) interprofessional placement 6) placement is outside of the traditional acute care setting 7) students are encouraged to consider where changes in policy and practice are appropriate Aim and theory of change: The primary aim of the placements are for students to experience: an authentic rural placement in a primary care environment with diverse patient populations. a real-life application of knowledge in a real community context, that cannot be replicated in a hospital or university setting. a student led, continuous, interprofessional, low intensity supervised placement. The diffusion of innovation theory is applied. Targeted population and stakeholders: Schools in small rural towns with a higher rate than the state average of Indigenous people, families experiencing poverty, and higher rates of trauma and domestic violence. Stakeholder are clinical supervisors, teachers, parents and principles. Timeline: The program has been in place for 18 months across 12 schools. Highlights (innovation, Impact and outcomes): The innovation aspects are 1) Continuous service provision 2) meeting rural healthcare needs 3) low intensity supervision 4) rural community immersion 6) non-traditional settings 7) students implementing policy and practice changes These non-traditional placements lead to students reporting: increased autonomy and confidence to work unsupported in a rural environment increased social accountability and a positive attitude towards working with disadvantaged rural populations feeling workforce ready Sustainability: The model delivers allied health services to rural communities. The stakeholders have expressed a commitment for the program to continue as they recognise improved health outcomes. Transferability: The model could be rolled out to other small rural towns and applied in other disciplines and services. The model is already applied in residential aged care demonstrating the transferability of the model. Conclusions: Students get to experience a real-life application of knowledge in a real community context, that cannot be replicated in a hospital or university setting. Discussions: Low intensity supervision. Workforce readiness. At-risk populations’ needs. Lessons learned These placements can provide an opportunity to increase students’ capability to work in rural settings and provide a solution to addressing: the lack of AH services in small rural communities and a low supply of rural AH clinicians.

Applying Persuasive Design Techniques to Influence Data-Entry Behaviors in Primary Care: Repeated Measures Evaluation Using Statistical Process Control.

BackgroundPersuasive design is an approach that seeks to change the behaviors of users. In primary care, clinician behaviors and attitudes are important precursors to structured data entry, and there is an impact on overall data quality. We hypothesized that persuasive design changes data-entry behaviors in clinicians and thus improves data quality.ObjectiveThe objective of this study was to use persuasive design principles to change clinician data-entry behaviors in a primary care environment and to increase data quality of data held in a family health team’s reporting system.MethodsWe used the persuasive systems design framework to describe the persuasion context. Afterward, we designed and implemented new features into a summary screen that leveraged several persuasive design principles. We tested the influence of the new features by measuring its impact on 3 data quality measures (same-day entry, record completeness, and data validity). We also measured the impacts of the new features with a paired pre-post t test and generated XmR charts to contextualize the results. Survey responses were also collected from users.ResultsA total of 53 users used the updated system that incorporated the new features over the course of 8 weeks. Based on a pre-post analysis, the new summary screen successfully encouraged users to enter more of their data on the same day as their encounter. On average, the percentage of same-day entries rose by 10.3% for each user (P<.001). During the first month of the postimplementation period, users compensated by sacrificing aspects of data completeness before returning to normal in the second month. Improvements to record validity were marginal over the study period (P=.05). Statistical process control techniques allowed us to study the XmR charts to contextualize our results and understand trends throughout the study period.ConclusionsBy conducting a detailed systems analysis and introducing new persuasive design elements into a data-entry system, we demonstrated that it was possible to change data-entry behavior and influence data quality in a reporting system. The results show that using persuasive design concepts may be effective in influencing data-entry behaviors in clinicians. There may be opportunities to continue improving this approach, and further work is required to perfect and test additional designs. Persuasive design is a viable approach to encourage clinician user change and could support better data capture in the field of medical informatics.