Primary Care Experts Research Articles

How can health practitioners support children and young people in social care?

Abstract Health practitioners are responsible for safeguarding, delivering preventive and responsive care for children and young people in social care settings. However, drivers and determinants that place children in care settings lie outside of the doctor’s office. In fact, primary care health practitioners often deal with children and young people who face or are at risk of severe neglect, abuse or vulnerability outside the care system. Recent findings from the UK’s Millennium cohort study have repeatedly demonstrated that social disadvantage in the early years accounts for more than 2/3 of health inequalities in adolescence. Professor Saxena is a practising GP with 25 years of experience of inner-city primary care and global expert on primary care of children. She will present dilemmas posed in clinical settings for health practitioners and professionals working in a broad range of areas including public health, education settings and social care. What responsibility do health professionals have when they encounter children living in social care settings? What should they be especially alert to? How can they make a difference to reduce health inequality faced by young people growing up in the care system.

P100 Clinical Indications Associated with New Opioid Use for Pain Management in the United Kingdom: Using National Primary Care Data

Abstract Background/Aims Prescription opioids for non-cancer pain in the UK have increased over the past two decades, alongside associated harms. There is an increasing recognition that policies to address opioid prescribing need to be tailored according to individual patient needs with specific indications and disease systems. This study aimed to evaluate clinical indications associated with new opioid initiation in non-cancer pain using UK large-scale data. Methods National primary care electronic health records from 01/01/2006 to 31/20/2021 were used from the Clinical Research Practice Datalink. Codelists for opioid-related conditions based on literature and experts in pain management, primary care, rheumatology, and pharmacy were applied to a one-year period before first opioid prescription for surgical indications (given the acute nature) and five-years prior for chronic conditions. Descriptive statistics were used for data analysis, accounting for overlapping indications. Results A total of 3,031,950 new opioid users were identified. Opioids were initiated more commonly in women (60.7%), people in age groups: 45-64 (40.0%) and ≥65 years (37.0%). Nine systems associated with opioid-initiation were identified. The most common were musculoskeletal (74.0%), respiratory (53.1%), infections (25.7%), trauma/injury (16.1%), neurology (16.0%), gastrointestinal (4.2%) within five years prior to the opioid prescription date and post-surgical within one-year prior (3.8%). Musculoskeletal conditions most frequently associated with opioid use were osteoarthritis (n = 1,536,338, 50.7%), low back pain (1,094,163, 36.1%), other non-inflammatory musculoskeletal conditions 344,3412 (11.4%), rheumatoid arthritis 63,365 (2.1%) and fibromyalgia 56,038 (1.9%). Post-surgical indications were associated with 3.8% of all prescriptions, with orthopaedic surgeries being the most common: 42.1% of all post-surgical indications, including total knee replacements (n = 31,944; 27.6%) and total hip replacements (n = 17,863; 14.5%). Conclusion This is the first study in the UK evaluating large scale national data to assess indications associated with opioid initiation. Almost three quarters of the new prescriptions of opioids for non-cancer pain were in people with a diagnosis of a musculoskeletal condition. Orthopaedic surgeries contributed to a third of all post-surgical indications. These findings could help inform prioritisation of targeted interventions in opioid de-prescribing, clinical vigilance, and policy development to support non-pharmacological interventions in patients with musculoskeletal conditions. Disclosure M. Lyon: None. C. Ramirez Medina: None. E. Davies: None. M. Jani: None.

“Nothing about us, without us”. Practical elaboration of experience experts in primary care

The health care sector sensed already for several years a shift in primary care to more complex situations and support questions. Tackling these challenges requires an integrated collaboration between health, wellbeing and social care. There was an urge to bring in a different approach of care. In order to fulfill that need Flanders was defined into 60 geographical areas in 2020: ‘The primary care zones’. Capturing local needs and working bottom-up became the foundation of the organization. The focus on goal-oriented, customized and integrated care made it possible to fill out the gap created by more complex situations.
 Representatives from health providers, welfare workers, local authorities and the person in need of care are brought together. The primary care zone promotes collaboration between these different partners. This extensive network ensures that primary care regions can as well pick up and unroll local needs as charges unrolled by the government.
 Person-centered care is the key to success of this new approach. Care and support goals from the people itself, depending on their quality of life, are the starting point. This in combination with more recognition for informal care, makes sure that socially vulnerable people are able to take control of their own life and the necessary care to sustain this. In order to realize a care policy in function of person-centered care, we need to listen to the people who live in our primary care zone. There’s continually increased attention and effort to cocreate and build our organization with socially vulnerable people. Self-determination and autonomy are ever highly valuated. As organization there’s the expectation of building bridges between professionals, but also between the professional and the client.
 The focus in the relationship between clients and professionals shifted the past years. There’s more attention for participation and democratic decision making and for the perspective of the people itself. Clients are not to be seen as passive recipients anymore. They say: ‘nothing about us, without us.’ and who are we to protest?
 In order to do so we established a group of 15 experts. From October 22 until November 23 we will meet up monthly to exchange ideas. The group has experience in different domains: informal care, chronic illnesses, poverty, addiction, psychic vulnerability, elderly care and disabilities. The experts hope to dive deeper into our participation process to show and explain to you how to co-design a care journey that responds to people’s needs. 
 Taking their experience in account, will help our board to pick up local needs and to adjust primary care to them. Focus on strength and possibilities of the people in the group are hereby necessary to accomplish our goal. Together with the group we strive to share the ownership on our plan of action We want them to have an impact on the policy and to cocreate an organization not only for them, but with them.

American College of Lifestyle Medicine Expert Consensus Statement: Lifestyle Medicine for Optimal Outcomes in Primary Care.

Identify areas of consensus on integrating lifestyle medicine (LM) into primary care to achieve optimal outcomes. Experts in both LM and primary care followed an a priori protocol for developing consensus statements. Using an iterative, online process, panel members expressed levels of agreement with statements, resulting in classification as consensus, near consensus, or no consensus. The panel identified 124 candidate statements addressing: (1) Integration into Primary Care, (2) Delivery Models, (3) Provider Education, (4) Evidence-base for LM, (5) Vital Signs, (6) Treatment, (7) Resource Referral and Reimbursement, (8) Patient, Family, and Community Involvement; Shared Decision-Making, (9) Social Determinants of Health and Health Equity, and (10) Barriers to LM. After three iterations of an online Delphi survey, statement revisions, and removal of duplicative statements, 65 statements met criteria for consensus, 24 for near consensus, and 35 for no consensus. Consensus was reached on key topics that included LM being recognized as an essential component of primary care in patients of all ages, including LM as a foundational element of health professional education. The practice of LM in primary care can be strengthened by applying these statements to improve quality of care, inform policy, and identify areas for future research.

Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome.

Recommendations From the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome.

Climate change mitigation: Qualitative analysis of environmental impact-reducing strategies in German primary care

BackgroundThe German healthcare system is responsible for 5,2% of the national emissions of greenhouse gases. Therefore, mitigation actions to reduce the carbon footprint are crucial. However, there have been few approaches to achieve this in German primary care.ObjectivesThis study aimed to identify environmental impact-reducing strategies of German primary care practices.MethodsDuring the summer of 2021, a qualitative study was conducted using interviews and focus groups with experts in primary care across Germany, such as physicians, medical assistants, health scientists and experts on the health system level. Verbatim transcribed data were analyzed using Thematic Analysis.ResultsThe sample comprised 26 individual interviews and two focus groups with a total of N = 40 participants. Findings provide a first overview of pursued mitigation strategies and contextual factors influencing their implementation. Strategies referred to the use of water and energy, recycling and waste management, supply chains and procurement, digitisation, mobility, patient care, behavioural changes and system level. Implementing sustainable actions in daily care was considered expensive and often unfeasible due to lack of staff, time and restrictive hygiene regulations. Participants called for more instruction on implementing mitigating actions, for example, through websites, podcasts, guidelines or quality indicators.ConclusionThis study’s findings can support the development of future environmental impact-reducing strategies in primary care. Potential options for guidance and support should be considered to facilitate sustainability.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome†.

Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome†.

Barriers to mental health treatment in primary care practice in low- and middle-income countries in a post-covid era: A systematic review.

General primary care workers and family physicians are a crucial work force in managing the mental health of people in any given region. However, the barriers they face in low- and middle-income countries (LMICs) may be worsened by the pandemic. This review aims to bring together evidence about mental health treatment challenges experienced by people in LMICs in primary care settings. The review focuses on the shortage of essential mental healthcare services, stigma and lack of competent primary care professionals in establishing these services and their importance in the COVID-19 pandemic context. The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the search strategy included keyword search terms (MeSH) to perform a search across three electronic databases - Critical Appraisal Skills Program assessed PubMed, SpringerLink, and Cochrane and quality of the articles. The articles selected were analyzed through thematic analysis to identify the main themes and conclude our findings. Findings indicate that out of 1792 publications found, 14 studies matched the desired criteria for the studies. Endnotes, database search filters, and Covidence data extraction tools were used to generate the relevant articles in this study. This study shows that primary care institutions have financial and management issues in providing mental health services and a shortage of competent mental health experts in primary care, especially mental health-trained family physicians. The study also identifies community stigma as the most prevalent barrier to seeking mental health therapy, reflecting the lack of community health education in LMICs.

Development of evidence-based guidelines for the treatment and management of periprosthetic hip infection.

Periprosthetic hip-joint infection is a multifaceted and highly detrimental outcome for patients and clinicians. The incidence of prosthetic joint infection reported within two years of primary hip arthroplasty ranges from 0.8% to 2.1%. Costs of treatment are over five-times greater in people with periprosthetic hip joint infection than in those with no infection. Currently, there are no national evidence-based guidelines for treatment and management of this condition to guide clinical practice or to inform clinical study design. The aim of this study is to develop guidelines based on evidence from the six-year INFection and ORthopaedic Management (INFORM) research programme. We used a consensus process consisting of an evidence review to generate items for the guidelines and online consensus questionnaire and virtual face-to-face consensus meeting to draft the guidelines. The consensus panel comprised 21 clinical experts in orthopaedics, primary care, rehabilitation, and healthcare commissioning. The final output from the consensus process was a 14-item guideline. The guidelines make recommendations regarding increased vigilance and monitoring of those at increased risk of infection; diagnosis including strategies to ensure the early recognition of prosthetic infection and referral to orthopaedic teams; treatment, including early use of DAIR and revision strategies; and postoperative management including appropriate physical and psychological support and antibiotic strategies. We believe the implementation of the INFORM guidelines will inform treatment protocols and clinical pathways to improve the treatment and management of periprosthetic hip infection.

Integrating User Preferences for Asthma Tools and Clinical Guidelines Into Primary Care Electronic Medical Records: Mixed Methods Study.

Asthma is a chronic respiratory disease that poses a substantial burden on individuals and the health care system. Despite published national guidelines for the diagnosis and management of asthma, considerable care gaps exist. Suboptimal adherence to asthma diagnosis and management guidelines contributes to poor patient outcomes. The integration of electronic tools (eTools) into electronic medical records (EMRs) represents a knowledge translation opportunity to support best practices. The purpose of this study was to determine how best to integrate evidence-based asthma eTools into primary care EMRs across Ontario and Canada to improve adherence to guidelines as well as measure and monitor performance. In total, 2 focus groups comprising physicians and allied health professionals who were considered experts in primary care, asthma, and EMRs were convened. One focus group also included a patient participant. Focus groups used a semistructured discussion-based format to consider the optimal methods for integrating asthma eTools into EMRs. Discussions were held on the web via Microsoft Teams (Microsoft Corp). The first focus group discussed integrating asthma indicators into EMRs using eTools, and participants completed a questionnaire evaluating the clarity, relevance, and feasibility of collecting asthma performance indicator data at the point of care. The second focus group addressed how to incorporate eTools for asthma into a primary care setting and included a questionnaire evaluating the perceived utility of various eTools. Focus group discussions were recorded and analyzed using thematic qualitative analysis. The responses to focus group questionnaires were assessed using descriptive quantitative analysis. Qualitative analysis of the 2 focus group discussions revealed 7 key themes: designing outcome-oriented tools, gaining stakeholder trust, facilitating open lines of communication, prioritizing the end user, striving for efficiency, ensuring adaptability, and developing within existing workflows. In addition, 24 asthma indicators were rated according to clarity, relevance, feasibility, and overall usefulness. In total, 5 asthma performance indicators were identified as the most relevant. These included smoking cessation support, monitoring using objective measures, the number of emergency department visits and hospitalizations, assessment of asthma control, and presence of an asthma action plan. The eTool questionnaire responses revealed that the Asthma Action Plan Wizard and Electronic Asthma Quality of Life Questionnaire were perceived to be the most useful in primary care. Primary care physicians, allied health professionals, and patients consider that eTools for asthma care present a unique opportunity to improve adherence to best-practice guidelines in primary care and collect performance indicators. The strategies and themes identified in this study can be leveraged to overcome barriers associated with asthma eTool integration into primary care EMRs. The most beneficial indicators and eTools, along with the key themes identified, will guide future asthma eTool implementation.

Evaluating the implementation of a referral system for virtual pharmacy counselling in a province-wide nurse phone line.

Digital technology offers several opportunities to improve access to professional expertise in primary care, and the offer of various "virtual" services has exploded in the past few years. The aim of this study was to evaluate the implementation of a direct-to-consumer on-line pharmacy consultation service (Ask Your Pharmacist - AYP) to a universal phone consultation service led by the universal public health system in Quebec (811 Info-Santé), through a direct bridge. Semi-structured interviews were conducted with clinician users of the service, and stakeholders involved in this pilot project funded by the Ministry of Economy (n = 22); documents were also analyzed, and content of the question was asked through the AYP service. Adoption of the service was low, and it suggests a poor alignment between the need and the service as implemented. Further research should investigate the mechanisms for an appropriate integration of digital services for primary care universal consultation services.

Oncologists' Perspectives on Cancer Survivorship: What Role Should Primary Care Play?

Background: Despite calls for an enhanced role for primary care for individuals with a history of cancer, primary medical care's role in adult survivorship care continues to be marginal.Methods: We conducted in-depth interviews with 8 medical oncologists with interest in cancer survivorship from 7 National Cancer Institute designated comprehensive cancer centers to understand perspectives on the role of primary care in cancer survivorship.Results: Two salient overarching thematic patterns emerged. (1) Oncologist's perspectives diverge on if, how, and when primary care clinicians should be involved in survivorship, ranging from involvement of primary care throughout treatment to a standardized hand-off years post-therapy. (2) Oncologist's lack understanding about primary care's expertise and subsequent value in survivorship care.Conclusion: As oncology continues to be overwhelmed by rising numbers of aging cancer survivors with multi-morbidities, NCI-designated cancer centers should take a leadership role in integrating primary care engaged cancer survivorship.

Nursing experts in primary care of chronically ill persons: Insights into an ongoing project

Nursing experts in primary care of chronically ill persons: Insights into an ongoing project Abstract. Background: The project HandinHand develops and tries out a new interprofessional form of care for chronically ill persons. On referral by the attending doctors, nursing experts visit chronically ill persons older than 60 years on a regular basis. In this framework a clinical supervision takes place and is complemented by a promotion of health and self-management competencies of the patients. According to advanced nursing practice, nursing experts function as consultants and instructors for the target group and their relatives. Methods: This paper describes the field of action and the vocational role of nursing experts. Following the delegation agreement and the development of the project, opportunities and boundaries of this new form of care are discussed. Results: The project HandinHand introduces a new role for nursing experts in the German health care system. Conclusion: This form of cooperation between doctors and nursing experts is a model of good practice. It can be seen as a starting point for the development of new fields of action and roles of advanced nursing practice for academically educated nurses.

Smart Brain Care – A novel approach to health care of mild cognitive impairment and mild dementia

Abstract Background Dementia is a huge burden. Trends for the aging European nations indicate a significant increase of people with dementia. Prevention and early detection are the key elements to reduce risk factors and to treat reversible causes. In addition, identifying people at the beginning of the disease process is crucial when disease-modifying therapy becomes available. Methods We aim to develop a complex intervention to improve the identification, diagnosis, and treatment of people with mild cognitive impairment (MCI) and mild dementia syndromes. Our goal is to reduce the time to diagnosis, raising awareness for MCI and increase patient involvement. First, barriers in pathways of care are determined in a systematic review and refined by conducting focus groups and interviews with primary care physicians (PCPs), specialists and experts in the field. A first theory about intervention components and how they interact are developed and will be further tested and adapted through development phase, feasibility and piloting. Results The first blueprint of Smart Brain Care addresses three identified key barriers for an improved care of MCI and mild dementia syndromes (communication, skills and awareness) by three interventions (1-3), all linked and accessible through an e-database: An online platform (1) for exchange between PCPs, specialists and experts, (2) a screening tool, diagnosis-algorithm and training for PCPs as well as (3) information materials (e.g., fact sheets, short videos) separately accessible for patients. Conclusions There is still low awareness about MCI under health care providers and the general population. A lack of knowledge, cooperation strategies and guidance seem to play an important role for the management of MCI and mild dementia syndromes. Key messages • We need to increase focusing on the identification of people with MCI and mild dementia syndromes. • Call for a structured diagnosis and treatment regimen to support primary care physicians as key players in the management of MCI and mild dementia syndromes.

The roles of primary care doctors in the COVID-19 pandemic: consistency and influencing factors of doctor's perception and actions and nominal definitions

BackgroundAt the end of 2019, the Coronavirus Disease 2019 (COVID-19) pandemic broke out. As front-line health professionals, primary care doctors play a significant role in screening SARS-CoV-2 infection and transferring suspected cases. However, the performance of primary care doctors is influenced by their knowledge and role perception. A web-based cross-sectional survey was conducted to assess the consistency and influencing factors of primary care doctor's role perception and expert advice in the guidelines (regulatory definition).MethodsWe designed the questionnaire using “Wenjuanxing” platform, distributed and collected the questionnaire through WeChat social platform, and surveyed 1758 primary care doctors from 11 community health service stations, community health service centers and primary hospitals in Zhejiang Province, China. After the questionnaire was collected, descriptive statistics were made on the characteristics of participants, and univariate analysis and multivariate analysis were used to determine the relevant factors affecting their role cognition.ResultsIn the reporting and referral suspected cases and patients receiving treatment, most participants’ cognition of their roles were consistent with the requirements of guidelines. However, 49.54% and 61.43% of participant doctors were not in line with the government guidelines for diagnosing and classifying COVID-19 and treating suspected cases, respectively. Having a middle or senior professional title and participating in front-line COVID-19 prevention and control work is beneficial to the accurate role perception of diagnosis and classification of COVID-19, the reporting and transfer of suspected cases, and the treatment of suspected cases.ConclusionsPrimary care doctors’ role perceptions in the COVID-19 pandemic are not always consistent with government guidelines in some aspects, such as transferring and diagnosing suspected cases. Therefore, it is essential to guide primary care doctors in performing their duties, especially those with lower professional titles.

Clinical Pathway for Suicide Risk Screening in Adult Primary Care Settings: Special Recommendations.

Suicide is a serious public health concern. On average, 80% of suicide decedents had contact with primary care within 1 year of their suicide. This and other research underscore the importance of screening for suicide risk within primary care settings, and implementation of suicide risk screening is already underway in many practices. However, while primary care practices may be familiar with screening for other mental health concerns (e.g., depression), many feel uncomfortable or unprepared for suicide risk screening. To meet the increasing demand for evidence-based suicide-risk-screening guidance, we provide a clinical pathway for adult primary care practices (to include family medicine, internal medicine, women's health). The pathway was developed by experts with research, clinical expertise, and experience in suicide risk screening and primary care. We also provide detailed guidance to aid primary care practices in their decisions about how to implement the clinical pathway.

EsReflux Protocol: Epidemiological Study of Heartburn and Reflux-like Symptoms in Spanish Community Pharmacies.

(1) Background: Heartburn and reflux discomfort are frequent reasons for consultation at the community pharmacy. To facilitate the assistance work of the community pharmacist and its coordination between different levels of care, a group of experts in Community Pharmacy, Primary Care, and Gastroenterology have recently worked on an algorithm to manage these symptoms in the community pharmacy (Professional Pharmaceutical Service). The objective of this study is to analyze the clinical and sociodemographic characteristics of patients with heartburn and/or reflux-like symptoms who go to a community pharmacy, and to evaluate the clinical and humanistic results after the implementation of a Professional Pharmaceutical Service. (2) Methods: A pre-post study will be carried out to evaluate clinical and humanistic results after the implementation of a Professional Pharmaceutical Service. We will include 1200 patients who ask for advice or get a non-prescription medication due to acid and/or reflux symptoms in 240 Spanish pharmacies. Clinical data will be collected at baseline and 15 days after the pharmaceutical intervention. The GERD Impact Scale (GIS) questionnaire will be applied to assess changes in heartburn/reflux-like symptoms and quality of life after the intervention.

Approach to Patients with Obesity and Other Cardiovascular Risk Factors in Primary Care Using the Delphi Methodology.

Background: Implementing preventive strategies for patients with obesity would improve the future burden of cardiovascular diseases. The objective was to present the opinions of experts on the approach to treating patients with obesity and other cardiovascular risk factors from a primary care perspective in Spain; Methods: Using the Delphi technique, a 42-question questionnaire was developed based on results from the scientific literature, and sent to 42 experts in primary care. Two rounds of participation were held; Results: There is a close relationship between obesity and cardiovascular risk factors among primary care physicians. It is necessary to use a checklist in primary care that includes metabolic parameters such as body mass index, waist circumference, and levels of C-reactive protein and ferritin. It is also useful to combine pharmacological treatment, such as liraglutide, with a change in lifestyle to achieve therapeutic goals in this population; Conclusions: There is a high level of awareness among experts in Spain regarding obesity and other cardiovascular risk factors, and the need to address this pathology comprehensively. The need to incorporate specific tools in primary care consultations that allow for better assessment and follow-up of these patients, such as cuffs adapted to arm size or imaging techniques to assess body fat, is evident. Teleconsultation is imposed as a helpful tool for follow-up. Experts recommend that patients with obesity and associated comorbidities modify their lifestyle, incorporate a Mediterranean diet, and administer liraglutide.

The paradigm shift from NAFLD to MAFLD: A global primary care viewpoint.

In 2020, a group of international experts reached a consensus to comprehensively revisit the current definition of fatty liver disease. In clinical settings, most of the patients with fatty liver disease are first identified and subsequently followed up in the community by primary care practitioners (PCPs). Therefore, it is crucial to understand PCPs perspectives regarding the proposed redefinition of fatty liver disease as well as the implications on primary care of patients. Thus, the aim of this paper is for an international team of experts in primary care to provide perspective regarding the proposed redefinition of metabolic-dysfunction associated fatty liver disease (MAFLD). Currently, numerous systemic barriers exist for PCPs who are managing fatty liver disease. These include the diagnosis and screening, efficient referral pathway, restrictive policies, disease awareness and continuum of care. The revolutionary simplification in diagnosis and evaluation that the MAFLD definition is providing, we believe can help to overcome some of these barriers and may facilitate the implementation of effective fatty liver disease management, prevent overdiagnosis and overtreatment in secondary and tertiary care but also reduce underdiagnosis in primary care by PCPs by promoting widespread active case findings of MAFLD and reaching to a balance on behalf of public health.

Multinational primary health care experiences from the initial wave of the COVID-19 pandemic: A qualitative analysis

ObjectiveTo learn from primary health care experts’ experiences from the COVID-19 pandemic across countries. MethodsWe applied qualitative thematic analysis to open-text responses from a multinational rapid response survey of primary health care experts assessing response to the initial wave of the COVID-19 pandemic. ResultsRespondents’ comments focused on three main areas of primary health care response directly influenced by the pandemic: 1) impact on the primary care workforce, including task-shifting responsibilities outside clinician specialty and changes in scope of work, financial strains on practices, and the daily uncertainties and stress of a constantly evolving situation; 2) impact on patient care delivery, both essential care for COVID-19 cases and the non-essential care that was neglected or postponed; 3) and the shift to using new technologies. ConclusionsPrimary health care experiences with the COVID-19 pandemic across the globe were similar in their levels of workforce stress, rapid technologic adaptation, and need to pivot delivery strategies, often at the expense of routine care.