Management Of Patients In Primary Care Research Articles

Prognostic Significance of Lung Ultrasound for Heart Failure Patient Management in Primary Care: A Systematic Review.

Background: Heart failure (HF) affects around 60 million individuals worldwide. The primary aim of this study was to evaluate the efficacy of lung ultrasound (LUS) in managing HF with the goal of reducing hospital readmission rates. Methods: A systematic search was conducted on PubMed, Embase, Google Scholar, Web of Science, and Scopus, covering clinical trials, meta-analyses, systematic reviews, and original articles published between 1 January 2019 and 31 December 2023, focusing on LUS for HF assessment in out-patient settings. There is a potential for bias as the effectiveness of interventions may vary depending on the individuals administering them. Results: The PRISMA method synthesized the findings. Out of 873 articles identified, 33 were selected: 19 articles focused on prognostic assessment of HF, 11 centred on multimodal diagnostic assessments, and two addressed therapeutic guidance for HF diagnosis. LUS demonstrates advantages in detecting subclinical congestion, which holds prognostic significance for readmission and mortality during out-patient follow-up post-hospital-discharge, especially in complex scenarios, but there is a lack of standardization. Conclusions: there are considerable uncertainties in their interpretation and monitoring changes. The need for an updated international consensus on the use of LUS seems obvious.

Differences in Primary Care Management of Patients With Adult Attention Deficit Hyperactivity Disorder (ADHD) Based on Race and Ethnicity

Objective: Examine differences in care patterns around adult ADHD between race (White/Non-White) and ethnic (Hispanic/Non-Hispanic) groups utilizing existing quality measures (QMs), concerning diagnosis, treatment, and medication prescribing. Methods: The AAFP National Research Network in partnership with SUNY Upstate Medical used an EHR dataset to evaluate achievement of 10 ADHD QMs. The dataset was obtained from DARTNet Institute and includes 4 million patients of 873 behavioral and primary care practices with at least 100 patients from 2010 to 2020. Patients 18-years or older with adult ADHD were included in this analysis. Results: White patients and Non-Hispanic/Latinx patients were more likely to achieve these QMs than Non-White patients and Hispanic/Latinx patients, respectively. Differences between groups concerning medication and monitoring demonstrate a disparity for Non-White and Hispanic/Latinx populations. Conclusions: Using QMs in EHR data can help identify gaps in ADHD research. There is a need to continue investigating disparities of quality adult ADHD care.

Abstract PD6-06: PD6-06 Racial and ethnic disparities with influenza vaccine use in long-term survivors of metastatic breast cancer

Abstract Background: Due to therapeutic advancements, people diagnosed with metastatic breast cancer (MBC) are living longer. This is particularly true for elderly patients who are often diagnosed with more indolent disease. However, elderly patients have higher rates of comorbidity and are vulnerable to other adverse health outcomes, but the primary care management of patients with advanced cancer may be sub-optimal. Every year influenza results in hundreds of thousands of hospitalizations and tens of thousands of deaths. Guidelines recommend the influenza vaccine annually for those over the age of 65 as well as those with cancer based on studies showing a 40-60% reduction in hospitalizations and death. Patterns of use in patients with MBC is unknown. Methods: A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked data. Patients were included if they were diagnosed with stage IV MBC from 1/1/2008 – 12/31/2017, were ≥65 years of age, and had continuous Medicare enrollment for 12 months prior to diagnosis and at least three months after. Our primary outcome of interest was influenza vaccine use identified via CPT codes and defined as any use, use among patients surviving > 3-years, use among patients surviving >5-years, and repeated vaccine use. We then conducted bivariate analyses using demographic variables, including race, ethnicity, SES, age, and marital status, and clinical factors, including chemotherapy use, ER/PR positivity, and HER2 positivity. A multivariable logistic model was used to identify factors associated with influenza vaccine use in each cohort. Results: We identified 5182 patients with stage IV MBC during the study period that met our inclusion criteria. Overall, the median survival was 21 months and only 44% received at least one vaccination at any time after diagnosis. Within the cohort with the > 3-year survival (n=1864), only 1222 (66%) received an influenza vaccination at least one time and only 54% received the vaccine at least two times during 3 years of follow-up. Among patients with at least five-years of survival (n=763), 73% received at least one vaccination and only 65% received the vaccine at least two times during 5 years of follow-up. In a bivariate analysis in the 3-year survival cohort, we found that black race (47% vs 67%, p< 0.001) and Hispanic ethnicity (53% vs 66%, p=0.026), compared to white race and non-Hispanic ethnicity, respectively, were significantly associated with decreased vaccine use. The only factor associated with increased use was chemotherapy exposure. A multivariable model found lower odds of influenza vaccine receipt for black patients (OR=0.44, 95% CI 0.30-0.65, p< 0.001) and Hispanic patients (OR=0.58, 95% CI 0.36-.94, p=0.026). Similar findings were found in the 5-year survival cohort. Ongoing landmark analyses will be presented evaluating the impact of vaccination on survival. Conclusions: Over 50% of survivors with MBC do not receive the influenza vaccine after diagnosis. Importantly black and Hispanic patients with MBC are about half as likely to receive the influenza vaccine as white patients. Given the known impact of influenza vaccination in the elderly, improving access to vaccination could be an important strategy to reduce disparities in health outcomes. Our findings demonstrate primary care access disparities amongst the MBC population and indicate a need for educational and policy-based interventions. Citation Format: Sahil D. Doshi, David DeStephano, Melissa K. Accordino, Elena B. Elkin, Jason D. Wright, Dawn Hershman. PD6-06 Racial and ethnic disparities with influenza vaccine use in long-term survivors of metastatic breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD6-06.

Development and evaluation of a mobile-based asthma clinical decision support system to enhance evidence-based patient management in primary care

BackgroundDespite tremendous efforts, satisfactory adherence to asthma care guidelines has remained an unmet need worldwide. There is a growing body of evidence that applying informatics-based solutions such as clinical decision support systems (CDSS) could enhance guideline adherence. The main objectives of our research include proposing a framework for translating evidence into a guideline-based CDSS and developing an asthma-specific CDSS based on the proposed framework. MethodsThe stepwise framework for those who want to implement guideline-based CDSS in form of a simple-to-use application was described in this research. Nested decision tree modeling was performed in an iterative process to model patient-related decisions under expert consultation. Six expert panel members were asked to evaluate the application based on actual patient data, once based on paper-based guidelines, and once based on the expert system to calculate the accuracy of our CDSS. In the usability evaluation phase, evaluators completed tasks based on the think-aloud protocol to find usability problems. Then, to determine the level of usability a standard SUS questionnaire was applied. ResultsIn total, 28 clinical decision trees (CDTs) and more than 220 rules were necessary to cover the whole guideline. Moreover, 336 knowledge statements were extracted from the GINA guideline. After modification with feedback from seven experts, our application was developed on the Android Platform. For asthma diagnosis, CDSS had a sensitivity, specificity, and accuracy of 100%, 86.71%, and 93.33%, respectively. The think-aloud usability evaluation revealed that the total problems (n = 32) were classified deductively into layout problems (43.8%), terminology problems (9.4%), data entry problems (18.8%), and comprehensiveness problems (28.1%). The overall usability score level was 90.22(±9.487), while learnability and usability scores were 4.43 and 4.52 out of 5, respectively. ConclusionThe ginasthma mobile-based CDSS can provide healthcare providers with an automated individualized action plan by combining patient data with embedded knowledge from the GINA guidelines with high accuracy.

Who are the patients being offered the faecal immunochemical test in routine English general practice, and for what symptoms? A prospective descriptive study

ObjectivesThe faecal immunochemical test (FIT) was introduced to triage patients with lower-risk symptoms of colorectal cancer (CRC) in English primary care in 2018. While there is growing evidence on its...

Keeping in balance on the multimorbidity tightrope: A narrative analysis of older patients’ experiences of living with and managing multimorbidity

Primary care management of patients with multimorbidity in the UK is underpinned by clinical guidelines, quality standards and measurable targets which govern practices of risk management and disease control. There is concern that standardised approaches may not always be appropriate for older patients living with multimorbidity.Using a narrative approach, we elicited the voices of older people living with multiple conditions in order to rethink chronicity, and consider what their accounts might mean for reconfiguring care practices. Within an ethnographic study of multimorbidity and polypharmacy, we conducted in-depth interviews, based on the Biographical Narrative Interpretive Method, with 24 participants aged 65 to 94. Participants were recruited from three general practices in England. All had two or more chronic conditions and were prescribed ten or more medicines.Our analysis draws on Bakhtinian theory, tracing the multiple ways in which participants voiced living with multimorbidity. In this paper, we focus on ‘keeping in balance’ which emerged as a key meta-conceptualisation across our dataset. Adopting the metaphor of the ‘multimorbidity tightrope’ we explore the precarity of patients' experiences and show their struggle to create coherence from within a deeply ambiguous living situation. We consider how and to what extent participants' narrative constructions co-opt or resist normative biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients' voices and values may sometimes be at odds with those promoted within professional guidelines. Narrative approaches may offer significant potential for reorienting healthcare towards enabling patients to live a flourishing life, even when facing significant adversity.

Current management of adults receiving oral anti-cancer medications: A scoping review.

Oral anti-cancer medication (OAM) has revolutionised oncology care. Due to their potential toxicities and associated safety challenges ongoing assessment and monitoring is essential; currently generally performed in acute care settings. Internationally there exists a transformative vision to shift patient care from acute to primary care. A nurse-led integrated model of care could be developed for OAM patient management in primary care. The aim of this study was to examine international literature regarding current clinical management practices for assessment and monitoring of patients receiving OAM. Following PRISMA-ScR guidelines, databases MEDLINE, CINAHL and Web of Science were searched for English studies published between 2010 and 2020 using keywords: assessment, cancer, care, management, oral anticancer medications. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize, collate and make a narrative account of the findings. 2261 papers were reviewed, 14 met inclusion criteria. Three phases of management are reported: 1. Patient treatment plan development; 2. Patient education; 3. Patient monitoring. Within these phases seven specific stages of care were identified broadly representing the patient's journey: (1) treatment decision, (2) prescribing of OAM, (3) OAM dispensing and administration, (4) maximising patient safety (5) ongoing patient assessment (6) patient support (7) communication with other health-care professionals. Despite a paucity of international literature, a dedicated OAM clinic was endorsed as a means to achieve improved care. Nurses and pharmacists were identified as being of particular importance especially in education and ongoing management of patients receiving OAMs.

Ревматическая полимиалгия в клинических рекомендациях 2018–2020 годов. Часть I. Группы риска, адъювантная терапия

В начале Декады здорового старения стал доступен ряд клинических рекомендаций по ведению ревматических болезней у пожилых. Цель публикации — характеристика и обсуждение руководства по ревматической полимиалгии Итальянского общества ревматологов (2020) и рекомендаций по применению позитронно-эмиссионной томографии/компьютерной томографии при васкулитах крупных сосудов и ревматической полимиалгии Европейской ассоциации ядерной медицины, Общества ядерной медицины и молекулярной визуализации и Американского общества ядерной кардиологии (2018). Материалы и методы. Содержание, первоисточники и методология разработки руководств изучены с помощью методов информационного анализа и сопоставлены с рекомендациями 2018–2020 гг. по ревматической полимиалгии и гигантоклеточному артерииту Европейской антиревматической лиги, Американской коллегии ревматологов, Немецкого, Австрийского, Швейцарского, Британского обществ ревматологов, Европейской федерации головной боли и их первоисточниками. Установлен приоритет консенсусного подхода в разработке современных руководств по ревматической полимиалгии. Особенность методологии создания итальянских рекомендаций состоит в сужении поиска прототипов до двух баз данных доказательной медицины и «серой» литературы и в отборе для адаптации трех руководств, включая разработку обществ ядерной медицины. Актуализированы вопросы ведения пациентов в первичном звене (предложен алгоритм), совместного принятия клинических решений, настороженности в отношении гигантоклеточного артериита. Доказательствами поддержаны лишь начальные дозы глюкокортикоидов как терапии первой линии; допускается альтернирующий режим их снижения. Обоснована неэффективность гидроксихлорохина, не обсуждается прием азатиоприна и средств альтернативной медицины. Следует установить факторы риска развития васкулита, рецидивов, длительного приема глюкокортикоидов и их побочных эффектов. Впервые для выявления васкулита рекомендовано применение позитронно-эмиссионной томографии/компьютерной томографии. Самой доказанной, сильной, согласованной является рекомендация по адъювантной терапии метотрексатом и отказу от биологических препаратов, наименее согласованной — позиция по направлению к ревматологу. Выводы. Решение такой актуальной проблемы здравоохранения, как повышение качества медицинской помощи при ревматической полимиалгии, предполагает усовершенствование медицинских стандартов по большинству клинически важных вопросов, выявление пациентов высокого риска, направление их к ревматологам и офтальмологам и рассмотрение преимуществ лечения метотрексатом.

Wireless Home Blood Pressure Monitoring System With Automatic Outcome-Based Feedback and Financial Incentives to Improve Blood Pressure in People With Hypertension: Protocol for a Randomized Controlled Trial.

BackgroundHypertension is prevalent in Singapore and is a major risk factor for cardiovascular morbidity and mortality and increased health care costs. Strategies to lower blood pressure include lifestyle modifications and home blood pressure monitoring. Nonetheless, adherence to home blood pressure monitoring remains low. This protocol details an algorithm for remote management of primary care patients with hypertension.ObjectiveThe objective of this study was to determine whether wireless home blood pressure monitoring with or without financial incentives is more effective at reducing systolic blood pressure than nonwireless home blood pressure monitoring (usual care).MethodsThis study was designed as a randomized controlled open-label superiority study. A sample size of 224 was required to detect differences of 10 mmHg in average systolic blood pressure. Participants were to be randomized, in the ratio of 2:3:3, into 1 of 3 parallel study arms :(1) usual care, (2) wireless home blood pressure monitoring, and (3) wireless home blood pressure monitoring with financial incentives. The primary outcome was the mean change in systolic blood pressure at month 6. The secondary outcomes were the mean reduction in diastolic blood pressure, cost of financial incentives, time taken for the intervention, adherence to home blood pressure monitoring, effectiveness of the framing of financial incentives in decreasing nonadherence to blood pressure self-monitoring and the adherence to antihypertensive medication at month 6.ResultsThis study was approved by SingHealth Centralised Institutional Review Board and registered. Between January 24, 2018 and July 10, 2018, 42 participants (18.75% of the required sample size) were enrolled, and 33 participants completed the month 6 assessment by January 31, 2019.ConclusionsDue to unforeseen events, the study was stopped prematurely; therefore, no results are available. Depending on the blood pressure information received from the patients, the algorithm can trigger immediate blood pressure advice (eg, Accident and Emergency department visit advice for extremely high blood pressure), weekly feedback on blood pressure monitoring, medication titration, or skipping of routine follow-ups. The inclusion of financial incentives framed as health capital provides a novel idea on how to promote adherence to remote monitoring, and ultimately, improve chronic disease management.Trial RegistrationClinicalTrials.gov NCT 03368417; https://clinicaltrials.gov/ct2/show/NCT03368417International Registered Report Identifier (IRRID)DERR1-10.2196/27496

Primary care management of patients with pain complaints and the influence of physician training in mechanical diagnosis and therapy

Chronic pain affects 20% of the adult population, and pain-related consultations comprise a significant amount of all primary care visits. The purpose of this study was to describe health care utilization by primary care physicians for patients with a consultation for pain and to compare subsequent health care utilization and costs for a physician trained in the McKenzie method, or mechanical diagnosis and therapy (MDT), with a group of physicians that were not trained in MDT. This study was a single-center retrospective quality and cost metrics data analysis performed at a community regional health-care system; patients seen by primary care physicians for a consultation for pain had subsequent health care utilization and costs compared for a physician trained in MDT with a group of 19 physicians who were not trained in MDT. A total of 22,907 continuously eligible patients were seen during the 12-month period for a pain-related complaint; 1282 patients (6%) were seen by the physician trained in MDT, and 21,625 patients (94%) were seen by the group of physicians that were not trained in MDT (n = 19). The patients seen by the physician trained in MDT had a decreased likelihood of medication use including both opioids and non-opioid pain pills, diagnostic imaging, electromyography/nerve conduction velocity testing, specialty referrals, injections (joint and spinal injections), surgeries, emergency room visits, and inpatient admissions. Also, patients who were seen by the physician trained in MDT cost significantly less to the system ($3481 per member per year versus $4852, p < 0.001), despite being older and having more medical problems and pain complaints. Although further research is necessary to either support or refute these findings, these results may have important implications for health policy decisions for designing optimal primary care models and consideration of MDT in primary care.

Stratified versus usual care for the management of primary care patients with sciatica: the SCOPiC RCT.

Sciatica has a substantial impact on patients and society. Current care is 'stepped', comprising an initial period of simple measures of advice and analgesia, for most patients, commonly followed by physiotherapy, and then by more intensive interventions if symptoms fail to resolve. No study has yet tested a model of stratified care in which patients are subgrouped and matched to different care pathways based on their prognosis and clinical characteristics. The objectives were to investigate the clinical effectiveness and cost-effectiveness of a stratified care model compared with usual, non-stratified care. This was a two-parallel group, multicentre, pragmatic, 1 : 1 randomised controlled trial. Participants were recruited from primary care (42 general practices) in North Staffordshire, North Shropshire/Wales and Cheshire in the UK. Eligible patients were aged ≥ 18 years, had suspected sciatica, had access to a mobile phone/landline, were not pregnant, were not receiving treatment for the same problem and had not had previous spinal surgery. In stratified care, a combination of prognostic and clinical criteria associated with referral to spinal specialist services was used to allocate patients to one of three groups for matched care pathways. Group 1 received advice and up to two sessions of physiotherapy, group 2 received up to six sessions of physiotherapy, and group 3 was fast-tracked to magnetic resonance imaging and spinal specialist opinion. Usual care was based on the stepped-care approach without the use of any stratification tools/algorithms. Patients were randomised using a remote web-based randomisation service. The primary outcome was time to first resolution of sciatica symptoms (six point ordinal scale, collected via text messages). Secondary outcomes (at 4 and 12 months) included pain, function, psychological health, days lost from work, work productivity, satisfaction with care and health-care use. A cost-utility analysis was undertaken over 12 months. A qualitative study explored patients' and clinicians' views of the fast-track care pathway to a spinal specialist. A total of 476 patients were randomised (238 in each arm). For the primary outcome, the overall response rate was 89.3% (88.3% and 90.3% in the stratified and usual care arms, respectively). Relief from symptoms was slightly faster (2 weeks median difference) in the stratified care arm, but this difference was not statistically significant (hazard ratio 1.14, 95% confidence interval 0.89 to 1.46; p = 0.288). On average, participants in both arms reported good improvement from baseline, on most outcomes, over time. Following the assessment at the research clinic, most participants in the usual care arm were referred to physiotherapy. The stratified care model tested in this trial was not more clinically effective than usual care, and was not likely to be a cost-effective option. The fast-track pathway was felt to be acceptable to both patients and clinicians; however, clinicians expressed reluctance to consider invasive procedures if symptoms were of short duration. Participants in the usual care arm, on average, reported good outcomes, making it challenging to demonstrate superiority of stratified care. The performance of the algorithm used to allocate patients to treatment pathways may have influenced results. Other approaches to stratified care may provide superior outcomes for sciatica. Current Controlled Trials ISRCTN75449581. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 49. See the NIHR Journals Library website for further project information.

What are the development priorities for management of type 2 diabetes by general practitioners in Ningbo, China: a qualitative study of patients’ and practitioners’ perspectives

ObjectivesTo explore patients’ and general practitioners’ (GPs’) perspectives on primary care management of patients with type 2 diabetes mellitus (T2DM) in Ningbo, China. We aimed to understand the current benefits...

Does Emergency Medical Services Transportation Mitigate Post-stroke Discharge Disability? A Prospective Observational Study.

Whether emergency medical services (EMS) transport improves disability outcomes compared with other transport among acute ischemic stroke (AIS) patients is unknown. To study severity-adjusted associations of hospital arrival mode (EMS vs. other transport) with in-hospital and discharge disability outcomes. Prospective observational study. AIS patients discharged April 2016 to October 2017 from a safety-net hospital in South Carolina. National Institutes of Health Stroke Scale (NIHSS) change at discharge (admission NIHSS score minus discharge NIHSS, continuous variable), 24-h NIHSS change (attaining high improvement, admission NIHSS minus 24-h NIHSS being 75th percentile or higher), door to neuroimaging (DTI) time, and IV alteplase receipt. NIHSS change was assessed within stroke severity groups, mild, moderate, and severe (admission NIHSS 0-5, 6-14, and ≥ 15, respectively). Of 1168 patients, 838 were study-eligible (52% male, 52.4% Black, 72.2% EMS arrivals, 56.6% mild strokes). Severe and moderate stroke patients were more likely than mild stroke patients to use EMS (adjusted odds ratios, AOR [95% CI] 11.7 [5.0, 27.4] and 4.0 [2.6, 6.3], respectively). EMS arrival was associated with shorter DTI time (adjusted difference - 88.4 min) and higher likelihood of alteplase administration (AOR 5.3 [2.5, 11.4]), both key mediating variables in disability outcomes. High 24-h NIHSS improvement was more likely for EMS arrivals vs. other arrivals among moderate strokes (AOR 3.4 [1.1, 10.9]) and severe strokes (AOR > 999). EMS arrivals had substantially higher NIHSS improvement at discharge within the severe stroke group (adjusted NIHSS change at discharge, 5.9 points higher, p = 0.01). Alteplase recipients showed higher discharge NIHSS improvement than non-recipients (by 2.8 and 1.9 points among severe and moderate strokes, respectively; p = 0.01, 0.02). The findings offer evidence for including stroke education as a standard of care in the primary care management of patients with stroke-risk comorbidities/lifestyle in order to minimize post-stroke disability.

Illustrating the patient journey through the care continuum: Leveraging structured primary care electronic medical record (EMR) data in Ontario, Canada using chronic obstructive pulmonary disease as a case study

BackgroundAlthough barriers exist to secondary use of primary care electronic medical record (EMR) data, the Alliance for Healthier Communities (the Alliance) in Ontario, Canada has successfully created one of the largest structured primary care EMR datasets in Canada. In 2018, the Alliance and the Canadian Institute for Health Information (CIHI), an organization that provides comparable and actionable data to accelerate improvements in health across Canada, entered into a partnership to share EMR data. In this paper, we describe (i) the processes that enabled the collection of structured EMR data by the Alliance; (ii) how CIHI connected with the Alliance to share data and assess its quality; and, (iii) demonstrate the value of linking structured EMR data to administrative acute care data in illustrating the patient journey through the care continuum, using COPD as a case study. MethodsCIHI and the Alliance entered into a formal data sharing agreement that enabled the sharing of linkable structured EMR data by the Alliance’s 75 community health centres (CHCs) with CIHI. By leveraging the Alliance’s Business Intelligence Reporting Tool, 3 years of EMR data containing patient-level clinical data were shared with CIHI. CIHI assessed the EMR data quality using its Data Source Assessment Tool to ensure fitness for analytical use. By linking the patient level EMR records with hospital records (CIHI’s discharge abstract database (DAD) and the national ambulatory care reporting system (NACRS)), we examined aspects of COPD patient management in primary care and followed their journey through the health care continuum, including follow-up in primary care after hospital discharge. ResultsAlliance EMR data representing approximately 570,000 patients and 8.5 million primary care encounters between April 1, 2015 and March 31, 2018 were shared with CIHI. A data quality assessment, centered on completeness and concordance, confirmed that the data was fit for analytical purposes. Overall, 13,023 enrolled primary care patients were identified as having COPD, representing an overall crude prevalence of 8.7%. The average age of COPD patients was 64 years and equally affected males and females. Patients were most likely to have completed high school education or equivalent, speak English, live alone, and have a household income less than $15,000. They most commonly had between 10–19 primary care encounters a year with a range of providers where they most commonly sought services for health advice/ instructions, to discuss their treatment plans and for medication renewals. By linking the EMR data to CIHI’s NACRS and DAD, we found that 74.1% of COPD patients had at least one ED visit and that 34.4% of COPD patients had at least one acute care hospitalization during the study period. Further, 16.2% of ED visits resulted in an acute care hospital admission. Of those hospitalized, the majority of COPD patients were discharged home (81.6%) and received timely follow-up in primary care (81.0% within 30 days). ConclusionStructured and linkable EMR data provides opportunities to examine the patient journey through the care continuum in an innovative way. Using structured EMR data from the Alliance, linked with CIHI’s NACRS and DAD databases, we were able to generate a cohort of patients with COPD, explore the complexities of their primary care encounters and follow them through the continuum of care, namely emergency department visits and hospitalizations. It is hoped that the partnership between the Alliance and CIHI will help drive future efforts on addressing the gap in comparable EMR data in Canada, and internationally.

Evaluation of HealthPathways: an appraisal of usage, experiences and opinions of healthcare professionals in Australia and New Zealand.

Objectives HealthPathways, pioneered in Canterbury, New Zealand, in 2008, is a web-based tool designed to promote health care integration and patient management in primary care and to reduce fragmentation in the delivery of health services. This cross-sectional study evaluated the utilisation and perceptions of this tool among health professionals in Australia and New Zealand. Methods A cross-sectional survey was administered online through Research Electronic Data Capture (REDCap) to general practitioners (GPs), practice nurses and managers, nurse practitioners, specialist and community nurses, hospital clinicians, nurses, managers, and allied health professionals between April and September 2018. The frequency of HealthPathways use in the previous month was modelled as an ordered response using an ordered logistic regression model after adjusting for the possible effects of sex, age, years in clinical practice, location and time spent in practice. Results Health professionals perceived HealthPathways to be useful in primary care management and referral, as well as in the prereferral treatment of patients. GPs in New Zealand, New South Wales and Victoria were 73%, 47% and 27% more likely to have used HealthPathways ≥10 times in the previous month respectively. Conclusion The results suggest that HealthPathways is having a positive effect on healthcare systems in New Zealand and Australia. However, differences in uptake suggests the need for focused implementation, integration into eReferral software and expanding the tool to medical students, registrars, allied health professionals and potentially patients to encourage behavioural change. What is known about the topic? Early evaluations suggest that HealthPathways is a useful tool for health professionals, although uptake and utilisation may be limited. However, there is no comparative evidence regarding uptake and implementation of the tool. What does the paper add? This study is among the first to provide a comparative narrative of the literature assessing the implementation and uptake of HealthPathways across Australia and New Zealand. It is also among the first to compare the perceptions of allied health professionals in the use of HealthPathways across Australia and New Zealand. What are the implications for practitioners? The results of this study suggest the need for focused implementation, integration into eReferral software and expanding the tool to medical students, registrars, allied health professionals and potentially patients to encourage behavioural change.

Рекомендации по ведению первичных пациентов с симптомами диспепсии

Рекомендации по ведению первичных пациентов с симптомами диспепсии

Mental Processes on The Clinical Problem Solving in Family Medicine

Family physicians deal mostly undifferentiated patient and unorganized symptoms. Therefore, there are differences in patient management in primary care. We aimed to provide information about mental processes that can be used for clinical problem solving in family medicine.

Primary Care Management of Patients With Type 2 Diabetes: Overcoming Inertia and Advancing Therapy With the Use of Injectables

Type 2 diabetes (T2D) is a progressive disease caused by insulin resistance and associated progressive β-cell functional decline, as well as multiple other related metabolic and pathophysiologic changes. Left unchecked, T2D increases the risk of long-term microvascular and cardiovascular complications and is associated with excess morbidity and mortality. Despite multiple effective options for reducing hyperglycemia, patients are not optimally managed, largely due to delays in appropriate and timely advancement of therapy. Glucagon-like peptide-1 receptor agonists and basal insulin are recommended by treatment guidelines as effective options for advancing therapy to achieve glycemic control. However, injected therapies often face resistance from patients and clinicians. Glucagon-like peptide-1 receptor agonists are associated with weight loss, low risk of hypoglycemia, and potential beneficial cardiovascular effects. The class is recommended for patients across the spectrum of disease severity and represents an attractive option to add to basal insulin therapy when additional control is needed. Newer second-generation basal insulin analogues offer advantages over first-generation basal insulins in terms of lower hypoglycemia rates and greater flexibility in dosing. Incorporating injectable therapy into patient care in a timely manner has the potential to improve outcomes and must not be overlooked. Primary care clinicians play a significant role in managing patients with T2D, and they must be able to address and overcome patient resistance and their own barriers to advancing therapy if optimal treatment outcomes are to be achieved. The purpose of this expert opinion article was to provide a commentary on the key principle of advancing therapy with injectables to control hyperglycemia.

Clinical effectiveness of care managers in collaborative care for patients with depression in Swedish primary health care: a pragmatic cluster randomized controlled trial

BackgroundDepression is one of the leading causes of disability and affects 10-15% of the population. The majority of people with depressive symptoms seek care and are treated in primary care. Evidence internationally for high quality care supports collaborative care with a care manager. Our aim was to study clinical effectiveness of a care manager intervention in management of primary care patients with depression in Sweden.MethodsIn a pragmatic cluster randomized controlled trial 23 primary care centers (PCCs), urban and rural, included patients aged ≥ 18 years with a new (< 1 month) depression diagnosis. Intervention consisted of Care management including continuous contact between care manager and patient, a structured management plan, and behavioral activation, altogether around 6-7 contacts over 12 weeks. Control condition was care as usual (CAU). Outcome measures: Depression symptoms (measured by Mongomery-Asberg depression score-self (MADRS-S) and BDI-II), quality of life (QoL) (EQ-5D), return to work and sick leave, service satisfaction, and antidepressant medication. Data were analyzed with the intention-to-treat principle.ResultsOne hundred ninety two patients with depression at PCCs with care managers were allocated to the intervention group, and 184 patients at control PCCs were allocated to the control group. Mean depression score measured by MADRS-S was 2.17 lower in the intervention vs. the control group (95% CI [0.56; 3.79], p = 0.009) at 3 months and 2.27 lower (95% CI [0.59; 3.95], p = 0.008) at 6 months; corresponding BDI-II scores were 1.96 lower (95% CI [− 0.19; 4.11], p = 0.07) in the intervention vs. control group at 6 months. Remission was significantly higher in the intervention group at 6 months (61% vs. 47%, p = 0.006). QoL showed a steeper increase in the intervention group at 3 months (p = 0.01). During the first 3 months, return to work was significantly higher in the intervention vs. the control group. Patients in the intervention group were more consistently on antidepressant medication than patients in the control group.ConclusionsCare managers for depression treatment have positive effects on depression course, return to work, remission frequency, antidepressant frequency, and quality of life compared to usual care and is valued by the patients.Trial registrationIdentifier: NCT02378272. February 2, 2015. Retrospectively registered.

Contemporary Recommendations for Primary Care Management of Patients with HIV Infection

The morbidity and mortality associated with HIV infection has decreased significantly in the current era of antiretroviral therapy, with HIV-infected individuals now anticipating a normal life expectancy in developed countries. HIV has transformed from a disease of certain death into a chronic condition that can be managed medically. Reflecting this change, the Infectious Disease Society of America (IDSA) recently released an update on the management of HIV with a new emphasis on primary care and enhanced screening for comorbid conditions. For individuals with well-controlled HIV infection, the frequency of viral load and CD4 cell count monitoringcan is reduced from every 3-4 months to every 6-12 months. Increased attention is devoted to immunizations with new recommendations for HPV vaccination in males and an updated pneumococcal vaccination schedule. There is also an enhanced section on sexually transmitted diseases including annual screening for trichomoniasisin women, yearly screening for gonorrhea and chlamydia in at risk individuals, and anal cytologic screening in certain risk groups. This article reviews the 2013IDSA guidelines, highlights significant changes from prior IDSA guidelines, and contrasts these recommendations with other United States screening guidelines.