People In Primary Care Research Articles

A 360° Approach to Personalize Lifestyle Treatment in Primary Care for People With Type 2 Diabetes: Feasibility Study.

Given the multifactorial nature of type 2 diabetes (T2D), health care for this condition would benefit from a holistic approach and multidisciplinary consultation. To address this, we developed the web-based 360-degree (360°) diagnostic tool, which assesses 4 key domains: "body" (physical health parameters), "thinking and feeling" (eg, mental health and stress), "behavior" (lifestyle factors), and "environment" (eg, work and housing conditions). This work examines the acceptability, implementation, and potential effects of the 360° diagnostic tool and subsequent tailored treatment (360° approach) in a 6-month intervention and feasibility study conducted in standard primary health care settings in the Netherlands. A single-group design with baseline, 3-month, and 6-month follow-ups was used. A total of 15 people with T2D and their health care providers from 2 practices participated in a 6-month intervention, which included the 360° diagnosis, tailored treatment, and both individual and group consultations. The 360° diagnosis involved clinical measurements for the "body" domain and self-reports for the "thinking and feeling," "behavior," and "environment" domains. After multidisciplinary consultations involving the general practitioner, pharmacist, nurse practitioner (NP), and dietitian, the NP and dietitian provided tailored advice, lifestyle treatment, and ongoing support. At the end of the intervention, face-to-face semistructured interviews were conducted with health care professionals (n=6) and participants (n=13) to assess the acceptability and implementation of the 360° approach in primary health care. Additionally, data from 14 participants on the "thinking and feeling" and "behavior" domains at baseline, 3 months, and 6 months were analyzed to assess changes over time. The semistructured interviews revealed that both participants with T2D and health care professionals were generally positive about various aspects of the 360° approach, including onboarding, data collection with the 360° diagnosis, consultations and advice from the NP and dietitian, the visual representation of parameters in the profile wheel, counseling during the intervention (including professional collaboration), and the group meetings. The interviews also identified factors that promoted or hindered the implementation of the 360° approach. Promoting factors included (1) the care, attention, support, and experience of professionals; (2) the multidisciplinary team; (3) social support; and (4) the experience of positive health effects. Hindering factors included (1) too much information, (2) survey-related issues, and (3) time-consuming counseling. In terms of effects over time, improvements were observed at 3 months in mental health, diabetes-related problems, and fast-food consumption. At 6 months, there was a reduction in perceived stress and fast-food consumption. Additionally, fruit intake decreased at both 3 and 6 months. Our findings suggest that the 360° approach is acceptable to both people with T2D and health care professionals, implementable, and potentially effective in fostering positive health changes. Overall, it appears feasible to implement the 360° approach in standard primary health care. Netherlands Trial Register NL-7509/NL-OMON45788; https://onderzoekmetmensen.nl/nl/trial/45788.

Desprescribing antihypertensives in older people in primary care: subgroup analysis of the MINOR randomised clinical trial.

Polypharmacy is often required for older adults with hypertension, and excessive treatment is associated with a high risk of adverse reactions, including hypotension. To evaluate the deprescribing of antihypertensive medications guided by pharmacists using home blood pressure monitoring in older adults with hypotension. A subgroup of older adults with signs or symptoms of hypotension, included in the MINOR clinical trial, was analysed. In the MINOR procedures, each patient was provided with a device to conduct blood pressure measurement at home for 1week, following which a report was generated and shared with pharmacists (intervention group) or family physicians (control group). In the intervention group, a pharmacist suggested optimising pharmacotherapy; meanwhile, in the control group, a family physician alone determined the necessary treatment adjustments. Differences in mean blood pressure, the patients with symptoms/signs of hypotension, and the antihypertensive medication deprescribing between both groups were analysed. Seventy-two patients were evaluated (35, control group; 37, intervention group). The intervention group showed a significant reduction in medication prescriptions (- 28.6%; P < 0.001), especially beta-blockers (- 74.2%), loop diuretics (- 83.3%), and aldosterone antagonists (- 80%). The mean office blood pressure in the intervention group increased (14.1mmHg systolic and 6.9mmHg diastolic), remaining below the target range (140/90mmHg). The intervention group showed a significantly reduction in hypotensive symptoms than the control group (64.9% vs. 20%) (P < 0.001). The data highlight an important role for pharmacists in optimizing hypertension management in older people. Deprescribing antihypertensives can limit symptomatic hypotension. Registered on ClinicalTrials.gov under number NCT04861727.

Prediabetes and cardiovascular risk factors: the effectiveness of a guided self-determination counselling approach in primary health care, a randomized controlled trial

BackgroundIdentify individuals who are at risk of Type 2 diabetes, who also are at a greater risk of developing cardiovascular disease is important. The rapid worldwide increase in diabetes prevalence call for Primary Health Care to find feasible prevention strategies, to reduce patient risk factors and promote lifestyle changes. Aim of this randomized controlled trial was to investigate how a nurse-lead Guided Self-Determination counselling approach can assist people at risk of type 2 diabetes to lower their coronary heart disease risk.MethodsIn this randomized controlled study, 81 people at risk of developing type 2 diabetes were assigned into an intervention group (n = 39) receiving Guided Self-Determination counselling from Primary Health Care nurses over three months and a control group (n = 42) that received a diet leaflet only. Measurements included the Finnish Diabetes Risk Score questionnaire and biological measurements of Hemoglobin A1c protein, Body Mass Index, fasting blood glucose, Blood pressure, Cholesterol, High-density lipoprotein, and triglycerides, at baseline (time1), 6 (time2) and 9 months (time 3).ResultsA total of 56 participants, equal number in intervention and control groups, completed all measurements. A significant difference between the intervention and control groups, in coronary heart disease risk was not found at 6 nor 9-months. However, within-group data demonstrated that 55.4% of the participants had lower coronary heart disease risk in the next ten years at the 9-month measurement. Indicating an overall 18% relative risk reduction of coronary heart disease risk by participating in the trial, with the number needed to treat for one to lower their risk to be nine. Within the intervention group a significant difference was found between time 1 and 3 in lower body mass index (p = 0.046), hemoglobin A1c level (p = 0.018) and diastolic blood pressure (p = 0.03).ConclusionsAlthough unable to show significant group differences in change of coronary heart disease risk by this 12-weeks intervention, the process of regular measurements and the guided self-determination counselling seem to be beneficial for within-group measures and the overall reduction of coronary heart disease risk factors.Trial registrationThis study is a part of the registered study ‘Effectiveness of Nurse-coordinated Follow-Up Programme in Primary Care for People at Risk of T2DM’ at www.ClinicalTrials.gov (NCT04688359) (accessed on 30 December 2020).

Advanced practitioners working with older people in primary care and community settings: a survey of roles and use of technology.

Advanced practitioner (AP) roles are becoming increasingly common in primary care and community settings for supporting older people and those living with frailty. The aim of this study was to explore health and social work AP roles in primary care and community settings in the UK, and understand how they support older people and factors that may impact on APs use of technology in practice. A cross-sectional, web-based survey was adopted to explore the views and perspectives of APs. The survey received 111 responses. There were different views as to whether technology was suitable for older people. Although digital exclusion was a concern, it was perceived that this would change in the future as generations become more digitally literate. Respondents suggested that using technology brought about efficiencies and the ability to respond sooner to symptom changes, with some concerns mentioned regarding the accuracy of technology that may miss signs and symptoms. This is the first national survey to explore advanced practice roles with older people in non-hospital settings. While APs have wide-ranging skills, few currently use technology in their practice. Findings will inform a future study on digitally enhanced comprehensive geriatric assessments.

Characterizing pulmonary rehabilitation referrals from primary care

BackgroundSupporting referral to pulmonary rehabilitation (PR) from primary care for people with chronic lung disease could improve equity of access. Understanding who is referred to PR from primary care, and by whom, could inform development of strategies to increase awareness of and referral to PR for people with chronic respiratory disease. We aimed to quantify the proportion of patients referred to PR from primary care in an Australian metropolitan setting; and to identify characteristic features of patients and referrers. MethodsA retrospective, single-site, audit of referrals was undertaken. Corresponding patient medical records were reviewed for referral details, patient demographics and baseline PR assessment measures. ResultsBetween January 2020 and December 2023 658 referrals to PR were received of which 6.2 % (n = 41) originated from a primary care source (98 % general practice; 2 % allied health). People referred to PR from primary care were typically diagnosed with COPD (71 %), were female (59 %), had moderate disease severity (mean(SD) forced expiratory volume in 1 s 70(26) %predicted) and had mild symptoms (53 % modified Medical Research Council dyspnoea score 0 or 1) and modest functional impairment (6-min walk distance 410(121) meters). Just 4 of 36 primary care practitioners referred more than one patient. ConclusionIn this audit the proportion of people referred to PR from primary care was very low. Processes to support the referral of more patients from primary care to PR, across the spectrum of chronic respiratory disease, remain a priority for improving access to this well-established treatment.

Who Guideline for Non-Surgical Management of Chronic Primary Low Back Pain in Adults in Primary and Community Care Settings

Low back pain is a very common condition that affects most people at some point in their lives. It represents a burden on those affected, reducing their ability to participate in activities of normal life; at the same time, dealing with it increases the economic costs of healthcare. The aim of this guideline was to contribute to WHO activities for reducing the impact of low back pain in adults and to support the WHO approach to integrated care for older people in primary care. In December 2023, the World Health Organization (WHO) published the "WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings". It was developed following the process according to the WHO handbook for guideline development. The team at the WHO Collaborating Centre for Evidence-Based Medicine at the University for Continuing Education Krems (Austria) translated the summary of this guideline for its application in German-speaking countries. The guideline addresses 37 interventions for the treatment of chronic primary low back pain in primary care and provides 24 recommendations and one good practice statement. No recommendations were made regarding twelve interventions due to equivocation or lack of sufficient evidence. The recommended interventions are intended to provide a range of options to support and personalize care for adults with chronic primary low back pain.

Healthcare for trans people in primary care

Healthcare for trans people in primary care

Advancing effective street outreach to people experiencing unsheltered homelessness: Concepts for public health nursing.

Homelessness, particularly unsheltered homelessness is a public health emergency in the U.S. Street outreach programs have demonstrated efficacy in connecting people to housing, initiating or retaining people in primary care, improving access to mental health services, and increasing treatment for substance use disorder. Effective outreach is generally characterized by trained, multidisciplinary teams that visit clients where they are, forming trusting relationships over time. Public health nurses working on outreach teams have opportunities to exercise their full scope and standards of practice and advance street outreach to the benefit of a distinctly marginalized group.

Patterns of Telemedicine Use in Primary Care for People with Dementia in the Post-pandemic Period

BackgroundThe pandemic rapidly expanded telemedicine, which has persisted as a widely available primary care modality. The uptake of telemedicine among people with dementia specifically in the primary care setting, who have more complex care needs but also benefit from more accessible primary care, is unknown.ObjectiveAmong people with dementia, assess uptake of telemedicine-based primary care in the post-pandemic period and determine associations with key socio-demographic characteristics.DesignRetrospective observational study.SubjectsPeople with dementia at UCSF and Kaiser Permanente Northern CA (KPNC) with at least one primary care encounter in pre- (3/1/2019-2/29/2020) or post-COVID (3/1/2021-2/28/2022) periods, post-COVID sample: N= 419 individuals (UCSF), N=18,037 (KPNC).Main MeasuresEncounter modality: in-person, video telemedicine, or telephone telemedicine. Focal socio-demographic characteristics: age, limited English proficiency, socioeconomic status, driving distance to clinic, and caregiver at encounter.Key ResultsThere was a large increase in telemedicine among people with dementia in the post-pandemic period at both sites. At KPNC, those with only in-person primary care visits shrunk from 60.47% (pre) to 26.95% (post). At UCSF, the change was even greater: 98.99% to 35.08%. Across both sites, the only measure significantly associated with use of telemedicine was greater driving distance from home to clinic. At KPNC, those over age 90 were most likely to use telemedicine while patients with limited English proficiency and those with a caregiver at the encounter used telemedicine at lower levels. The relationships were similar at UCSF but not statistically significant.ConclusionsTelemedicine use is high for people with dementia in the primary care setting in the post-pandemic period. Those with longer drives to clinic and the oldest patients were most likely to use telemedicine, likely due to challenges traveling to appointments. Still, not all people with dementia used telemedicine equally—particularly those with limited English proficiency.

Selection of outcome measurement instruments for a core outcome set for trials aimed at improving appropriate polypharmacy in older people in primary care: a Delphi consensus study

BackgroundDespite developing a polypharmacy core outcome set (COS) in primary care, it is not clear how these outcomes should be measured.AimTo select outcome measurement instruments (OMIs) for a COS targeting appropriate polypharmacy in older patients in primary care.MethodFollowing the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline, OMIs were identified from a Cochrane review focusing on appropriate polypharmacy. The quality of OMIs was assessed using a published checklist. Subsequently, two rounds of Delphi questionnaires were conducted via the SoGoSurvey® platform, engaging stakeholders (researchers, clinicians and journal editors specialising in geriatric primary care) to achieve consensus on OMIs using a scale encompassing “agree”, “disagree”, or “unsure”. Consensus was achieved if 70% or more participants chose “agree” and 15% or fewer chose “disagree.”ResultsThe quality of 20 OMIs identified from the Cochrane review was evaluated. Seven OMIs were selected based on meeting the COSMIN guideline’s minimum requirements. Out of 188 potential participants, 57 (30.3%) consented to participate. Rounds 1 and 2 of Delphi exercises were completed by 50 respondents, achieving agreement on three OMIs: ‘number of serious adverse drug reactions (ADRs)’ (98%), ‘number of deaths’ (76%), and ‘number of patients who fell’ (70%) for measuring ‘serious ADRs,’ ‘mortality,’ and ‘falls,’ respectively. No agreement was reached for ‘medication appropriateness,’ ‘medication side-effects,’ ‘quality of life,’ and ‘medication regimen complexity.’ConclusionOMIs were selected for a limited number of outcomes in the polypharmacy COS. Future research should identify suitable OMIs for the remaining four outcomes.

Effects of cardiac rehabilitation on the functional capacity of hypertensive elderly people in primary care

Effects of cardiac rehabilitation on the functional capacity of hypertensive elderly people in primary care

Rethinking continuity in primary care for people with mesothelioma.

Mesothelioma is a terminal disease that is linked to asbestos exposure. Continuity is difficult for GPs, and other healthcare professionals (HCPs), to provide within the current NHS primary care system, but is highly valued by people with mesothelioma. To understand the experiences of continuity in primary care among people with mesothelioma, their close persons, and their HCPs; how they achieve this (or not); and how it affects their healthcare service use. Realist case studies of patient journeys through the healthcare system (involving longitudinal interviews with people with mesothelioma, their close persons, and HCPs; and exploration of the organisational context). Data analysis allowed understanding of hidden mechanisms (resources and reasoning), triggered in certain contexts, leading to specific outcomes. Forty-eight interviews (involving 9 patients, 8 close persons, and 12 HCPs) were undertaken (totalling 30.8 hours/1848 minutes). Context-Mechanism-Outcome configurations related to: challenges unique to mesothelioma; capacity of patients/close persons/HCPs to facilitate continuity; multidisciplinary (MDT) approach differs from the family doctor model; and 'the NHS primary care system is broken'. Patients perceive their continuity needs to be unmet by the inflexible primary care system, which needs to adapt to a society in which people receive increasingly novel treatments and live longer with complex healthcare needs. A societal perspective shift is required to understand that an MDT now shares responsibility for care, rather than an individual family doctor. Policy documents continue to focus on access, and still do not advocate strongly enough for continuity, despite unequivocal evidence demonstrating its worth.

A rapid review to inform the policy and practice for the implementation of chronic disease prevention and management programs for Aboriginal and Torres Strait Islander people in primary care

BackgroundMore than 35% of Aboriginal and Torres Strait Islander adults live with cardiovascular disease, diabetes, or chronic kidney disease. There is a pressing need for chronic disease prevention and management among Aboriginal and Torres Strait Islander people in Australia. Therefore, this review aimed to synthesise a decade of contemporary evidence to understand the barriers and enablers of chronic disease prevention and management for Aboriginal and Torres Strait Islander People with a view to developing policy and practice recommendations.MethodsWe systematically searched for peer-reviewed published articles between January 2014 to March 2023 where the search was performed using subject headings and keywords related to “Aboriginal and Torres Strait Islander peoples,” “Chronic Disease,” and “Primary Health Care”. Quality assessment for all included studies was conducted using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. The data were extracted and summarised using a conventional content analysis approach and applying strength-based approaches.ResultsDatabase searches identified 1653 articles where 26 met inclusion criteria. Studies varied in quality, primarily reporting on 14 criteria of the Aboriginal and Torres Strait Islander Quality Appraisal Tool. We identified six key domains of enablers and barriers of chronic disease prevention and management programs and implied a range of policy and practice options for improvement. These include culturally acceptable and safe services, patient-provider partnerships, chronic disease workforce, primary health care service attributes, clinical care pathways, and accessibility to primary health care services. This review also identified the need to address social and cultural determinants of health, develop the Aboriginal and Torres Strait Islander and non-Indigenous chronic disease workforce, support multidisciplinary teams through strengthening clinical care pathways, and engage Aboriginal and Torres Strait Islander communities in chronic disease prevention and management program design and delivery.ConclusionEnabling place-based partnerships to develop contextual evidence-guided strategies that align with community priorities and aspirations, with the provision of funding mechanisms and models of care through policy and practice reforms will strengthen the chronic disease prevention and management program for Aboriginal and Torres Strait Islander people.

UNIVERSALITY, INTEGRALITY AND EQUITY IN CARE FOR THE DEAF PATIENTS PAIN PRIMARY CARE: A SYSTEMATIC REVIEW

This article aims to systematically identify scientific production regarding basic health care for deaf people. Through a systematic literature review, the search for published works using the SCIELO BR, BVS and PUBMED platforms as a database was carried out by two researchers, directing the selection and exclusion process, respectively, of data for analysis. In this sense, from a scope of careful and objective choices, original articles were sought, published in Portuguese, English and Spanish, and which addressed the perspective of care for deaf people in primary care. Dissertations, book chapters, case studies and editorials were excluded. From this, 508 articles were found, 396 were excluded by the filters applied, 03 were repeated, 75 were excluded by the title and 89 by reading the abstract. 04 were read in full and evaluated. Therefore, 04 articles were chosen for this review. The reality is that the care and experience experienced by deaf people in primary care require reformulations that occur quickly and effectively, both in communication, accessibility, care and research, and in the applicability of the right to health guaranteed by law.

Brief cognitive behavioural therapy for eating disorders symptomatology among a mixed sample of adolescents and young adults in primary care: A non-randomised feasibility and pilot study.

Brief and accessible therapies for people with an eating disorder is an important health target. Ten-session cognitive behavioural therapy (CBT-T) is a brief treatment evaluated in people with a non-underweight eating disorder. This study aimed to evaluate the feasibility and preliminary effectiveness of CBT-T for young people in primary care. This cohort pilot study used group (adolescents vs. young adults) by time (over four time points) Generalised Linear Mixed Model analysis. Participants included 13-25-year-olds attending an early intervention mental health service, receiving 10 sessions of CBT-T. Feasibility was assessed using recruitment, retention and satisfaction. Eating and other pathology measures were administered at baseline, weeks four and 10, and 12-week follow-up. Of the 63 commencing treatment, 38 completed 10 CBT-T sessions (60%). Most (94%) reported high treatment satisfaction. Significant reductions in eating pathology, depression and stress were found. Age group did not yield differences in CBT-T outcome, with large to very large effect sizes across outcome variables. Anxiety was associated with attrition. This study provides preliminary support for the use of CBT-T in primary care, across adolescence and early adulthood. Findings require replication in other clinical settings and comparison to other clinical approaches and control populations.

Lists of potentially inappropriate medications for older people in primary care: a systematic review of health outcomes.

This study is a systematic literature review of the association between lists of potentially inappropriate medications (PIM) in clinical practice and health outcomes of older adults followed up in primary health care. For this purpose, the PRISMA protocol was used to systematize the search for articles in the PubMed, Web of Science, Scopus, Cochrane Central, LIVIVO and LILACS databases, in addition to the gray literature. Studies with randomized clinical trials were selected, using explicit criteria (lists) for the identification and management of PIM in prescriptions of older patients in primary care. Of the 2,400 articles found, six were used for data extraction. The interventions resulted in significant reductions in the number of PIM and adverse drug events and, consequently, in potentially inappropriate prescriptions (PIP) in polymedicated older adults. However, there were no significant effects of the interventions on negative clinical outcomes, such as emergency room visits, hospitalizations and death, or on improving the health status of the older adults. The use of PIM lists promotes adequate medication prescriptions for older adults in primary health care, but further studies are needed to determine the impact of reducing PIM on primary clinical outcomes.

Assessment and management of endometriosis in young people in primary care.

Assessment and management of endometriosis in young people in primary care.

Deriving and validating an asthma diagnosis prediction model for children and young people in primary care.

Introduction: Accurately diagnosing asthma can be challenging. We aimed to derive and validate a prediction model to support primary care clinicians assess the probability of an asthma diagnosis in children and young people. Methods: The derivation dataset was created from the Avon Longitudinal Study of Parents and Children (ALSPAC) linked to electronic health records. Participants with at least three inhaled corticosteroid prescriptions in 12-months and a coded asthma diagnosis were designated as having asthma. Demographics, symptoms, past medical/family history, exposures, investigations, and prescriptions were considered as candidate predictors. Potential candidate predictors were included if data were available in ≥60% of participants. Multiple imputation was used to handle remaining missing data. The prediction model was derived using logistic regression. Internal validation was completed using bootstrap re-sampling. External validation was conducted using health records from the Optimum Patient Care Research Database (OPCRD). Results: Predictors included in the final model were wheeze, cough, breathlessness, hay-fever, eczema, food allergy, social class, maternal asthma, childhood exposure to cigarette smoke, prescription of a short acting beta agonist and the past recording of lung function/reversibility testing. In the derivation dataset, which comprised 11,972 participants aged <25 years (49% female, 8% asthma), model performance as indicated by the C-statistic and calibration slope was 0.86, 95% confidence interval (CI) 0.85-0.87 and 1.00, 95% CI 0.95-1.05 respectively. In the external validation dataset, which included 2,670 participants aged <25 years (50% female, 10% asthma), the C-statistic was 0.85, 95% CI 0.83-0.88, and calibration slope 1.22, 95% CI 1.09-1.35. Conclusions: We derived and validated a prediction model for clinicians to calculate the probability of asthma diagnosis for a child or young person up to 25 years of age presenting to primary care. Following further evaluation of clinical effectiveness, the prediction model could be implemented as a decision support software.

Deriving and validating an asthma diagnosis prediction model for children and young people in primary care

Introduction: Accurately diagnosing asthma can be challenging. We aimed to derive and validate a prediction model to support primary care clinicians assess the probability of an asthma diagnosis in children and young people. Methods: The derivation dataset was created from the Avon Longitudinal Study of Parents and Children (ALSPAC) linked to electronic health records. Participants with at least three inhaled corticosteroid prescriptions in 12-months and a coded asthma diagnosis were designated as having asthma. Demographics, symptoms, past medical/family history, exposures, investigations, and prescriptions were considered as candidate predictors. Potential candidate predictors were included if data were available in ≥60% of participants. Multiple imputation was used to handle remaining missing data. The prediction model was derived using logistic regression. Internal validation was completed using bootstrap re-sampling. External validation was conducted using health records from the Optimum Patient Care Research Database (OPCRD). Results: Predictors included in the final model were wheeze, cough, breathlessness, hay-fever, eczema, food allergy, social class, maternal asthma, childhood exposure to cigarette smoke, prescription of a short acting beta agonist and the past recording of lung function/reversibility testing. In the derivation dataset, which comprised 11,972 participants aged &lt;25 years (49% female, 8% asthma), model performance as indicated by the C-statistic and calibration slope was 0.86, 95% confidence interval (CI) 0.85–0.87 and 1.00, 95% CI 0.95–1.05 respectively. In the external validation dataset, which included 2,670 participants aged &lt;25 years (50% female, 10% asthma), the C-statistic was 0.85, 95% CI 0.83–0.88, and calibration slope 1.22, 95% CI 1.09–1.35. Conclusions: We derived and validated a prediction model for clinicians to calculate the probability of asthma diagnosis for a child or young person up to 25 years of age presenting to primary care. Following further evaluation of clinical effectiveness, the prediction model could be implemented as a decision support software.

Jumpstarting Advance Care Planning with Alaska Native and American Indian People in Primary Care (Sch441)

Jumpstarting Advance Care Planning with Alaska Native and American Indian People in Primary Care (Sch441)