Primary Care Population Research Articles

The Role of Nurses in Rehabilitation in Primary Health Care for Ageing Populations: A Secondary Analysis from a Scoping Review.

With the ageing of the global population and the rise in noncommunicable diseases, there is an increased need for rehabilitation services, especially those that address the specific needs of ageing populations. Through their proximity to patients, nurses play a critical role in providing rehabilitation interventions for older adults in primary health care. However, they are not yet established as typical rehabilitation providers and further research is needed to clarify their role and competencies to optimize rehabilitation interventions for ageing populations. Therefore, this secondary analysis of a scoping review aims to describe the role of nurses in the provision of rehabilitation interventions to ageing populations in primary health care. This review was carried out following the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. It is built on all inclusion and exclusion criteria from the primary analysis and focused on studies including nurses and taking place in primary health care. Data analysis included descriptive statistics, as well as qualitative analysis on the role of nurses. A total of 68 studies from high- and upper-middle income countries were included. Nurses typically had a managerial and clinical role (76%) and worked in multidisciplinary teams (54%), most often with physical therapists. Nurses provided 355 interventions, with assessments (n = 106; 30%), and coordination and management of the rehabilitation process (n = 105; 30%) being the most frequent ones. They had 117 different job titles and little information was available about their educational background. This paper contributes to a better understanding of the key role nurses play in providing rehabilitation interventions to ageing populations in primary health care. Matching nurses' competencies with their level of proficiency is essential to ensure quality care in rehabilitation.

Preventive treatment patterns in the adult migraine population: an observational UK study over 7 years

BackgroundCalcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) are recommended by the United Kingdom National Institute of Health and Care Excellence for the prevention of migraine as treatment beyond third line. We report migraine prevalence and preventive treatment patterns in the adult United Kingdom primary care population over a 7.5-year period, focusing on patients ceasing ≥ 3 oral preventive medication classes.MethodsStudy populations were retrieved from the Clinical Practice Research Datalink GOLD database (study period: 19 September 2012 to 1 January 2020; inclusion criteria: ≥12 months follow-up, current-in-dataset, adult on 1 January 2020). Patients who used ≥ 1 oral preventive medication with ≥ 3-year follow-up after first prescription were considered preventive treatment users; class cessation was defined as cessation without evidence of restart within 6 months from end-of-supply date.ResultsOn 1 January 2020, 3.0% of the total study population were diagnosed with migraine (n = 81,190/2,664,306); of these, 42.4% were preventive treatment users (n = 34,448/81,190). The most frequently used oral migraine preventive medication classes were beta-blockers (n = 14,713), tricyclic antidepressants (n = 14,415) and antiepileptics (n = 6497). Among preventive treatment users, 7.7% (n = 2653/34,448) ceased ≥ 3 oral preventive medication classes; of these, 21.7% (n = 576/2653) had been referred to a neurologist.ConclusionsCompared to existing population-based estimates of migraine prevalence, our data further corroborates that a considerable proportion of patients with migraine do not seek treatment. Among those who sought primary care within a 7.5-year period, almost half received empirical oral preventive treatment. Importantly, nearly 1 of 10 preventive treatment users ceased ≥ 3 oral preventive medication classes, highlighting a need for additional therapeutic options. These patients may benefit from CGRP antagonists and/or injectable onabotulinumtoxinA; however, only a minority was referred to specialist care, where these options would be more available.Trial RegistrationNot applicable.

Healthcare Utilization Differences Among Primary Care Patients Using Telemedicine in the Veterans Health Administration: a Retrospective Cohort Study

BackgroundThe COVID-19 pandemic encouraged telemedicine expansion. Research regarding follow-up healthcare utilization and primary care (PC) telemedicine is lacking.ObjectiveTo evaluate whether healthcare utilization differed across PC populations using telemedicine.DesignRetrospective observational cohort study using administrative data from veterans with minimally one PC visit before the COVID-19 pandemic (March 1, 2019–February 28, 2020) and after in-person restrictions were lifted (October 1, 2020–September 30, 2021).ParticipantsAll veterans receiving VHA PC services during study period.Main MeasuresVeterans’ exposure to telemedicine was categorized as (1) in-person only, (2) telephone telemedicine (≥ 1 telephone visit with or without in-person visits), or (3) video telemedicine (≥ 1 video visit with or without telephone and/or in-person visits). Healthcare utilization 7 days after index PC visit were compared. Generalized estimating equations estimated odds ratios for telephone or video telemedicine versus in-person only use adjusted for patient characteristics (e.g., age, gender, race, residential rurality, ethnicity), area deprivation index, comorbidity risk, and intermediate PC visits within the follow-up window.Key ResultsOver the 2-year study, 3.4 million veterans had 12.9 million PC visits, where 1.7 million (50.7%), 1.0 million (30.3%), and 649,936 (19.0%) veterans were categorized as in-person only, telephone telemedicine, or video telemedicine. Compared to in-person only users, video telemedicine users experienced higher rates per 1000 patients of emergent care (15.1 vs 11.2; p < 0.001) and inpatient admissions (4.2 vs 3.3; p < 0.001). In adjusted analyses, video versus in-person only users experienced greater odds of emergent care (OR [95% CI]:1.18 [1.16, 1.19]) inpatient (OR [95% CI]: 1.29 [1.25, 1.32]), and ambulatory care sensitive condition admission (OR [95% CI]: 1.30 [1.27, 1.34]).ConclusionsTelemedicine potentially in combination with in-person care was associated with higher follow-up healthcare utilization rates compared to in-person only PC. Factors contributing to utilization differences between groups need further evaluation.

Lessons learned from applying established cut-off values of questionnaires to detect somatic symptom disorders in primary care: a cross-sectional study.

Based on two diagnostic accuracy studies in high-prevalence settings, two distinctly different combinations of cut-off values have been recommended to identify persons at risk for somatic symptom disorder (SSD) with the combination of the Patient-Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Disorder-B Criteria Scale (SSD-12). We investigated whether the reported sensitivity and specificity of both recommended cut-off combinations are transferable to primary care. In a cross-sectional study, 420 unselected adult primary care patients completed PHQ-15 and SSD-12. Patients scoring ≥9 and ≥ 23 (recommended cut-off combination #1) or ≥ 8 and ≥ 13 (recommended cut-off combination #2) were considered test-positive for SSD, respectively. To assess the validity of the reported sensitivity and specificity in different low- to high-prevalence settings, we compared correspondingly expected proportions of test positives to the proportion observed in our sample. Based on combination #1, 38 participants (9%) were found to be test positive, far fewer than expected, based on the reported values for sensitivity and specificity (expected minimum frequency 30% with a true prevalence ≥1%). This can only be explained by a lower sensitivity and higher specificity in primary care. For combination #2, 98 participants (23%) were test positive, a finding consistent with a true prevalence of SSD of 15% or lower. Our analyzes strongly suggest that the sensitivity and specificity estimates reported for combination #1 are not applicable to unselected primary care patients and that the cut-off for the SSD (≥23) is too strict. Cut-off combination #2 seems more applicable but still needs to be tested in studies that compare screening findings by questionnaires with validated diagnostic interviews as reference standards in primary care populations.

Improved accuracy and efficiency of primary care fall risk screening of older adults using a machine learning approach.

While many falls are preventable, they remain a leading cause of injury and death in older adults. Primary care clinics largely rely on screening questionnaires to identify people at risk of falls. Limitations of standard fall risk screening questionnaires include suboptimal accuracy, missing data, and non-standard formats, which hinder early identification of risk and prevention of fall injury. We used machine learning methods to develop and evaluate electronic health record (EHR)-based tools to identify older adults at risk of fall-related injuries in a primary care population and compared this approach to standard fall screening questionnaires. Using patient-level clinical data from an integrated healthcare system consisting of 16-member institutions, we conducted a case-control study to develop and evaluate prediction models for fall-related injuries in older adults. Questionnaire-derived prediction with three questions from a commonly used fall risk screening tool was evaluated. We then developed four temporal machine learning models using routinely available longitudinal EHR data to predict the future risk of fall injury. We also developed a fall injury-prevention clinical decision support (CDS) implementation prototype to link preventative interventions to patient-specific fall injury risk factors. Questionnaire-based risk screening achieved area under the receiver operating characteristic curve (AUC) up to 0.59 with 23% to 33% similarity for each pair of three fall injury screening questions. EHR-based machine learning risk screening showed significantly improved performance (best AUROC = 0.76), with similar prediction performance between 6-month and one-year prediction models. The current method of questionnaire-based fall risk screening of older adults is suboptimal with redundant items, inadequate precision, and no linkage to prevention. A machine learning fall injury prediction method can accurately predict risk with superior sensitivity while freeing up clinical time for initiating personalized fall prevention interventions. The developed algorithm and data science pipeline can impact routine primary care fall prevention practice.

Validation of the IberScore model in a primary care population

BackgroundThis study aimed to validate the IberScore cardiovascular risk model in a population attended in the primary care setting. MethodsA cohort of patients with no history of cardiovascular disease visited in a primary care center during the years 2008 and/or 2009 and followed up until 2018 was selected.Cardiovascular risk was calculated with the IberScore formula for all the subjects of the cohort and the model was calibrated, graphically represented by risk deciles the proportion of expected events and proportion of observed events at 10-year follow-up, stratified by sex. The area under the ROC curve was calculated to assess the discrimination of the model. ResultsA total of 10,085 patients visited during the years 2008 and/or 2009 were included in the study. Men showed a mean 10-year risk of suffering a fatal or non-fatal cardiovascular events according to IberScore of 17.07% (SD 20.13), with a mean estimated vascular age of more than 4 years higher than the biological age; while women had a mean 10-year risk of 7.91% (SD 9.03), with an estimated vascular age of more than 2 years above the biological age.The area under the ROC curve showed a discrimination index of the model of 0.86 (95% CI 0.84–0.88) in men and 0.82 (95% CI 0.79–0.85) in women. ConclusionIberScore model discriminates well in the population attended in primary care but the model overestimates the risk.

Recalibration of a Non-Laboratory-Based Risk Model to Estimate Pre-Diabetes/Diabetes Mellitus Risk in Primary Care in Hong Kong.

A non-laboratory-based pre-diabetes/diabetes mellitus (pre-DM/DM) risk prediction model developed from the Hong Kong Chinese population showed good external discrimination in a primary care (PC) population, but the estimated risk level was significantly lower than the observed incidence, indicating poor calibration. This study explored whether recalibrating/updating methods could improve the model's accuracy in estimating individuals' risks in PC. We performed a secondary analysis on the model's predictors and blood test results of 919 Chinese adults with no prior DM diagnosis recruited from PC clinics from April 2021 to January 2022 in HK. The dataset was randomly split in half into a training set and a test set. The model was recalibrated/updated based on a seven-step methodology, including model recalibrating, revising and extending methods. The primary outcome was the calibration of the recalibrated/updated models, indicated by calibration plots. The models' discrimination, indicated by the area under the receiver operating characteristic curves (AUC-ROC), was also evaluated. Recalibrating the model's regression constant, with no change to the predictors' coefficients, improved the model's accuracy (calibration plot intercept: -0.01, slope: 0.69). More extensive methods could not improve any further. All recalibrated/updated models had similar AUC-ROCs to the original model. The simple recalibration method can adapt the HK Chinese pre-DM/DM model to PC populations with different pre-test probabilities. The recalibrated model can be used as a first-step screening tool and as a measure to monitor changes in pre-DM/DM risks over time or after interventions.

Modelo de atención sanitaria a la infancia y adolescencia en Atención Primaria. La realidad de una atención integral compartida

Currently, the health care model for the paediatric and juvenile population in primary care varies throughout Spain. Primary care is the first contact for paediatric patients and their families, care that was mainly provided by paediatricians and which must be addressed in an integrated manner by the professional categories involved in the promotion, health education and comprehensive care of children, such as paediatricians, paediatric nurses and nurses in charge of educational centres. The paediatrician and the paediatric nurse are the professionals adequately trained to care for the paediatric population in primary care and good care requires the interdependence of both professionals and cooperation with other professional figures in the educational centre and the health centre. Community health activities are necessary, working with the assets of the community to achieve health care based on equity and quality from a global perspective of the child in his or her biopsychosocial nature.

Diagnostic accuracy of a point-of-care antigen test for SARS-CoV-2 and influenza in a primary care population (RAPTOR-C19)

ObjectivesLimited evidence exists for the diagnostic performance of point-of-care tests for SARS-CoV-2 and influenza in community healthcare. We carried out a prospective diagnostic accuracy study of the LumiraDx™ SARS-CoV-2 and influenza A or B assay in primary care. MethodsTotal of 913 adults and children with symptoms of current SARS-CoV-2 infection were recruited from 18 UK primary care practices during a period when Omicron was the predominant COVID variant of concern (June 2022 to December 2022). Trained health care staff performed the index test, with diagnostic accuracy parameters estimated for SARS-CoV-2 and influenza against real-time reverse-transcription PCR (rtRT-PCR). Results151/887 participants were SARS-CoV-2 rtRT-PCR positive, 109 positive for Influenza A, 6 for Influenza B. Index test sensitivity for SARS-CoV-2 was 80.8% (122 of the 151, 95% CI, 73.6–86.7%) and specificity 98.9% (728 of the 736, 95% CI, 97.9–99.5%). For influenza A, sensitivity was 61.5% (67 of the 109, 95% CI, 51.7–70.6%) and specificity 99.4% (771 of the 776, 95% CI, 98.5–99.8%). Sensitivity to detect SARS-CoV-2 and influenza dropped sharply at rtRT-PCR cycle thresholds (Ct) > 30. DiscussionsThe LumiraDx™ SARS-CoV-2 and influenza A/B assay had moderate sensitivity for SARS-CoV-2 in symptomatic patients in primary care, with lower performance with high rtRT-PCR Ct. Negative results in this patient group cannot definitively rule out SARS-CoV-2 or influenza.

A Cross-Sectional Study of the Prevalence and Determinants of Common Mental Health Problems in Primary Care in Switzerland.

Objective: This study investigated the prevalence of the most common mental health symptoms in a large primary care patient population and characterized their determinants. Methods: Data came from a 2015-16 cross-sectional study of a primary care population in Switzerland. An investigator presented the study to patients in waiting rooms, and 1,103 completed a tablet-based questionnaire measuring stress in daily life, sleep disorders and anxiety and depressive symptoms. Diagnoses and treatments were recorded. Results: Moderate-to-high anxiety and depressive symptoms concerned 7.7% of patients; 27.6% felt stressed at least once a week; 17.2% had severe sleep disorders. Sociodemographic determinants were associated with psychiatric symptoms: female sex, young age, and frequency of consultations with a GP. Participants taking psychotropics had high levels of mental distress. Conclusion: Even though most patients were regularly monitored by their GP, a significant number of mental health problems were found. GPs should be provided with concrete tools to manage these patients better. Collaboration with mental health specialists should be encouraged in primary care settings.

Impact of weight loss and weight gain trajectories on body composition in a population at high risk of type 2 diabetes: A prospective cohort analysis.

In a primary care population at high risk of type 2 diabetes, 24-month weight change trajectories were used to investigate the impact of weight cycling on fat mass (FM) and fat-free mass (FFM). Cohort data from the Walking Away from Type 2 Diabetes trial was used, which recruited adults at-risk of type 2 diabetes from primary care in 2009/10. Annual weight change trajectories based on weight loss/gain of ≥5% were assessed over two 24-month periods. Body composition was measured by bioelectrical impedance analysis. Repeated measures were analysed using generalized estimating equations with participants contributing up to two 24-month observation periods. In total, 622 participants were included (average age = 63.6 years, body mass index = 32.0 kg/m2 , 35.4% women), contributing 1163 observations. Most observations (69.2%) were from those that maintained their body weight, with no change to FM or FFM. A minority (4.6% of observations) lost over 5% of body weight between baseline and 12 months, which was then regained between 12 and 24 months. These individuals regained FM to baseline levels, but lost 1.50 (0.66, 2.35) kg FFM, adjusted for confounders. In contrast, those that gained weight between baseline and 12 months but lost weight between 12 and 24 months (5.5% of observations) had a net gain in FM of 1.70 (0.27, 3.12) kg with no change to FFM. Weight cycling may be associated with a progressive loss in FFM and/or gain in FM in those with overweight and obesity at-risk of type 2 diabetes.

Analysis of primary care electronic health record data of people living with hepatitis B virus: infection and hepatocellular carcinoma risk associated with socio-economic deprivation

ObjectivesWe set out to characterise chronic hepatitis B (CHB) in the primary care population in England and investigate risk factors for progression to hepatocellular carcinoma (HCC). Study designRetrospective cohort study. MethodsWe identified 8039 individuals with CHB in individuals aged ≥18 years between 1999 and 2019 in the English primary care database QResearch. HCC risk factors were investigated using Cox proportional hazards modelling. ResultsMost of those with a record of CHB were males (60%) of non-White ethnicity (>70%), and a high proportion were in the most deprived Townsend deprivation quintile (44%). Among 7029 individuals with longitudinal data, 161 HCC cases occurred. Increased HCC hazards were significantly associated with male sex (adjusted hazards ratio [aHR] 3.17, 95% confidence interval [95% CI] 1.92–5.23), in the fifth deprivation quintile as compared to the third quintile (aHR 1.69, 95% CI 1.01–2.84), with older age (for age groups 56–65 and ≥66 years, compared to 26–35 years, aHRs 2.82 [95% CI 1.45–5.46] and 3.76 [95% CI 1.79–7.9], respectively), Caribbean ethnicity (aHR 3.32, 95% CI 1.43–7.71, compared to White ethnicity), ascites (aHR 3.15, 95% CI 1.30–7.67), cirrhosis (aHR 6.55, 95% CI 4.57–9.38) and peptic ulcer disease (aHR 2.26, 95% CI 1.45–3.51). ConclusionsTargeting interventions and HCC surveillance at vulnerable groups is essential to improve CHB outcomes and to support progress towards international goals for the elimination of hepatitis infection as a public health threat.

Lifestyle and cardiovascular risk factors in a Swedish primary care population with self-reported psychiatric symptoms

ObjectiveIndividuals with psychiatric illness suffer from poorer physical health compared with the general population and have a higher risk of developing cardiovascular and metabolic diseases. This cross-sectional study aims to describe the prevalence of lifestyle and cardiovascular risk factors and the association with self-reported psychiatric symptoms in a population of 40-year-old individuals screened with targeted Health Dialogues in southern Sweden. MethodsAll 40-year-old individuals registered at 99 primary healthcare centers in southern Sweden were invited to participate. Self-reported lifestyle habits on a web questionnaire, anthropometric measurements, blood pressure, and blood tests were collected. The Health Dialogue resulted in a risk level assessment for different lifestyle habits and a meeting with a trained coach. ResultsA total of 1831 individuals completed a Health Dialogue between 1st January 2021 and 30th June 2022. There were more individuals with high-risk levels for several lifestyle habits in the group with self-reported psychiatric illness compared with the rest of the study population. The analysis showed that physical inactivity, unhealthy diet, high-risk alcohol intake, tobacco use, psychosocial strain, higher BMI, and waist-hip ratio were associated with increased levels of psychiatric symptoms after adjustment for sex and socioeconomic factors. ConclusionUnhealthy lifestyle habits were associated with self-reported psychiatric symptoms in 40-year-old individuals assessed with targeted Health Dialogues in a primary care context. Organized screening might contribute to early detection of modifiable risk factors for cardiovascular disease. Individuals with psychiatric symptoms should be prioritized for screening of unhealthy lifestyle behaviors.

Acceptability and barriers of a GP-physiotherapist partnership in the diagnosis and management of COPD in primary care: A qualitative study.

Chronic obstructive pulmonary disease (COPD) is commonly diagnosed and managed in primary care but there is evidence that this has been suboptimal, with low confidence expressed in providing interventions requiring behaviour change. The aim of this study was to determine the acceptability of a general practitioner (GP)-physiotherapist partnership in the diagnosis and management of COPD in primary care and to explore the experiences of participants during the implementation of the model. Semi-structured interviews were conducted with physiotherapists (n = 3), GPs (n = 2), practice nurses (PNs) (n = 2) and patients (n = 12) who had participated in the InNovaTivE Gp-physiotheRapist pArTnErship for copD (INTEGRATED) trial. We sought to explore participants' views about their experiences and perceived benefits, barriers and facilitators to the implementation of this model of care. Interviews were transcribed, coded and thematically analysed. Synthesis of the data was guided by the Theoretical Domains Framework for clinician interviews and the health belief model for patient interviews. All clinicians felt that this integrated model helped to optimise care for patients with COPD by facilitating evidence-based practice. GPs and PNs valued the physiotherapist's knowledge and skills relating to diagnosis and management, which was reported to complement their own management and improve patient outcomes. Patients reported a sense of empowerment following their appointments and acknowledged improved self-management skills. However, physiotherapists reported many patients were already engaging in positive health behaviours. Responses were mixed on the effectiveness of the model in facilitating teamwork between clinicians with different perspectives concerning management, communication pathways and logistical issues, such as time and room availability, being cited as barriers. An experienced cardiorespiratory physiotherapist embedded into a small number of primary care practices to work in partnership with GPs for COPD diagnosis and management was acceptable and viewed as beneficial for patients. Barriers relating to logistics and resources remain, which must be addressed to optimise implementation. Patient input was obtained from qualitative feedback from a prior study conducted by two authors and was used to refine the model of care to determine the added value of a physiotherapist integrated into the primary care team. This feedback was also used to refine the interview guides utilised in this study determine the acceptability of this model of care. We had health service involvement from the rehabilitation service of the local health district who were directly involved in determining study aims and establishing the project around the priorities for their chronic disease integration service. For example, this project aimed to engage with a less severe patient population in primary care who would benefit from pulmonary rehabilitation. The findings from this study will be used to further tailor the model of care to the needs of the public and patients. ACTRN12619001127190.

Clinical and Organizational Nursing Innovations in Primary Care: Findings From a Stakeholders' Symposium.

Nursing innovations in primary care, based on interprofessional care models, could be better identified, recognized, and deployed. This article presents the results of a symposium discussing the implementation of nursing innovations in primary care in Quebec, Canada, in partnership with researchers and stakeholders. Built on the appreciative inquiry approach, 9 nursing innovations were described. To support the implementation of such nursing innovations responding to current primary care issues and population needs, 4 recommendations emerged: the need to implement strategies to achieve optimal scope of practice for primary care nurses; the importance to develop funding and organizational models that support primary care nursing innovation; the need to enhance a collaborative and democratic governance open to innovation; and the opportunity to create partnerships with the research community and teaching institutions.

QRISK3 underestimates the risk of cardiovascular events in patients with COPD

BackgroundPatients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease (CVD). The extent to which the excess CVD risk is captured by risk factors in QRISK,...

Rapid screening for suicide risk: An algorithmic approach.

In the United States, primary medical care settings are the first accessed resource for both medical and behavioral health care. Thus, there is a clear need for accurate and efficient behavioral health screening in this setting, including routine surveillance screening for suicide risk. The Multidimensional Behavioral Health Screen (MBHS), a broadband but very brief screening tool developed specifically for primary care, has been updated to include an algorithm that classifies suicide risk based on the interpersonal-psychological theory of suicide, and associated interview and decision framework. This study aims to evaluate the predictive accuracy of the new MBHS 2.0 suicide risk algorithm, with actual risk determined by clinical suicide risk interview. Data were collected as part of a larger study that, overall, included 551 college student participants. Of these, 309 completed the MBHS 2.0 and the clinical suicide risk interview, the two measures reported here. The final participant count was 299 following the removal of incomplete or invalid cases. Predicted suicide risk as determined by the MBHS 2.0 (Low, Mild, At least Moderate) was compared to actual risk as determined by clinical interview (Low, Moderate, Severe, Extreme). Utilizing chi-square analyses, data show a significant association between the predicted suicide risk category based on the MBHS 2.0 algorithm and the actual risk category based on the semi-structured clinical interview. Furthermore, classification analyses suggest that primary care providers will be able to confidently assess the suicide risk level for the majority of their patients when using the MBHS. Findings suggest that the MBHS 2.0 can be an accurate and efficient tool for use by primary care providers in classifying suicide risk. Future research will be useful to evaluate the utility of the suicide risk algorithm among primary care populations.

A Primary Care-Based Quality Improvement Project to Reduce Asthma Emergency Department Visits.

Asthma exacerbation is a common and often preventable cause of Emergency Department (ED) utilization. Children eligible for Medicaid are at increased risk of poor asthma control and subsequent ED visits. In 2010, we implemented a multicomponent longitudinal quality improvement project to improve pediatric asthma care for our primary care population, which was 90% Medicaid-eligible. Our goal was to reduce asthma-related ED visits by patients ages 2 to 18 years by 3% annually. The setting was a multisite large urban high-risk primary care network affiliated with a children's hospital. We implemented 5 sequential interventions within our network of pediatric primary care centers to increase: use of asthma action plans by clinicians, primary care-based Asthma Specialty Clinic visits (extended asthma visits in the main primary care site), use of a standard asthma note at all visits, documentation of the Asthma Control Test, and step-up therapy for children with poorly controlled asthma. At baseline in 2010, there were 21.7 asthma-related ED visits per 1000 patients per year. By 2019, asthma-related ED visits decreased to 14.5 per 1000 patients per year, a 33% decrease, with 2 center line shifts over time. We achieved and sustained our goal metrics for 4 of 5 key interventions. We reduced ED utilization for asthma in a large, high-risk pediatric population. The interventions implemented and used over time in this project demonstrate that sustainable outcomes can be achieved in a large network of primary care clinics.

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population.

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings. Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates. Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979). Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Risk of bleeding in patients with and without cancer on antiplatelet therapy following myocardial infarction: a study in primary care

Abstract Background Antithrombotic medication and antiplatelet therapy (ATPL) are used in the treatment and prevention of thrombotic disorders, especially in patients following a myocardial infarction (MI). However, the risk reduction of future ischaemic events must be balanced against the potential bleeding risk. Co-morbidities may predispose individuals to bleeding events. Cancer influences risk of bleeding either directly through bleeding of fragile cancer-associated blood vessels or by indirectly increasing the risk of bleeding remote from the cancer site. In patients with cancer, bleeding risk may be increased due to ATPL given for concomitant cardiovascular disease. Purpose To investigate the association between pre-existing cancer and risk of bleeding in patients on ATPL after myocardial infarction in a primary care population. Methods We performed a matched cohort analysis using data from the Clinical Practice Research Datalink (CPRD) and linked Hospital Episodes Statistics (HES) in England. People with an MI between 2006–2017 were matched to patients without an MI at a 1:5 ratio. Four groups: patients with both MI and cancer (breast, digestive tract, lung, prostate at baseline [within 1-year prior to MI]), patients with only cancer or MI; and patients without either condition. Using flexible parametric methods, hazard ratios were calculated to determine the association between patient group and risk of bleeding, as well as between APTL-regimen after MI and bleeding risk during 1-year of follow-up after MI. All data were processed using STATA/SE16, using a significance level of ≤0.05. Results We included 58,951 patients with an average (mean) age of 74±10 years (66% male). Of all patients, 12,526 (21%) patients had cancer, and 9,942 (17%) had an MI; numbers per subgroup are presented in Figure 1. A bleeding event was observed in 1,193 (2%) patients. The vast majority (N=56,148 [95%]) of patients did not take ATPL. Of those who did receive ATPL, aspirin was the most common (N=2,359 [4%]). In a multivariable model (adjusted for age, gender, ethnicity, prior bleeding, diabetes, renal disease, smoking status, drug, hypertension, hypercholesteraemia and cancer), people with MI had a risk (hazard) of bleeding of 2.52 (95% CI 2.23-2.86), p&amp;lt;0.001. For people with cancer only, the risk of bleeding was 1.26 (95% CI 1.10-1.44), p&amp;lt;0.001. Conclusion(s) Bleeding risks are higher in people with cancer after an MI than those with MI or cancer alone. More research is needed on individual anti-platelet therapies for people with cancer who have a MI to minimize the risk of bleeding and future cardiovascular events.Figure 1