Primary Care Centers Research Articles

“A bit of a cough, tired, not very resilient – is that already Long-COVID?” perceptions and experiences of GPs with Long-COVID in year three of the pandemic. a qualitative interview study in Austria

BackgroundLong-COVID is a new multisectoral healthcare challenge. This study aims at understanding experiences, knowledge, attitudes and (information) needs that GPs had and have in relation to Long-COVID and how these evolved since the beginning of the COVID-19 pandemic.MethodsThe study used an exploratory qualitative research design using semistructured interviews. A total of 30 semistructured interviews with GPs in different primary care settings (single practices, group practices, primary care centres) were conducted between February and July 2022. The data were analysed using qualitative thematic content analysis with the software Atlas.ti.ResultsThis is the first study that empirically investigated Long-COVID management by GPs in Austria during the third year of the pandemic. All GPs indicated having experience with Long-COVID. In cities, GPs tended to have slightly better networks with specialists. The GPs who already worked in teams tended to find the management of Long-COVID easier. The symptoms that the physicians described as Long-COVID symptoms corresponded to those described in the international literature, but it is unclear whether syndromes and symptomes such as Post-Exertional-Malaise, autonomic dysfunction such as postural tachycardia syndrome or Mast-Cell-Overactivation-Syndrom, and cognitive dysfunctions were also recognized and correctly classified since they were never mentioned. Most GPs reacted quickly by granting the needed sick leaves and by seeing and discussing with the patients often.The treatment of the patients is described as an enormous challenge and frustrating for patient and GP if the treatment does not yield to significantly improved health also due to the high costs for the patient.ConclusionLong-COVID will continue to preoccupy our health care systems for a long time to come, as new variants of COVID-19 will continue to produce new patients without adequate prevention strategies. Therefore, it is not a question of if but when good support for GPs and adequate care pathways for people with Long-COVID will be implemented. Specific contact points that are familiar with therapy-refractory postacute infection syndromes like the postacute COVID condition as a subgroup of Long-COVID are urgently needed.

Photo-supported conversations about well-being (BeWellTM) for patients with exhaustion disorders – a controlled clinical intervention study

Introduction Health-promotion approaches to address stress-related exhaustion disorders, reduce personal suffering, improve coping and participation in everyday life are needed in primary care. The aim of this study was to investigate self-reported health and well-being before and after an intervention focusing on well-being with photo-supported conversations (BeWellTM). Material and methods Eighty-one patients (69 women), 20–67 years old, with exhaustion disorders were recruited at Swedish primary health care centres (PHCC) to a controlled clinical study. The intervention group (n = 40) were offered BeWell™ by therapists in addition to care as usual. Controls (n = 41) received only care as usual. The primary outcome, self-rated symptoms of exhaustion (Karolinska exhaustion disorder scale, KEDS), and secondary outcomes, anxiety and depression, sense of coherence, quality of life, occupational balance, and work ability, were assessed by validated questionnaires. Non-parametric statistical analyses were used to compare data collected directly after the treatment period with baseline measures. Results Demographics and self-rated baseline measures of health and well-being were comparable between the groups, apart from sick leave being more common in the intervention group. Participants in the intervention group reduced their level of exhaustion more than the control group (median difference on KEDS −9.0 vs −4.0, p = .035). However, the size of the KEDS reduction was related to baseline KEDS and, not independently associated with group assignment. Both groups improved regarding secondary outcome measures. Conclusion Stress-related symptoms decreased considerably over the treatment period for both groups. The potential benefit of the BeWell™, which was intended to facilitate recovery, needs to be further evaluated.

Patient Satisfaction with Primary Health Care Services in Qatar: A Quality Improvement Study in a Government Staff Clinic

Introduction: Patient satisfaction (PS) is a crucial measure of healthcare quality to ensure effective healthcare systems. Most previous studies focused on PS in primary health care centers, tertiary hospitals, or other settings while only a few addressed PS in staff/employee clinic settings. This study aimed to measure PS and identify factors affecting PS in a government staff clinic in Qatar. Methods: A cross-sectional quantitative research design based on a self-administered validated questionnaire was employed. The study population consisted of employees who visited the “Primary Health Care Corporation” staff clinic for a “physical” consultation between January and November 2023. Phone numbers were extracted from 942 patients’ electronic medical records. SMS texts containing links to the online questionnaire were sent. SMS and telephone reminders were conducted to reach a sufficient sample size. Results: 262 participants yielded a 28% response rate. 92% were satisfied with the overall primary health care services with aspects involving clinic accessibility (86%), physicians’ skills (84%), consultation duration (90%), condition explanation (87%), screening recommendations (80%), and shared decision-making (86%). These variables correlated significantly with the overall PS. Multivariate logistic regression analysis identified two key predictors of PS in the staff clinic: satisfaction with overall GP performance (OR=5.00; 95% CI=1.27–19.78; p=0.022) and satisfaction with overall nursing care (OR=27.88; 95% CI=5.83–133.27; p<0.001). Conclusion: The primary health care services provided in the staff clinic exceeded expectations across structural, clinical, and technical aspects. These results align with the “Qatar National Vision 2030” to foster a mentally and physically resilient population.

Primary care physicians' attitudes, practices, and perceived barriers toward depression screening in older people in the Kingdom of Bahrain

PurposeThis study aimed to explore attitudes, practices, and perceived barriers of primary care physicians (PCPs) toward depression screening in older people.MethodsThis cross-sectional study enrolled PCPs from randomly selected representative primary care centers in Bahrain. A self-administered piloted semi-structured questionnaire was used for data collection.ResultsWe enrolled 248 PCPs in the study (82.3% females, and the mean age = 40 ± 8.7 years). More than half of the participants (54.4%) had a positive attitude toward depression screening in older people. However, only 10.9% of the participants reported systematically screening for this condition without using specific tools for screening in 45.5%. The most reported barriers toward this service are short consultation time (95%), the presence of multiple co-morbidities in this age group (90%), and the absence of guidelines or appropriate training in around 30%. Positive attitudes were significantly higher among older PCPs (p = 0.039), family physician consultants (p = 0.008), those with more than 10 years of work experience (p = 0.024), and those who participated in related educational activities (p = 0.007). Under-screening practice is associated with perceived short consultation time (p = 0.002), insufficient continuous medical education (CME) activities attendance in older people's mental health (p = 0.048) as well as having a general physician's title (p = 0.049). Only the PCPs' job title, Adjusted Odds Ratio (OR) = 3.513, 95 C.I [1.225-10.074] and attendance of CME activities, OR = 1.278, 95 C.I [1.098 – 3.192] remained significant when controlled for age and experience.ConclusionMore training on older people's mental health and provision of screening and management guidelines are priorities to promote older people's mental health in primary care settings.

Psychometric Testing of the Cross-Culturally Adapted Thai Version of the Caregiver Self-Efficacy in Contributing to Patient Self-Care Scale in Caregivers of Patients With Chronic Illnesses.

To evaluate the psychometric properties of the Caregiver Self-Efficacy in Contributing to Patient Self-Care Scale (CSE-CSC). The CSE-CSC scale was developed congruently with the Caregiver Contribution to Self-Care of Patient with Chronic Illness Inventory (CC-SC-CII) to assess caregiver self-efficacy (CSE), the motivation factor of caregiving. Its applicability in Asian populations, including Thailand, was limited. Psychometric tests were guided by COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) principles. This included translating the English version into Thai, following the principles of good practice for the translation and cultural adaptation process for patient-reported outcome (PRO) measures. Nine nursing experts evaluated the content validity. The analysis included caregivers of patients with chronic conditions from 16 primary care centres in Thailand. We tested the structural validity using exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and concurrent validity for CC-SC-CII-v2. We tested the scale's reliability with methods for multidimensional and unidimensional constructs, the intraclass correlation coefficients (ICCs) and measurement error variance. Kappa coefficient (k = 1.00) indicated the scale's excellent content validity. The final analysis included a total of 407 samples. The EFA with the first split-half subsample (n = 194) extracted a two-dimensional structure. One reflected CSE in Maintenance and Monitoring behaviour and another captured CSE in Management behaviour. CFA with the second split-half subsample (n = 213) and the overall sample (n = 407) supported the scale's bidimensional model with high factor loadings. Each dimension and the overall CSE-CSC scale positively correlated with each scale and the overall CC-SC-CII-v2. McDonald's ω and Cronbach's α (both ranged from 0.91-0.94) indicated excellent internal reliability. Test-retest reliability showed ICCs between 0.95 and 0.96. Measurement error yielded satisfactory results. Testing of the Thai CSE-CSC scale supported validity and reliability, indicating that the scale can apply to Thai caregivers. This scale can be used in clinical practice and research to evaluate CSE in contribution to patient self-care.

The effectiveness of a problem-solving intervention with workplace involvement on self-reported sick leave, psychological symptoms and work ability: a cluster randomised clinical trial.

Problem-solving interventions with workplace involvement (PSI-WPI) have been shown to reduce sick leave and increase return to work in an occupational health services context. However, many employees struggle with reduced work functioning, anxiety-, and depressive symptoms up to 12months after a sick leave episode, and it is unclear if the intervention affects outcomes other than sick leave. The aim of this study is to investigate if a PSI-WPI added to care as usual (CAU) is superior to CAU with respect to self-reported sick leave, psychological symptoms, work ability, work performance, and health after RTW when provided in primary care. Employed individuals aged 18-59years on sick leave (2 to 12weeks) diagnosed by a physician at a primary care center with mild to moderate depression, anxiety, or adjustment disorder were enrolled in a two-armed cluster-randomised trial evaluating the effectiveness of a PSI-WPI. Multiple outcomes were recorded at baseline, six months, 12months, and every fourth week during the study period. Outcomes were categorised into psychological symptoms, health, work ability, work performance, and self-reported sick leave. Data were analysed using MANOVA, GEE (Generalized Estimating Equations), and cox regression. One hundred ninety-nine individuals responded to the invitation to participate; one participant withdrew, one was excluded as the employment ended, nine did not answer the baseline survey, and three were removed from the analysis due to missing data. The analysis included 81 subjects who received the intervention and 104 subjects who received the control. Baseline characteristics were similar across both groups. No differences between the groups were found among either variables except one. There was a significant difference between the groups in self-rated health (EQ5D) in favour of the CAU group from baseline to six-month follow-up, with a mean difference of -8.44 (-14.84, -2.04). A problem-solving intervention with workplace involvement added to CAU did not result in statistically significant reductions in outcomes. Further research is needed to understand why problem-solving interventions appear to have an effect on sick leave in an occupational health services context and not in a primary care context. NCT3346395, registration date 2017-11-17.

THE IMPACT OF PAEDIATRIC EMERGENCY MANAGEMENT SKILLS ON PATIENT OUTCOMES IN ZARIA

Paediatric emergencies represent a critical challenge in Nigeria, where approximately 2,300 children under the age of five die daily, predominantly from preventable and treatable conditions such as pneumonia, malaria, and diarrheal diseases. Mortality rates are disproportionately higher in rural areas, where primary health care (PHC) centers often serve as the only point of access to medical services. The effectiveness of these centers is largely dependent on the emergency management skills of their healthcare workers. Despite their importance, there has been limited research on how the skills of PHC workers in managing paediatric emergencies impact patient outcomes. This study aimed to assess the proficiency of healthcare workers in primary healthcare centers in Zaria in managing common paediatric emergencies. A cross-sectional descriptive study was conducted among 139 health workers selected through a multi-stage sampling technique in Sabon Gari and Zaria Local Government Areas. Data collection was carried out using a pre-tested semi-structured self-administered questionnaire. The data were analyzed using SPSS version 21, and associations were tested using the chi-square test, with results presented in tables and charts. The findings revealed a significant deficiency in the emergency management skills of healthcare workers. A majority of respondents demonstrated inadequate skills in handling paediatric emergencies, with 66 (48.5%) exhibiting very poor competency in the management of common paediatric emergencies, and 32 (23.5%) displaying poor competency. Only a small fraction, 4 (2.9%) of respondents, demonstrated excellent skills in emergency management. Similarly, 46.7% of the respondents had very poor skills in the treatment of common paediatric emergencies, while only 3.0% exhibited excellent treatment skills. A statistically significant relationship was observed between the level of academic qualification and emergency management skills (p < 0.05). The results underscore the critical need to enhance the skill levels of healthcare workers in PHCs through continuous professional development. This could be achieved through collaborative efforts between the Department of Paediatrics at Ahmadu Bello University Teaching Hospital and the Primary Health Care Departments of Zaria and Sabon Gari local governments, focusing on regular training and workshops. Improving the skills of healthcare workers in managing paediatric emergencies is essential for reducing child mortality and improving health outcomes in the region.

Validation of the adult asthma epidemiological score: a secondary analysis of the EPI-ASTHMA population-based study.

The A2 score is an eight-question patient-reported outcome measure that has been validated for ruling in (score ≥4) and ruling out (score 0-1) asthma. However, this screening tool has been validated in a cohort similar to the derivation cohort used. This study aims to validate the predictive accuracy of the A2 score in a primary care population against general practitioner (GP) clinical assessment and to determine whether the proposed cut-offs are the most appropriate. This accuracy study is a secondary analysis of the EPI-ASTHMA population-based study. Primary care centres in Portugal. Random adult participants answered the A2 score by phone interview. Those with an A2 score ≥1 (plus 5% with an A2 score of 0) were invited to a diagnostic visit carried out by a GP to confirm or not a diagnosis of asthma. Diagnostic accuracy was assessed using receiver operating characteristic (ROC) curves. A total of 1283 participants (median 54 (p25-p75 43-66) years; 60% women) were analysed. The A2 score showed high discriminatory power in identifying asthma, with an area under the ROC curve of 82.9% (95% CI 80.4% to 85.4%). The proposed cut-off ≥4 was the most appropriate to rule in asthma (specificity 83.1%, positive predictive value 62.4%, accuracy 78%). Similarly, the proposed cut-off<2 was the most suitable for excluding asthma (sensitivity 92.7%, negative predictive value 93.7%, accuracy 60.5%). The A2 score is a useful tool to identify patients with asthma in a primary care population. NCT0516961.

Proactive total diet replacement referral for type 2 diabetes: A service evaluation

AimsType 2 Diabetes Mellitus morbidity disproportionally effects the most socioeconomically deprived 20 % of England. Total Diet Replacement (TDR) is a high impact intervention currently commissioned by Integrated Care Boards (ICB). Finding and referring eligible, motivated patients is a significant challenge. This study evaluates a 12-month population health management, proactive referral intervention commissioned by Nottingham and Nottinghamshire ICB during a 2-year TDR pilot designed to supplement referrals from primary care. MethodsA Diabetes specialist nurse clinically reviewed a list of potentially eligible patients found by searching routinely collected health care data from 16 primary care centres in 3 PCNs. Results19.7 % (50/254) of potential patients were referred during the intervention period. 19.3 % (49/254) were uncontactable. 39.8 % (101/254) declined referral. 17.7 % (45/254) were ineligible after clinical review. An interrupted time series analysis suggests monthly referrals increased during the study period due to the intervetion (F (1,22) = 5.19 p=0.0345). Searching for patients from more socioeconomically deprived areas (index of multiple deprivation deciles 1–3) did not meaningfully alter the referral yield (19.6 %, 19/97). ConclusionsProactive care interventions could be used to facilitate referrals to the TDR or other high impact interventions by healthcare commissioning bodies.

Challenges to the Digital Inclusion of Women in a Vulnerable Area in ColombiaDesafios da inclusão digital das mulheres em uma área vulnerável na Colômbia

To identify women's technological capabilities and describe their appropriation and use of technology in a community in a vulnerable area of Colombia. Observational cross-sectional study conducted in the subregion of Urabá, Colombia. A survey was conducted in primary health care centers, in which 1478 women between 18 and 49 years of age responded to questions about their technological capabilities, their experience with the use of web-based information, and their appropriation of technology. Access to and use of information and communication technologies (ICTs) varied according to age, educational level, and socioeconomic stratum, with observed differences in preferences and critical consumption of information. The women in this study faced multiple access barriers to appropriate use of ICTs for health promotion. The appropriation of these tools in Colombia, specifically in the Urabá subregion, is a complex challenge that requires a comprehensive and multidimensional approach.

Perception of parents on barriers and facilitators of treatment outcomes among children and adolescents attending psychotherapy services in a primary health care centre in Belize

Background: The study assessed the perception of parents on barriers and facilitators treatment outcomes among children and adolescents attending psychotherapy services in a primary health care centre. Methods: A cross sectional descriptive study using both quantitative and qualitative methods. The quantitative method used retrospective review of records of 65 children and adolescent clients who accessed psychotherapy services between January 2022 and December 2023 at Port Loyola Health Centre in Belize city. The qualitative method used in-depth interviews of twenty parents of the patients randomly selected from the clinic registers. Univariate and bivariate analyses was used for the quantitative data while thematic analysis was used for the qualitative data. Results: 25 (38.5%) of the patients completed their treatment and 34 (52.3%) dropped out, with half dropped out after the first visit. The identified parental perceived barriers and facilitators are organized into four main themes. The first theme was related to knowledge and understanding of mental health problems by the parents which showed that respondents had good knowledge about mental health problems. The second theme identified attitudes towards treatment as a major factor to completion of treatment. The third theme was related to structural factors like transportation cost and parents’ work schedule identified as key barriers. The fourth theme was related to inconvenient appointment time and lack of flexibility in the scheduling of appointment at the clinic. Conclusions: The study highlights key areas of interventions to minimize barriers to completion of treatment among children accessing mental health services.

PHC visits trends effects on control of blood pressure for hypertensive patients following up in PHCs in Makkah, Saudi Arabia

Hypertension is a major risk factor for cardiovascular disease, stroke, and kidney disease. In Saudi Arabia, the prevalence of hypertension is estimated to be 14%. Primary health care centers (PHCCs) play a major role in the diagnosis, treatment, and follow-up of hypertensive patients in Saudi Arabia. This study employed a cross-sectional design to collect data from medical records of hypertension patients registered with primary health care centers (PHCCs) in Makkah, Saudi Arabia. The data was obtained through a comprehensive review of these medical records. Out of the 16,623 patients included in the study, the average annual visit frequency was 5.5 for females and 6 for males. 65.6% (10,910 patients) completed all four annual visits. There was no statistically significant difference in visit completion rates between males and females. The visit count was found to be negatively correlated with Systolic BP (-0.151, 95% CI [-0.195, -0.165]), Diastolic BP (-0.137, 95% CI [-0.147, -0.117]), and MAP (-0.176, 95% CI [-0.191, -0.161]), with a P-value &lt; 0.001 for all parameters. Our findings indicate that the number of visits to Makkah Primary Health Centers positively influences blood pressure control in hypertensive patients.

Evaluating the psychological antecedents of vaccination in applicants to primary health care centers

Abstract Background Vaccine acceptance can be enhanced by understanding the psychological antecedents of vaccination. The 5C model identifies relevant factors: confidence, complacency, constraints, calculation, and collective responsibility. This study aims to evaluate these factors among primary health care center applicants in Ankara. Methods A total of 1712 individuals aged 18 and over, who visited primary health care centers, participated in the study. The face-to-face survey included questions about sociodemographic characteristics, Vaccination Psychological Antecedents Scale, individuals’ attitudes and behaviors towards vaccination, and internet usage. Factors with a significance level of p &amp;lt; 0.20 from previous analyses were assessed using multivariate logistic regression analysis. The factors influencing the decision to get vaccinated without hesitation when necessary were investigated. Results The likelihood of getting vaccinated without hesitation in necessary situations is higher among those with higher income than expenditure(OR:1,517, 95%CI=1,094-2,104), those without chronic diseases in their family(OR:1,411, 95%CI=1,109-1,795), and those who do not actively use social media(OR:1,380, 95%CI=1,051-1,813). Additionally, an increase in the confidence score(OR:1,276, 95%CI=1,239-1,315) and the collective responsibility score(OR:1,096, 95%CI=1,058-1,134), was associated with an increased likelihood, while an increase in the calculation dimension(OR:0,928, 95%CI=0,895-0,962) was associated with a decreased likelihood. Conclusions Income status, presence of chronic illness in the family, active social media usage, confidence, collective responsibility, and calculation are factors influencing vaccine acceptance without hesitation. Communication strategies based on trust and collective responsibility should be developed to improve vaccine acceptance. The risk factors causing vaccine hesitancy among social media users should be investigated, and measures should be taken. Key messages • Develop trust-based, collective responsibility-focused communication to boost vaccine acceptance. • Investigate and address social media-driven vaccine hesitancy.

Uncovering the health system burden of pneumococcal infections in adult and elderly populations

Abstract Background Health system resources dedicated to vaccination and infectious disease prevention are often directed towards infants and children, through extensive childhood vaccination schedules. This focus has led to the near eradication of several preventable childhood diseases and had positive impacts on population health, but despite this track record of success, the ability of our health systems to make vaccinations accessible throughout the full life course has been less consistent. This project aims to address this issue by providing new data about the burden that pneumococcal infections, which are vaccine-preventable, have on adult and elderly populations. Methods This research aims to uncover the health system burden of invasive pneumococcal disease and pneumococcal pneumonia at all levels of the health system in 5 EU countries (Austria, Belgium, France, Italy &amp; Portugal). This involves a survey of managers and care providers working in hospitals, long-term care facilities, and primary care centres who may be affected by the health system impacts of pneumococcal infections. The survey covers several dimensions of health service delivery to collect a broad range of data on existing disruptions. The survey was translated into the study country languages and its formulation was further validated through interviews with experts in each study country to ensure that it can capture context-specific health system insights. The data collected through this survey will be further enhanced through a series of in-depth interviews before being synthesised, analysed and eventually published in a detailed report. Results Data collection begins as of 15 May 2024, and full results are expected to be published and available for the EPH Conference in November 2024. The results of this research will offer valuable evidence to public health professionals, health managers and policy-makers across Europe who are working to improve life-course access to pneumococcal vaccination. Key messages • Effective vaccination programmes for adult and elderly populations require expanding focus beyond childhood. • Data about the health system burden of pneumococcal infections in adult and elderly populations improves evidence-based decision-making and public health services.

Cardiometabolic multimorbidity and associated risk factors in a cohort identified through community-based screening in Eastern Nepal

Abstract Background Cardiometabolic multimorbidity constitutes a major cause of premature mortality and morbidity in low- and middle-income countries like Nepal. Early detection of associated risk factors and timely management at primary care centres can significantly reduce the impact at individual level. Lack of quality research data in resource poor setting often pose a challenge to plan for efficient delivery of health services. Purpose This analysis of secondary data from a cohort identified through a community based NCD intervention program intends to explore the distribution of cardiometabolic multimorbidity and associated risk factors in adult population of Eastern Nepal. Methods This report is a part of integrated NCD management strategy, a KHDC (Kidney, Hypertension, Diabetes, and Cardiovascular disease) program, implemented through community-based screening and interventions focused on primary level healthcare centres. The KHDC program involved screening of 14,517 individuals aged 18 years and above at baseline during a period of 2019-2023 for selected NCDs, including, cardiovascular diseases, hypertension, diabetes, and kidney disease. Individual level data was collected through anthropometric measurements, participants’ self-report, vitals assessment, laboratory parameters and diagnostic adjuncts including ECG and Echocardiography. Outcome of cardiometabolic multimorbidity1 was defined as presence of two or more of diabetes mellitus, and cardiovascular diseases including myocardial infarction and stroke. Results About 12.8% (n=1862) of the participants had at least one cardiometabolic multimorbidity, while less than one per cent (n=47) had two or more multimorbidity. Presence of at least one multimorbidity was associated with older age ≥ 40 years [OR: 3.870 (95% CI: 3.285-4.558)], male gender [OR: 1.326 (95% CI: 1.202-1.463)], BMI ≥ 23 kg/cm2 [OR: 1.348 (95% CI: 1.208-1.503)], current tobacco consumption [OR: 1.164 (95% CI: 1.038-1.305)] and co-occurrence of hypertension [OR: 1.736 (95% CI: 1.550-1.943)]. The presence of both diabetes mellitus and cardiovascular disease was associated with age ≥ 40 years [OR: 7.612 (95% CI: 1.846-31.395)] and co-occurrence of hypertension [OR: 2.544 (95% CI: 1.401-4.620)]. Conclusion Disproportionate burden of cardiometabolic multimorbidity was apparent among adult population screened in our program. Older age and co-occurrence of hypertension was identified as contributing factors for the presence of such multimorbidity. A baseline information on the distribution and risk factors for the same among general population can provide a valuable insight into understanding the disease progression and prognostic outcomes.Table of Outcomes

An intersectional approach on menstrual inequity as lived by women in circumstances of socioeconomic vulnerability in an urban and rural setting in Spain: a qualitative study

Since menstrual health and menstrual inequity are determined by social power structures, this study proposes to analyse, from an intersectional perspective, the experiences of menstrual inequity of women and people who menstruate (PWM) (≥18 years) under circumstances of socioeconomic vulnerability in an urban and rural setting in Catalonia (Spain), focusing on menstrual poverty, menstrual management and access to health care for menstrual health. An exploratory and interpretative qualitative study was conducted. Venue-based convenience sampling was carried out, recruiting women from a non-governmental organisation and a primary health care centre. Eighteen individual semi-structured interviews were conducted between October 2022 and February 2023. Data were analysed through reflexive thematic analysis. Analysis revealed that menstrual care was generally a distant preoccupation that revolved around circumstances of socioeconomic vulnerability, housing, and productive/reproductive work. Menstrual poverty, menstrual management and menstrual self-care challenges, barriers to accessing health care for menstrual health, and menstrual taboo, stigma and discrimination were commonplace and deepened by socioeconomic vulnerability. In this way, women’s menstrual experiences were rooted in intersecting axes of inequity, based on gender, race and class. Intersectional and critical participatory research, policy and practice are imperative to develop counter mechanisms that confront systems of privilege-oppression to modulate menstrual experience, health and equity.

Real world data after the implementation of coronary computed tomography angiography in Swedish primary care to rule out coronary artery disease, a cross-sectional study based on pre-test probability

Abstract Background In primary care, most patients with of non-acute chest pain will neither receive a heart related diagnosis nor be referred to a cardiologist. Studies indicate a better cardiovascular prognosis in chest pain patients referred to Coronary Computed Tomography Angiography (CCTA) as compared to risk stratification solely based on risk prediction instruments(1). CCTA is recommended since 2019 for low to intermediate cardiovascular (CV) risk patients(2). In the study setting, the primary care has implemented CCTA as first line test for patients with suspected obstructive coronary artery disease (CAD) and a Pre-Test Probability (PTP) of &amp;lt;15% and any CV risk factor, with PTP mandatorily entered in the referral letters. Purpose To study the outcome of CCTA based on referred PTP values categorised into &amp;lt;5%, 5-15% and &amp;gt;15%. We hypothesized that the presence of significant stenosis would be on par with the mean PTP. Methods In this cross-sectional retrospective cohort study, all consecutive clinical referrals for a CCTA from primary health care centres with a catchment area of ~470 000 inhabitants in the country of Sweden between 1 June 2021 and 7 Dec. 2022, with PTP estimates and completed CCTA were included. CCTA findings were stratified as normal, atheromatosis, or significant stenosis (≥50% coronary lumen obstruction). Patient baseline characteristics routinely registered on the day of CCTA was retrieved from a nationwide quality registry, SWEDEHEART(3). Pearsons’s Chi2 and one-way ANOVA was used to test differences in group distributions. Results During the study period, 381 patients with a PTP had obtained CCTA, of which 75% (n=286) had PTP &amp;lt;15%. The mean age was 60 years (standard deviation [SD] 11), 70% were female, 30% were prescribed lipid-lowering medication and 47% anti-hypertensives (Table 1). In total, the mean PTP was 12.4% (SD 8.7) and in 18% a suspected significant stenosis was identified. (Figure 1). Among patients referred with PTP 5-15%, the presence of suspected significant stenosis was 12% and cardiology consultation was less frequently described than for PTP &amp;lt;5 or ≥15% (14% vs 33% vs 44%, p &amp;lt; 0.001). Conclusions This study indicates that PTP is an efficient means to select patients for CCTA in primary care. In total, about 1/5 had a suspected significant stenosis, which often requires further investigations, and about 4/5 could be reassured that symptoms were not due to coronary artery disease. In 31% atheromatosis was identified, potentially facilitating counselling on CV prevention. We conclude that CCTA is a clinically effective option for primary care physicians to rule out CAD in patients with low PTP.Figure 1Table 1

Utility of mobile phone app-assisted screening for heart failure and heart stress in primary care

Abstract Background As heart failure (HF) still has a similar prognosis to some of the most common cancers, a timely diagnosis of HF is of paramount importance. We sought to determine whether a mobile phone app can facilitate screening for HF in primary care. Material and methods The national echocardiographic society conducted a multicenter screening programme for HF in which general practitioners from 13 primary care centres used a mobile phone app to decide whether patients without a prior HF diagnosis should be referred to one of the 6 university hospitals for transthoracic echocardiography (TTE) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing. The app would recommend further testing (TTE and NT-proBNP) to patients with symptoms potentially associated with HF, atrial fibrillation, pathologic electrocardiogram (ECG), previous myocardial infarction or exposure to cardiotoxic cancer therapies, or at least two other risk factors listed in Figure (left panel). Patients with signs of HF were not eligible for the programme. The algorithms proposed in the 2021 ESC guidelines were used to diagnose HF across the entire spectrum of left ventricular ejection fraction (EF). Results Of the 930 screened outpatients (mean age 66±11 years, age range 21-91 years, 61% female), 318 symptomatic patients (34.2%) were diagnosed with new HF (Figure). HF with preserved (HFpEF) was diagnosed more frequently than HF with mildy reduced (HFmrEF) and reduced EF (HFrEF). Heart stress, defined as elevated plasma NT-proBNP in asymptomatic individuals with risk factors irrespective of the presence or absence of structural heart disease or cardiac dysfunction, was found in 22.3% (Figure, right panel). In multivariate regression analysis, advanced age, atrial fibrillation, pathological ECG, long-standing history of arterial hypertension and chronic kidney disease were independently associated with HF, while other risk factors were not (Figure, middle panel). Conclusions Screening in primary care based on symptoms and risk factors, facilitated by a mobile phone app, resulted in a new HF diagnosis in approximately one third of screened patients, with the majority of them having HFpEF. Recalibration of the referral criteria might further improve the performance of the app for screening purposes.

Unveiling the clinical profiles of heart failure across diverse stages and phenotypes: insights from the national echocardiographic society registry

Abstract Background The modern comprehension of heart failure (HF), based on a staging paradigm, demands systematic screening to promptly identify individuals at risk, those in the pre-HF stage, and symptomatic HF patients across various phenotypes (HFpEF, HFmrEF, and HFrEF). The discernment of clinical profiles within these categories holds significant potential for improving screening and ensuring timely therapeutic interventions. Material and Methods Our national echocardiographic society executed a multicenter HF screening program. General practitioners in 13 primary care centers utilized the original mobile app to determine referrals for transthoracic echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing in patients without a prior HF diagnosis. The 2021 ESC guidelines' algorithms were employed for HF diagnosis (HFpEF, HFmrEF, HFrEF). This study identifies two pre-heart failure (pre-HF) stages: "heart stress" (elevated NT-proBNP in asymptomatic individuals with risk factors, regardless of structural heart disease or cardiac dysfunction) and individuals "at risk for HF" (normal NTproBNP and at least one HF risk factor). Ultimately, all patients were categorized into six groups: (I) no HF, no risk; (II) at risk for HF; (III) heart stress; (IV) HFpEF; (V) HFmrEF; and (VI) HFrEF. Subsequently, the eleven clinical variables were compared among groups (II) to (VI) using chi-square test. Results Among 930 screened outpatients (mean age 66±11 years, 61% female), diagnosis of HF was established in 34.2% (Figure, pie). Heart stress was found in 22.3% patients, and 38.1% were at risk for HF, while 5.5 % had neither HF nor risk factors. Group comparison revealed that older individuals were more frequent in the HFpEF group, females predominated in the heart-stress and HFpEF groups, and males in the HFrEF group (Figure, table). Obesity was the most frequent among those at risk and HFmrEF. Atrial fibrillation and pathological ECG increased gradually from those at risk to HFrEF. Previous MI was the most common in heart stress and HFmrEF groups, while arterial hypertension &amp;gt;10 years prevailed in HFpEF and HFmrEF patients. Diabetes mellitus &amp;gt; 5 years was present in 24-28% across groups. CKD or eGFR≤60 ml/min/1.73m² increased gradually towards HFmrEF. The family history of CMP or SCD was positive in 17-24%, with no significant differences observed across groups. Additionally, a small number of patients had a history of previous cardiotoxic cancer treatment, and no significant differences were found between groups. Conclusions The mobile phone application used in primary care successfully identified a significant number of pre-heart failure patients requiring further evaluation. Different HF stages and phenotypes exhibit distinct clinical profiles, aiding in the screening process and contributing to a deeper understanding of the heart's pathophysiological adaptation to diverse risk factors during HF development.

A comparative analysis of conventional echocardiographic findings among different heart failure stages and phenotypes: insights from the national echocardiographic society registry

Abstract Background The contemporary conceptualization of heart failure (HF) encompasses four developmental stages (at risk for HF, pre-HF, symptomatic HF, and advanced HF) and three distinct HF phenotypes categorized by left ventricular ejection fraction (LVEF) (HFpEF, HFmrEF, HFrEF). However, there is a need for a more comprehensive understanding of echocardiographic similarities and differences among pre-HF stages and various HF phenotypes. Material and Methods Our national echocardiographic society conducted a multicenter HF screening initiative. General practitioners in 13 primary care centers utilized the original mobile phone app to determine referrals for transthoracic echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing in individuals without a prior HF diagnosis. The 2021 ESC guidelines' algorithms were used to diagnose HF phenotypes and 2016 EACVI/ASA recommendation² to assess diastolic function. This study defined "heart stress" (elevated NT-proBNP in asymptomatic individuals with risk factors, regardless of structural heart disease or cardiac dysfunction) and "patients at risk for HF" (normal NTproBNP and at least one HF risk factor). All patients were categorized into six groups: (I) no HF, no risk, (II) at risk for HF, (III) heart stress, (IV) HFpEF, (V) HFmrEF, and (VI) HFrEF. Echocardiographic findings were compared among groups (II) to (VI), using ANOVA, Kruskal-Wallis and Chi-squared test, when needed. Results In a cohort of 930 outpatients (mean age 66±11 years, 61% female), 34.2% were diagnosed with HF, 22.3% experienced heart stress, 37.8% were at risk for HF, and 12.8% had neither HF nor risk factors (Figure). While NT pro BNP showed progressive increase, LVEF showed a progressive decline across the groups, reaching its lowest in HFrEF patients (Table). Simultaneously, left ventricular mass index (LVMi), left atrial volume index (LAVi), and maximal velocity of tricuspid regurgitation (TR Vmax) significantly increased in a stepwise manner. Variations in predominant LV geometry were significant across groups (p&amp;lt;0.001): normal LV geometry in those without HF (60.8%), concentric LV remodeling in at-risk patients (38.6%), normal LV geometry in heart stress (49%), concentric LV hypertrophy (LVH) in HFpEF (27.7%), eccentric LVH in HFmrEF (42.3%), and both concentric and eccentric LVH in HFrEF (43.3% each). Diastolic dysfunction increased prevalence across the groups (12.9% vs 24.7% vs 37.6% vs 19.6% vs 51.1%, p&amp;lt;0.001). Remarkably, HFmrEF group had the highest proportion of undetermined diastolic function (14.7% vs 23.1% vs 27.9% vs 50% vs 26.7%, p&amp;lt;0.001). Conclusions The mobile phone app used in primary care setting allowed identification of significant number of individuals in the pre-HF stages, warranting further investigation. Distinct echocardiographic differences in pre-HF stages and HF phenotypes provide valuable insights for early detection and tailored treatments.