Primary Care Clinics Research Articles

Assessing the effects of Enhanced Multicomponent Proactive Navigator-Assisted Cessation of Tobacco Use within a federally qualified health center (EMPACT-Us): a protocol study

BackgroundCalifornia’s relatively low smoking rate (10.1% in 2019–2020) (About CHIS, UCLA Center for Health Policy Research, 2024) masks deep disparities among low-income populations, where smoking rates are nearly double that of their middle- to upper-income peers. Low-income smokers report a similar desire to quit and similar rates of recent quit attempts as smokers from other groups; yet, they often face barriers in accessing effective resources to facilitate successful cessation.MethodsOur team will conduct a pragmatic stepped-wedge cluster, randomized controlled trial of Enhanced Multicomponent Proactive Navigator-Assisted Cessation of Tobacco Use (EMPACT-Us), a suite of tobacco cessation services supported by patient navigators, designed in close partnership with patients, providers, and community stakeholders. The study will take place at Family Health Centers of San Diego (FHCSD), the largest federally qualified health center (FQHC) in San Diego. Eight primary care clinics are included, where 70% (n = 13,496) of smokers at FHCSD receive care.DiscussionWe hypothesize that multiple points of engagement and integration of navigation services into the workflow of existing staff will improve utilization and cessation success. This study will examine if the enhanced suite of services offers insights on how to best integrate evidence-based tobacco treatment services into usual care.Trial registrationClinicalTrials.gov, NCT05750537, Registered on March 1, 2023.https://clinicaltrials.gov/study/NCT05750537.

Individual and clinical factors associated with patient acceptance of referrals to social services and community resources at a multi-purpose resource hub.

Emerging evidence suggests that bi-directional communication and referral pathways, when employed strategically, can lead to favorable health outcomes by connecting patients with complex, multi-faceted health and social needs to appropriate services and resources. However, despite these benefits, patient acceptance of referrals via these pathways remains suboptimal. In this study, we describe individual and clinical factors associated with patient acceptance of these referrals. We extracted individual-level demographic and clinical data for patients referred primarily from a large safety-net health system to a multi-purpose resource hub co-located on the campus of its largest hospital, for the period October 2019 to June 2023. Descriptive statistics, Chi-square analyses, and multinomial regression modeling were performed to examine these data. Of 1865 patients in the study sample, 54.2% accepted a referral, 27.4% were lost to follow-up, and 18.4% declined. Most patients who accepted referrals were female (67.1%), Latino (81.5%), and had hypertension and/or prediabetes or diabetes (84.1%). In modeling analyses, those who accepted referrals tended to be female, and were referred from primary care clinics; many were referred for multiple service/resource categories. We found associations between patient acceptance of referrals and gender and source of referral. Drawing upon these results as well as experience implementing these systems, we propose several practical strategies for increasing successful referrals, including identifying and addressing barriers for patients who declined or were lost to follow-up; using standardized screening tools to routinely assess for multi-faceted health and social needs; increasing provider awareness about the benefits and functioning of these pathways; and monitoring progress so mid-course adjustments can be made when necessary.

Focusing on Caregiver Neglect: A Novel Strategy for Mistreatment of Older Adults Screening and Intervention.

Mistreatment of older adults is common and has serious health consequences but is under-recognized and under-reported. Screening for mistreatment of older adults and initiation of intervention in primary care clinics may be helpful, but the value of existing tools is not supported by evidence. We argue that shifting the focus to individual sub-types of mistreatment of older adults can provide improved approaches to screening and ultimately to intervention. We focus on the example of caregiver neglect, the subtype associated with highest mortality. To develop caregiver neglect screening and intervention programs and to measure their effectiveness and impact, we assert that it is critical to: (1) define the phenomenon, (2) develop a conceptual model to explain why it occurs, (3) develop measurement strategies, and (4) systematically examine existing literature. We describe here the initial components of this development process.

Melanoma toolkit for early detection for primary care clinicians: a 1-year follow-up on outcomes

IntroductionPrimary care providers or clinicians (PCPs) have the potential to assist dermatologists in screening patients at risk for skin cancer, but require training to appropriately identify higher-risk patients, perform skin checks, recognize and biopsy concerning lesions, interpret pathology results, document the exam, and bill for the service. Very few validated dermatology training programs exist for PCPs and those that are available focus primarily on one emphasis area, which results in variable efficacy and single-topic limited scope.MethodsWe have created a free, online, continuing education program (Melanoma Toolkit for Early Detection, MTED) that allows learners to choose from a variety of multimedia tools (image recognition, videos, written material, in-person seminars, self-tests, etc.) that suits their learning style and time availability. Here we present the toolkit, the development and validation of the curriculum, and report on 1-year outcomes of a nested survey study. Because the goal of the program is to maximize participation by allowing PCPs to tailor their experience to their own needs and interests, the majority of participants did not complete every element of the program.ResultsA total of 8,683 PCPs have accessed at least one element of the toolkit from 2019–2024. Participants completed a pre-survey, online training module, and post-survey that included self-reported screening behaviors, changes in confidence, and malignant and benign lesion categorization based on clinical images. A total of 139 pre-surveys and 92 post-surveys were completed, including 55 matched participants that completed both the pre- and post-training surveys. There were significant improvements in PCP confidence (P < 0.001) and malignant (P < 0.001) and benign image (P = 0.029) identification respectively.DiscussionPCPs may serve as a valuable aid in skin cancer screening efforts, but additional studies are needed to evaluate the impact of these curricula in clinical practice.

Becoming a leader for underserved patients—the importance of student run free clinics

Many students enter medical school with aspirations of expanding healthcare to underserved communities and reducing healthcare access barriers; yet they lack the leadership skills to achieve this goal. This perspective discusses the role of student-run free clinics in developing medical students’ leadership abilities—problem-solving, partnership building, planning, decision-making, and resource acquisition—to address the healthcare needs of marginalized patient populations. It also discusses how fostering leadership skills in the context of serving underserved patients also develops medical students’ structural competency and thus awareness of how inequities embedded within hierarchies and social institutions shape health outcomes. We use the example of the development of the Coachella Valley Free Clinic, a student-led and community engaged primary care clinic, to illustrate how student-run free clinics create opportunities for medical students to build leadership skills while addressing the healthcare needs of marginalized patient populations. Medical students, working alongside community health workers and federally qualified healthcare centers, devised a “pop-up” clinic model aimed at delivering care that is both culturally sensitive and linguistically appropriate, thereby addressing health disparities rooted in systemic inequality. As we argue, SRFCs create real-world settings where medical students can develop their leadership skills and understanding of inequities in health ultimately contributing to the broader goal of reducing health inequities by improving healthcare access for underserved patient populations.

From Clinician to Commissioner

The need to develop a workforce who can deliver on the purpose of enhancing equity of access to primary care has been identified by one of the 31 Primary Health Networks (PHN) established by the Australian Government in 2015. Over almost a decade, Hunter New England and Central Coast PHN has been undertaking assessments of its organisational capability to commission primary care services for the local community. The outcome of these assessments and of a training needs analysis for team members engaged in commissioning has lead to the development of a training program which is growing in sophistication. This has lead to the development of a Primary Care Commissioning Development Centre, which coordinates education and training for PHN teams, service providers and primary care clinicians in many aspects of the commissioning of primary care.

The pattern of anti-IL-6 versus non-anti-IL-6 biologic disease modifying anti-rheumatic drugs use in patients with rheumatoid arthritis in Wales, UK: a real-world study using electronic health records.

Investigating factors associated with drug initiation and discontinuation in patients treated with anti-IL-6 biologic DMARDs (bDMARDs) (tocilizumab or sarilumab) vs non-anti-IL-6 (anti-TNF, B or T cell therapies) bDMARDs for RA. A retrospective cohort study of patients with the diagnosis of RA in the Secure Anonymised Information Linkage Databank, comprising primary and secondary care and specialist rheumatology clinic records for >90% of the population in Wales, UK. Patients initiated on first bDMARD treatment, discontinuation and clinical outcomes including infection and hospitalisation were analysed using Cox regression analysis. Of patients identified with RA in their primary care records, 95.7% (4691/4922) received conventional synthetic DMARDs (csDMARDs). More than one-third (36.2%) were treated with bDMARDs (1784/4922). Of these biologic-naïve patients, 6.5% (116) were treated with anti-IL-6 bDMARDs; this treatment was associated with a previous history of infection [difference 8.8% (95% CI 1.1, 17.8)] and kidney disease [14.3% (95% CI 8.0, 22.5)]. Treatment discontinuation was significantly higher in the non-anti-IL-6 bDMARD-treated patients (23.1%) compared with the anti-IL-6 bDMARD-treated individuals (18.1%) [difference 9.4% (95% CI 1.1, 15.7)]. For those discontinuing a first line of treatment, 385 patients (23%) and 21 patients (18%) switched to an alternative bDMARD from the non-anti-IL-6 and anti-IL-6 groups, respectively. Comorbidities, history of infection and kidney disease were associated with choosing anti-IL-6 bDMARDs in biologic-naïve RA patients in Wales. Anti-IL-6 bDMARD-treated biologic-naïve patients were more likely to continue treatment than non-IL-6 bDMARD-treated patients.

THE COST OF SMS REMINDER TO IMPROVE ARV ADHERENCE AMONG KEY POPULATIONS

Background: HATI is an implementation trial aimed at improving HIV care and treatment, including through SMS reminders. Aims: This study aimed to estimate the cost and analyze the outcomes of providing SMS Reminders within the HATI program in different settings. Methods: Data were analyzed using a micro-costing approach from providers' and health systems' perspectives. Subjects were divided into intervention and control groups for outcome analysis, with adherence as the outcome indicator. Results: From a provider's perspective, the highest cost was incurred in primary health care (PHC) clinics, while the lowest was in hospital clinics, most likely due to a much higher volume of SMS sent from hospitals. Costs from the health system perspective were more than two times higher than those from the provider perspective, as they included costs borne by HATI management and intervention setup. In one year, the number of patients with >95% adherent visits was higher in the intervention group than the control group, although visits decreased over time in both groups. The highest number of patients with >95% adherent visits was found in PHC clinics, while the lowest was in hospital clinics. Conclusion: SMS reminders can be expensive initially due to setup and program costs. However, they become cheaper once they are embedded into the existing system. Further studies are necessary to determine better site options for scaling up SMS reminder intervention and to study the declining adherence rate in all clinics. Keywords: Adherence, cost analysis, HIV, Indonesia, SMS reminder

Utilizing Quality Improvement Methodology to Address Disparities in Colorectal Cancer Screening Between Faculty and Resident Physicians.

Health system data from a large academic medical center revealed a 14% lower rate of colorectal cancer (CRC) screening in resident patient panels compared to faculty patient panels. This resident-led quality improvement (QI) work identified causes for disparities in CRC screening and implemented an innovative panel management intervention to reduce CRC screening disparities. Analysis was conducted across two academic primary care clinics at a single institution. Residents engaged key stakeholders in the CRC screening process to identify causes for disparities and potential solutions in the CRC screening process. A novel interprofessional panel management protocol was implemented to guide residents on how to perform population health strategies to increase CRC screening and to streamline the navigation process. The effectiveness of each intervention in improving CRC screening was analyzed. After four months of protocol implementation, CRC screening for resident patient panels improved from 62 to 68% based on analysis done on a run chart. The difference in CRC screening between faculty and resident patient panels decreased from 14 to 10%, reducing the disparity by 29%. This interprofessional panel management protocol significantly increased the CRC screening rates among patients receiving primary care from resident physicians. This further highlights the importance of multipronged interventions to improve disparities in CRC screening and to improve overall screening rates.

A Literature Review of the Educational Gaps and Needs in Migraine Management: An Asian Perspective Within a Global Context.

Migraine is a common neurological disorder that presents considerable challenges to healthcare systems worldwide. These changes are especially relevant in rapidly developing regions such as Asia, with an increasingly productive population and ongoing advancements in healthcare systems and infrastructure. Despite its substantial impact, migraine management remains inadequate, potentially due to deficiencies in medical education. We hypothesized that significant gaps in basic and advanced medical training and continuing professional education contribute to the suboptimal management of migraine in various healthcare settings across Asia. A comprehensive literature review was conducted using PubMed and Google databases. The search focused on cross-sectional studies published in English from inception until September 2024 that examined educational needs among medical trainees and clinicians and clinical gaps in migraine management in Asia. These studies were then contextualized within a global perspective. The review identified significant shortcomings in migraine education at all levels of educational training in Asia, which also translated to poor management of migraines in clinical practice. Undergraduate medical curricula in Asia inadequately address headache disorders, while postgraduate training programs provide insufficient guidance in headache management, especially for complex cases. Primary care clinicians exhibited variable levels of understanding and frequently incorrectly diagnosed and managed migraine.Additionally, many Asian countries lack standardized clinical practice guidelines (CPGs) and specialized training programs for headache management. A multidimensional approach is required to tackle the pre-existing educational and clinical practice limitations. The approach should include improving the medical school curriculum, providing focused continuing medical education programs or developing migraine modules for primary care physicians (PCPs), and developing region-specific CPGs. Besides educational initiatives, integrating and coordinating systems of care, where primary and specialist services complement each other, are crucial for improving patient care. Robust education combined with comprehensive referral and linkage protocols ensures continuity of care across healthcare levels. Moreover, collaboration, communication, and cooperation among healthcare providers (HCPs) and organizations are vital to enhancing the quality of life and productivity of migraine patients in the region.A synergistic approach that combines robust collaboration with innovative educational delivery can catalyze the widespread adoption of evidence-based medicine (EBM).

Development and implementation of a firearm safety intervention by medical and physician assistant students in an adult primary care setting

Firearm ownership is associated with an increased risk of adverse health outcomes, including violence, suicide, and accidental firearm injury. Numerous medical governing bodies have placed emphasis on firearm screening and counseling within the healthcare setting. However, few physicians discuss firearm ownership and safety with patients, likely due to limited physician familiarity with firearms or perceived risk to the doctor-patient relationship, among other barriers. Clinical trainees have the capability to confidentially screen for unsafe firearm practices and potentially prevent fatal injury. In this study, we provide one of the first reports of a universal firearm screening and safety intervention developed and implemented by medical and physician assistant students in an adult primary care clinic as part of a longitudinal clerkship experience. Students learned the basics of firearm ownership and storage, developed interview skills for sensitive topics, developed a screening tool for safe firearm storage, and gained a better understanding of firearm safety in the community. Through partnership with the Chicago Police Department, students offered firearm cable locks to all patients who screened positive for unsafe firearm storage practices. Overall, this study aimed to assess the feasibility of a universal firearm safety screening tool and intervention in a primary care clinic. We conclude that such a tool is feasible in a student-led primary care clinic, provides unique educational opportunities for students, and can be adopted in numerous healthcare teaching settings. Future steps may include evaluating other ways to promote firearm safety, such as screening for intimate partner violence and/or concomitant mental illness.

Transforming community-based primary health care delivery through comprehensive performance measurement and reporting: examining the influence of context

BackgroundCommunity-based primary health care represents various community-based health care (CBPHC) models that incorporate health promotion and community development to deliver first-contact health services. Learning health systems (LHSs) are essential for improving CBPHC in which feedback from relevant stakeholders is used to continuously improve health systems with the goal of achieving population health and health equity. Performance reporting is one way to present data to clinicians and decision makers to facilitate a process of reflection, participation, and collaboration among partners to improve CBPHC.MethodsOur objective was to obtain feedback on a regional CBPHC performance portrait through key informant interviews. We used purposive convenience sampling to recruit participants who were clinicians in primary care and/or decision-makers in primary care at a regional level. The performance portrait summarized results of survey questions asked of patients, providers, and primary care organizations. The portrait was organized by the 10 pillars of the Patient’s Medical Home (PMH) model. Interview questions specifically asked about portrait content, formatting, interpretability, utility, and dissemination strategies. Content analysis was used to analyze interview data.ResultsWe completed 19 interviews with key informants from the Canadian provinces of Nova Scotia (n = 8), Ontario (n = 6) and British Columbia (n = 5). We coded transcripts into four content areas: (1) Usability as influenced by content and interpretability, (2) Formatting, (3) Utility, and (4) Dissemination. Using data and reporting back to clinicians and decision-makers about how their practices and jurisdictions are performing in primary care in meaningful ways is important. Our results suggest having available methodology notes, including the analysis used to develop any scoring, sampling and sample sizes, and interpretation of the statistics is necessary.ConclusionsThis research was the first to create a comprehensive performance portrait using data driven by factors that are important to primary care partners. We obtained important feedback on the portrait in the context of usability, formatting, utility, and dissemination. This data needs to be used to provide feedback in continuous cycles to evaluate and improve CBPHC models as part of a LHS.

Buprenorphine prescribing practices for older adults in 2019 and 2020.

Opioid use disorder (OUD) prevalence has increased threefold among Medicare beneficiaries 65 years and older (hereafter "older adults") since 2013, with a prevalence of 15.7 per 1000 Medicare beneficiaries in 2018. Yet, access to treatment that addresses the needs of older adults with OUD is limited, including patterns of buprenorphine prescribing to older adults. Therefore, we sought to describe buprenorphine treatment patterns among older adults and prescribing clinician specialties. We conducted a retrospective observational study using 2019-2020 IQVIA Real World Data-Longitudinal Prescriptions. High-prescribing clinicians are those who prescribed buprenorphine to >15 unique older adults within a calendar year. We used T-test and chi-square tests to compare characteristics associated with differences in prescribing. Among 26,202 clinicians prescribing buprenorphine to 67,921 unique older adults, 1232 (5%) prescribed to more than 15 older adults (mean 28.1, SD = 23.6), corresponding to buprenorphine prescribing for 24,672 (36%) older adults. Among older adults dispensed buprenorphine, the majority (58%) were 66-70 years of age and male (54%). Individuals older than 70 years (44%) and males (51%) were slightly more common among high prescribers than non-high-prescribing clinicians (41% and 49%, respectively). Primary care clinicians (42%) and advance practice providers (APPs) (29%) were the most common specialties prescribing buprenorphine. Most (87%) buprenorphine prescribers were in urban counties; with a slightly higher percentage of high-prescribing clinicians in urban counties (91%). A relatively small subset of clinicians prescribes most buprenorphine to older adults. This work provides evidence of gaps in care delivery. Scalable systems-level interventions should be developed and tested to improve treatment availability mindful of existing clinical infrastructure.

A Qualitative Study to Describe the Nature and Scope of Street Medicine Programs in the United States

Street medicine is a health delivery model designed to provide direct patient care to people experiencing unsheltered homelessness where they are physically located, whether that be on the streets or in encampments. The model has developed in response to the barriers people experiencing homelessness (PEH) encounter when accessing care through traditional points of access such as primary care clinics. Street medicine programs are rapidly emerging across the United States (U.S.) in response to the health needs and challenges associated with care access and coordination for unsheltered homeless individuals. Although street medicine is a rapidly growing field, existing street medicine programs have rarely been studied collectively, limiting our understanding of the nature, scope, and range of street medicine programs in the U.S. This study examined 13 programs from across the U.S. to develop a broad characterization of street medicine programs. Results from interviews with representatives from each of the 13 programs show that there is a high degree of variability among the structure, operations, and scope of care of street medicine programs. However, consistent among street medicine programs is the adoption of a patient-centered approach to care and the use of harm-reduction principles. Street medicine programs are also highly engaged with community partners and affiliate organizations that work in their local and regional areas. Because street medicine programs often serve as a bridge between formal healthcare entities and PEH, street medicine offers a strategy for reconnecting individuals to vital healthcare services.

A Compelling Health Promoting Primary Care Clinic Using a Settings-Based Approach: A Demonstration Project.

The Ottawa Charter for Health Promotion, issued by the World Health Organization in 1986, called for several strategies to promote the public's health. One of the strategies was to create health-promoting health services. Over 35 years have passed since the Ottawa Charter was released, since then, efforts to improve health care have been implemented such as the Patient-Centered Medical Home, the Triple Aim, and the Affordable Care Act, yet little has been done to reorient the cultural and physical environment of health care services to one focused on health promotion. In this perspective, the author offers a compelling description of how one primary care clinic, serving an ethnically and economically diverse population, utilized a settings-based approach to design and implement several health-promoting policies, systems, and environmental strategies. This reorientation of a primary care clinic to one that is health-promoting leveraged the clinical specialty of lifestyle medicine as a cornerstone of the settings-based approach.

Gastrointestinal disorders – Clinical challenges for the primary care clinician

Gastrointestinal (GI) associated symptoms are among the most common medical concerns resulting in visits to primary and specialty care. Especially challenging is the wide range of causative disorders and exposures associated with symptoms ranging from mild to life threatening - from within the GI tract as well as extra-gastrointestinal. Some of these are well described, and common, including infections, while others are newly emerging, such as cannabinoid hyperemesis syndrome. Others are well known but clinical success can remain elusive, such as food associated GI disorders - lactose intolerance and related. Although entire references have been written to address gastrointestinal diseases, in this edition of Disease a Month we will address some of the more challenging GI disorders; some of which are common but often difficult to control - food associated for example, and emerging GI illnesses such as radiation or cannabinoid hyperemesis, that lead patients to the Emergency Department, primary care clinician or specialty referral. What follows is a discussion of diverse but clinically important GI disorders, and the newer therapeutic strategies to help patients better manage their symptoms, and improve their quality of life.

Risk Factors in Chronic Kidney Disease in Newly Diagnosed Type 2 Diabetes Mellitus Patients Attending a Tertiary Care Hospital in South Tamil Nadu, India: A Cross-sectional Study

Introduction: Chronic Kidney Disease (CKD) has become a major cause of global morbidity and mortality, especially in developing countries like India. When diagnosed at the end stage, the overall average cost incurred by the health system per haemodialysis session is INR 4,148, and the mean Out-of-Pocket Expenditure (OOPE) per patient is INR 2,838, which a poor can not afford. Indian CKD registry infers that Type 2 Diabetes Mellitus (T2DM) attributes for 31.2% of CKD cases. The high cost of haemodialysis and the expenditure spent out of pocket by impoverished patients warrants the need for the present study, which was aimed to assess CKD risk among newly diagnosed diabetics. Aim: To assess CKD risk among newly diagnosed diabetics using the Kidney Disease Improving Global Outcomes (KDIGO) 2021 guidelines, which utilise estimated Glomerular Filtration Rate (eGFR) and urine microalbuminuria as assessment tools. Materials and Methods: The present cross-sectional study was conducted in the Non Communicable Disease (NCD) Outpatient Department (OPD), Madurai Medical College (attached to the Government Rajaji Hospital), Madurai, Tamil Nadu, India, from July 1st 2022 to August 30th, 2022. Study was conducted among 200 newly diagnosed T2DM patients (diagnosed for less than 6 months), selected by consecutive sampling. After the initial administration of a questionnaire, blood and random spot urine samples were collected. CKD risk was assessed based on eGFR and urine microalbuminuria using the KDIGO 2021 guidelines, with eGFR calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. Statistical analysis was done using Statistical Package for the Social Sciences (SPSS) software 21.0, employing the Chi-square test and Pearson’s correlation tests. Results: Of the total 200 study participants, 130 (65%) were females and 70 (35%) were males with a mean age of 47.74±10.35 years. Of the study participants, 106 (53%), belonged to the low-risk category, 74 (37%) to the moderaterisk category, and 20 (10%) to the high/very high-risk category for CKD. A statistically significant association was observed between alcohol intake and CKD (p-value=0.034). A significant negative correlation (p-value <0.001) was found between age and eGFR (Pearson’s coefficient=-0.400). In the present study, age and gender were not significant factors in CKD risk. While no link was found between carbonated drink consumption and CKD risk, alcohol intake did show a notable association. The study also noted a statistically significant negative correlation between age and eGFR. Conclusion: Identifying CKD risk in diabetic patients using KDIGO guidelines based on eGFR and microalbuminuria is crucial. Early detection is vital to slow progression, particularly from moderate to high-risk categories, thereby reducing personal and societal burdens. Regular monitoring with eGFR testing and follow-ups can improve outcomes and reduce the likelihood of advanced CKD. Collaborative efforts among primary care clinicians and specialists are essential for early CKD risk detection and management using these tools.

Screening of Diabetic and Heart failure Patients for Silent Atrial Fibrillation

BackgroundAtrial fibrillation (AF) is a common heart rhythm disorder with various clinical presentations, including asymptomatic AF, known as silent AF. High-risk patients not treated with anticoagulants are at increased risk of stroke. Therefore, systematic screening has been evaluated to reduce death and cardiovascular complications. Concentrating screening efforts on high-risk populations may optimize the effectiveness of future screening strategies. The aim of our study was to determine the prevalence of silent AF in a high-risk population 65 years or older with diabetes mellitus type 2 (DM2) and/or congestive heart failure (CHF). MethodsA multicentre, observational, prospective cohort study of 645 patients with DM2 and/or CHF screened for AF in primary care and outpatient clinics in Denmark, Sweden and Austria from 2016 to 2020. Patients were examined by intermittent electrocardiogram (ECG) recordings using a handheld ECG device four times daily for two weeks. AF was diagnosed with at least one recording (30 seconds) of AF. Patients with fewer than 40 recordings were excluded from the analyses. ResultsOverall 3.3 %, respectively, 3.0% and 3.9% of the patients with DM2 and CHF, and 5.5% of patients older than 74 years were diagnosed with previously undetected AF. ConclusionsIntermittent handheld ECG screening revealed AF in one in every 30 patients in a high-risk population, with an increased observed risk in elderly patients.

Gastrointestinal disorders–Clinical challenges for the primary care clinician: Conclusion

Gastrointestinal disorders–Clinical challenges for the primary care clinician: Conclusion

Retention in primary care among unstably housed residents of a low-income, inner-city neighborhood with a high prevalence of substance use and related disorders

IntroductionAccess to and engagement with primary healthcare can be difficult for marginalized low-income populations residing in inner cities in high-income countries. We designed a study to examine retention in primary care among clients of a novel interdisciplinary primary care clinic in the Downtown Eastside of Vancouver, Canada who did not previously have access to care.MethodsBeginning in June 2021, clients of the Hope to Health clinic were offered enrolment in a cohort study which involved a baseline and follow-up surveys every six months, and linking their data to information from the clinic’s electronic medical records. We used Chi-square or Fisher’s Exact test and Wilcoxon rank sum test to compare clients who were lost to follow-up (LTFU) or deceased, with clients who were retained in care at the end of follow-up, Cox proportional hazards modeling was used to examine independent associations with mortality or LTFU.ResultsAmong 425 participants enrolled, the median age was 50 years (IQR 40–59), 286 (67.3%) participants were men and 128 (25.4%) were unstably housed at enrollment. Among 338 participants with at least six months of follow-up after enrolment, 262 participants (67.5%) were retained in care, 20 (5.2%) had moved, 57 (14.7%) were classified as LTFU, and 28 (7.2%) had died with a median of 19.9 months of follow-up time. The risk of death or LTFU was independently associated diagnosed with alcohol use disorder (AUD) (adjusted hazard ratio [AHR] = 2.23 vs. not; 1.38–3.60), frequency of medical doctor visits (AHR = 0.69 per visit per 3 months; 0.60–0.79) and social work visits (AHR = 0.73 per visit per 3 months; 0.59–0.90. Stimulant use disorder or asthma were not significantly associated with retention in care.ConclusionWe found that a primary healthcare model of care was successful in retaining over two-thirds of clients in primary healthcare after more than 18 months of follow-up. Additional supports for those diagnosed with alcohol use disorder are needed to retain them in care.