Community Primary Care Research Articles

FRI032 - Identifying advanced liver disease in asymptomatic patients in primary care: an evaluation of patient outcomes 24 months after implementing a primary care liver pathway and community liver service

FRI032 - Identifying advanced liver disease in asymptomatic patients in primary care: an evaluation of patient outcomes 24 months after implementing a primary care liver pathway and community liver service

Clinical diagnosis of seasonal influenza by physicians: a retrospective observational study

ObjectiveTo elucidate the diagnostic accuracy of pretest probability of influenza (%) by physicians and the factors affecting the clinical diagnosis.DesignRetrospective, single-centre observational study.SettingA community primary care clinic in Japan.ParticipantsThe participants...

Walk the Talk: A Program Model of Community-Oriented Primary Health Care

While there is a dearth of value-based primary care services in low- and middle-income countries, primary care has been demonstrated to be associated with enhanced access to health services and better health outcomes. The demonstrated barriers to high-quality primary care are under-resourcing, inadequate payment models, lack of community linkages, limited scope and comprehensiveness, limited integration with other components of the health system, and unexciting/unattractive conditions for physicians. Based on global data, we propose a transformative community-oriented primary care program model with a network of ambulatory, virtual, and comprehensive community services. Community-oriented primary care is medical practice that undertakes responsibility for the health of a defined population. Key components of this medical service program are 1. Community health workers (CHWs) responsible for specific populations, with expanded portfolios to provide communicable and noncommunicable disease home health care, health education, and disease registry maintenance; 2. A 24/7 virtual care service to back up and supplement CHW activities; 3. A primary care ambulatory service facility with major paraprofessional-specialist conduct of routine processes and record-keeping utilizing algorithmic guidelines; 4. Multiple point-of-care diagnostic capacities and immediate tele-consults for both ambulatory facility and CHW services; 5. A customized interoperable electronic medical record system, focused on patient care functionalities such as charting and decision-support; 6. Wireless broadband connections for all program workers; and 7. Sustainable economics with revenue from locally determined subscription systems, sliding scale fees for services from ambulatory care facilities, limited CHW service fees, core per capita government support, research projects, and philanthropy.

Misalignment: understanding the challenge of engaging with self-management advice for people living with diabetes in UK Black African and Caribbean communities

Objectives: The incidence of type 2 diabetes in UK Black African and Caribbean communities is up to three times higher than in the general population, and engagement with self-management advice is poorer. This study explores the perspective of those living with diabetes to understand how the cultural salience of advice could be improved. Design: Participants were recruited via community venues, faith institutions and primary care. Eight focus groups were conducted with 41 individuals (Black African n = 23, Black Caribbean n = 18). Grounded theory methods were used for analysis. Results: Although motivated to manage the condition, individuals experienced a misalignment between elements of the care provision and cultural norms. Explanatory models of diabetes differed from the biomedical model reducing trust in treatment protocols. A lack of cultural salience reduced the accessibility of advice. Furthermore, elements of self-management advice were seen to conflict directly with some cultural traditions and practices. Individuals had to reconcile the two perspectives in order to proceed with self-management, often prioritising cultural norms and advice from informal sources over healthcare advice. Building personal relationships with the healthcare team improved trust and engagement. Conclusion: Findings suggest the needs in these communities were not being fully met. The healthcare interaction was pivotal in improving trust and engagement and reducing misinformation. However, appropriately informed community support also offers the potential to mitigate misalignment and to improve equity of access.

Health status of young adults with serious mental illness enrolled in integrated care.

People with serious mental illness (SMI) are more likely to develop chronic health conditions and die prematurely. Timely identification of modifiable health risk factors may enable early intervention. We aimed to describe the physical health characteristics and service utilization of young people with SMI. Young people with SMI enrolled in an integrated community mental health clinic (CMHC) and primary care program were assessed for physical and mental health history and past year service utilization. A total of 122 participants, ages 16-35 (m=27.0 ± 5.0 years), half male, 78.3% White were assessed. Half smoked cigarettes, half had obesity, almost half (47.5%, n=56) had hypertension, and about a third had laboratory metabolic abnormalities. The group averaged 10.7 ± 5.1 h of sedentary behavior per day. Obesity was associated with high blood pressure, prediabetes, poor self-rated health abilities, sedentary behavior and low health satisfaction. Over half had been to the emergency department (ED) for a medical reason (55.0%, n=66) and 24.6% had been hospitalized for a health condition in the past year. Over half had a lifetime cardiovascular risk score indicating a 50-67% chance of having a cardiovascular event; simply quitting smoking would reduce the number with this risk by almost half. Most physical health diagnoses were not recorded in the CMHC record. Young people with SMI newly enrolled in integrated care had high rates of smoking, obesity, hypertension, and other cardio-metabolic abnormalities contributing to high risk for future disease. Research is needed to examine appealing, scalable interventions to improve health, reduce unnecessary medical care, and prevent disparate chronic disease in this group.

967-P: Decentralizing Diabetes Specialty Care Improves Glycemic Control

Parkland Health and Hospital System (PHHS) is the Dallas County safety-net health system and serves indigent Dallas County residents. PHHS has primary care clinics (COPCs) located in underserved areas of the county to provide easier access to its residents. The Diabetes Specialty Clinic (DSC) is located next to the Parkland Hospital, but this location can be difficult to access for patients with limited means. We studied the effect of co-locating a diabetes specialty practice (H-DSC) at a community primary care practice (Hatcher Station COPC (HSC)) by comparing the A1c change between the patients managed by primary care providers at HSC alone or by specialists at H-DSC. Table 1 displays the results of this study. The data show that there was a significant reduction in A1c in the HSC patients seen by primary care and H-DSC patients of -0.2% and -0.5% respectively. There is also a significant difference in baseline and final A1cs between both groups that show that H-DSC patients had poorer baseline glycemic control but also greater improvement in glycemic control. H-DSC patients were also being seen by their primary care providers at HSC, and without the co-location of the DSC to H-DSC, many of these patients would not have accessed care at the DSC main location. This suggests that co-locating diabetes specialty services at local, easy-to-access primary care centers at a safety-net health system can improve the glycemic control of patients with diabetes. Disclosure U.Gunasekaran: None.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

The challenge of care coordination by midwives during the COVID-19 pandemic: a national descriptive survey

BackgroundAs part of a decades-long process of restructuring primary care, independent (also known as community) healthcare workers are being encouraged to work in groups to facilitate their coordination and continuity of care in France. French independent midwives perform about half of the early prenatal interviews that identify mothers' needs during pregnancy and then refer them to the appropriate resources. The French government, however, structured the COVID-19 pandemic response around public health institutions and did not directly mobilise these community healthcare workers during the lockdown phase. These responses have raised questions about their role within the healthcare system in crises. This survey’s main objectives were to estimate the proportion of independent midwives who experienced new difficulties in referring women to healthcare facilities or other caregivers and in collaborating with hospitals during the first stage of this pandemic. The secondary objective was to estimate the proportion, according to their mode of practice, of independent midwives who considered that all the women under their care had risked harm due to failed or delayed referral to care.MethodsWe conducted an online national survey addressed to independent midwives in France from 29 April to 15 May 2020, around the end of the first lockdown (17 March–11 May, 2020).ResultsOf the 5264 registered independent midwives in France, 1491 (28.3%) responded; 64.7% reported new or greater problems during the pandemic in referring women to health facilities or care-providers, social workers in particular, and 71.0% reported new difficulties collaborating with hospitals. Nearly half (46.2%) the respondents considered that all the women in their care had experienced, to varying degrees, a lack of or delay in care that could have affected their health. This proportion did not differ according to the midwives’ form of practice: solo practice, group practice with other midwives only, or group practice with at least two types of healthcare professionals.ConclusionsThe pandemic has degraded the quality of pregnant women’s care in France and challenged the French model of care, which is highly compartmentalised between an almost exclusively independent primary care (community) sector and a predominantly salaried secondary care (hospital) sector.

Understanding the Role of Misinformation in COVID-19 Vaccine Hesitancy in a Rural State.

Objective: to identify factors associated with COVID19 vaccine hesitancy, including sources of information among residents of Maine. Methods: 148 study participants, recruited through community partners and primary care offices in Maine, completed an anonymous 15 item online survey. Recruitment and data collection occurred from May to September, 2021. Hesitancy was determined through a single question, “Will you get one of the COVID vaccines when it is offered to you?” Results: vaccine hesitant respondents were younger than not hesitant respondents (p = 0.01). Hesitant individuals were significantly more likely to report concerns regarding the speed of COVID-19 vaccine production, vaccine efficacy, and potential vaccine side effects (p < 0.05 for each). Hesitant individuals were also significantly more likely to have discussed vaccination with their primary physician (p = 0.04). Conclusions: overall, hesitant individuals are more likely to be younger and had less trust in information from government sources, but they sought input from primary care. They were also more concerned about efficacy, side effects, and the rapid development of COVID-19 vaccines. Primary care physicians are in key positions to address these concerns due to contact with individuals who need accurate information.

Improving care for patients with depression: A collaborative project with community pharmacy and primary care providers

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Affordable Care Act Medicaid expansion and access to primary-care based smoking cessation assistance among cancer survivors: an observational cohort study

BackgroundSmoking among cancer survivors can increase the risk of cancer reoccurrence, reduce treatment effectiveness and decrease quality of life. Cancer survivors without health insurance have higher rates of smoking and decreased probability of quitting smoking than cancer survivors with health insurance. This study examines the associations of the Affordable Care Act (ACA) Medicaid insurance expansion with smoking cessation assistance and quitting smoking among cancer survivors seen in community health centers (CHCs).MethodsUsing electronic health record data from 337 primary care community health centers in 12 states that expanded Medicaid eligibility and 273 CHCs in 8 states that did not expand, we identified adult cancer survivors with a smoking status indicating current smoking within 6 months prior to ACA expansion in 2014 and ≥ 1 visit with smoking status assessed within 24-months post-expansion. Using an observational cohort propensity score weighted approach and logistic generalized estimating equation regression, we compared odds of quitting smoking, having a cessation medication ordered, and having ≥6 visits within the post-expansion period among cancer survivors in Medicaid expansion versus non-expansion states.ResultsCancer survivors in expansion states had higher odds of having a smoking cessation medication order (adjusted odds ratio [aOR] = 2.54, 95%CI = 1.61-4.03) and higher odds of having ≥6 office visits than those in non-expansion states (aOR = 1.82, 95%CI = 1.22-2.73). Odds of quitting smoking did not differ significantly between patients in Medicaid expansion versus non-expansion states.ConclusionsThe increased odds of having a smoking cessation medication order among cancer survivors seen in Medicaid expansion states compared with those seen in non-expansion states provides evidence of the importance of health insurance coverage in accessing evidence-based tobacco treatment within CHCs. Continued research is needed to understand why, despite increased odds of having a cessation medication prescribed, odds of quitting smoking were not significantly higher among cancer survivors in Medicaid expansion states compared to non-expansion states.

Antimicrobial stewardship intervention bundle decreases outpatient fluoroquinolone prescribing for urinary tract infections.

An antimicrobial stewardship bundle was implemented in 23 community health system urgent care and primary care clinics to reduce fluoroquinolone prescribing in urinary tract infections. The percentage of urinary tract infection (UTI) visits prescribed a fluoroquinolone subsequently decreased from 17.6% to 3% in urgent care and from 23.8% to 6.8% in primary care.

Lessons Learned Through Two Phases of Developing and Implementing a Technology Supporting Integrated Care: Case Study.

BackgroundAs health care becomes more fragmented, it is even more important to focus on the provision of integrated, coordinated care between health and social care systems. With the aging population, this coordination is even more vital. Information and communication technology (ICT) can support integrated care if the form of technology follows and supports functional integration. Health TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) is a program centered on the health of older adults, supported by volunteers, primary care teams, community engagement and connections, and an ICT known as the Health TAPESTRY application (TAP-App), a web-based application that supports volunteers in completing client surveys, volunteer coordinators in managing the volunteer program, and primary care teams in requesting and receiving information.ObjectiveThis paper describes the development, evolution, and implementation of the TAP-App ICT to share the lessons learned.MethodsA case study was conducted with the TAP-App as the case and the perspectives of end users and stakeholders as the units of analysis. The data consisted of researchers’ perspectives on the TAP-App from their own experiences, as well as feedback from other stakeholders and end user groups. Data were collected through written retrospective reflection with the program manager, a specific interview with the technology lead, key emailed questions to the TAP-App developer, and viewpoints and feedback during paper drafting from other research team members. There were 2 iterations of Health TAPESTRY and the TAP-App and we focused on learnings from the second implementation (2018-2020) which was a pragmatic implementation scale-up trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework at 6 primary care sites across Ontario, Canada.ResultsTAP-App (version 1.0), which was iteratively developed, was introduced as a tool to schedule volunteer and client visits and collect survey data using a tablet computer. TAP-App (version 2.0) was developed based on this initial experience and a desire for a program management tool that focused more on dual flow among users and provided better support for research. The themes of the lessons learned were as follows: iterative feedback is valuable; if ICT will be used for research, develop it with research in mind; prepare for challenges in the integration of ICT into the existing workflow; ask whether interoperability should be a goal; and know that technology cannot do it alone yet—the importance of human touch points.ConclusionsHealth TAPESTRY is human-centered. The TAP-App does not replace these elements but rather helps enable them. Despite this shift in supporting integrated care, barriers remained to the uptake of the TAP-App that would have allowed a full flow of information between health and social settings in supporting patient care. This indicates the need for an ongoing focus on the human use of ICT in similar programs.

The association between the rate of potentially pharmacist-manageable emergency department visits and community income level and primary care provider availability: A spatial analysis.

The association between the rate of potentially pharmacist-manageable emergency department visits and community income level and primary care provider availability: A spatial analysis.

A communication procedure between community pharmacists and primary care professionals resolves medication errors and other administrative issues.

The aim of this study was to implement a communication procedure, with agreed-upon protocols, to resolve daily medication errors and other administrative issues that require communication between community pharmacists (CPs) and primary healthcare professionals (PHCPs). A 6-month pilot study followed by a year-length principal study was carried out in the Donostialdea Integrated Healthcare Organisation (IHO). Afterwards, the project was extended to other IHOs. The CPs identified medication errors or other administrative issues that required communication with PHCPs, contacting the customer service staff by telephone for urgent problems and by email for non-urgent problems. In total, 49 community pharmacies participated in the study. A total of 1179 medication errors and other administrative issues were detected, and over 90% of problems were solved in less than 24 h (n = 1079, 91.5%). Email was the more frequently used communication method (n = 874, 74.1%), and the most prevalent problems were due to absent (n = 766, 65.0%) and expired (n = 226, 19.2%) electronic prescriptions. Most of the participants were satisfied with the programme. The present communication procedure between CPs and PHCPs is an efficient tool to resolve a variety of challenges that occur in community pharmacies.

Investigating group-based classes ('weaning workshops') to support complementary infant feeding in Irish primary care settings: a cross-sectional survey.

This study aims to (1) investigate current practice regarding 'weaning workshops' to support complementary infant feeding delivered within Irish primary care, (2) explore the experiences and opinions of community dietitians regarding optimal content and modes of delivery of weaning workshops and (3) identify the key factors to be considered in the development and implementation of weaning workshops delivered within primary care. Cross-sectional survey. Irish primary care. Forty-seven community-based dietitians. Sixteen dietitians reported that workshops were run in their area with variable frequency, with ten reporting that workshops were never run in their area. Participants reported that mostly mothers of medium socio-economic status (SES) attended weaning workshops when infants were aged between 4 and 7 months, and that feedback from workshop attendees was predominantly positive. Dietitians identified that key factors to be considered in future development and delivery of weaning workshops are (1) workshop characteristics such as content, timing and venue, (2) organisational characteristics such as availability of resources and multidisciplinary involvement and (3) attendee characteristics such as SES. This study highlights substantial variability regarding provision of weaning workshops in Ireland, and a lack of standardisation regarding the provider, content and frequency of workshops where workshops are being delivered. The study also provides unique insights into the experiences and opinions of primary care community dietitians regarding the development and delivery of weaning workshops in terms of optimal content and delivery options. These perspectives will make a valuable contribution given the dearth of evidence in this area internationally.

Bringing Geospatial Awareness to Community Pediatrics and Primary Care.

Bringing Geospatial Awareness to Community Pediatrics and Primary Care.

Minimally Adequate Treatment for Depression and Anxiety Associated With Mortality in Primary Care Older Adults.

To assess the association between receipt of minimally adequate treatment (MAT) and mortality in a sample of community primary care older adults with depression and anxiety. The present study was conducted among a sample of 358 older adults ( ≥ 65 years old) with depression or an anxiety disorder recruited in primary care practices between 2011 and 2013. Participants agreed to link their health survey and administrative data for the 3 years preceding and following the baseline interview. Depression and anxiety disorders were based on self-reported symptoms aligned with DSM-5 criteria and physician diagnoses (International Classification of Diseases [ICD], 9th and 10th revisions). MAT was defined according to Canadian guidelines and include receipt of pharmacotherapy and ≥ 4 medical visits within 3 months or a number of psychotherapy sessions (individual, group, or family) over 12 months (depression: ≥8; anxiety disorders: ≥5 to 7). All-cause 3-year mortality was ascertained from the vital statistics death registry in Québec. Propensity score weighted regression analysis was conducted to assess the association between receipt of MAT and mortality adjusting for individual, clinical, and health system study factors. Receipt of MAT was associated with a reduced risk of mortality (hazard ratio [HR]: 0.27; 95% confidence interval [95% CI], 0.12 to 0.62). Individual and clinical factors associated with increased mortality included older age, male sex, being single, low functional status, and increased physical disorders and cognitive functioning. Lifestyle factors associated with reduced and increased mortality included alcohol consumption and smoking, respectively. Health system factors such as perceived adequate number of visits to speak to the doctor about emotional problems and continuity of care were associated with reduced mortality. The current study highlights the important role of primary care physicians in detecting and providing MAT for older adults with depression and anxiety, as this may have an effect on longevity.

Community Volunteers and Primary Care Providers Supporting Older Adults in System Navigation: A Mixed Methods Study.

Introduction:Primary care providers and community volunteers have important roles in supporting patient system navigation and utilization of community-based health and social services (CBHSS). This study aimed to explore the experiences and impacts of system navigation in a complex intervention supporting older adults.Methods:We used a convergent mixed methods design. Participants included primary care team members (n = 67), community volunteers (n = 38), and programme clients (n = 128) across six communities in Ontario, Canada. Data sources included focus groups, interviews, system navigation function survey for volunteers, CBHSS use survey for clients, and implementation data on CBHSS recommended by providers and volunteers and used by clients.Results:Results showed the different patterns of how CBHSS categories were recommended and ultimately used. Exercise-related CBHSS were both recommended and used, independence-related CBHSS were mostly only recommended with less uptake, and chronic health condition and diet/nutrition CBHSS were most often used by clients.Discussion:Primary care teams’ practice of system navigation was impacted by programme participation, including through learning about local CBHSS. However, volunteers felt more confident in tasks that did not include connecting to CBHSS. The programme did seem to result in many referrals, though the actual client uptake tended to be to more clinical rather than healthy lifestyle resources.

Direct-to-Consumer Academic Telemedicine.

Over the past 2 years, telemedicine has skyrocketed as COVID-19 propelled innovation and implementation at unparalleled rates. Within the UC Davis academic health system, a new paradigm for telemedicine emerged: direct-to-consumer telemedicine. The video-based telemedicine program has become the largest of its kind in California and is staffed by 80 providers (MDs, APPs) across five clinical departments/groups (primary care practice group, family and community medicine department, emergency medicine department, the nursing department, and the physical medicine and rehabilitation department). September 2021 marked the 1-year anniversary of a journey that has opened access, improved coordination, and become a workforce engine for our evolving virtual health infrastructure.