Primary Care Consultations Research Articles

FC23: Dementia and Triadic (Doctor-Patient-Carer) Interactions in Primary Care

Objective:Primary care visits of persons with dementia often bring together triads composed of patients, family carers and general practitioners (GPs), as previously discussed (1). Communication dynamics potentially affect dementia outcomes, not least because primary care is a health setting where these triad encounters often occur naturally. Our aim is to present further data from Portuguese primary care consultations with persons with dementia, their carers and GPs.Methods:We refer to the conclusion of our study ‘Dementia in Primary Care: the Patient, the Carer and the Doctor in the Medical Encounter - Bayer Investigation Grant | NOVAsaúde Ageing 2018’ (1). Fieldwork was interrupted during the COVID-19 pandemic and resumed in 2022. Sixteen consultations with persons with dementia, their carers and GPs (purposive sampling) were audio- recorded and transcribed verbatim. Interactions were thematically analysed using NVIVO® software. The analytical framework combined codes derived from the transcripts with codes from the literature.Results:Dementia-related content took up less than half of consultations’ time, despite their considerable length (as compared to the average in primary care). Most GPs assessments lacked breadth, although efforts towards positive attitudes were present. Themes specifically related to social health in dementia were not (or were poorly) covered. Frequently, carers facilitated GPs’ assessment of dementia consequences, but their own needs were neglected. Patients’ self-expression tended to be limited.Discussion:Our findings suggest that doctor-patient interactions in many GPs’ consultations seemingly compromise patient-centred approaches. There are challenges regarding how to assess the biopsychosocial consequences of dementia in a context of fragmented care (2,3). Given the scarcity of evidence from live-recorded primary care consultations about triadic dynamics, our findings are important to guide further explorations.

Symptoms and signs in patients with heart failure: association with 3-month hospitalisation and mortality

ObjectivesTo determine the association between symptoms and signs reported in primary care consultations following a new diagnosis of heart failure (HF), and 3-month hospitalisation and mortality.DesignNested case–control study with density-based...

Hoarseness as A Window into the Complexity of Supraglottic Carcinoma: A Case Report and Literature Review

ABSTRACT Laryngeal carcinoma ranks among the most prevalent malignancies affecting the head and neck, with supraglottic carcinoma emerging as the predominant subtype, particularly in certain developing regions characterized by prevalent risk factors such as alcohol consumption and smoking. Hoarseness, characterized by a change in the voice, constitutes approximately 1% of all primary care consultations. The predominant etiologies include acute and chronic laryngitis, responsible for 42.1% and 9.7% of cases, respectively, followed by functional dysphonia, benign and malignant tumors, neurogenic factors, and the natural aging process. A 65-year-old male, with a history of active smoking, was referred from a primary healthcare center due to complaints of throat pain and worsening hoarseness that had persisted for one year. The significant airway obstruction observed in this patient underscores the importance of discussing available management options in such cases. It is crucial for primary care physicians to recognize the clinical signs presented by the patient promptly in order to initiate the appropriate management without delay. Regrettably, tend to seek medical attention at an advanced stage of the disease, resulting in a notably unfavorable overall survival rate. Keyword: Laryngeal Carcinoma, Supraglottic Carcinoma, Hoarseness, Survival Rate

The cost of primary care consultations associated with long COVID in non-hospitalised adults: a retrospective cohort study using UK primary care data

BackgroundThe economic impact of managing long COVID in primary care is unknown. We estimated the costs of primary care consultations associated with long COVID and explored the relationship between risk factors and costs.MethodsData were obtained on non-hospitalised adults from the Clinical Practice Research Datalink Aurum primary care database. We used propensity score matching with an incremental cost method to estimate additional primary care consultation costs associated with long COVID (12 weeks after COVID-19) at an individual and UK national level. We applied multivariable regression models to estimate the association between risk factors and consultations costs beyond 12 weeks from acute COVID-19.ResultsBased on an analysis of 472,173 patients with COVID-19 and 472,173 unexposed individuals, the annual incremental cost of primary care consultations associated with long COVID was £2.44 per patient and £23,382,452 at the national level. Among patients with COVID-19, a long COVID diagnosis and reporting of longer-term symptoms were associated with a 43% and 44% increase in primary care consultation costs respectively, compared to patients without long COVID symptoms. Older age, female sex, obesity, being from a white ethnic group, comorbidities and prior consultation frequency were all associated with increased primary care consultation costs.ConclusionsThe costs of primary care consultations associated with long COVID in non-hospitalised adults are substantial. Costs are significantly higher among those diagnosed with long COVID, those with long COVID symptoms, older adults, females, and those with obesity and comorbidities.

Continuity and breaches in GP care and their associations with mortality for patients with chronic disease: an observational study using Norwegian registry data.

Despite many benefits of continuity of care with a named regular GP (RGP), continuity is deteriorating in many countries. To investigate the association between RGP continuity and mortality, in a personal list system, in addition to examining how breaches in continuity affect this association for patients with chronic diseases. A registry-based observational study using Norwegian primary care consultation data for patients with asthma, chronic obstructive pulmonary disease (COPD), diabetes mellitus, or heart failure. The Usual Provider of Care (UPC, value 0-1) Index was used to measure both disease-related (UPCdisease) and overall (UPCall) continuity with the RGP at the time of consultation. In most analyses, patients who changed RGP during the study period were excluded. In the combined group of all four chronic conditions, the proportion of consultations with other GPs and out-of-hours services was calculated. Cox regression models calculated the associations between continuity during 2013-2016 and mortality in 2017-2018. Patients with COPD with UPCdisease <0.25 had 47% increased risk of dying within 2 years (hazard ratio 1.47, 95% confidence interval = 1.22 to 1.64) compared with those with UPCdisease ≥0.75. Mortality also increased with decreasing UPCdisease for patients with heart failure and decreasing UPCall for those with diabetes. In the combined group of chronic conditions, mortality increased with decreasing UPCall. This latter association was also found for patients who had changed RGP. Higher disease-related and overall RGP UPC are both associated with lower mortality. However, changing RGP did not significantly affect mortality, indicating a compensatory benefit of informational and management continuity in a patient list system.

Remote heart rhythm assessment using smartphone-based photoplethysmography in primary care to detect undiagnosed atrial fibrillation in patients with chronic obstructive pulmonary disease

Abstract Introduction Atrial fibrillation (AF) is the most common cardiac arrhythmia leading to healthcare consultation in primary care. The increased risk to develop AF when suffering from chronic obstructive pulmonary disease (COPD) has been extensively described in literature. However, it remains challenging to perform in-office, opportunistic screening for AF in COPD patients during daily routine using pulse checks or single-spot ECGs due to the increasing pressure on primary care. Purpose The goal of this study was to evaluate the accuracy and effectiveness of a smartphone-based photoplethysmography (PPG) technology to enable remote heart rhythm monitoring and new AF detection in patients with COPD. Methods Diagnosed COPD patients, without an established AF diagnosis, were identified via the electronic medical record. Patients who fulfilled these criteria and hadn’t had an ECG in the past two years were selected to take part in this study. Other inclusion criteria were access to a smartphone and the physical ability to place their fingertip on a smartphone camera. Eligible patients were contacted via text message and after providing informed consent, the study team invited them to activate a 7-day invitation code to access a medically certified smartphone application. Patients were instructed to perform PPG measurements twice daily and when experiencing symptoms. Those with possible AF based on the PPG recordings were invited for a confirmatory ECG to establish the AF diagnosis. Results In total, 90/270 eligible patients (30%) provided informed consent and activated the on-demand invitation code to remotely monitor their heart rhythm using a PPG-based smartphone application. Of these, 50 (55.6%) were female and the median age was 68 years old (IQR: 59-74). The newly discovered AF detection yield was 5.6% (5/90). In-office 12-lead ECG confirmed AF in 3/5 patients (60%). The remaining patients, with a negative in-office 12-lead ECG, were invited for long-term intermittent ECG monitoring using a handheld ECG device (Zenicor). One patient accepted the proposal and paroxysmal AF was confirmed after 4 weeks of intermittent, symptom-triggered ECG monitoring. The remaining patient was not willing to perform long-term monitoring after the negative in-office ECG. However, this patient was diagnosed with paroxysmal AF as well after presentation at the emergency department while suffering from a transient ischemic attack three months after the initial AF detection using PPG technology. Conclusion Remote heart rhythm assessment using smartphone-based PPG in primary care within a COPD population was feasible and resulted in the detection of newly diagnosed AF in COPD patients. All patients identified with possible AF based on PPG monitoring were confirmed and diagnosed via ECG which enabled the initiation of guideline-based AF management.

Integrated behavioral health services in pediatric primary care and emergency department utilization for suicide risk.

Universal screening for suicide risk in primary care settings is a promising avenue for preventing self-harm and improving health outcomes. Triaging youth to an appropriate level of care, including diverting lower-risk patients from the emergency department (ED) is a meaningful goal. Previous research indicates integrated behavioral health (IBH) may prevent unnecessary admission to the ED on the day of suicide risk screening. We hypothesized that youth who received an IBH consultation the same day as suicide risk screening would be less likely to be admitted to the ED, but more likely to contact IBH services and utilize primary care in the following month. We conducted a retrospective chart review of 3,649 youth aged 10-18 years who were screened with the Ask Suicide-Screening Questions (ASQ) in two pediatric primary care practices. We collected demographic data, ASQ and Patient Health Questionnaire-9 (PHQ-9) scores, as well as patient contacts with IBH, the ED, and medical primary care the day of screening and the following 31 days. We conducted a series of logistic regressions and chi-square analyses to determine whether contact with IBH on the same day as positive suicide risk screenings predicted same-day admission to the ED, IBH contact, and medical primary care utilization. Among the 7,982 ASQ scores, 1,380 (18%) were non-acute and 87 ASQs (1%) screened acutely positive. Over 90% of positive screens were diverted from the ED regardless of IBH contact. None of the patients died from suicide. Same-day IBH was associated with higher likelihood of general ED visits for all positive screens (acute and non-acute together). None of the positive screens that received an IBH consultation on the same day as screening were admitted to the ED in the subsequent month. Contact with IBH the same day as screening positively predicted utilization of IBH and medical primary care services in the subsequent month, especially for youth with minority race and ethnicity identities. In the context of clinics with IBH and systematic risk assessment processes, most youth who screen positive for suicide risk are diverted from the ED. However, contrary to our hypothesis, our study showed that youth who received same-day IBH consultations were more likely to be admitted to the ED compared to peers who did not receive IBH consultations. These findings suggest that systematic suicide screening combined with IBH consultations in pediatric primary care can effectively identify risk levels and triage patients to appropriate care.

Patients with severe mental illness and their carers' expectations for GPs' communication skills: a qualitative approach in Spain.

Effective communication with GPs (General Practitioners) enables higher rates of patient satisfaction and adherence to treatment plans. People with severe mental illness (SMI) and their caregivers present unique characteristics that present difficulties in the GP-carer-patient communication process. To explore the expectations of patients with SMI and their caregivers regarding GPs' communication skills in primary care consultations. Face-to-face interviews, using focus group methodology, which were undertaken in southern Spain. Forty-two participants took part in 21 paired semi-structured interviews with an average duration of 19±7.2 minutes. Information was audio-recorded and transcribed verbatim. Qualitative content analysis was undertaken, obtaining a codification in categories by means of triangulation. Four themes emerged from the analysis. Theme 1 was interviewer communication characteristics. The ability of GPs to use a language that was colloquial and adapted to each person was perceived as a determinant of the quality of care provided. An empathetic attitude, low reactivity, and efficient time management were the most valued communication skills. Theme 2 was telemedicine: telephone consultation and video consultation. The telephone consultation was perceived as a useful tool to care for people with SMI. Video consultation was valued as a requirement in isolated rural areas. Theme 3 was the role of the caregiver during the clinical interview. The caregiver was considered by the patients as an ally who improves the clinical interview. Theme 4 was the perceived barriers and facilitators during the clinical interview. The continuity of care, defined by a low turnover of GPs, determined the quality perceived by those who required care. Themes emerging from this study have suggested that people with SMI require an inclusive, collaborative, and personalised approach in the care they receive from the public health system. Improved communication between GPs and patients with SMI is an essential requirement for quality medical care.

Ethnic differences in early onset multimorbidity and associations with health service use, long-term prescribing, years of life lost, and mortality: A cross-sectional study using clustering in the UK Clinical Practice Research Datalink.

The population prevalence of multimorbidity (the existence of at least 2 or more long-term conditions [LTCs] in an individual) is increasing among young adults, particularly in minority ethnic groups and individuals living in socioeconomically deprived areas. In this study, we applied a data-driven approach to identify clusters of individuals who had an early onset multimorbidity in an ethnically and socioeconomically diverse population. We identified associations between clusters and a range of health outcomes. Using linked primary and secondary care data from the Clinical Practice Research Datalink GOLD (CPRD GOLD), we conducted a cross-sectional study of 837,869 individuals with early onset multimorbidity (aged between 16 and 39 years old when the second LTC was recorded) registered with an English general practice between 2010 and 2020. The study population included 777,906 people of White ethnicity (93%), 33,915 people of South Asian ethnicity (4%), and 26,048 people of Black African/Caribbean ethnicity (3%). A total of 204 LTCs were considered. Latent class analysis stratified by ethnicity identified 4 clusters of multimorbidity in White groups and 3 clusters in South Asian and Black groups. We found that early onset multimorbidity was more common among South Asian (59%, 33,915) and Black (56% 26,048) groups compared to the White population (42%, 777,906). Latent class analysis revealed physical and mental health conditions that were common across all ethnic groups (i.e., hypertension, depression, and painful conditions). However, each ethnic group also presented exclusive LTCs and different sociodemographic profiles: In White groups, the cluster with the highest rates/odds of the outcomes was predominantly male (54%, 44,150) and more socioeconomically deprived than the cluster with the lowest rates/odds of the outcomes. On the other hand, South Asian and Black groups were more socioeconomically deprived than White groups, with a consistent deprivation gradient across all multimorbidity clusters. At the end of the study, 4% (34,922) of the White early onset multimorbidity population had died compared to 2% of the South Asian and Black early onset multimorbidity populations (535 and 570, respectively); however, the latter groups died younger and lost more years of life. The 3 ethnic groups each displayed a cluster of individuals with increased rates of primary care consultations, hospitalisations, long-term prescribing, and odds of mortality. Study limitations include the exclusion of individuals with missing ethnicity information, the age of diagnosis not reflecting the actual age of onset, and the exclusion of people from Mixed, Chinese, and other ethnic groups due to insufficient power to investigate associations between multimorbidity and health-related outcomes in these groups. These findings emphasise the need to identify, prevent, and manage multimorbidity early in the life course. Our work provides additional insights into the excess burden of early onset multimorbidity in those from socioeconomically deprived and diverse groups who are disproportionately and more severely affected by multimorbidity and highlights the need to ensure healthcare improvements are equitable.

Are primary care consultations in Trinidad patient-centered? A cross-sectional study of patients with non-communicable diseases

BackgroundThe aim of this study was to measure the patient’s perception of patient centeredness in their consultations for non-communicable diseases (NCDs). We also measured consultation length and patient enablement.MethodA cross-sectional study was conducted over 2 months at four primary care clinics at the St. Joseph cluster of the North Central Regional Health Authority (NCRHA) in Trinidad and Tobago. Interviewers timed the consultation and completed post-consultation questionnaires using the Patient Perception of Patient-Centeredness (PPPC) questionnaire and the Patient Enablement Index (PEI). The PPPC is a 14-item (each scored 1–4) Likert-scaled instrument. The total score is averaged and a PPPC score of 4 is the maximum. The PEI measures the ability of the patient to cope with life and their disease. The PEI consists of 6 questions scored 0–2, with a maximum score of 12.ResultsThere were 180 respondents (response rate = 82.5%). Participants were female (75.6%), aged over 65 years (50.6%), married (51.1%), Indo-Trinidadian (52.2%), and Christian (60.6%). Half achieved a primary school education, and 37.2% secondary. The consultation length ranged between 1.32 and 31.22 min. The average, median and mode of the consultation length were 8.5, 7.74 and 10 min, respectively. The average, median and mode of the measures of patient-centeredness were PPPC (3.67, 3.86 and 4) and PEI score (5.93, 6 and 6). The PPPC average was lower in patients with a stroke (p = 0.022), and higher among those with more than 2 consultation interruptions (p = 0.015) and those who knew the doctor very well (p = 0.015). The PEI score was lower in patients with heart disease (p = 0.022). The consultation length was longer in those with tertiary education (p = 0.044) and those with two consultation interruptions (p = 0.032). PPPC Average and PEI Score correlated well (ρ = 0.408, p < 0.001). The consultation length correlated with the PPPC Average (ρ = 0.168,p = 0.025).ConclusionPrimary Care consultations in this cluster of health centres in NCRHA in Trinidad were often patient centered. The consultation length, patient-centeredness, measured with the PPPC instrument, and patient enablement scores, measured with the PEI instrument, in consultations for NCDs in Trinidad compare favourably with international reports.

The impact of residency training in family medicine on hospital admissions due to Ambulatory-care Sensitive Conditions in Rio de Janeiro.

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

THE IMPORTANCE OF NURSING CARE IN LOW-RISK PRENATAL CARE: a case study with data from the Family Health Strategy (ESF I) - Dona Andrezina – João Pinheiro – MG

The study carried out points to the need for quality nursing care during low-risk prenatal consultations in Primary Care, with the aim of promoting health, ensuring the necessary care for a healthy pregnancy, birth and postpartum period for the pregnant woman and the baby. Furthermore, a set of actions is observed that results in guaranteeing women's health, as pregnant women must know their rights and clarify their doubts about pregnancy, the right to a companion and the changes experienced during this period. It is remarkable that in addition to technical action, the nursing team is responsible for promoting a relationship of trust with the pregnant woman, in order to facilitate adherence to prenatal care in the first trimester of pregnancy, and quality monitoring in all consultations. A brief bibliographical review was carried out, using renowned research platforms. The objective was to search for data from pregnant women in the Family Health Strategy I Dona Andrezina, about the beginning of prenatal care and the age of pregnant women indirectly through tables provided by the nurse manager of the unit, preserving identity and personal data , the research result shows satisfactory data, since 91.67% of pregnant women inserted to prenatal care in the first trimester, as recommended and, in relation to age most of the percentage is in the usual risk parameters while 16.67% had late pregnancies.

Understanding the Impact of Community Family Physician Contracting (CFPC) on Community Medical Resources Consumption: A Case Study from Beijing in China

Object. In order to achieve Healthy China 2030 and an effective and sequential diagnosis and treatment system, family doctor contracting is a crucial strategy for improving graded diagnosis and treatment and achieving universal health. Through the examination of data on community members’ medical expenditures, this research investigates the influence of contracting on residents’ primary care consultation behavior. Methods. Using a quantitative research approach based on information about residents’ medical payment patterns, this study aims to examine the effect of family doctor contracting on residents’ medical costs. Therefore, a two-part model and a Heckman two-stage model are used to explore the impact of contracting on residents’ medical expenses in the community hospital based on the sample of contracted and noncontracted residents and the basic information and monthly checkout data of the residents provided by a community hospital in Beijing. Conclusion. Specifically, contracting increased residents’ healthcare expenditures in community hospitals by increasing the number of departments and the frequency of visits, according to the results, which indicate that contracting significantly increased residents’ healthcare costs in community hospitals. The frequency and number of departments in community hospitals for two target groups—the elderly and patients with chronic diseases—have increased significantly as a result of contracting, according to subgroup analysis. This finding suggests that family physicians make it possible for the daily care and treatment of these two priority groups to be met to a greater extent at the primary level. The empirical findings of this study reveal that the family doctor contracting system has a significant impact on how primary care and hierarchical treatment patterns are established.

Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adults.

Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread. With remote consultations likely to continue in UK primary care, it is important to understand people's perceptions of remote consultations and identify potential resulting inequalities. To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels. A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic. In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021). Items included satisfaction with remote consultations and demographic variables. Associations were analysed using multivariable regression. A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties. Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = -0.82, 95% confidence interval [CI] = -1.41 to -0.23) or those with low or no qualifications (B = -1.65, 95% CI = -2.29 to -1.02). People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = -1.94, 95% CI = -3.11 to -0.78), although caution is warranted due to small group numbers. These findings can inform the use and adaptation of remote consultations in primary care. Adults with lower educational levels may need additional support to improve their experience and ensure equitable care via remote consultations.

Realizacja praw pacjenta w dobie stanu epidemii COVID-19 a udzielanie teleporad w ramach podstawowej opieki zdrowotnej – rozważania w świetle sygnałów wpływających do Rzecznika Praw Pacjenta

A specific situation related to the COVID-19 pandemic had a significant impact on the functioning of the healthcare system. It was necessary to guarantee both the safety of entities participating in the process of providing health services, as well as the implementation of patients' rights in terms of availability and continuity of health services. The study aims to identify and classify the most frequent problems related to the provision of online consultation in primary medical care in a specific epidemic situation. The analysis was carried out based on signals reported to the Patient Ombudsman. To sum up, the subject of the difficulties reported by patients changed during the state of the epidemic. It could be distinguished not only problems characteristic for above form of provision of health services but also systemic obstacles. The main issue was the availability of health care services, which are appropriate for the patient's health needs. Over time the problems also related to the quality of online consultation and using this form of service to take care of the patient over an extended period.

Development and External Validation of Individualized Prediction Models for Pain Intensity Outcomes in Patients With Neck Pain, Low Back Pain, or Both in Primary Care Settings.

The purpose of this study was to develop and externally validate multivariable prediction models for future pain intensity outcomes to inform targeted interventions for patients with neck or low back pain in primary care settings. Model development data were obtained from a group of 679 adults with neck or low back pain who consulted a participating United Kingdom general practice. Predictors included self-report items regarding pain severity and impact from the STarT MSK Tool. Pain intensity at 2 and 6months was modeled separately for continuous and dichotomized outcomes using linear and logistic regression, respectively. External validation of all models was conducted in a separate group of 586 patients recruited from a similar population with patients' predictor information collected both at point of consultation and 2 to 4weeks later using self-report questionnaires. Calibration and discrimination of the models were assessed separately using STarT MSK Tool data from both time points to assess differences in predictive performance. Pain intensity and patients reporting their condition would last a long time contributed most to predictions of future pain intensity conditional on other variables. On external validation, models were reasonably well calibrated on average when using tool measurements taken 2 to 4weeks after consultation (calibration slope = 0.848 [95% CI = 0.767 to 0.928] for 2-month pain intensity score), but performance was poor using point-of-consultation tool data (calibration slope for 2-month pain intensity score of 0.650 [95% CI = 0.549 to 0.750]). Model predictive accuracy was good when predictors were measured 2 to 4weeks after primary care consultation, but poor when measured at the point of consultation. Future research will explore whether additional, nonmodifiable predictors improve point-of-consultation predictive performance. External validation demonstrated that these individualized prediction models were not sufficiently accurate to recommend their use in clinical practice. Further research is required to improve performance through inclusion of additional nonmodifiable risk factors.

“I wanted to know what was hurting so much”: a qualitative study exploring patients’ expectations and experiences with primary care management

BackgroundThe management of shoulder pain is challenging for primary care clinicians considering that 40% of affected individuals remain symptomatic one year after initial consultation. Developing tailored knowledge mobilization interventions founded on evidence-based recommendations while also considering patients’ expectations could improve primary care for shoulder pain. The aim of this qualitative study is to explore patients’ expectations and experiences of their primary care consultation for shoulder pain.MethodsIn this qualitative study, participants with shoulder pain and having consulted a primary care clinician in the past year were interviewed. All the semi-structured interviews were transcribed verbatim, and inductive thematic analysis was performed to identify themes related to the participants’ expectations and experiences of primary care consultations for shoulder pain.ResultsThirteen participants with shoulder pain were interviewed (8 women, 5 men; mean age 50 ± 12 years). Eleven of them initially consulted a family physician or an emergency physician, and two participants initially consulted a physiotherapist. Four overarching themes related to patients’ expectations and experiences were identified from our thematic analysis: 1) I can’t sleep because of my shoulder; 2) I need to know what is happening with my shoulder; 3) But… we need to really see what is going on to help me!; and 4) Please take some time with me so I can understand what to do!. Several participants waited until they experienced a high level of shoulder pain before making an appointment since they were not confident about what their family physician could do to manage their condition. Although some participants felt that their physician took the time to listen to their concerns, many were dissatisfied with the limited assessment and education provided by the clinician.ConclusionsImplementing evidence-based recommendations while considering patients’ expectations is important as it may improve patients’ satisfaction with healthcare. Several participants reported that their expectations were not met, especially when it came to the explanations provided. One unexpected finding that emerged from this study was the waiting period between the onset of shoulder pain and when patients decided to consult their primary care clinician.

Income and immunity: The consequences of a pre- and neo-natal income shock on childhood infection risk

ObjectivesThe experiences and conditions that children are exposed to in utero and early infancy impact their health in adulthood. Understanding the channels through which these effects emerge is important, because this may help us to anticipate which children are at highest risk of adverse effects, and provide early interventions to help. In this paper, we test a new channel linking perinatal experiences to later-life health: immunity.&#x0D; MethodWe use administrative birth records, linked with hospital admissions episodes and primary care consultations for children in the Northern Territory of Australia. This data forms part of the Child and Youth Development Partnership data linkage project. We analyse the impact of a shock to household income in Aboriginal communities, resulting from a change in government transfer policy. We estimate the impact of exposure to this shock in utero or in the first 3 months of life, relative to exposure later in childhood, to isolate the impact of an income shock during this key developmental period.&#x0D; ResultsWe find that children who were exposed to the shock in utero or in their first three months of life were at higher risk of severe infection requiring hospital admission. They spend, on average, 4.5 more days in hospital from birth to their 6th birthday (a 45 percent increase). Most of this impact is concentrated in admissions for infection. Only a small share of the effect can be explained by the immediate impact of the policy on birthweight.&#x0D; ConclusionOur findings are consistent with the explanation that an income shock worsens nutrition, and that worse nutrition during key developmental stages can permanently weaken children’s immune systems. This finding speaks to the importance of attention to key phases in childhood development, when designing policies that affect households’ financial resources. Furthermore, we find birthweight is a poor predictor of childhood hospital admission. However, use of longitudinal administrative data helps us to identify alternative markers of new-born health that are better predictors.

Structured communication methods for mental health consultations in primary care: a scoping review

BackgroundMajority of people with mental health problems attend primary care for support. Interventions that structure consultations have been found effective for physical health conditions and secondary mental health care. The aim of the review is to identify what tools or interventions exist to structure communication in primary care for appointments related to mental health problems and examine existing evidence for effectiveness for mental health and quality of life outcomes.MethodsQuantitative and qualitative studies were eligible for inclusion if staff was based in a primary care setting and the intervention involved bi-directional communication with adult patients. Six databases were searched (MEDLINE, Web of Knowledge, EMBASE, PsycINFO, The Cochrane Library, CINAHL) with no time restriction. Search terms combined four concepts with key words such as “structured” and “interaction” and “mental illness” and “primary care”. Reference lists of eligible studies were searched.ResultsAfter removing duplicates, 3578 records were found and underwent further screening. A total of 16 records were included, representing eight different interventions from five countries. The majority were delivered by primary care doctors and focused on patients experiencing psychological distress. Similarities across interventions’ service delivery were that most were created for a broad patient population, used self-report assessments at the start and actions or plans as the end point, and employed group settings and didactic methods for training staff in the intervention. Booster and follow-up trainings were not offered in any of the interventions, and supervision was only part of the process for one. The evidence for effectiveness for mental health and quality of life outcomes was mixed with three out of five RCTs finding a positive effect.ConclusionsAlthough the idea of structuring communication for mental health consultations has been around since the 1980s, relatively few interventions have attempted to structure the conversations within the consultation, rather than modifying pre-visit events. As the evidence-base showed feasibility and acceptability for a number of interventions, there is scope for those interventions to be developed further and tested more rigorously.

Impact of a deprescribing tool on the use of sedative hypnotics among older patients: study protocol for a cluster randomised controlled trial in Swiss primary care (the HYPE trial)

IntroductionBenzodiazepines and other sedative hypnotics (BSH) are potentially inappropriate and harmful medications in older people due to their higher susceptibility for adverse drug events. BSH prescription rates are constantly high...