Primary Care Evaluation Research Articles

Designing an intervention to improve cognitive evaluations in primary care

Abstract Background Early diagnosis is crucial to the optimal management of patients with cognitive impairment due to Alzheimer’s disease (AD) or AD-related dementias. For some patients, early detection of cognitive impairment enables access to disease-modifying therapies. For all patients, it allows access to psychosocial supports. Patients typically first present their concerns about their cognition to a primary care provider, but in this setting, cognitive impairment is commonly underdiagnosed. There is also high variability in how cognitive evaluations are performed. We sought to understand barriers to and facilitators of cognitive evaluations in primary care, map barriers to implementation strategies, and gain consensus from stakeholders on possible strategies to improve dementia diagnosis in primary care. Methods Semi-structured interviews conducted with primary care providers (PCPs). We used the Consolidated Framework for Implementation Research to inform our question guide and analysis, and incorporated chart-stimulated recall – using actual patients who had cognitive complaints who had presented to these providers – to understand clinicians’ medical decision-making processes. These data were used to map identified barriers and facilitators to targeted implementation strategies. Then, this candidate list of strategies was presented to an expert stakeholder panel including clinicians and clinical operations specialists. Through a modified Delphi process, the list was narrowed to select the most promising strategies to incorporate in an intervention to improve cognitive evaluations in primary care. Results Twenty PCPs were interviewed and mentioned barriers included lack of expertise to perform or interpret an assessment, time pressures, lack of incentives, competing priorities, lack of decision-making supports, and limited access to dementia specialists. Facilitators included the presence of an informant or caregiver and having additional staff to conduct cognitive testing. Implementation mapping resulted in a list of 15 candidate strategies. Using the modified Delphi process, these were narrowed to six. Conclusions We used a rigorous process to identify barriers to and facilitators of cognitive assessments in primary care, identify promising implementation strategies to address these barriers, and obtain the feedback of front-line users on these strategies. This holds substantial promise for improving cognitive assessments in primary care in future implementation trials.

DEVELOPING A PRACTICAL, SCALABLE QI INITIATIVE FOR FQHCS IN WASHINGTON STATE: THE COGNITION IN PRIMARY CARE PROGRAM

Abstract In November 2020, the University of Washington (UW) was awared funding from the Centers for Disease Control (CDC) to adapt the Gerontological Society of America’s K.A.E.R. Toolkit for implementation in a large health system. Using focus group interviews, we developed a quality improvement initiative, Cognition in Primary Care (CPC), consisting of concise continuing education (CE) for primary care providers (PCPs) paired with tools to put that training into practice. The CE consists of Webinars which introduce the tools, which take the form of electronic health record (EHR) checklists and resource folders to facilitate performing cognitive evaluations in primary care. Between 2021 and 2023, the CPC program was implemented in 14 community-based primary care clinics at UW. Measures to assess outcomes showed positive effects including uptake of the EHR tools by PCPs, increased cognitive-tests entered into the EHR, and increased number of patients identified with cognitive impairment. During the symposium, attendees will learn the components of the CPC approach for quality improvement, as well as the methodology used to implement it and assess its effects. Finally, we will present an overview for how the CPC model is being packaged for dissemination to health systems across Washington State, with a focus on federally qualified health centers, supported by new CDC funding in the form of a grant through the BOLD Public Health Initiative.

Using Patient‐Reported Outcomes in Two Program Examples Measuring Health Status in Primary Care: An Observational Study

ABSTRACTBackground and AimsPatient‐reported outcome measures (PROMs) are increasingly used in primary care practices; however, the broad characteristics of this population pose unique challenges. Generic PROMs (e.g., EQ‐5D‐5L) measure general health status from the patient's perspective, contributing towards a comprehensive evaluation of health programming. This study describes the integration of the EQ‐5D‐5L within program evaluation in primary care in Alberta, Canada, using two program examples.MethodsA retrospective, longitudinal, observational design was used. The Edmonton O‐day'min Primary Care Network (EOPCN) routinely collects the EQ‐5D‐5L in their exercise and active living and nutrition programs. Data collected between January 1, 2021 and March 31, 2022 was analyzed descriptively, by dimension, index, and visual analog scale (VAS) scores. Minimally important differences were used to interpret index (0.04) and VAS scores (7.0) and the Pareto Classification of Health Change was applied to the dimensions. Effect size of change in index and VAS scores and population comparisons were examined.ResultsIn the exercise and active living program (n = 301), 72% were female with a mean age of 57 (±16) years, and 90.2% reported any problems (levels 2–5) in pain/discomfort. The mean index and VAS scores were 0.74 (±0.18) and 66.5 (±18.9), respectively. Among those with repeated measurement (n = 112), the greatest improvement was in usual activities (17%); the greatest deterioration was in pain/discomfort (25%). In the nutrition program (n = 573), 71% were female with a mean age of 50 (±17) years, and 75.9% reported any problems in pain/discomfort. The mean index and VAS scores were 0.77 (±0.19) and 70.1 (±15.6), respectively. Among those with repeated measurement (n = 212), the greatest improvement was in anxiety/depression (16%); the greatest deterioration was in pain/discomfort (26%). In both, health status was lower than the general Alberta population norms. No baseline characteristics were found to be statistically significant.ConclusionThese results inform future programming, to help patient needs.

A service evaluation of the implementation of a novel digital intervention for hypertension self-monitoring and management system in primary care (SHIP): protocol for a mixed methods study

BackgroundHypertension is a key risk factor for death and disability, and blood pressure reduction is associated with significant reductions in cardiovascular risk. Large trials have shown that interventions including self-monitoring of blood pressure can reduce blood pressure but real-world data from wider implementation are lacking.AimThe self-monitoring and management service evaluation in primary care (SHIP) study will evaluate a novel digital intervention for hypertension management and medication titration platform (“Hypertension-Plus”) that is currently undergoing initial implementation into primary care in several parts of the UK.Methods and analysesThe study will use a mixed methods approach including both quantitative analysis of anonymised electronic health record data and qualitative analyses of interview and customer support log data. Pseudonymised data will be extracted from electronic health records and outcomes compared between those using the digital intervention and their own historical data, as well as to those not registered to the system. The primary outcome will be difference in systolic blood pressure in the 12 months before and after implementation. A further analysis will utilise self-monitored blood pressure data from the Hypertension-Plus system itself. Semi-structured qualitative interviews will be completed with implementation and clinical leads, staff and patients in six general practices located in two different geographical areas in England. Informed by the non-adoption, abandonment, scale-up, spread, and sustainability (NASSS) framework, our analysis will identify the challenges to successful implementation and sustainability of the digital intervention in routine clinical practice and in patients’ homes.Ethics and disseminationThe analyses of pseudonymised data were assessed by the sponsor (The University of Oxford) as service evaluation not requiring individual consent and hence did not require ethical approval. Ethics approval for the qualitative analyses was provided by Wales REC 4 (21/WA/0280) and individual written informed consent will be gained for all participants. Results will be published in peer-reviewed journals, presented at national and international conferences and disseminated via patient and health service organisations.DiscussionThis study will provide an in-depth analysis of the impact and acceptance of initial implementation of a novel digital intervention, enhancing our understanding and supporting more effective implementation of telemonitoring based hypertension management systems for blood pressure control in England.

A Simple Screening Tool Reduces Unnecessary Preoperative Evaluation for Cataract Surgery.

Cataract surgery is common and low-risk. Preoperative evaluation and preoperative testing have not been shown to improve patient outcomes but do increase cost. Our process improvement aimed to reduce unnecessary preoperative primary care evaluation for cataract surgery. We implemented a simple process involving a brief chart review and conversation with the patient to determine the appropriateness of preoperative primary care evaluations. After implementation of the screening tool, we reviewed 100 patient charts, 50 who underwent cataract surgery prior to and 50 after the intervention. The screening tool resulted in a decrease in primary care provider referrals from 100% to 4% and a decrease in primary care provider evaluation from 94% to 6%. Implementation of a simple screening tool resulted in a dramatic decrease in unnecessary primary care preoperative testing.

Adoption of self-measured blood pressure monitoring in underserved communities: Program evaluation in primary care.

Self-measured blood pressure (SMBP) monitoring is crucial for hypertension management, yet its adoption, particularly among disadvantaged populations, remains low. 'Love Your Heart' is a quality improvement program providing free standard SMBP devices to hypertensive patients, aiming to enhance adoption and assess its impact on blood pressure control. This study evaluates the 'Love Your Heart' program's implementation success through assessing adoption rates and exploring changes in systolic blood pressure (SBP) among participants. We aim to understand factors influencing adoption and potential benefits of SMBP monitoring in a diverse, socially disadvantaged patient population. We retrospectively evaluated the 'Love Your Heart' program using electronic health records (EHR) at a primary care site in Chicago. Adult patients with hypertension were enroled in the 6-month program, which included education sessions and free SMBP devices. Adoption was measured by participation in program components, and changes in SBP were analysed based on adoption status. Statistical analyses were conducted using SAS software, adhering to STROBE reporting guidelines. Of 621 eligible patients, 104 participated, with 83 included in the evaluation. Despite all participants receiving free SMBP devices, adoption rates were modest, with only 7% sharing readings with the care team. However, patients who received device instructions demonstrated greater decreases in SBP compared to those who did not. Although not statistically significant, clinically meaningful decreases in SBP were observed among adopters. The 'Love Your Heart' program highlights the challenges of promoting SMBP monitoring among disadvantaged patient populations. While providing free devices addresses access barriers, low reporting to the care team suggests the need for further support mechanisms. Future research should explore strategies to enhance SMBP adoption and integration into clinical care, particularly in settings lacking automated data transmission systems.

A cross sectional survey on burnout and career satisfaction in surgeons: a joint work from the SAGES quality, outcomes, and safety and reimaging the practice of surgery burnout task forces.

The growth of surgeon burnout is of significant concern. As we work to reimagine the practice of surgery, an accurate understanding of the extent of surgeon burnout is essential. Our goal was to define the current prevalence of burnout and quality of life (QOL) among SAGES surgeons. An electronic survey was administered to SAGES members to establish a current baseline for QOL, burnout, depression, and career satisfaction. To assess outcomes, we utilized the validated Maslach Burnout Inventory for Medical Personnel, the Medical Outcomes Study Short Form, and the Primary Care Evaluation of Mental Disorders. All scoring followed validated norm-based methods. Of 4194 active members, 604 responded (14.40%). 69% met burnout threshold, with high levels of emotional exhaustion and depersonalization, and low personal accomplishment. 81% reported "being at the end of their rope", 74% felt emotionally drained, and 65% felt used up daily. Nearly all maintained caring about what happened to their patients (96%), easily understanding how their patients feel (84.3%) and being capable of dealing effectively with their patient's problems (87.6%). However, respondents never, rarely, or occasionally felt energetic (77.5%) or experienced a sense of professional accomplishment (57.8%). The overall QOL score was 69/100, with lower Mental than Physical scores (62.69 (SD 10.20) vs.77.27 (SD 22.24)). More than half of respondents met depression criteria. While 77% supported they would become a physician again, less than half would choose surgery again or recommend surgery to their children. Furthermore, less than a third felt work allowed sufficient time for their personal lives. Participating SAGES surgeons reported alarmingly high rates of burnout and depression. Despite experiencing emotional exhaustion and depersonalization, they maintained a strong commitment to patient care. These findings likely reflect the broader state of surgeons, underscoring the urgent need for action to address this critical issue.

ECHO Autism Washington: Autism Diagnostic Evaluations in Primary Care.

ECHO (Extensions for Community Healthcare Outcomes) Autism is a telementoring learning model to increase community capacity for autism-related health care. Seventy-seven pediatric providers (mostly primary care, seeing exclusively Medicaid patient populations) enrolled in 1 year of ECHO Autism Washington. Analysis of self-report surveys showed a significant increase in autism diagnoses made by ECHO providers after 1 year, F(1, 65) = 7.52, P = .008. Providers who attended more sessions reported making more diagnoses, F(2, 613.26), P = .045. Of note, autism diagnoses were not externally validated. The total number of reported barriers reduced, F(2, 61) = 13.5), P < .001, and confidence ratings increased F(2, 60) = 24.21, P < .001. The average number of diagnostic referrals from ECHO providers to the state's largest autism specialty clinic significantly reduced, t(43) = 4.23, P < .001, with significantly fewer diagnostic referrals made during and after ECHO training compared with a comparison group of 28 non-ECHO providers, t(58.77) = -3.36, P < .001. Overall, 1 year of ECHO Autism Washington participation led to significant changes in autism diagnostic practices.

Clinician-reported Factors Influencing Performance of Cognitive Evaluations in Primary Care (P4-10.004)

Clinician-reported Factors Influencing Performance of Cognitive Evaluations in Primary Care (P4-10.004)

The yield of routine laboratory examination in osteoporosis evaluation in primary care

SummaryThis study evaluated the yield of routine laboratory examination in a large population of older women in primary care. The prevalence of laboratory abnormalities was low and the clinical consequences in follow-up were limited. There was a weak association of laboratory abnormalities with osteoporosis but no association with vertebral fractures and recent fractures.PurposeMost osteoporosis guidelines advice routine laboratory examination. We have investigated the yield of laboratory examinations in facture risk evaluation of elderly women in primary care.MethodsWe assessed the prevalence of laboratory abnormalities and their association with risk factors for fractures, recent fractures, low bone mineral density (BMD), and prevalent vertebral fracture in 8996 women ≥ 65 years of age participating in a primary care fracture risk screening study. In a sample of 2208 of these participants, we also evaluated the medical consequences in the medical records during a follow-up period of ≥ 1 year.ResultsVitamin D deficiency (< 30 nmol/L) was present in 13% and insufficiency (< 50 nmol/L) in 43% of the study sample. The prevalence of other laboratory abnormalities (ESR, calcium, creatinine, FT4) was 4.6% in women with risk factors for fractures, 6.1% in women with low BMD (T-score ≤ − 2.5), 6.0% after a prevalent vertebral fracture, 5.2% after a recent fracture and 2.6% in the absence of important risk factors for fractures. Laboratory abnormalities other than vitamin D were associated with low BMD (OR 1.4, 95%CI 1.1–1.8) but not with prevalent vertebral fractures nor recent fractures. Low BMD was associated with renal failure (OR 2.0, 95%CI 1.3–3.4), vitamin D insufficiency (OR 1.2, 95%CI 1.0–1.3) and deficiency (OR 1.3, 95%CI 1.1–.5). In the follow-up period, 82% of the laboratory abnormalities did not result in a new diagnosis or treatment reported in the medical records.ConclusionsWe identified a low prevalence of laboratory abnormalities in a primary care population of older women and the majority of these findings had no medical consequences.

A Quality Improvement Initiative for Detection of Attention-Deficit/Hyperactivity Disorder in an Urban, Academic Safety Net Hospital.

Improve detection of Attention Deficit/Hyperactivity Disorder (ADHD) in a safety net, hospital-based, academic pediatric practice by optimizing screening with the Pediatric Symptom Checklist attention score (PSC-AS) and further evaluation with the Vanderbilt ADHD Diagnostic Rating Scale (VADRS). We implemented a multi-component intervention by (1) optimizing electronic medical record (EMR) features; (2) adjusting clinic operational workflow; and (3) creating a decision-making algorithm for pediatric primary care clinicians (PPCCs). We extracted 4 outcomes manually from the EMR (pediatrician acknowledgment of a positive PSC-AS, documentation of a plan for further evaluation, distribution of VADRS, and completion of at least 1 VADRS). Outcomes were measured monthly in run charts compared to the pre-intervention control period, and implementation was optimized with Plan-Do-Study-Act cycles. PPCCs were significantly more likely to acknowledge a positive PSC-AS in the intervention versus control (65.3% vs 41.5%; p < 0.001), although this did not change documentation of a plan (70% vs 67.1%; p -value = 0.565). Significantly more children with a positive PSC-AS were distributed a parent or teacher VADRS in the intervention versus control (30.6% vs 17.7%; p -value = 0.0059), but the percentage of returned VADRS rating scales did not improve (12.9% vs 9.2%; p -value = 0.269). Our ADHD detection quality improvement initiative improved use of the PSC-AS to identify attention problems and distribution of VADRS diagnostic rating scales, but additional interventions are needed to improve the completion of ADHD evaluations in primary care to ensure that children are appropriately identified and offered evidence-based care.

(082) Integrated Urology and Primary Care Model Improves Outcomes for Men with Testosterone Deficiency

Abstract Introduction Testosterone deficiency affects approximately 4-5 million men in the United States. The bidirectional association between testosterone deficiency and metabolic syndrome has been well-established. The diagnosis of testosterone deficiency should serve as a trigger for medical evaluation of other comorbidities. Furthermore, male sex is an independent predictor of decreased routine health maintenance; men are 40% less likely to have a primary care provider (PCP) compared to women in the United States. Thus, many patients who present to the urologist for symptomatic testosterone deficiency might have undiagnosed or poorly managed comorbidities coupled with a lack of a PCP. Objective We sought to investigate the impact of offering primary care access within an integrated Men’s Health Center to men presenting for initial evaluation of symptomatic testosterone deficiency. Methods This is a retrospective single institution study. All new patients presenting with testosterone deficiency between October 2019 and October 2022 were offered evaluation by a PCP within a university-based Men’s Health Center. Patients who were seen by the PCP underwent standard health screening and blood work including a lipid profile, liver function testing, and diabetes screening with hemoglobin (Hgb) A1c. All data were collected from the electronic medical record and deidentified. Institutional review board (IRB) exemption was obtained. Variables collected for analysis included age, race, body mass index (BMI), testosterone level on presentation, prior access to a pre-existing PCP, and number of visits attended with our PCP. Outcomes measured include new diagnoses made by the PCP and referral patterns to other specialties. All statistical analysis was conducted utilizing SPSS version 28. Results 81 men were evaluated over the 3-year study period. Median age was 49.0 (range: 21.2-93.7 years). 48 men (59%) established continuity of care and were seen by our PCP for more than 1 visit. 33 men (41%) did not have a pre-existing PCP. Older men were significantly more likely to have a pre-existing PCP (OR 1.06 [95% CI: 1.02-1.10], p&amp;lt;0.001). Hispanic men were significantly less likely to have an existing PCP (OR 0.16 [95% CI: 0.03-0.84], p=0.01). Newly diagnosed comorbidities included hypertension (41%), obesity (37%), hyperlipidemia (27%), obstructive sleep apnea (OSA; 25%), depression (23%), and diabetes (14%). 41 patients (51%) were prescribed a new medication. 21 patients (26%) were referred to nutrition, with mean BMI decrease of 1.75. 26 patients (32%) underwent sleep medicine evaluation for OSA. 27 (33%) and 37 patients (46%) received a flu vaccination and immunization updates. 11 patients (14%) were referred for screening colonoscopy. Patients who established continuity of care were significantly more likely to be treated for a new diagnosis (p&amp;lt;0.001) and receive a flu vaccination (p=0.007; Table 1). Conclusions This is the first report of integrated primary care and urology evaluation for testosterone deficiency. This comprehensive model results in improved outcomes including increased access to subspecialty referrals, objective weight loss, treatment of new diagnoses, updated immunizations, and cancer screening. Further studies are needed to assess reproducibility across other institutions, cost-effectiveness of this model, and patient satisfaction. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific, Endo Pharmaceuticals.

Evolution of the availability of Information and Communication Technologies in primary health care in Brazil, 2012 to 2018.

To verify the evolution of the availability of information and communication technology equipment and inputs in primary health care services that participated in the external evaluation of the Access and Quality Improvement Program in Primary Care and its distribution according to context characteristics social and geographic. Cross-sectional study, analyzed the distribution of information and communication technology equipment in basic health units in Brazil, during the three cycles (2012 to 2018) of the Program for Improving Access and Quality in Primary Care. The variables were examined at the municipal level and stratified by geopolitical region. Univariate analysis was performed, using the chi-square test and testing the distributions of exposures among themselves and between the outcome and exposures. The availability of information and communication technology equipment increased from 9.4% (2012) to 17.5% (2018), with emphasis on the Southeast and South regions, in municipalities with a population size of up to 10,000 inhabitants², with greater family health coverage and high/very high HDI-M. Over the period from 2012 to 2018, basic units joined the program and increased availability of information and communication technologies, such as Internet access, which ranged from 45.2% (n=6,249) to 74.0% (n=21,423), with emphasis on the Northeast region, which increased from 19.1% (n=970) to 58.8% (n=7,087). Investment in technologies and constant evaluation of primary care in the country is necessary, contributing to its strengthening.

Stakeholders' Perceived Barriers and Successes of Quality Improvement Programs for Patients With Diabetes Comment on "Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China".

Rasooly et al performed a qualitative evaluation to characterize the experiences of 26 stakeholders with the implementation of diabetes-related quality and performance measures delivered in primary healthcare to patients with diabetes in metropolitan China. Results from this cross-sectional investigation identified relevant gaps in primary care delivery for people with diabetes from one major center in China. As diabetes is a prevalent condition worldwide, lessons learned from this research can be useful to guide, refine, and improve quality measurement evaluations in primary care in China and other countries. In this commentary, we comment on the strengths and weaknesses of the study, suggest future directions, and discuss how lessons learned from this research can be helpful to guide, refine, and improve the quality measurement of diabetes care in other countries.

Increasing Cognitive Evaluations in Primary Care: Implementing the GSA KAER Model at a Large Healthcare System

AbstractThere is widespread recognition that patients with Alzheimer’s disease and related dementias (ADRD) receive better care if they receive an earlier diagnosis. In 2022, the Alzheimer’s Association published a survey of primary care providers (PCPs) indicating that a large majority agree that making an early diagnosis of ADRD is important. However, more than half of PCPs said that they lack the knowledge and confidence to assist in making such a diagnosis.Starting in 2021, the University of Washington launched the Cognition in Primary Care Program to meet that need. Developed with funding from the Centers for Disease Control and Prevention, as an adaptation of the Gerontological Society of America’s KAER Toolkit, the primary goals of the Cognition in Primary Care Program are to increase cognitive evaluations by PCPs and to increase the number of patients diagnosed with ADRD and mild cognitive impairment (MCI).Using practical training modules for PCPs with concise, evidence‐based checklists embedded in the electronic health record (EHR), the program has now been widely adopted by PCPs in a wide variety of clinics serving diverse populations of patients. Evaluations by PCPs describe the program as being of high quality and relevant to their practice. Results on the General Practitioners’ Attitude and Confidence Scale for Dementia (GPACS‐D) six months after the intervention show confidence in evaluating cognition. In addition, the number of MoCA tests uploaded to the EHR increased from 2.7 per month to 5.8 per month, and there was high utilization of the EHR checklist tools. Preliminary data also show that the number of visits in which PCPs have billed a diagnosis of MCI increased from 7.5 per month to 14.4 per month.The strengths of the Cognition in Primary Care Program include its emphasis on actions that PCPs can take to promote brain health and the implementation of innovative EHR tools which PCPs can use in their clinical practice. The Cognition in Primary Care Program is an effective model, shown to be acceptable to PCPs, easy to integrate into a large health system, and successful at increasing cognitive evaluations in the primary care setting.

Differences in Health Care Utilization of High-Need and High-Cost Patients of Federally Funded Health Centers Versus Other Primary Care Providers.

Primary care providers (PCP) differ in their ability to address the needs and reduce use of costly services among complex Medicaid beneficiaries. Among PCPs, Health Resources and Services Administration (HRSA)-funded health centers (HCs) are shown to provide high-value care. We compared health care utilization of complex Medicaid managed care beneficiaries whose PCPs were HCs versus 3 other groups. Cross-sectional study using propensity score matching comparing health care use by provider type, controlling for demographics, health status, and other covariates. California Medicaid administrative data for complex adult managed care beneficiaries with at least 1 primary care visit in 2018. Primary and specialty care evaluation & management visits and services; emergency department (ED) visits; and hospitalizations. PCPs included HCs, clinics not funded by HRSA, solo, and group practice providers. HRSA-funded HCs had lower predicted rates of specialty evaluation & management and other services than all others; lower predicted probability of any ED visits than clinics not funded by HRSA [54% (95% CI: 53%-55%) vs. 56% (95% CI: 55%-57%)] and group practice providers [51% (95% CI: 51%-52%) vs. 52% (95% CI: 52%-53%)]; and lower PP of any hospitalizations than solo [20% (95% CI: 19%-20%) vs. 23% (95% CI: 22%-24%)] and group practice providers [21% (95% CI: 20%-21%) vs. 24% (95% CI: 23%-24%)]. Differences in HC care delivery and practices were associated with lower use of specialty, ED, and hospitalization visits compared with other PCPs for complex Medicaid managed care beneficiaries. Understanding the underlying reasons for these utilization differences may promote better outcomes among these patients.

Pediatric growth faltering: Evaluation and management in primary care.

Pediatric growth faltering (GF), previously known as failure to thrive and now also called pediatric malnutrition and weight faltering, is a common clinical finding in primary care. Most pediatric GF cases are caused by inadequate caloric intake, not organic disease states. Evaluation requires clinicians to obtain detailed nutritional, medical, psychosocial, and family histories; take accurate anthropometric measurements; and perform a careful physical examination. Evaluation findings should be analyzed to determine whether targeted diagnostic workup, specialty referral, or a trial of nutritional counseling is indicated. Management includes caregiver education about childhood nutrition and frequent monitoring of growth parameters. A multidisciplinary approach that includes nutritionist, developmental therapist, and other specialty team member involvement is desirable.

Defining the pathway to timely diagnosis and treatment of interstitial lung disease: a US Delphi survey

IntroductionTimely diagnosis of interstitial lung disease (ILD) is limited by obstacles in the current patient pathway. Misdiagnosis and delays are common and may lead to a significant burden of diagnostic...

Presurgical Evaluation in Primary Care: A Case Study Approach

Presurgical evaluations are an important component of perioperative services but also pose challenges for nurse practitioners (NPs) in primary care regarding disease optimization, interdisciplinary communication, knowledge of surgical risk, and potential for surgical delays. The complexities of comorbid conditions, advancements in surgical procedures, and nuances of pharmacologic therapy compound perioperative management. Application of evidence-based information for perioperative decision-making helps NPs perform comprehensive, high-quality evaluations with an emphasis on the overall reduction of perioperative morbidity and mortality.

Evaluation of primary health care by users during the COVID-19 pandemic: A cross-sectional study.

To evaluate the primary health care (PHC) attributes and associated factors during the COVID-19 pandemic using the perspective of users. This cross-sectional, quantitative study included 422 PHC users from 96 Family Health Teams in a city in Brazil. The assessment used the Primary Care Assessment Tool (PCATool) and a structured questionnaire on the sociodemographic and epidemiological characteristics of users and basic health units (BHU). The Person's chi-square test was used to analyze the association between high overall scores in PCATool and characteristics of users and BHU. Crude and adjusted prevalence ratios (PR) with a 95% confidence interval were also calculated. Poisson regression and Rao Scott's Chi-square test were used to estimate crude PR. Most users were aged 30 to 39 years (26.3%), women (75.4%), registered at the BHU for over ten years (59.5%), and had incomplete secondary education (30.6%). The mean of PHC essential attributes and overall scores were low (6.10 ± 0.81 and 5.78 ± 0.77, respectively). "First-contact care-use" received the highest score (9.22 ± 1.62), while "first-contact care-accessibility" received the lowest (2.82 ± 0.90). High overall scores were associated with an average employment time of professionals (doctors and nurses) at the BHU (PR = 1.31; 95% CI 1.17-1.48; p < 0.001) and lower educational level of users (PR = 1.71; 95% CI 1.54-1.90; p < 0.001. "First-contact care-use" was the best evaluated, while "first-contact care-accessibility" was the worst. High scores were associated with a lower educational level of users and BHU with more experienced professionals.