Primary Care Level Research Articles

Quality of Care and Management of Atopic Dermatitis Across Different Levels of Healthcare-A Survey-Based Patient Experience.

Atopic dermatitis (AD) is a chronic and fluctuating disease. Optimal management of AD and related comorbidities requires seamless coordination across multiple layers of the healthcare system. The objective of this survey was to explore patients' experiences with current management of AD. Out of 251 responders to this anonymous survey, 76% reported to have moderate or severe AD. Sixty-nine percent with moderate and 45% with severe AD were followed up at primary care level only. Use of advanced systemic treatment options was rare, and the majority experienced itch (97%), dry skin, rash, negative impact on self-esteem and comorbidities despite ongoing treatment. Only 36% received a treatment plan, more often in secondary (78.3%) than primary care (25.0%). Forty-three percent did not know who was responsible for their follow-up and 54% felt no one was responsible. Treatment options were commonly not known or understood. The survey results demonstrate undertreatment, lack of a holistic approach for management of AD. A national pathway including clear referral criteria and timelines can streamline management of AD across multiple levels of the healthcare system.

2023 Global Survey of Optometry: Defining Variations of Practice, Regulation and Human Resources Between Countries.

To provide information on the demographics of optometrists and regulation of the optometry profession in countries who were members of the World Council of Optometry (WCO) during the period 2022-2023. A non-random, purposive sampling and a key informant strategy was employed to conduct a survey-based cross-sectional study on the professional landscape and distribution of optometrists; educational landscape; legislative aspects of the profession; and the scope of optometry practice in countries who were members of WCO during the period 2022-2023. Key informants were identified by WCO country members' leadership. In the 39 countries surveyed, one optometrist serves 23,200 persons on average. Only 46.2% of the countries met the internationally suggested 1:10,000 optometrist-to-population ratio. The average male-to-female ratio was 45% males/55% females, with a division of average age as follows: under 45 years of age 46% as compared to above 45 years of age 54%. It was reported that optometry is not regulated in France, Portugal, India, Kenya and Cameron. Thirteen countries (33%) do not require a Bachelor's degree as a minimum to practice optometry. Use of diagnostic drugs is prohibited in 20% of the countries, with 25% of the countries limiting the use of therapeutic pharmaceutical agents. Many countries where optometry is recognized struggle to have an adequate number of optometrists; this hinders access to eye care. This is compounded by unregulated minimum levels of education for entry-level optometric practitioners. In addition, several countries limit or prohibit many optometric procedures that restrict the ability of optometrists to provide eye care and vision health services at the primary care level.

Mind the gap in kidney care: translating what we know into what we do.

Historically, it takes an average of 17 years for new treatments to move from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. Now is the time to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions are diagnosed worldwide, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because it is often silent in the early stages. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from the patient to the clinician to the health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Assessment of population satisfaction with medical care in conflict conditions.

In the context of health care reform, the primary task is to ensure the delivery of high-quality medical services and good end results in the performance of individual physicians, structural units, and general medical services. The healthcare sector is one of the most socially significant spheres of functioning in every country. The problem of conflicts presents special social importance in this field, as a result of the rather close relationship between doctor and patient. The main objective of this study was to determine patients' satisfaction with the quality of healthcare at the primary level. The survey was conducted using an electronic questionnaire. The sample consisted of 1,146 residents of Chernivtsi and the Chernivtsi region, aged 18-56 and older. Almost half of the respondents (42.5%) offered a neutral overall rating of the quality of medical services at the primary care level. Only 25.5% gave a positive valuation of the quality of health care services they received, while 32% gave a negative evaluation. Patients' actions, opinions, and ideas shape and complement industry policies and the way they are implemented. In this context, if a dialogue is established among the main actors in the healthcare system, improvements in the system can be achieved, which will lead to better health and quality of life for people in the future.

Managing diabetes and hypertension in western Kenya: A qualitative study of experiences of patients supported by the primary health integrated care for chronic conditions (PIC4C) model of care.

The Primary Health Integrated Care for Chronic Conditions (PIC4C) pilot project was launched in 2018 to strengthen prevention and control of four non-communicable conditions at primary health care level in western Kenya. We conducted a qualitative study to explore the extent to which PIC4C integrated services supported people with hypertension and/or diabetes towards timely diagnosis and referral, treatment, follow-up and adherence, from the perspective of those receiving care. Semi-structured interviews were conducted with a purposively sampled patient cohort at two time points, with the intention of capturing changes over time (total (n) = 43, completion of both interviews (n) = 37). We extracted existing survey data to describe socio-demographic characteristics and analyzed qualitative data thematically. We identified two cross-cutting contextual factors, individual's financial resources and their social situation, which shaped each stage of their interactions with PIC4C services. The PIC4C model successfully engaged people in accessing screening services to enable timely diagnosis and referred them to enter care. Free community level screening services and decentralization of care to lower level facilities reduced cost barriers for patients. However, retention in care and adherence to treatment were affected by the wider system context in which PIC4C was operating, including inconsistencies in medication availability and patients' limited financial capacity. Individually tailored advice from health care workers to work around some of these challenges supported self-management strategies. Further development of the service should focus on supporting health care workers to adopt flexible, contextually responsive approaches in order to support patients facing economic and other constraints to engage in (self) care.

Comparative Analysis of Methods of Audiological Screening of the Adult Population: Global and Kazakhstani Experience

Hearing impairment is currently recognized as the most prevalent sensory impairment and one of the leading causes of disability worldwide. It is estimated that one in five people on Earth has at least minimal hearing loss, and more than 5% of the population has disabling hearing loss. There are many methods for screening detection of hearing impairment, and the most common ones are mobile applications, recognition of whispered speech, a portable audiometer, questionnaires, the speech intelligibility test in noise, and others. Nevertheless, the “gold standard” for hearing testing has been and remains the method of pure-tone threshold audiometry. The purpose of this review is to study the currently available literature, analyze ongoing research in the field of audiological screening of adults, study the cost-effectiveness of ongoing screening activities, study the situation in Kazakhstan, and the possibility of using these screening methods in Kazakhstan. We selected 25 full-text articles that met the following criteria: the 2018-2023 time interval, adult population, screening methods, effectiveness, and article language (English, Russian, Kazakh). Conclusions. Despite a sufficient number of hearing screening methods, their sufficient reliability, sensitivity, and specificity, and their obvious cost-effectiveness in comparison with the costs of rehabilitation of hearing impairments, none of the hearing assessment methods are included in the National Screening Program for examining adult population in any country in the world. In Kazakhstan, a screening test of hearing function using a one-question survey, the HHIA/HHIE questionnaire, a study of whispered speech at the primary health care level, and also the use of a mobile version of a hearing test as a hearing self-diagnosis are applicabl

Are social determinants associated with depression among married women of reproductive age? A mixed methods study from urban slums of Islamabad, Pakistan.

Depression among married women of reproductive age is on the rise in Pakistan, owing to post-COVID-19 phase, super-inflation, increasing poverty, deteriorating law and order situation and perpetuating the uncertain political situation in the country. This study aimed to investigate the factors associated with depression among married women of reproductive age in Pakistan, using a mixed methods approach. The quantitative phase utilized the Urdu version of the Patient Health Questionnaire-9 (PHQ-9) to assess depression among 340 married women. Twelve women with higher scores on the PHQ-9 were selected for in-depth interviews in the qualitative phase. The quantitative analysis revealed a higher prevalence of depression among women with poor socioeconomic status, lower educational levels, larger family sizes, and recent deaths in the family. In the qualitative phase, the main themes identified were the impact of social conditions, such as societal expectations and gender roles, the influence of medical conditions on mental health, financial difficulties, the stress associated with caring for a larger number of children, and the emotional burden of recent deaths in the family. This study highlights the importance of addressing depression among married women of reproductive age in Pakistan. It is crucial to focus on early diagnosis and prompt treatment to mitigate the adverse effects of depression on the affected individuals and their families. Targeted interventions should consider the social determinants of depression, including improving socioeconomic conditions through safety nets, providing mental health support at the primary health care level, and addressing the specific health issues and needs of women in the reproductive age group. A multi-pronged approach and health system's thinking can reduce the burden of depression among women, ultimately enhancing their overall well-being, productivity and quality of life.

Analysis of the effectiveness of the advanced training program "Rehabilitation of children with autism spectrum disorder"

The growth of children with Autism Spectrum Disorder (ASD) throughout the world requires a review of the provision of assistance to them in all areas, where multidisciplinary assistance should be provided. A systematic review found that clinicians have limited capacity to care for people with ASD and that specialized autism education programs need to be developed. The purpose of this study is to analysis of the effectiveness of the training program "Rehabilitation of children with autism spectrum disorder" for primary healthcare specialists. Methods. At the first stage, a multidisciplinary team was created, and the content course was discussed based on the competences that are of need at the primary care level specialists. As a result of the discussion, a professional development program (here in after referred to as the Program) was developed for two credits (60 hours). To study the effectiveness of the Program on the final day, feedback was received from listeners using QR codes, anonymously. For a more in-depth analysis, interviews were conducted with various primary care specialists who participated in the Program. Results. 9 participants of the training program completed the survey, of which 3 had less than 5 years of work experience; from 6-10 years -1; and more than 10 years - 5. All participants gave the highest score in assessing the presentation material; productivity, usefulness and relevance of the work done. Conclusions. The advanced training course for primary care specialists allowed us to identify further directions for improving the program. The feedback received about the program indicates the quality of the product, which was developed directly by a multidisciplinary team. It is necessary to continue work in this area with a larger coverage of program participants.

Evaluating the implementation of a hypertension program based on mHealth and community pharmacies integration to primary care centers at a municipality level in Argentina during the COVID-19 pandemic.

While pharmacists-led interventions in hypertension have proven effective in high-income countries, their implementation and impact in low- and middle-income countries (LMIC) remain limited. This study assessed the implementation and outcomes of the hypertension program FarmaTeCuida (FTC), which integrated community pharmacies into the public primary care level using information and communication technologies. The study took place during the pandemic in General Pueyrredón, Buenos Aires, Argentina, so modifications to the implementation strategy and expected outcomes were also analyzed. A mixed-methods study was conducted using the non-adoption, abandonment, scaling-up, dissemination, and sustainability (NASSS) conceptual model. Qualitative in-depth interviews were conducted with key stakeholders using snowball sampling until thematic saturation was achieved. The quantitative approach employed a quasi-experimental, prospective, longitudinal design in a cohort of hypertensive patients enrolled in the FTC program since October 2020 to March 2022. Adoption, access, adherence to follow-up, and blood pressure levels were assessed. Clinical outcomes were compared to a cohort of hypertensive patients attending primary health care centers (PHCCs) in 2021 but not enrolled in the FTC program. Routine data from this cohort was obtained from the municipal health information system (HIS). Out of 33 PHCCs, 23 adopted the FTC program, but only four collaborated with community pharmacies. A total of 440 patients were recruited, with 399 (91%) enrolled at PHCCs. Hypertension was detected in 63% (279/440) of cases at the first visit (113 were possible hypertensive patients; 26 new hypertensive patients and 140 already diagnosed). During follow-up, FTC identified 52 new hypertensive patients (12% out of 440). Reduction of systolic blood pressure (SBP) was observed in patients enrolled in both the FTC program and the comparison group over 60 days. In the multivariate analysis that included all hypertensive patient (FTC and HIS) we found strong evidence that for each month of follow up, SBP was reduced by 1.12 mmHg; however, we did not find any significant effect of the FTC program on SBP trend (interaction FTC*months has a p-value = 0.23). The pandemic was identified as the main reason for the program's underperformance; in addition we identified barriers related to technology, patient suitability, implementation team characteristics, and organizational factors. Our study, grounded in the NASSS model, highlights the profound complexity of introducing innovative strategies in low- and middle-income settings. Despite substantial challenges posed by the pandemic, these obstacles provided valuable insights, identified areas for improvement, and informed strategies essential for reshaping the care paradigm for conditions like hypertension in resource-constrained environments.

Post-acute care in China: development, challenges, and future prospects

Introduction: Post-acute care has been proved to be a crucial component of the health care system which promotes autonomous living functions, reduce unnecessary hospitalization, prevent unnecessary placement in a long-term care facility, and coordinate care between different levels of care.Different countries have built various forms of a PAC systems for decades. In light of the ongoing payment reform and population aging, PAC is becoming increasingly important as a part of the integrated health system in China. Based on comprehensive literature review, this paper summarizes Chinese health policies and progress that addressed PAC system in recent decades and provides outlook for future development.
 Methods: We based our review on published work and grey literature, including reports (international and domestic) and government policy documents. We searched PubMed, Google Scholar, EconLit, MEDLINE, Social Science Research Network, Wiley Online Library, and China Knowledge Resource Integrated Database for relevant research published since January 2009, until June 2022. We restricted our search to works published in English or Chinese and used the search terms “post-acute care”, “rehabilitation”, “nursing care”, “intermediate/transitional care”, “continuous medical/healthcare”, AND “China”, and combinations of these terms.
 Results: In the past decade, China has released various policies to support and regulate the development of rehabilitative and nursing facilities, in order to meet the increasing demand for PAC, including the building of rehabilitation and nursing facilities, strengthening PAC at the primary care level, constructing a tiered rehabilitative network, and experimenting innovative payment methods. However, the challenges and gaps remain. China lacks clinical consensus for PAC delivery and continues to face a severe shortage of PAC resources, both in terms of facilities and professionals. Moreover, quality of PAC at the primary level health facilities needs improvement for the hierarchical care system to function well. The development of a sound financing and payment mechanism for PAC services is still at the initial stage.
 Conclusions: This is the first paper comprehensively examining the current development progress of PAC as a whole, and point direction for future PAC system development in China.In its overall health system design, although the name of PAC is not explicitly stated in domestic policy documents, it is considered as an integral part towards a more continuous system, and a preliminary framework of the PAC system has been established through various efforts. To promote the further development of China’s PAC system, attention should be given to setting up of official definition and clinical guidelines, development of sound financing and payment models, increasing public and private investment in PAC infrastructures, establishing health provider requirements, strengthening the training and retaining of professionals and development of unified information system for PAC based on functional assessment. 
 

Towards More Appropriate Care for Low Back Pain: Understanding Primary Care Factors that Increase Best Practices and Collaborative Approaches to Care

Moving towards more appropriate care for low back pain is an important health services research issue in Ontario, Canada especially as evidence suggests there is overuse of health care resources for this problem. Low back pain involves excessive imaging, over-referrals for specialist care, and overuse of drug therapy. At the present time, there is also poor uptake of best practices, an evidence to practice gap, and low back pain management and outcomes have changed little over the past 35 years. 
 The emerging field of implementation science will be useful to address the central research question which asks “What factors amongst primary care physicians that manage low back pain, enable or constrain their ability to implement best practices in their care?“ Implementation science (IS) is drawn upon to help advance the uptake of research findings into practice and provide understanding as to why the implementation of evidence into practice may be successful or not. 
 Using the Consolidated Framework for Implementation Research (CFIR) model helps to identify barriers and facilitators to the uptake of best practices. Older frameworks have focused narrowly on physician behavior change, but CFIR recognizes that implementation must also consider features of context and setting to have a greater chance of success. As such, CFIR informs the study by using a meta-analytic framework, and focuses on elements of intervention characteristics, outer setting, inner setting, individual characteristics and process, which have been found to influence uptake of interventions. 
 The study uses a mixed methods approach which is appropriate when attempting to understand the social and practice environment involved in providing primary care. In this multi-phase study, a literature review was first conducted to provide a current understanding of what is currently known on the topic. This informed Phase 2, which involved sending quantitative surveys to a sample of Ontario primary care providers, mainly including family physicians. A final Phase 3 involved qualitative in-depth interviews with a subset of those providers to provide context and help explain patterns in the research findings.
 Results from 240 surveys will be presented, including a discussion of descriptive statistics, inferential statistics, hypothesis testing and a principal components analysis (PCA). Findings from 21 interviews will also be discussed, where 7 themes and multiple subthemes were found, with a particular emphasis on: the usage of evidence, inter-professional practice, changing practice patterns, expanding virtual care, and centering patient preferences. Overall, multiple barriers and facilitators for the adoption of best practices including the use of clinical practice guidelines will be discussed. 
 The research committee, engaged in the project co-design, is made up of an interdisciplinary team of health service researchers, clinicians and academics with diverse expertise and experience. The study aims to address gaps in the application of best practices for providers delivering low back pain care and recommends more integrated models of care. An overall goal is to help improve low back pain management at the primary care level, as this remains a prevalent and costly issue for the Canadian province of Ontario. 

Implementation of blood pressure and blood glucose telemonitoring in the elderly population in primary care practices: a right step towards integrated care?

Background: Arterial hypertension (AH) and type 2 diabetes (T2D) represent a significant burden on the public health system, with an exceptionally high prevalence in patients aged ≥65 years. One of the possible solutions to improve disease outcomes, promote integrated care with high patient engagement and support self-management in patients with AH and T2D at the primary care level is blood pressure and blood glucose telemonitoring.
 Target Population: Patients aged ≥65 years with AH and T2D 
 Stakeholders Engagement: In designing the intervention, we involved stakeholders at the micro-level (patients, health professionals), meso-level (managers of the included community health centres, representatives of the national association of general practitioners and associations of patients with chronic diseases) and macro-level (representatives of the Medical Faculty and Ministry of Health). 
 Description Of Intervention: We conducted a multicentre, prospective, randomised, controlled pilot study. Patients aged ≥ 65 years with AH and T2D were randomised 1:1 to an mHealth intervention or standard care group. Patients in the intervention group measured their blood pressure twice weekly and their blood glucose once monthly. The readings were synchronously transmitted via a mobile application to the telemonitoring platform, where they were reviewed by a general practitioner who indicated changes in the measurement scheme or performed a teleconsultation. Patients in the control group received standard care. The intervention lasted 12 months.
 Results Of Intervention: We enrolled 63 patients with a mean age of 71.9 ± 5.0 years, of whom 36 (57.1%) were men. The mean duration of AH was 15.1 ± 11.2 years and that of T2D was 9.1 ± 8.1 years. Mean systolic blood pressure at baseline was 141.2 ± 13.9 mmHg, diastolic blood pressure was 77.8 ± 9.0 mmHg and HbA1c was 7.2 ± 1.2%. At baseline, we found no significant differences between groups in sociodemographic and clinical variables. Compared with standard care, we observed an additional reduction in systolic blood pressure of -9.1 mmHg (95% CI -16.5 to -1.7, p=0.018), diastolic blood pressure of -2.3 mmHg (95% CI -6.1 to 1.4, p=0.215) and HbA1c of -0.7% (95% CI -1.2 to -0.1, p=0.022) in the telemonitoring group after 12 months. The intervention proved feasible and acceptable among included health professionals and patients (qualitative methods). 
 Take-Home Message: Telemonitoring of blood pressure and blood glucose is a feasible, acceptable and clinically effective method of remote care for elderly patients, particularly with regard to systolic blood pressure and blood glucose control in the first 12 months. The major limitation of remote care in elderly remains the lack of skills in using modern technology. To maximise clinical and cost-effective impact, careful patient selection is required (i.e., patients with newly diagnosed disease, poor adherence, poor disease control).
 Next Steps: For further scale-up and implementation, further research is needed to assess the long-term impact of telemonitoring. Due to the high implementation costs, other applications of telemonitoring could be tested, with telemonitoring serving only as a short-term educational tool in the hands of registered nurses and primary care physicians during more complex health education interventions.
 
 
 

Factors influencing the technical efficiency of diabetes care at primary care level in Mexico.

Diabetes prevalence is rising globally, especially in low- and middle-income countries like Mexico, posing challenges for healthcare systems that require efficient primary care to manage the disease. However, healthcare efficiency is influenced by factors beyond decision-makers, including socioeconomic and political conditions. This study aims to evaluate the technical efficiency of primary healthcare for diabetes patients in Mexico over a 12-year period and explore the impact of contextual variables on efficiency. A longitudinal analysis was conducted using administrative and socio-demographic data from 242 health jurisdictions between 2009 and 2020. Data envelopment analysis with bootstrapping and output orientation was used to measure the technical efficiency; health resources in infrastructure and human resources were used as inputs. As outcome, the number of patients receiving treatment for diabetes and the number of patients with controlled diabetes were considered. Machine learning algorithms were employed to analyse multiple factors affecting the provision of diabetes health services and assess heterogeneity and trends in efficiency across different health jurisdictions. The average technical efficiency in primary healthcare for diabetes patients was 0.44 (CI: 0.41-0.46) in 2009, reaching a peak of 0.71 (CI: 0.69-0.72) in 2016, and moderately declining to 0.60 (CI: 0.57-0.62) in 2020; these differences were statistically significant. The random forest analysis identified the marginalization index, primary healthcare coverage, proportion of indigenous population and demand for health services as the most influential variables in predicting efficiency levels. This research underscores the crucial need for the formulation of targeted public policies aimed at extending the scope of primary healthcare services, with a particular focus on addressing the unique challenges faced by marginalized and indigenous populations. According to our results, it is necessary that medical care management adjust to the specific demands and needs of these populations to guarantee equitable care in Mexico.

Screening for diabetes complications and associated factors in primary care in Galle, Sri Lanka

Introduction: Diabetes (DM) and its complications show an increasing trend and pose a huge burden on the health system. Thus, early detection of complications is essential. Primary care institutions treat and follow up patients with diabetes in their territories. The aim of the study was to assess awareness, practices, and service-related factors associated with screening for diabetes complications among patients attending the medical clinics of primary care level hospitals in the Galle district.Methods: A descriptive cross-sectional study was conducted at three Divisional Hospitals in Galle District, among patients attending medical clinics. Data was collected through an interviewer-administered questionnaire designed to assess awareness and screening practices for diabetes complications, screening done for diabetes complications, and associated factors were analyzed.Results: Four hundred patients with diabetes participated in the study. The majority (more than 95%) were aware of common organs affected by DM and were aware of investigations and their availability at primary care institutions (more than 85.0%). Adherence to recommended screening tests and frequency was very low (ranging from 3% to 16%) and nearly half of the patients never had any form of screening. Older age was associated with better retinopathy screening {OR = 0.61 95% CI (0.41-0.91)} while having co-morbidities was associated with better screening for retinopathy {OR = 1.67 95% CI (1.02-2.71)} and ischemic heart disease.{OR = 2.03 95% CI (1.22-3.40)}. A better awareness was associated with better screening for DM complications.Conclusions: In conclusion, awareness about screening for diabetes complications was satisfactory among the study sample. However, the screening practices were sub-optimal as the recommended screening protocols have not been followed. Better screening was associated with better awareness, older age, having comorbidities, and being employed.

Atopic dermatitis: A global health perspective.

The International Society of AD (ISAD) organized a roundtable on global aspects of AD at the WCD 2023 in Singapore. According to the Global Burden of Disease (GBD) consortium, at least 171 million individuals were affected with AD in 2019, corresponding to 2.23% of the world population, with age-standardized prevalence and incidence rates that were relatively stable from 1990 to 2019. Based on the panel experience, most AD cases are mild-to-moderate. Without parallel data on disease prevalence and severity, the GBD data are difficult to interpret in many regions. This gap is particularly important in countries with limited medical infrastructure, but indirect evidence suggests a significant burden of AD in low-and-medium resource settings, especially urban areas. The Singapore roundtable was an opportunity to compare experiences in World Bank category 1 (Madagascar and Mali), 3 (Brazil, China) and 4 (Australia, Germany, Qatar, USA, Singapore, Japan) countries. The panel concluded that current AD guidelines are not adapted for low resource settings and a more pragmatic approach, as developed by WHO for skin NTDs, would be advisable for minimal access to moisturizers and topical corticosteroids. The panel also recommended prioritizing prevention studies, regardless of the level of existing resources. For disease long-term control in World Bank category 3 and most category 4 countries, the main problem is not access to drugs for most mild-to-moderate cases, but rather poor compliance due to insufficient time at visits. Collaboration with WHO, patient advocacy groups and industry may promote global change, improve capacity training and fight current inequalities. Finally, optimizing management of AD and its comorbidities needs more action at the primary care level, because reaching specialist care is merely aspirational in most settings. Primary care empowerment with store and forward telemedicine and algorithms based on augmented intelligence is a future goal.

Quality of life of elderly users of long-term health care in and outside the institution

<p><strong>Introduction. </strong>Long-term care is series of health and social care services provided at home or in an institutional environment to people with reduced functional capacity. Even though it is known that the quality of life (QoL) of elderly is on a lower level when compared to younger people, there is a small amount of information about QoL of long-term health care patients. The aim of our study was to determine the difference in QoL, depression, anxiety and stress of longterm health care users placed in and outside the institution.</p> <p><strong>Methods.</strong> This cross-sectional study included 100 long-term healthcare users, divided in two groups. First group consisted of 50 respondents from primary level of health care and second group consisted of 50 residents of nursing home. The research was conducted in the period from June to July 2022. A general socio-demographic questionnaire, SF-36 health questionnaire for estimating the QoL and the scale of depression, anxiety and stress (DASS-21) were used as instruments in this study.</p> <p><strong>Results. </strong>Respondents who were institutionalized had significantly lower values of domains and summary scores of QoL compared to respondents whose health care took place outside of institutions, where the difference was observed in physical health summary score (37.67±6.20% vs. 50.39±10.74%, p<0.001), and the mental health summary score (44.87±11.82% vs. 51.83±16.01%, p =0.015). Respondents who received long-term health care institutionally had significantly (p=0.011) more mild anxiety (12%) and moderate anxiety (34%) compared to respondents who received long-term health care outside the institution (4% vs. 14%).</p> <p><strong>Conclusion. </strong>Our results showed that residents of nursing home had significantly worse physical and mental functioning, as well as more frequent occurrence of anxiety symptoms compared to users of longterm health care placed outside institutions, in home environment.</p>

Mortality and subsequent healthcare use among older patients discharged to a municipality with excess demand for elderly care

There is limited knowledge on how excess demand for elderly care influences patient outcomes. We used a natural experiment to estimate the causal effect of discharging elderly patients from hospital to municipalities with excess demand. In Norway, hospital in-patients are defined as ready-for-discharge when hospital treatment is completed, but the patient needs further care from municipal services. After this, the municipality of residence is obliged to either provide care for the patient or to pay the hospital a fixed fee per day that the patient spends in hospital. Municipal fee-days may thus indicate excess municipal demand. In the current paper, we studied how excess municipal demand, indicated by the number of fee-days accumulated in the municipality 30 days before an acute admission, influenced patient outcomes. To minimize confounding, we compared patients living within the same municipality, admitted during the same type of day, in the same year, but with varying excess demand. Our outcomes were mortality, resource use and healthcare costs at the primary and secondary care level, within 30 days. Between 2012 and 2016, 354,834 individuals (age≥70 years) had a total of 895,892 acute admissions. There was a 2% increased 30-day mortality per standard deviation change in accumulate fee-days (Hazard ratio (HR) of 1.02, 95% confidence interval (CI) 1.01-1.03). Individuals living in small municipalities (population<10,000) had HR of 1.04, (95% CI 1.02-1.07), while individuals living in larger municipalities (population>10,000) had HR of 1.01 (95% CI 1.00-1.03). We found no substantial effect on subsequent healthcare use or costs. Relevance tests supported that fee-days was a good indication of excess demand, and balance tests supported that patients were comparable between periods with different excess demand. In conclusion, our results imply that older patients who are discharged to a municipality with excess demand have slightly elevated mortality, particularly in small municipalities.

Results of a non-interventional observational multicenter study of the management of patients with axial psoriatic arthritis in real-life clinical practice (NiSaXPA)

Psoriatic arthritis (PsA) is a chronic immunoinflammatory disease of the joints, spine and entheses from the group of spondyloarthritis, which is usually observed in patients with psoriasis. In recent years, the axial form of PsA (axPsA) has been actively researched. However, there is insufficient data on approaches to the diagnosis and treatment of patients with axPsA in real-life clinical practice. This article presents the results of an interim analysis of data from a non-interventional multicenter observational study on the treatment of patients with axPsA in real-life clinical practice (NiSaXPA) in Russian centers.Objective: to identify patients with axPsA, their characteristics and describe treatment tactics in real-life clinical practice.Material and methods. Patients with PsA who met the inclusion criteria were prospectively followed up during routine visits to a rheumatologist. Participants' axial radiographs were uploaded to a database in order for it to be confirmed the presence or absence of axPsA by two independent experts, a rheumatologist and a radiologist. Patients with a confirmed axPsA diagnosis participated in a further data collection phase (Visit 2, week 24).Results and discussion. Six hundred patients were enrolled into the study. At the time of analysis, 386 (64.3%) of them (209 men and 177 women) were screened for axPsA. The diagnosis of axPsA was confirmed in 241 (62.4%) cases; these patients formed the Per Protocol (PP) population. The mean age of patients with axPsA in the PP population was 46.30±12.6 years and the body mass index (BMI) was 27.4±5.2 kg/m2 . In 14.9% of patients, the duration of psoriasis was less than 1–5 years, in 21.5% – 5–10 years and in 63.6% – more than 10 years. The duration of PsA symptoms was less than 1–5 years in 31.2 % of patients, 5–10 years in 31.6 % and more than 10 years in 37.2 %. Low disease activity (BASDAI ˂ 4) was achieved in 33.3 % of patients with axPsA at visit 1 and in 64.3 % at visit 2; the BASDAI index declined on average from 4.67±1.95 to 3.31±1.89 points.In real-life clinical practice, patients were most frequently prescribed non-steroidal anti-inflammatory drugs (NSAIDs) – 88.7% and 71.7% (visits 1 and 2, respectively), and synthetic disease-modifying antirheumatic drugs (sDMARDs) –79.1% and 70.7%, respectively; therapy with biologic disease-modifying antirheumatic drugs (bDMARDs) was initiated in 40.2% and 60.6% of patients, respectively.Conclusion. The results of the interim analysis of this observational study showed that in 87.2% of patients who met the CASPAR criteria for PsA there was a suspicion of axial manifestations of PsA on the primary care level. However, only 62.4% of them had a confirmed diagnosis of axPsA on centralized expert assessment, which may indicate a possible overdiagnosis of axial lesions in real-life practice and emphasizes the importance of collaboration between a rheumatologist and a radiologist when analyzing the results of imaging studies. 33.3% of patients with axPsA had low disease activity according to BASDAI at baseline and 64.3% after 24 weeks, meaning that the disease was only adequately controlled in one third of cases despite therapy; the number of these patients doubled after a change in therapy. In real-world clinical practice, patients with axPsA are most commonly prescribed drugs from the NSAID and sDMARD groups; the frequency of use of biologic drugs varied between 40.2 and 60.6% by the end of the observation period.

Diabetes-related distress and quality of life among people with type 2 diabetes at primary care level in Brazil.

Living with diabetes can be challenging, particularly when it comes to dealing with psychological distress and requiring self-care directives. Patients may feel frustrated, angry, overwhelmed, and discouraged. This study aimed to investigate the diabetes-related distress and quality of life among people with type 2 diabetes mellitus (T2DM). A cross-sectional study carried out at the Clinical Research Centre at the University of Campinas, Brazil, between September 2020 and April 2021. Patients answered data regarding demographic and clinical variables, the Brazilian version of the Diabetes Distress Scale and the Diabetes Quality of Life (QOL) Measure by telephone contact. The data were managed using the RedCap System. For statistical analysis of the data, the Mann-Whitney and Kruskal-Wallis tests were applied for comparisons, and the Chi-square test for associations. The correlations were evaluated using the Spearman correlation coefficient. Out of the 302 participants we recruited, 50.33% exhibited significant diabetes-related distress. Those with elevated diabetes-related distress scores had shorter education levels (p < 0.05), lower HbA1c levels (p < 0.05), and lower total scores in Diabetes QOL Measure (p < 0.0001), particularly in the QOL impact (p < 0.0001), social/vocational worry (p < 0.05), and diabetes worry (p < 0.0001) subscales compared to the group with the lowest diabetes-related distress. Elevated diabetes-related stress scores significantly affect patients' QOL. Therefore, early screening of individuals at risk for this condition, using well-coordinated protocols, could mitigate adverse QOL effects and enhance their overall experience during disease management.

FioSchisto's expert perspective on implementing WHO guidelines for schistosomiasis control and transmission elimination in Brazil.

The World Health Organization (WHO) recognizes schistosomiasis as one of the Neglected Tropical Diseases targeted for global elimination in the 2030 Agenda of the Sustainable Development Goals. In Brazil, schistosomiasis mansoni is considered a public health problem, particularly prevalent among vulnerable populations living in areas with poor environmental and sanitary conditions. In 2022, the WHO published a Guideline encompassing recommendations to assist national programs in endemic countries in achieving morbidity control, eliminating schistosomiasis as a public health problem, and advancing towards interrupting transmission. The perspectives presented here, collectively prepared by members of the Oswaldo Cruz Foundation's (Fiocruz) Schistosomiasis Translational Program (FioSchisto), along with invited experts, examine the feasibility of the WHO recommendations for the Brazilian settings, providing appropriate recommendations for public health policies applicable to the epidemiological reality of Brazil, and suggests future research to address relevant issues. In Brazil, the provision of safe water and sanitation should be the key action to achieve schistosomiasis elimination goals. The agencies involved in measures implementation should act together with the Primary Care teams for planning, executing, monitoring, and evaluating actions in priority municipalities based on their epidemiological indicators. Host snails control should prioritize judicious ecological interventions at breeding sites. The Information, Education, and Communication (IEC) strategy should be associated with water and sanitation and other control actions, actively involving school community. To identify infected carriers, FioSchisto recommends a two-stage approach of immunological and molecular tests to verify transmission interruption during the intervention and beyond. Praziquantel administration should be done under medical supervision at the Primary Care level. MDA should be considered in exceptional settings, as a measure of initial attack strategy in locations presenting high endemicity, always integrated with water and sanitation, IEC, and snail control. To assist decision-making, as well as the monitoring and evaluation of strategic actions, there is a need for an Information System. FioSchisto considers this systematization essential to make investments in strategic research to support the improvement of schistosomiasis control actions. Efforts toward schistosomiasis elimination in Brazil will succeed with a paradigm shift from the vertical prescriptive framework to a community-centered approach involving intersectoral and interdisciplinary collaboration.