Primary Care Patients Research Articles

Health Catch-UP!: a realist evaluation of an innovative multi-disease screening and vaccination tool in UK primary care for at-risk migrant patients

BackgroundMigrants to the UK face disproportionate risk of infections, non-communicable diseases, and under-immunisation compounded by healthcare access barriers. Current UK migrant screening strategies are unstandardised with poor implementation and low uptake. Health Catch-UP! is a collaboratively produced digital clinical decision support system that applies current guidelines (UKHSA and NICE) to provide primary care professionals with individualised multi-disease screening (7 infectious diseases/blood-borne viruses, 3 chronic parasitic infections, 3 non-communicable disease or risk factors) and catch-up vaccination prompts for migrant patients.MethodsWe carried out a mixed-methods process evaluation of Health Catch-UP! in two urban primary healthcare practices to integrate Health Catch-UP! into the electronic health record system of primary care, using the Medical Research Council framework for complex intervention evaluation. We collected quantitative data (demographics, patients screened, disease detection and catch-up vaccination rates) and qualitative participant interviews to explore acceptability and feasibility.ResultsNinety-nine migrants were assessed by Health Catch-UP! across two sites (S1, S2). 96.0% (n = 97) had complete demographics coding with Asia 31.3% (n = 31) and Africa 25.2% (n = 25), the most common continents of birth (S1 n = 92 [48.9% female (n = 44); mean age 60.6 years (SD 14.26)]; and S2 n = 7 [85.7% male (n = 6); mean age 39.4 years (SD16.97)]. 61.6% (n = 61) of participants were eligible for screening for at least one condition and uptake of screening was high 86.9% (n = 53). Twelve new conditions were identified (12.1% of study population) including hepatitis C (n = 1), hypercholesteraemia (n = 6), pre-diabetes (n = 4), and diabetes (n = 1). Health Catch-UP! identified that 100% (n = 99) of patients had no immunisations recorded; however, subsequent catch-up vaccination uptake was poor (2.0%, n = 1). Qualitative data supported acceptability and feasibility of Health Catch-UP! from staff and patient perspectives, and recommended Health Catch-UP! integration into routine care (e.g. NHS health checks) with an implementation package including staff and patient support materials, standardised care pathways (screening and catch-up vaccination, laboratory, and management), and financial incentivisation.ConclusionsClinical Decision Support Systems like Health Catch-UP! can improve disease detection and implementation of screening guidance for migrant patients but require robust testing, resourcing, and an effective implementation package to support both patients and staff.

Lessons learned from implementing a digital rehabilitation care planning platform to improve care access for patients with work disability: qualitative process evaluation of the RehaPro-SERVE study

BackgroundInpatient rehabilitation therapies can be applied for in Germany by patients of working age to support their return to work. However, there are some problems that impede an easy and uncomplicated application process. An interdisciplinary case management approach for rehabilitation care planning was developed to facilitate the access to rehabilitation. Case conferences (CCs) were held with relevant stakeholders and took place on a digital communication platform. We conducted a qualitative process evaluation to understand the implementation of the intervention and to identify contextual factors as well as mechanisms for a successful implementation in the context of primary care.MethodsThe process evaluation included interviews with primary care physicians (PCPs), patients and stakeholders involved in the intervention process. Reflexive thematic analysis was used to analyse the data. Emerging themes were structured according to the Donabedian framework of structure, process and outcomes.ResultsA total of 18 interviews were conducted. Important results included the desire for more patient involvement and case management. Patients especially valued the opportunity to receive support from a social worker. Limitations of the platform related to usability and limited opportunities for stakeholder communication. Despite training for PCPs, several problems arose regarding the clarity of the intervention process. Patients were satisfied with their application process and the treatments offered, while PCPs reported an increase in workload.ConclusionsA digitalisation of the application procedure for rehabilitation and further treatment options is acceptable to patients and personal support of a social worker is particularly valued. However, patients should be included in the CC in terms of a shared decision-making process. The digital platform requires sufficient training and adjustments have to be made to enhance usability and to improve the efficiency of the process for PCPs. Overall, the exchange between the various stakeholders in the CC is considered particularly useful in more complex cases.Trial registrationDRKS German Clinical Trials Register, DRKS0 00242 07. Registered on 22 March 2021.

Gout diagnoses uncertain when made by general practitioners without serum uric acid testing: an observational study.

General practitioners (GPs) diagnose the majority of all gout patients. They make their diagnosis clinically. Serum uric acid (SUA) level >0.35mmol/l is largely determinative for the clinical diagnosis of gout. We aimed to assess to what extent GPs test SUA when making a first gout diagnosis, and to consider consequences regarding diagnostic certainty of not testing it. We calculated proportions of patients from 87 Dutch general practices (1-1-2013 to 1-1-2022) with a first gout diagnosis and a recorded SUA test, evaluated if SUA testing was punctually timed with respect to the diagnosis date, whether SUA levels were >0.35mmol/L, and whether diagnoses corresponded with diagnoses according to the 'Acute Gout Diagnosis Rule' (AGD-rule). In 43.0% of 7782 patients (mean age 64.4 years; 68.8% male) no SUA test result was recorded, with substantial variation among practices: median 41.9% (IQR 20.2%). 'Gout very likely' according to the AGD-rule was seen in all males and in 83.1% of females when a punctually timed SUA >0.35mmol/L was present. When such SUA level was lacking, 'Questionable or indeterminate gout diagnosis' was seen in all males and in 67.1% of females, and 'Arthritis diagnosis other than gout' in 32.9% of females. GPs diagnosed gout without testing SUA in ~40% of cases. This implies avoidable diagnostic uncertainty with impact for the clinical care of many patients as well as for studies that include primary care patients with gout. Key Points • Serum uric acid (SUA) level > 0.35mmol is determinative when diagnosing gout: however, it is unknown how often SUA testing is applied as such. • More than 40% of patients with a first gout diagnosis according to general practitioners (GPs) had no SUA test result registered in their medical record. • Gout diagnosing by GPs without SUA testing appeared to lead to avoidable diagnostic uncertainty, as diagnoses are often questionable or sometimes even wrong. • Researchers investigating gout need to take into account diagnostic uncertainty if they include gout patients who are diagnosed in primary care in their studies without SUA information.

Incident heart failure: comparing management and outcome in primary care and hospital settings in Western Sweden 2008-2017

Abstract Background Heart failure (HF) is a major problem in primary care (PC) and hospital care (HC). HF patients managed in these two settings may differ in their demography, comorbidities, treatment and outcomes. Aim We aimed to compare the patient management in PC and HC in the Västra Götaland Region (VGR) in Sweden. Methods The VEGA database is an administrative database includes all patients living in VGR. Patients with a first principal or contributory diagnosis of HF (I50) ≥18 years old between 2008 and 2017 were included. One-year mortality was used as the outcome. Results In total, 62,229 new-onset HF cases were included, with 18,722 identified only in PC and 16,651 in HC. HF patients in PC were older (80.7±10.9 vs 76.1±13.6), more women (57.1% vs 44.9%), with more hypertension, musculoskeletal and mental disorders, but less myocardial infarction. Guideline directed medical therapy was more frequently used in HC despite similar medication before HF diagnosis. Patients in HC had almost 4 times higher all-cause 1-year mortality [3.92 (3.77 - 4.08), p<0.0001] compared with PC after adjustment for age and sex. Over 10-year period, despite decreasing mortality in both settings, hazard ratios for HC vs. PC were significantly increased for all patients (p for interaction 0.0004), which was more marked in female and for 70-80 years old patients. Conclusion Over a 10-year period, not withstanding decreasing mortality in HF patients in both PC and HC settings, differences remain between these two HF populations not only demographic profile and medications but also outcomes.

Inclusion of Long Covid patients in the care trajectory post-Covid-19: evidence from Belgium

Abstract Background Evidence suggests that 10-30% of COVID-19 infected people develop persistent symptoms that can be diagnosed as Long Covid. Most Long Covid cases are in patients with a mild acute COVID-19 infection and are mainly treated in primary health care. In July 2022, a care trajectory (CT) post-Covid-19 was launched in Belgium, in which Long Covid patients can benefit from reimbursement of treatment costs when consulting health professionals in primary health care for their rehabilitation. Patients are included in this CT mainly through their general practitioner (GP) and depending on patients’ care needs, treatment is organized in a monodisciplinary or multidisciplinary way. Methods A population-based study on data collected by the Belgian network of Sentinel General Practitioners (SGP) on all Long Covid patients consulting their GP during March-December 2023. Information on inclusion in the CT post-Covid-19 was also registered. Descriptive statistics were performed. Results End of 2023 in Belgium, GPs initiated the CT post-Covid-19 for more than 1000 patients, this mainly for monodisciplinary treatment, less than 10% of included patients received multidisciplinary follow-up. By the SGP, among the registered Long Covid sufferers (N = 14), a total of six cases were included in the CT post-Covid-19. Of these cases, the majority were female, of older age, higher educated and had one or two chronic conditions. Most had a mild or moderate prior COVID-19 infection and all were vaccinated multiple times against COVID-19. Symptoms lasted one year or more for 83.3% of included patients. Treatment focused mainly on self-management, energy management and physical exercise programs, mainly in collaboration with physiotherapists. Conclusions This study yields recent data on patients included in the CT post-COVID-19 in primary care in Belgium. It is important to focus on guidance, follow-up and rehabilitation of Long Covid sufferers by healthcare professionals in Belgium. Key messages • Long Covid patients included in the care trajectory post-Covid-19 in Belgium experience years of debilitating symptoms after their prior COVID-19 infection. • The establishment of the care trajectory post-Covid-19 for Long Covid patients in primary care since July 2022 stimulated collaboration between care givers in Belgian primary health care.

Implications of five different risk models in primary prevention guidelines

Abstract Background A lack of consensus exists across guidelines as to which risk model should be used for the primary prevention of cardiovascular disease (CVD). Purpose The objective of this study was to determine potential improvements in the number needed to treat (NNT) with statins using different risk models in patients eligible for risk stratification. Methods A retrospective observational cohort was assembled from primary care patients in Ontario, Canada between January 1st, 2010, to December 31st, 2014 and followed for up to 5 years. Risk estimation was undertaken in patients 40-75 years of age, without CVD, diabetes, or chronic kidney disease using the Framingham Risk Score (FRS), Pooled Cohort Equations (PCEs), a recalibrated FRS (R-FRS), Systematic Coronary Risk Evaluation 2 (SCORE2), and the low-risk region recalibrated SCORE2 (LR-SCORE2). Results The cohort consisted of 47,399 patients (59% women, mean age 54). The NNT at 5 years with statins was lowest for SCORE2 at 40, followed by LR-SCORE2 at 41, R-FRS at 43, PCEs at 55, and FRS at 65. Models that selected for individuals with a lower NNT recommended statins to fewer, but higher risk patients. For instance, SCORE2 recommended statins to 7.9% of patients (5-year CVD incidence 5.92%). The FRS, however, recommended statins to 34.6% of patients (5-year CVD incidence 4.01%; Figure). Conclusions Newer models such as SCORE2 may improve statin allocation to higher risk groups with a lower NNT.Figure

Using English General Practice Patient Survey data to explore Long Covid prevalence

Abstract Background High global burden of Long Covid (LC) has significant implications for population wellbeing, health/social care and the economy. We aimed to assess prevalence of LC, the level of uncertainty general practice (GP) patients felt about whether they were experiencing it and patient characteristics associated with LC. Methods This is a secondary data analysis of GP Patient Survey 2023 data (759,149 participants aged 16+yrs in England). The outcomes included self-reported LC, and being unsure about having LC. Identity and socioeconomic characteristics were explored in relation to these outcomes using univariable and multivariable regression analyses. Results 4.8% of respondents described themselves as having LC, and 9.1% were unsure whether they had it. Patient age (highest odds at 35-54 years), sex (females more than males), ethnicity (highest odds in Gypsy or Irish Traveller), sexual orientation (increased odds in gay or lesbian or bisexual compared to heterosexual), religion, smoking, carer status, parental status, having a long-term condition, and area-level index of multiple deprivation (higher odds in more deprived areas) were all significantly associated with reporting having LC in the multivariable model compared to answering that question with ‘no’. Generally, similar patterns of association to the above were observed in those who answered the Long Covid question with ‘unsure’ compared to those answering ‘no’, except for parental status and sexual orientation which were not significantly associated with the outcome in the multivariable model. Conclusions This study quantitatively highlights the high levels of uncertainty among primary care patients around experiencing LC, and the unequal distribution of LC burden among population groups. Our findings underline the need for better public health and primary care messaging to raise awareness around LC and ensure that those needing support can access services, particularly those already disadvantaged in society. Key messages • There are high levels of uncertainty about having Long Covid among people attending primary care services. • There is unequal burden of Long Covid in England underlining the need for improved awareness and access to support, particularly for minoritised groups.

Prediction of mortality, future arrhythmia and cardiovascular disease: an artificial intelligence-enhanced electrocardiography platform

Abstract Background Artificial intelligence-enhanced electrocardiography (AI-ECG) can be used to identify existing disease, but could additionally be used to predict occurrence of future disease and death. Purpose We developed an AI-ECG platform that predicts mortality and a wide spectrum of future arrhythmia and cardiovascular disease. Methods The AI-ECG risk estimation platform (AIRE) was developed in a dataset of 1,163,401 ECGs from 189,539 patients from a secondary care setting in the USA. Uniquely, AIRE uses deep learning with a residual convolutional neural network with a discrete-time survival loss function to output subject-specific survival curves (Fig 1A). AIRE was fine-tuned to additionally predict the endpoints described below. Results AIRE accurately predicts risk of all-cause mortality (C-index 0.775 (0.773-0.776) and can differentiate prognosis in high- and low-risk subjects, even when only cardiologist-defined normal ECGs are considered (Fig 2B). Additionally, in Cox regression analyses, AIRE was superior to conventional risk factors (Fig 1B). AIRE accurately predicted future ventricular arrhythmia (c-index 0.760 (0.756-0.763)), future complete heart block (CHB) (0.809 (0.805-0.814), future atrial fibrillation (0.753 (0.751-0.756), future atherosclerotic cardiovascular disease (0.696 (0.694-0.698)) and future heart failure (0.787 (0.785-0.789)) . AIRE was superior to left ventricular ejection fraction (LVEF) in predicting risk of future ventricular arrhythmias in subjects with LVEF <50% (C-index 0.649 (0.638 – 0.660) vs 0.615 (0.603 – 0.626) p < 0.0001 ). For CHB prediction, AIRE was able to further risk stratify subjects with bifascicular block and syncope into low (1.9% 5 year CHB), intermediate (8.8%), and high risk (20.7%) groups, and could guide treatment decisions. We externally validated our findings in four diverse, transnational cohorts from Brazil and the UK, including volunteers, primary care subjects and patients with Chagas disease, and found AIRE accurately predicted all-cause mortality in all four external cohorts (Fig 2). Non-mortality endpoints were successful externally validated in the UKB. In explainability analyses, we found features of QRS morphology, low QRS voltage, poor precordial R wave progression, inverted and biphasic T waves and ST segment changes were the most significant morphological features associated with high predicted mortality (Fig 1D). Through phenome- and genome-wide association studies (GWAS), we identified candidate biological pathways including changes in cardiac structure (LV mass, LV trabeculation and left atrial size). GWAS identified variants adjacent to VGLL2, KCNQ1, CCDC91 and TBX3 which have been described in association with QT interval, biological aging and metabolic syndrome (Fig 1E). Conclusion AIRE could be used worldwide across a range of clinical contexts for risk estimation of not only mortality but a wide spectrum of future arrhythmia and cardiovascular diseases.Figure 1Figure 2

From Data to Decisions: Analyzing PaRIS for Health Policy Insights

Abstract To inform countries on how well they perform from the perspective of people living with chronic conditions in comparison with other countries, we propose an analytical framework for the data collected in the PaRIS survey, detailing how the data will be analysed in a multilevel approach for cross-country comparison. The data structure of the PaRIS survey represents three levels: countries/health systems, primary care practices and patients. Multilevel analysis is used because of its accuracy in estimating country-level outcomes, its flexibility in modelling relationships, and its opportunities in connecting to relevant policy questions. Country-level outcomes will be estimated to facilitate cross-country comparison and (future) within-country comparison over time. A first indication for areas for cross-country learning and policy making is the distribution of variation over patients, care providers and countries. Characteristics of patients that potentially explain variation in patient-reported outcomes and experiences can be linked to primary care practice and country/health system characteristics. The second indication for areas for cross-country learning and policy making is the variation in the slope of the association between patient and practice characteristics and patient-reported outcomes and experiences. This makes it possible to address policy-relevant questions relating, e.g., to whether some health systems or providers are better able to produce positive outcomes and experiences for (e.g.) older patients, and to the impact of chronic care management on patients with a specific chronic condition. To ensure fair cross-country comparisons, all outcomes will be estimated for an OECD (age and sex standardised) reference population, also including case-mix adjustment where necessary. Analyses will be repeated using a country-specific standard population.

Fall risk factors and prevention among older adults in primary care in Belgium, 2019-2021

Abstract Background Falls are a major public health problem and ageing populations further increase the burden of fall-induced injuries. Falling among older persons is a multifactorial health condition needing multifactorial care. General practitioners (GPs) are well placed to implement a multifactorial management. A surveillance study of accidental falls studied characteristics of falls, risk groups and fall risk factors as well as fall prevention by GPs. Methods A 3-year retrospective population-based study by the Belgian network of Sentinel General Practitioners (SGP) on all patients aged ≥ 65 years consulting their GP for new fall-related injuries. Descriptive statistics were used to characterize falls, fallers, fall risks and preventive measures. Logistic regression analyses were performed to identify factors associated with a multifactorial fall risk profile. Results During 2019-21, 1138 accidental falls were registered. Medical and/or nursing intervention was required for 24% and 22% had a severe injury. During consult, 30% was referred to hospital. 61% of patients showed at least one of the four most prevalent fall risks, i.e. deficits of mobility or balance, polypharmacy, cognitive impairment or psychotropic medication. A multifactorial fall risk profile was observed in 45% of fallers and was associated with recurrent falling (p < 0.001), fall location (p < 0.05), activity when falling (p < 0.01) and pandemic year 2020 (p < 0.05). Addressing surrounding and walking problems were the most frequently delivered preventive measures. For 28% of patients, other primary care providers (mainly nurse and physiotherapist) were involved in preventive care. Conclusions This study highlights the importance of identifying fall risk factors among fallers in primary care. Preventive fall measures, taken in about one in four general practice patients in collaboration with other healthcare providers, are crucial for preventing accidental falls in older persons in Belgium. Key messages • A multifactorial management of fall risk factors by GPs is crucial for preventing accidental falls in older primary care patients. • Strengthening collaboration between primary healthcare professionals is needed for improving fall prevention in Belgium.

Social prescribers’ referral processes and decision-making about healthy eating and physical activity

Abstract Background Social Prescribing (SP) connects primary care patients with non-medical sources of support within the community. There are various SP models, with different referral routes. Many involve patients being referred to a link practitioner, who considers their needs and then “prescribes” or links them to appropriate local support services or resources, typically provided by the third sector. The present study aimed to explore the SP process and the decision-making of link practitioners, particularly around food and physical activity practices. Methods Sixteen semi-structured interviews were conducted with link practitioners working across Aberdeen City. A pragmatic Thematic Framework analysis was undertaken. Findings Participating link practitioners described their approach with clients as building rapport and trust while maintaining boundaries and managing expectations, and their community role as resource mapping and networking. Three broad categories of factors were considered during referral: 1) practicality (e.g., location, transport, cost, mobility, availability), 2) clients’ engagement (e.g., interest, motivation, readiness for change), and 3) link practitioners’ past experiences with services. Challenges identified included navigating waiting lists and service limitations, clients’ engagement and expectations, under-resourced services, navigating waiting lists with caseloads and the emotional burden of seeing people in very difficult situations. All link practitioners considered diet and exercise to fit within the remit of social prescribing but emphasised that clients should lead this discussion. Dietary support via social prescribing typically revolved around poverty rather than health. Discussion The study provides insight into the practical reality of making social prescribing decisions and has the potential to inform training and evaluation processes and support the development of health-focused social prescribing lifestyle interventions. Key messages • Social prescribing – a personalised approach, with clients supported to identify and achieve their health and wellbeing goals based on their strengths and resources available in the local community. • Social Prescribing - a promising platform for offering healthy eating interventions tailored to individual needs.

Primary care nurses’ readiness to promote digital health technology use among patients

Abstract Background Digital health technologies (DHTs) aim to optimise resource allocation and improve public health outcomes as care supplements. However, many patients do not access them independently. Nurses, as central contacts for primary care patients, can integrate digital health assessments, patient portals, remote monitoring, and teleconsultations into practice. Insight into their readiness to promote patients’ use of DHTs is important for efficient dissemination strategies. We examined nurses’ referral of patients to use DHTs and whether digital dedication (enthusiasm, inspiration, and pride for DHTs) and service guidance skills were associated with referral behaviour. Methods In spring 2023, the national ‘2023 survey on information systems for registered nurses’ gathered data from 549 nurses in Finnish primary care, comprising registered nurses (62%) and public health nurses (38%). The outcome, frequency of nurses’ DHT referrals, was assessed on a scale ranging from never to daily. We used multivariable ordinal logistic regression to examine associations, adjusted for career length, unit, and location. Results Among the nurses, 31% never or seldom referred patients to DHTs, while 19% did so monthly, 32% weekly, and 18% daily. Multivariable model showed that with each one-point increase in digital dedication (scale 1-5), the odds of referring patients to DHTs more frequently increased by 43% (OR = 1.43, 95% CI 1.21-1.70). Nurses who rated their service guidance skills as good (OR = 1.76, 1.01-3.05) or excellent (OR = 2.89, 1.28-6.62) had greater odds of referring patients to DHTs more frequently compared to those with less advanced skills. Conclusions Referring patients to DHTs is not a common practice for primary care nurses and can undermine care equity. Nurses’ motivation and knowledge about DHTs should be fostered, which may enhance patient referrals. Developing guidelines to assess patients’ digital capability and needs for effective service coordination is paramount. Key messages • Digitally committed and service-aware primary care nurses may refer patients to use DHTs more often than their peers, but we could not consider if suitable DHTs were available for patients encountered. • Nurses should be motivated to use digital tools and provided with instructions for proficiently coordinating services in order to address patients’ underutilisation of DHTs and promote equitable care.

Exploring heart failure prevalence and overlooked dimensions: a comprehensive NT Pro-BNP study in high-risk primary care patients

Abstract Background Heart failure (HF) is a prevalent syndrome linked to significant morbidity and mortality, especially in those with comorbid conditions like diabetes, hypertension, and atherosclerotic cardiovascular disease. Early detection and intervention are crucial. Natriuretic peptides, particularly NT-proBNP, are promising biomarkers for identifying at-risk individuals, but their use in primary care settings is not fully understood. Methods This prospective cohort study enrolled 874 participants aged 40 and above with documented risk factors for HF, such as diabetes mellitus, hypertension, metabolic syndrome, obesity, atherosclerotic cardiovascular disease, genetic variants for cardiomyopathy, or exposure to cardiotoxic agents. NT-proBNP levels were measured in blood samples collected at primary care clinics, and participants underwent comprehensive cardiac evaluations at a referral hospital. Clinical characteristics, laboratory findings, electrocardiography, and echocardiography results were recorded. Results The study included 874 patients with at least one risk factor for HF, with a mean age of 62.5 ± 9.1 years and 51.9% female. According to the 2022 AHA/ACC/HFSA HF Guideline, 69.1% were Stage A HF, 21.9% Stage B HF, and 9% Stage C HF. Clinical characteristics, laboratory and echocardiographic findings are shown in Picture 1. The majority had hypertension (71.1%), while other prevalent comorbidities included diabetes mellitus (43.4%), dyslipidemia (35.2%), obesity (27.1%), and atherosclerotic cardiovascular disease (26.2%). Laboratory findings showed a significant decrease in HbA1C, eGFR, LDL, triglycerides, and hemoglobin from Stage A to C HF. Median NT-proBNP levels rose from Stage A to C HF (46.4 pg/mL in Stage A, 219 pg/mL in Stage B, and 268.5 pg/mL in stage C), with 84.8% of Stage B HF patients exhibiting elevated levels. NT-proBNP levels were correlated positively with left atrial volume index, left ventricular mass index, age, E/e’, and estimated systolic pulmonary artery pressure levels. Conversely, NT-proBNP levels showed a negative correlation with estimated glomerular filtration rate and left ventricular ejection fraction. Among Stage C patients, 92.4% had HFpEF. The Picture 2 depicted the study's design and outcomes, providing a comprehensive visual representation. Conclusion NT-proBNP screening in primary care settings identified a substantial proportion of individuals with undiagnosed HF, particularly those in Stage B and Stage C. The high prevalence of HFpEF underscores the need for comprehensive evaluation and management strategies targeting this population. Early detection facilitated by NT-proBNP screening may lead to timely interventions and improved outcomes in individuals at risk for HF.

Evaluation of the effectiveness of cognitive–behavioural therapy for insomnia delivered by nurses and physicians for patients in primary care (the NPD study): protocol for a cluster randomised controlled trial

IntroductionInsomnia is the most common sleep disorder, and it adversely impacts daily living and increases the risk of chronic and acute health problems. Of the few individuals who seek treatment...

AUDIT‐C shows reliability when used online in patient portals

The Alcohol Use Disorders Identification Test–Consumption (AUDIT‐C) is a validated screen, but until recently has not been evaluated in routine conditions for adult primary care patients. A new study has found that AUDIT‐C screens have “excellent” test‐retest reliability, which assesses the consistency of results when given at two different times. Excellent test‐retest reliability means that there are similar results across separate test administrations, and the study, supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), shows that the AUDIT‐C can be used reliably in adult primary care patients. The study, led by Claire B. Simon, M.D., of the University of Washington in Seattle, used electronic health record (EHR) data from Kaiser Permanente. For the study, more than 18,000 adult primary care patients completed two AUDIT‐C screens at 1 to 21 days apart as part of routine care in 2021. Screen results were reliable whether completed in person or online through patient portals. However, reliability was higher when the patient completed both screens using online patient portals, compared to completing both screens in the clinic or one in the clinic and one online. Therefore, completing two screens may be a better option than just doing one. The study, High test–retest reliability of the Alcohol Use Disorders Identification Test–Consumption (AUDIT‐C) questionnaire completed by primary care patients in routine care, is published in the February 2024 issue of Alcohol, Clinical and Experimental Research. The researchers also found that reliability was lower for American Indian/Alaska Native (AI/AN) patients and multiracial patients.

Using Panel Management to Identify Adult Patients With High-Risk Metabolic Dysfunction-Associated Steatotic Liver Disease/Metabolic Dysfunction-Associated Steatohepatitis Fibrosis in a Primary Care Clinic: A Pilot Study.

As rates of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) rise, national organizations have released new guidance for primary care-driven detection of patients with advanced fibrosis who are most likely to have clinically relevant morbidity. Yet time constraints, workflow, and practitioner awareness limit integration of risk identification into clinical care. At the authors' primary care clinic, they implemented a panel management strategy that utilized the electronic health record to identify patients older than 35 years of age at risk for MASLD fibrosis with abnormal Fibrosis-4 (Fib-4) scores. Using a proactive model, these patients were offered elastography-based screening and follow-up appointments focused on metabolic health, with referrals to subspecialty care when indicated. Of 855 patients older than 35 years of age, 384 were identified as having risk factors for MASLD/MASH. Of these, 53 had abnormal Fib-4 scores with no prior work-up; 29 patients consented to a shear wave elastography; 16 underwent shear wave elastography; and 6 had moderate or high results concerning for at-risk fibrosis. Twenty patients attended MASLD-focused appointments. Reluctance to pursue testing was driven by skepticism surrounding preventative medicine, perceived cost, and desire to focus on other medical problems, some of which were life-limiting. Panel management represents a scalable strategy to quickly identify patients in primary care most likely to experience complications from MASLD/MASH and provides a targeted intervention to direct further management. Limitations include access to care, medical complexity, and patient acceptance.

Prevalence of Cannabis Use Disorder Among Primary Care Patients with Varying Frequency of Past-Year Cannabis Use.

Valid, single-item cannabis screens for the frequency of past-year use (SIS-C) can identify patients at risk for cannabis use disorder (CUD); however, the prevalence of CUD for patients who report varying frequencies of use in the clinical setting remains unexplored. Compare clinical responses about the frequency of past-year cannabis use to typical use and CUD severity reported on a confidential survey. Among adult patients in an integrated health system who completed the SIS-C as part of routine care (3/28/2019-9/12/2019; n = 108,950), 5000 were selected for a confidential survey using stratified random sampling. Among 1688 respondents (34% response rate), 1589 who reported past-year cannabis use on the SIS-C were included. We compared patients with varying frequency of cannabis use on the SIS-C (< monthly, monthly, weekly, daily) to survey responses on the Composite International Diagnostic Interview Substance Abuse Module for CUD (any and moderate-severe CUD) and cannabis exposure measures (typical use per-week, per-day). Adjusted multinomial (categorical) and logistic regression (binary), weighted for population estimates, estimated the prevalence of outcomes across frequencies. Patients were predominantly middle-aged (mean = 43.3years [SD = 16.9]), male (51.8%), white (78.2%), non-Hispanic (94.0%), and commercially insured (68.9%). The prevalence of any and moderate-severe CUD increased with greater frequency of past-year cannabis use reported on the SIS-C (p-values < 0.001) and ranged from 12.7% (6.3-19.2%) and 0.9% (0.0-2.7%) for < monthly to 44.6% (41.4-47.7%) and 20.3% (17.8-22.9%) for daily use, respectively. Greater frequency of use on the SIS-C in the clinical setting corresponded with greater per-week and per-day use on the confidential survey. Among patients who reported past-year cannabis use as part of routine screening, the prevalence of CUD and other cannabis exposure measures increased with greater frequency of cannabis use, underscoring the utility of brief cannabis screens for identifying patients at risk for CUD.

Health Coaching Impacts Stage-Specific Transitions in Multiple Health Behaviors for Patients at High Risk for Coronary Heart Disease and Type 2 Diabetes: A Multigroup Latent Transition Analysis.

Multiple behavior change interventions have gained traction in the behavioral health space. Yet, previous studies on health coaching (HC) focused on testing its effect on stages of change for individual health behaviors. The purpose of this study was to examine the effects of HC on stages of change across multiple health behavior domains among patients at high risk of coronary heart disease and type 2 diabetes. This secondary analysis of a randomized clinical trial included 200 primary care patients (mean age of 47.7 years, 49.0% women, 60.5% Whites) who completed transtheoretical model-based questionnaires related to weight reduction, exercise, healthier eating, and stress management. Multigroup latent transition analysis was used to compare the stage of change distributions and transitions over time between HC and controls at baseline, midpoint of the intervention (3 months), and postintervention (6 months). Three distinct categories of behavior change were identified ("Contemplation," "Preparation to Action," and "Action"), and membership in these categories changed over time as a function of intervention exposure. Both groups exhibited positive transitions through stages of change from baseline to 3 months. Pronounced intervention effects emerged from 3 to 6 months, revealing larger differences in transition probabilities between the groups. In particular, HC increased patients' likelihood of transitioning from "Contemplation" to both "Preparation for Action" and "Action," as well as from "Preparation for Action" to "Action." The control group remained stagnant during the same period. Although HC produces changes across multiple behavioral domains, it was most effective for patients who were reluctant or ambivalent about changing their behaviors.

03 Best practice for transition from paediatric complex pain care: A scoping review

Abstract Background Many adolescent and young adults (AYA) experiencing chronic pain often continue to have pain in adulthood and thus must make the transition from paediatric care to adult care. Persistent pain and disability due to chronic pain throughout young adulthood can disrupt the attainment of important developmental milestones at transition to adulthood that impact quality of life. Inadequate transition planning may be associated with poor health outcomes and increased health utilization. However, only few studies have described the specific transition protocol from paediatric to adult care that AYA with chronic pain must make. Objectives To improve understanding of transitional care needs during transition planning and after transition (quality of care), this paper will determine known barriers to successful transition from paediatric chronic pain care to adult care as well as factors associated with successful transition from paediatric multidisciplinary paediatric chronic pain care, identify patient care needs at transition from paediatric chronic pain care, and finally describe the best practice (existing frameworks) to support youth at transition from paediatric chronic pain care. Design/Methods This scoping review used previously published Arksey and O’Malley framework and followed the PRISMA guidelines. It sought to answer the following questions. What are the barriers to successful transition and what factors are associated with successful transition from paediatric chronic pain care to adult care? What are patient care needs at transition from paediatric chronic pain care? How can we best support youth at transition from interdisciplinary paediatric chronic pain care? A literature search was carried on Ovid Medline and 12 studies (11 research articles and 1 dissertation) published from 2015 to 2022 were included in the review, with only one theoretical transition framework that may be useful in the Canadian healthcare setting. Results In this scoping review, interpersonal, organizational, and systemic barriers and enablers for successful transition were identified. The most frequently identified barriers to successful transition include lack of self-efficacy, trust, communication, coordination of care between paediatric and adult care. A need of early transition, an individualized approach, fluid and dynamic transition process, and age-appropriate resources were identified as primary patient care needs during transition. Four frameworks supporting transitional care for AYA with chronic health conditions were identified. Conclusion Limited evidence suggests that there is lack of standardized transition protocol for clinical use. There is an urgent need for an evidence-based transition tools for clinical use for AYA with chronic pain.

Interaction of Val66Met Brain-Derived Neurotrophic Factor and 5-HTTLPR Serotonin Transporter Gene Polymorphisms with Lifetime Prevalence of Post-Traumatic Stress Disorder in Primary Care Patients

Background/Objectives: Post-traumatic stress disorder (PTSD) is a complex condition influenced by both genetic and environmental factors. This longitudinal study aimed to explore the connection between two specific genetic polymorphisms, Val66Met and 5-HTTLPR, and the lifetime prevalence of PTSD in patients from primary care settings. We also examined the role of sociodemographic and psychosocial factors to provide a more comprehensive view of PTSD risk. Methods: We recruited a cohort of primary care patients and diagnosed PTSD using a standardized diagnostic interview. Genetic analyses focused on Val66Met and 5-HTTLPR polymorphisms. We applied logistic regression to assess the association between these genetic markers and PTSD, considering factors such as gender, family history of depression, and experiences of childhood maltreatment. Results: Our findings show that women, individuals with a family history of depression, and those exposed to childhood maltreatment have a higher risk of developing PTSD. While the Val66Met polymorphism was not significantly associated with PTSD, the 5-HTTLPR polymorphism showed a marginal relationship. No significant interaction was found between the two polymorphisms in relation to PTSD. Conclusions: This study underscores the multifactorial nature of PTSD, influenced by both genetic and environmental factors. The findings point to the importance of further research on genetic predispositions and highlight the value of early interventions for high-risk populations in primary care settings.