Primary Care Physicians Research Articles

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.

Chronic kidney disease in patients with heart failure in German primary care practices: the InspeCKD study

Abstract Background Chronic kidney disease (CKD) is, alongside type 2 diabetes mellitus, the most common comorbidity in patients with heart failure (HF), with a prevalence of 40-50%. HF patients should therefore be screened, monitored, and treated according to international Kidney Disease Improving Global Outcomes (KDIGO) conclusions for early identification and intervention of CKD, with annual determination of eGFR to monitor kidney function and annual urine albumin-to-creatinine ratio (UACR) testing as appropriate. Early diagnosis is important as therapeutic options can be offered to slow the progression of CKD and reduce the risk of cardiovascular complications and mortality. Purpose Currently, there are only limited data available regarding screening, diagnosis and treatment of CKD for HF patients in German primary care physician (PCP) practices. Therefore, this analysis of the InspeCKD study was designed to examine the frequency of use of CKD-specific laboratory diagnostics in HF patients in routine PCP care. Methods In the current data analysis, fully anonymized patient data from German PCP practices were evaluated. In accordance with the screening recommendation of the KDIGO guideline, adult patients with diabetes, hypertension and/or cardiovascular disease, including HF, with at least one year of observation period were included in the analysis. Results The overall patient cohort comprised 448.837 patients from 1.244 German PCP practices. Of the 7.9% HF patients, 6.1% participated in a disease management program (DMP) for coronary heart disease. The average age of HF patients was 74 years. The prevalence of diagnosed CKD in HF patients during the observational period (mean: 1.7 years) was 26.8%. Within the subgroup of patients with HF, serum creatinine to estimate GFR was measured at least once in 48.5% of patients. Urine dipstick testing for albuminuria was performed in 7.4% of patients and UACR was measured at least once in 0.3% of patients. In patients with at least one documented measurement, eGFR and UACR were checked 2.2 and 0.9 times, respectively, per patient and year. Of the HF patients with laboratory-confirmed CKD according to KDIGO criteria, 81.8% were not diagnosed with CKD. Conclusion The analysis shows that, given the high prevalence of CKD in HF patients and the current KDIGO recommendations for early identification and intervention of CKD, a substantial proportion of HF patients in German PCP practices did not receive adequate laboratory diagnostics for early diagnosis of CKD. In addition, the majority of patients with laboratory-confirmed CKD were not diagnosed. Early detection of CKD and the use of evidence-based therapeutic options can significantly reduce the risk of CKD progression. In conclusion, there is an urgent need to raise awareness among PCPs about secondary and tertiary prevention of CKD in patients with HF and to include coordinated CKD screening recommendations in HF guidelines.

Monitoring the digital healthcare transition in Italy: Initiatives, metrics and feedback from Primary Care Physicians

Abstract Italy’s healthcare sector has undergone significant digital transformation since 2008, driven by national strategies and reforms overseen by the Ministry of Health, the Ministry of Economy and Finance, and the Agency for Digital Italy. Key initiatives include the establishment of centralized booking systems, electronic health records (EHR), ePrescription, dematerialization of medical reports and disease certificates, patient summary, and telemedicine services. Despite regional variations, progress in the EHR adoption has been notable. Ongoing investments under the 2021 National Recovery Plan aim to further enhance digital healthcare infrastructure by 2025 through the involvement of the Italian National Agency for Regional Healthcare Services (AGENAS). Currently, Italy monitors progress through comprehensive measurement frameworks tracking digital health initiatives’ implementation and impact. These encompass indicators reported quarterly by public healthcare facilities regarding the implementation of patient portals, regional registries, network infrastructure, regional EHR systems (i.e., n° of users), and digital laboratory reports. In parallel, we conducted a cross-sectional survey assessing knowledge, opinions and concerns among primary care physicians (PCPs) following the 2022 reform, which introduced Community Hospitals, Community Houses, and telemedicine in primary care. The survey highlighted mixed opinions and insufficient knowledge among PCPs regarding the novelties. Clearer communication and coordination with territorial services appears necessary. Many GPs are engaging in telemedicine, but digital literacy gaps remain, as only 35.7% believed they had necessary digital literacy. This is an insight into Italy’s digital health roadmap, mainly involving primary care and focusing on achievements, challenges, and future prospects in utilizing digital solutions across healthcare settings.

Barriers and facilitators to remote healthcare services use: perspectives of women and providers

Abstract Background The remote health services (RHS) proliferation raises concerns regarding relatively low use among minorities. Arab women in Israel belong to a minority that experiences health disparities, stigmatization, social and economic marginalization. This study aimed to identify barriers and facilitating means to RHS use relevant to Arab women in Israel from the perspective of women, primary care physicians (PCPs), and nurses. Methods Semi-structured interviews were conducted with 25 Arab women, 18 PCPs, and 4 nurses from different parts in Israel between December 2023-March 2024. We used a positive deviance approach by interviewing 14 women who succeeded in using RHS and 11 who did not. Interviews were audiotaped, transcribed, and thematically analyzed using Atlas qualitative analysis software. Findings The data distilled three main barriers to RHS use: sociocultural- importance of close relations with PCPs, privacy concerns of revealing the body or conversing with unfamiliar physicians, strict supervision by the family (Bedouin society); logistical-limited internet access and infrastructure, personal- unawareness to RHS, digital literacy, normative conceptions of limited quality of care and believing that only some health conditions are suitable for RHS. Facilitating means to RHS use: gender roles-women’s role as family health caretakers, mothers maintaining work-family balance and younger women generation feeling responsible for the older generation RHS adoption, accessibility- wider access to care due to limited transportation. Conclusions It is important to identify facilitating conditions (e.g., training opportunities, social, technological support), cultured elements (gender roles, limited mobility), and trust to adopting RHS by minority populations. The study provide data for developing requirements to ensure more equitable access to RHS to Arab women including addressing privacy concerns, guidelines for RHS-related information dissemination, and for RHS providers. Key messages • The findings help develop approaches and means to improve RHS use for Arab women from diverse backgrounds by identifying barriers associated with access, culture, and normative conceptions. • Developing RHS systems into routine care must ensure equitable use across social groups and address economic, logistical, and sociocultural barriers and guidelines for RHS information dissemination.

Multidisciplinary management of gastroesophageal reflux disease: an italian retrospective study

Abstract Background Millions of individuals are affected by gastroesophageal reflux disease (GERD) that causes significant discomfort negatively affecting patients’ overall quality of life. For a collaborative approach of continuous improvement in public health we wanted to know the real-world perspectives in the multidisciplinary and multimodal management pathway. Methods We aimed to interview a sample of gastroenterologists (GE), primary care physicians (GP), and otolaryngologists (ENT) to investigate the management of the intake and treatment of patients reporting symptoms of GERD. Symptoms were divided into typical and extraesophageal, and their severity and impact on quality of life was explored with the GERD Impact Scale (GSI) and Reflux Symptom Index (RSI). Results A total of 6211 patients were analyzed of whom with typical symptoms were 53.5%, while those with extraesophageal symptoms were 46.5%. The latter were more frequently reported by ENT patients (53.6%, p < 0.0001). GSI was highest in patients followed by GE (9 points) and GP (9 points) than ENT specialists (8 points), while the RSI was higher in the ENT group (14.3 ± 6.93) than in the groups of GP and GE, respectively (10.36 ± 6.36 and 10.81 ± 7.30, p < 0.0001). Chest pain had the greatest negative impact on quality of life (p < 0.0001). Of the 3,025 patients who used (proton pump inhibitors) PPIs, non-responders had a lower GSI when treated with a combination of adjunctive drug treatments and bioadhesive compounds, compared with single-component drugs. Conclusions The multidisciplinary and multimodal approach to the management pathway of GERD patients reveals variations in patient profiles by physician specialty, directing toward more appropriate and targeted treatments. In addition, the combination of adjunctive drug treatments and bioadhesive compounds appears to be effective in the management of patients refractory to PPIs. Key messages • The presentation of GERD symptoms is different in accordance with the physician’s speciality: the patients with GERD referred to a gastroenterologist had more severe disease and poorer quality of life. • The combination of adjunctive pharmacological treatments and bioadhesive compounds seems to be effective in the management of PPI refractory patients.

Primary clinics achieving regular follow-up of patients: Teamwork aspects among healthcare staff

Abstract Backgrounds Studies have shown that more temporally regular primary care visits, or visits more evenly spaced in time, are associated with improved patient outcomes. However, no study has examined what clinic staff can do to encourage greater temporal regularity (TR). We aimed to understand factors related to healthcare staff dynamics that contribute to higher TR for adults with chronic conditions. Methods The study is part of a two-stage mixed methods project. In the first stage, we ranked clinics according to their TR level. In this qualitative stage, we interviewed staff at 6 clinics with extremely high TR (regular follow-up with primary care physician, or PCP), and 6 clinics with extremely low TR. Interviews were conducted with 15 PCPs, 12 nurses, 15 administrative staff, and 4 pharmacists between July 2022- September 2023. Interviews were audiotaped, transcribed, and analyzed using Atlas qualitative analysis software. Findings Themes emerged regarding best ways to promote regular follow-up of patients with chronic conditions. Strategies included having a defined system to reach out to no-show patients, having routine staff meetings to discuss no-shows, adapting workflow to meet the needs of challenging patients, dealing with bureaucracy on patients’ behalf, informal channels of communication with patients, and consulting social workers more often. Relational aspects among staff members at high TR clinics emphasized flat as opposed to hierarchical relationships, as well as high levels of teamwork. Conclusions Teamwork between staff members in primary care settings can contribute to more proactive care delivery, with greater potential to prevent long-term complications. The findings suggest that a high-functioning multidisciplinary care team that focuses on creating the right sorts of interactions and teamwork among staff members, and uses proactive strategies to help engage patients, can contribute to more temporally regular care and thus improved outcomes. Key messages • Stronger teamwork and flat relationships between staff members in primary care settings can result in proactive medicine and developing strategies that improve patients’ regular follow-ups. • Programs focusing on how medical staff utilize their dynamics/relations to improve health outcomes and how doctors’ role align with the staff, can facilitate regular follow-ups of challenging patients.

The state of primary health care systems in ten high-income countries

Abstract Primary care systems in high-income countries perform comparatively better than the U.S. system in large part due to decades of investment, an adequate workforce supply, and universal healthcare. This research identifies successes and areas of improvement of 10 high-performing primary care systems in four areas of care: 1) access, 2) continuity, 3) comprehensiveness, 4) and coordination. Cross-national comparisons using primary data from the 2022 CMWF International Health Policy Survey of Primary Care Physicians (N ranged from 321-2,092) and the 2023 CMWF International Health Policy Survey on the General Population (N ranged from 750-4,820). Countries included: Australia, Canada, France, Germany, Netherlands, New Zealand, Sweden, Switzerland, the U.K., and the U.S. • More than 90% of adults in all surveyed countries reported having a regular primary care doctor except Sweden, the U.S., and Canada. • Less than 5% of physicians reported high telehealth use in their patient encounters, except for in the U.K. and New Zealand where over 10% reported high use. • Over a quarter of physicians in the U.S., Germany, and France report screening patients for social needs, compared to just 8% in the Netherlands. • Care coordination with social services was a major challenge in all surveyed countries, with over 75% of physicians in the U.K., Australia, and France reporting major challenges. Primary care systems in 10 other high-income countries outperform the U.S. system, particularly when it comes to access to care and care continuity. Policy options to consider for U.S. policymakers include narrowing the wage gap between generalist and specialist physicians and rewarding and holding providers accountable for continuity of care. On the other hand, countries like Sweden and the Netherlands can learn from the U.S. on how to adequately coordinate care between primary care physicians, specialists, and hospitals. Key messages • Investment in primary care yields better health outcomes, greater equity and lower costs. • Many high-income countries in Europe have high performing primary care systems, something the U.S. system can learn from.

Time taken for cardiology care and one-year results for primary care physicians' referrals for cardiology consultation in heart failure patients: clinical implications for heart failure management

Abstract Background and Purpose The clinical trajectory of patients with heart failure (HF) is characterised by frequent episodes of decompensation requiring urgent medical assistance, hospitalisations, and an increased risk of mortality. HF clinical guidelines recommend early visits by health professionals after hospital discharge, yet little evidence exists regarding the associations between delayed medical attention and outcomes in HF patients. To assess the clinical impact of the time taken to receive cardiology care for referrals from primary care physicians (PCPs) to a cardiology department in HF patients, we selected 6,859 HF patients who visited the cardiology service at least once between 2010 and 2021. Methods Using an interrupted time series regression model, we analysed the impact of integrating e-consultations into the healthcare model (implemented in 2013) and evaluated the time taken to receive cardiology care, as well as all-cause, cardiovascular (CV), and HF-related hospital admissions and mortality. The primary objective of this analysis was to examine the associations between delays in cardiology care following a PCP referral and 1-year outcomes (HF-related, cardiovascular, and total hospitalisations; and HF-related, cardiovascular, and total mortality). Results Almost 50% were women, and the mean age was 77.8 years. Arterial hypertension (79.6%), diabetes (34%), atrial fibrillation (51.4%), ischemic heart disease (20.4%), and cerebrovascular disease were the most prevalent comorbidities. The mean time from PCP referral to cardiology consultation in the overall population was 22.3 days: <8 days in 53.9%, 8-14 days in 17.1%, 15-30 days in 15.9%, and >30 days in 13.0% of patients, respectively. One year after cardiology consultation, 68.6% of patients required assistance in an Emergency Department; 22.5% were hospitalised for any cause, 14.9% for cardiovascular reasons, and 9.2% for HF-related issues. Moreover, total mortality at 1-year was 8.6%, comprising 4.3% cardiovascular mortality and 1.3% HF-related deaths. Multivariate analysis of the relationship between the time taken to receive cardiology care and 1-year outcomes revealed a significant increased risk associated with a longer delay in cardiology assistance, particularly evident in the subgroup of patients with previous hospital admissions due to worsening HF (see Table). Conclusions Throughout the follow-up period, a reduced time taken to receive care was independently associated with better 1-year outcomes. We believe that our experience can contribute to the development of a more efficient ambulatory care pathway for HF patients, especially those at high risk, such as those with a history of hospitalisation due to worsening events. Our findings further support the clinical guideline recommendation for early contact by health professionals following hospital discharge, extending it to include PCP referrals for cardiology consultations.

Decision support systems as supporters of clinical work: perspectives from physicians in Finland

Abstract Background The digitalisation of healthcare has changed physicians’ clinical and administrative work. For example, decision support systems (DSSs) are expected to support physicians’ daily work. The present study examined physicians’ experiences of DSSs’ support for their work analysed by age, gender, employment sector and leadership position. Methods Altogether 4630 physicians (64% women) from Finland responded to the online survey. Logistic regression analyses were conducted to examine the associations of age, gender, employment sector, and leadership position with experiences of DSSs’ support for their work. Results Of the respondents, 21.3 % agreed that DSSs supported their work, whereas 43.5 % were neutral and 35.2 % disagreed with the statement. Age (Wald’s F = 15.5, p = 0.001), employment sector (Wald’s F = 84.6, p < 0.001), and leadership position (Wald’s F = 16.3, p < 0.001) were significantly associated with the assesment, whereas gender was not. Those aged between 45 and 54 (OR 0.65, 95% CI 0.51-0.81) and between 55 and 64 (OR 0.74, 95% CI 0.59-0.93) had lower odds for agreeing compared to those aged 35 or under. Compared to physicians in hospitals, primary care physicians had 2.18 times (95%CI=1.84-2.59) greater odds for agreeing that DSSs support their work. Those who were in leadership positions had 1.50 times (95%CI=1.23-1.82) greater odds for agreeing compared to those not in leadership positions. Conclusions Finnish physicians did not experience DSSs supporting their work. Especially older physicians, hospital physicians and those not in leadership positions gave negative assessments. DSSs should be better integrated to physician workflow, it is also possible that usability problems of DSSs such as alert fatigue affected user experiences. More attention should be paid to developing DSSs in a way that they support physicians work better. Key messages • Finnish physicians did not experience that decision support systems would actually support their work. • Especially older physicians, hospital physicians and those not in leadership positions did not agree that decision support systems would support their work.

Mortality and survival rate in a scottish cohort of adults with congenital heart disease

Abstract Background Adult patients with congenital heart disease (ACHD) experience higher rates of morbidity and reduced long-term survival in comparison to the general population. The care of this cohort of patients requires specialist expertise which is mainly delivered at tertiary centers. Aims We aim to report the clinical characteristics, mortality rates and causes of death in a contemporary cohort of ACHD patients followed up in a North- East Scottish Health Board. Methods We prospectively followed up ACHD patients aged ≥17 years (n=645) under review at the Regional NHS ACHD Clinic in a North- East Scottish Health Board between the years 2020 and 2023. We recorded the number and the causes of death as documented on our electronic records and on correspondence with primary care physicians. Survival analysis was performed according to the 2020 ESC Guidelines classification of congenital heart disease complexity (Table 4) classes using Kaplan-Meier method with log-rank (Mantel-Cox) test done in IBM SPSS v.24. Results Our ACHD cohort (n=645, 54% females and 46% males) included patients of all three ESC complexity classes (30% mild, 60% moderate and 10% severe). Between 2020 and 2023, 18 patients (2.8%) died, with a total incidence of 0.93 deaths/100 patient years. Median age of death was 59 years (IQR 45–71), and the majority of deceased patients were males (56%). There were 2 deaths in the mild complexity group, 11 deaths in the moderate complexity group and 5 deaths in the severe complexity group (See Table 1). This was found to correspond to an incidence of 0.34, 0.95 and 2.64 deaths/100 patient years respectively. The leading causes of death were heart failure (28%) and malignancy (22%). Using Kaplan-Meier survival analysis we found that the survival distributions for the mild, moderate and severe ACHD complexity groups were statistically significantly different by log-rank test (χ2(2) = 11.47, p < .005) (See Figure 1). Patients with moderate ACHD complexity had a median survival age 67 years (95% CI 58.1-75.9), patients with severe ACHD had median survival age 57 years (95% CI 44.7-69.2). Median survival could not be calculated for the mild group due to lack of data points. Conclusion The ACHD patient group is characterised for a variety of pathophysiology and clinical presentations. They require lifelong medical input and in spite of the local and national expertise, the mortality and morbidity rates are still high. Heart failure was the leading cause of death in this cohort which is similar to previous reported data. Mortality rates were proportional to the complexity of the underlying ACHD diagnosis. The survival rate of patients in the severe complexity group was ten years less than the moderate complex group. ACHD patients in the moderate and severe complexity groups have significantly reduced life expectancy and require access and clinical expertise from National ACHD Specialty Centers.

Electronic consultation from primary care to a cardiology department improves outcomes in patients with cancer

Abstract Background The number of cancer patients with known cardiovascular (CV) disease is increasing due to improved cancer prognosis. Purpose The objective of this study is to assess the long-term results of cancer patients referred to a cardiology department by primary care using electronic consultation (e-consultation). Methods We analysed the patients with previous diagnosis of cancer referred to a cardiology department (CD) from 2010 to 2021 (n=6.889), selected from a total of 68.518 patients (61.629 without cancer), and compared two assistance models: in-person practice (from 2010 to 2012) and e-consultation (from 2013 to 2021). In the first period, all the patients referred by primary care physicians (PCPs) were seen in an in-person consultation and in the e-consultation model the cardiologist reviewed the electronic records (e-consultation) and decided to solve without any visit or, if it was necessary, with an in-person consultation. The outcomes between both periods were analysed using an interrupted time series regression model: 1) delay time to cardiology assistance; 2) all-cause and cardiovascular hospital admissions, and 3) all-cause and cardiovascular mortality during the first year after the initial consultation or e-consultation to the CD. Results Among cancer patients referred to cardiology consultation, the introduction of e-consultation decreased waiting times to cardiology care by 51,8% (95% CI: 51,7%-51,9%) (Fig 1). Over 60% of referrals were resolved in less than 8 days, with this proportion significantly higher after the e-consultation program was introduced (p<0,001). Furthermore, we observed a reduction in the one-year rate of outcomes, with an incidence rate ratio (iRR) [IC 95%] of 0,75 [0,73-0,77] for CV-related hospitalizations (Fig 2b), 0,43 [0,42-0,44] for all-cause hospitalization (Fig 2a), and 0,87 [0,86-0,88] for all-cause mortality. In the multivariate analysis, the delay in receiving cardiology care was significantly associated with an independent increase in 1-year mortality (OR [95% CI] 1,39 [1,06-1,83]) and hospital admission (OR [95% CI] 1,25 [1,02-1,52]). Furthermore, the implementation of the e-consult model was associated with a reduction in hospital admission rates (OR [95% CI] 0,19 [0,14-0,25]). Conclusions In comparison to the in-person consultation period, an outpatient care program that incorporates e-consultation for cancer patients significantly reduced waiting times for cardiology care and shown to be safe, associated with lower rates of hospital admissions.Figure 1Figure 2

Chronic Illness and visiting clinic before hospitalization at the onset of Stroke: Shiga Registry

Abstract Background Prompt action at stroke onset is required to improve prognosis. Some previous studies indicated that visiting local clinics may initially delay access to specialized care. We examined the relationship between the presence of chronic diseases known as risk factors for stroke and visiting a local clinic before admission to the hospital for acute stroke care. Methods This study utilized data from stroke patients aged 18 and older who were registered in the Shiga Stroke and Heart Attack Registry (SSHR) from January 2011 to December 2015. We excluded cases with onset during hospitalization or those with impaired consciousness assessed by the Japan Coma Scale (JCS > =10). The presence of comorbid chronic diseases was determined based on the past history and medications presented at admission. Local clinics are defined as clinics or hospitals that are not equipped to provide acute stroke treatment. Multivariate logistic regression analyses, adjusting for sex, age, modified Rankin Scale score before onset, and stroke subtypes, were performed to calculate odds ratios and 95% confidence intervals for visiting a clinic before hospitalization according to the presence of chronic diseases such as hypertension, diabetes, dyslipidemia, and atrial fibrillation, respectively. Results Data from 11,111 out of 14,620 registered cases were analyzed. Among these participants, 5,774 had hypertension, 1,951 had diabetes, 2,111 had dyslipidemia, and 882 had atrial fibrillation. A total of 2,405 (21.6%) cases visited a local clinic at stroke on set. The adjusted odds ratios for visiting clinics by the presence of hypertension were (1.22, 95% CI: 1.11 -1.34), diabetes (1.14, 1.01-1.28), dyslipidemia (1.07, 0.95 -1.20), and atrial fibrillation (0.80, 0.67 -0.95). Conclusions The present study indicated that individuals with hypertension and/or diabetes are more likely to initially visit a local clinic at stroke onset, whereas those with atrial fibrillation were not. Key messages • Approximately 20% of mild stroke patients first consult local or primary care doctors at stroke onset. This trend was particularly observed in individuals with hypertension and diabetes. • Emphasizing the need for direct access to specialized emergency care for individuals with chronic diseases is important to avoid delays in acute stroke care.

Clinical coordination in cancer diagnosis: healthcare stakeholders’ viewpoints in Latin America

Abstract Background Delays in diagnosis contribute to increasing cancer mortality rates in Latin American countries due to, among others, highly fragmented healthcare systems. The objective of this study, part of a larger research project (EquityCancer-LA), was to analyze cross-level coordination during cancer diagnosis and factors influencing it from healthcare stakeholders’ perspectives in Chile, Colombia, and Ecuador. Methods This descriptive-interpretative qualitative study was based on 114 semi-structured individual interviews in 2022-23 using a criterion sample of health professionals from primary care (PC) (n = 40) and secondary care (SC) (n = 44) as well as managers and policy makers (n = 30) from two public healthcare networks in each country. Sample reached saturation. A thematic analysis was conducted first by country and then comparatively, guided by the theoretical framework of clinical coordination. Results In all countries, informants highlighted limited cross-level exchange of information and limited coordination of clinical management, delays in referral, and long waiting times after referral, leading to diagnostic delays. Factors hindering coordination differed across countries: structural (insufficient personnel, access to diagnostic tests in PC); organizational (limited/inadequate coordination mechanisms, e.g. shared clinical records; poor working conditions); and health professional characteristics (limited knowledge and skills among PC doctors). Direct feedback was emphasized to facilitate coordination of cancer diagnosis: virtual joint clinical conferences in Chile, co-location of PC and SC in Colombia, and informal networks (based on personal contacts) in Ecuador. Conclusions The findings underscore the critical coordination problems contributing to delays in cancer diagnosis. Addressing these challenges requires strategic interventions aimed at strengthening primary care and fostering cross-level coordination. Key messages • Cancer diagnosis in Latin America suffers from coordination deficits due to structural, organizational, and professional factors. • Strengthening primary care and cross-level coordination is needed.

Medicare Transitional Care Management Service Association with Readmissions and Mortality

Abstract In 2013 CMS introduced codes to reimburse outpatient providers for post-discharge Transitional Care Management (TCM). Understanding the implications of TCM reimbursement on outcomes is crucial for evaluating CMS’s investment and guiding future policy. We analyzed the association between physician organization (PO) TCM code use and post-discharge readmissions and mortality using 100% fee-for-service Medicare claims. Employing a difference-in-differences approach we compared 1131 “high-TCM” POs (top quartile of TCM code use from 2015-2017) to 1133 “low-TCM” POs (bottom quartile) from before (2012) and after (2015-2017) TCM code implementation, controlling for PO and beneficiary attributes and readmission risk. TCM code use was associated with decreased 30- and 90-day readmissions [-0.31 (95%CI -0.52, -0.09) and -0.42 (95%CI -0.71, -0.14) percentage points, respectively], but no significant difference in mortality. Year-by-year, 2017 saw greatest readmission reduction, with a slight mortality reduction in that year only. Readmission reductions were greatest in POs not affiliated with health systems, Accountable Care Organizations (ACOs), or academic medical centers, and least in those with fewer primary care physicians. Narrow, indirect interventions like fee-for-service TCM billing code reimbursement may have limited potential to improve post-discharge outcomes overall. However, small independent practices may derive somewhat greater benefit from this support for post-discharge care.

Real world data after the implementation of coronary computed tomography angiography in Swedish primary care to rule out coronary artery disease, a cross-sectional study based on pre-test probability

Abstract Background In primary care, most patients with of non-acute chest pain will neither receive a heart related diagnosis nor be referred to a cardiologist. Studies indicate a better cardiovascular prognosis in chest pain patients referred to Coronary Computed Tomography Angiography (CCTA) as compared to risk stratification solely based on risk prediction instruments(1). CCTA is recommended since 2019 for low to intermediate cardiovascular (CV) risk patients(2). In the study setting, the primary care has implemented CCTA as first line test for patients with suspected obstructive coronary artery disease (CAD) and a Pre-Test Probability (PTP) of <15% and any CV risk factor, with PTP mandatorily entered in the referral letters. Purpose To study the outcome of CCTA based on referred PTP values categorised into <5%, 5-15% and >15%. We hypothesized that the presence of significant stenosis would be on par with the mean PTP. Methods In this cross-sectional retrospective cohort study, all consecutive clinical referrals for a CCTA from primary health care centres with a catchment area of ~470 000 inhabitants in the country of Sweden between 1 June 2021 and 7 Dec. 2022, with PTP estimates and completed CCTA were included. CCTA findings were stratified as normal, atheromatosis, or significant stenosis (≥50% coronary lumen obstruction). Patient baseline characteristics routinely registered on the day of CCTA was retrieved from a nationwide quality registry, SWEDEHEART(3). Pearsons’s Chi2 and one-way ANOVA was used to test differences in group distributions. Results During the study period, 381 patients with a PTP had obtained CCTA, of which 75% (n=286) had PTP <15%. The mean age was 60 years (standard deviation [SD] 11), 70% were female, 30% were prescribed lipid-lowering medication and 47% anti-hypertensives (Table 1). In total, the mean PTP was 12.4% (SD 8.7) and in 18% a suspected significant stenosis was identified. (Figure 1). Among patients referred with PTP 5-15%, the presence of suspected significant stenosis was 12% and cardiology consultation was less frequently described than for PTP <5 or ≥15% (14% vs 33% vs 44%, p < 0.001). Conclusions This study indicates that PTP is an efficient means to select patients for CCTA in primary care. In total, about 1/5 had a suspected significant stenosis, which often requires further investigations, and about 4/5 could be reassured that symptoms were not due to coronary artery disease. In 31% atheromatosis was identified, potentially facilitating counselling on CV prevention. We conclude that CCTA is a clinically effective option for primary care physicians to rule out CAD in patients with low PTP.Figure 1Table 1

The evaluation of an eHealth tool to prevent and alleviate migraine complaints in adults

Abstract Background Migraines attacks cause great suffering in individual patients. There is great unfulfilled potential to increase patients’ knowledge about various personal triggers and subsequent treatments. The objective of this study is to pilot test an e-Health tool that aims to increase migraine patients’ knowledge. It takes into account personal preferences and contributes to informed decision-making in choosing the appropriate method. Considering the shortage of primary care physicians and other health care providers, such an e-Health tool could be of great value. Methods lessmigraine.nl consists of a website with information plus an electronic decision aid. It was evaluated on its content, development process and effectiveness, and its contribution to the patients’ empowerment process. A first round of usability testing was done using semi-structured interviews and thematic analysis with 12 patients from a Dutch General Practice until data saturation. After minor improvements to the e-tool, in a first implementation step subsequently 85 patients used the e-tool. Results Patients’ expectations were exceeded in terms of the content of the e-Health tool, as all patients discovered new potential migraine triggers. Most patients found the tool effective in the sense that it provided enough information to decide on an appropriate treatment. The implementation was successful in the sense that all 85 participants completed the e-tool. Most important triggers were stress, sleeping problems, changes in weather and flickering or bright light. Conclusions The majority of the migraine patients were satisfied with the e-Health tool. It enlarged their knowledge of prevention and treatment options and therefore empowered them in their decision-making process and communication with their GP. Other aspects of implementation need to be studied. This study needs to be repeated in other clinical settings. Key messages • Migraines cause great suffering in individual patients: Considering the shortage of primary care physicians and other health care providers, an e-Health tool could be of great value. • The e-Health tool increases patients’ knowledge about migraine, including personal triggers and subsequent treatments.

Remnant cholesterol and mortality in 37.559 patients from LIPIDOGRAM 2004, 2006 and 2015 studies

Abstract Introduction Remnant cholesterol (remnant-C) is produced by metabolism of triglyceride rich proteins and contributes to residual cardiovascular (CVD) risk. Purpose To asses association between remnant cholesterol and all-cause mortality in a large cohort of patients under the care primary care physicians. Methods The LIPIDOGRAM studies were carried out in the primary care in Poland in 2004, 2006 and 2015. Patients (n=47,398) recruited in all 16 administrative regions in Poland and physicians were proportionally distributed to the number of inhabitants in each administrative region. Each patient was asked to fill the questionnaire on risk factors, chronic diseases, treatment, and lifestyle. In the present analysis we included consecutive patients with body mass index (BMI) >18.5 kg/m2 aged 18-70 years. Median follow up was (5.3 years (interquartile range 5.7-17.3). For this analysis we approved the cut-off point of fasting remnant cholesterol >30 mg/dL (>0.77 mmol/L) that differentiated subjects at high risk of cardiovascular events. We used univariate and multivariate Cox regression modelling to assess the association between remnant-C and all-cause mortality. Results Finally, 37,559 patients were included meeting the inclusion criteria and for which the follow-up data was available. Mean remnant-C concentration was: 27 mg/dl / 0.7 mmol/l (standard deviation 15 mg/dl/ 0.38 mmol/l). Remnant-C was associated with 5-year mortality and overall mortality during the study period, with hazard ratios (HR) of 1.21 (95% CI: 1.04-1.41, p<0.001) and 1.42 (95% CI: 1.32-1.53, p<0.001) for each 1 mmol/l increase, respectively. After adjusting for age, sex, BMI, education level, place of residence, hypertension, diabetes mellitus, smoking, previous myocardial infarction, metabolic syndrome presence, and statin and fibrate treatments, remnant-C was associated with long-term mortality—HR (per 1 mmol/l) of 1.08 (95% CI: 1.00-1.17, p=0.049)—but not with 5-year mortality—HR (per 1 mmol/l) of 0.97 (95% CI: 0.83-1.13, p=0.7). Predefined level of remnant-C > 30 mg/dl (0.77 mmol/l) was associated with higher 5 year (HR- 1.15, 95%CI (1.02-1.31, p=0.021) (Figure 1A) and long-term all-cause mortality (HR- 1.26, 95%CI (1.19-1.33, p<0.001) (Figure 1B). Conclusions Higher remnant-C cholesterol levels are associated with long term all-cause mortality in patients aged 18-70 years.

Variability of pre-test probability for obstructive coronary artery disease between referring primary care physicians and estimations from the referral letters

Abstract Background Estimation of Pre-Test Probability (PTP) for obstructive Coronary Artery Disease (CAD), derived from sex, age and characterization of chest pain or dyspnea, is recommended by European guidelines to guide further investigation. When Coronary Computed Tomography Angiography (CCTA) was introduced as first line investigation in patients with PTP <15%, in the primary care of a catchment area of ~470 000 inhabitants in Sweden, attachment of PTP was made compulsory to the referral. The interrater variability, or consistency of agreement, of PTP estimation is not known. The validity of PTP to guide healthcare decisions depends to some extent on the reliability of estimations. Appropriate prioritization of invesigations is reliant on the information included in referral letters. Purpose The purpose was to study the interrater variability of estimations of PTP. We hypothesized: 1) the interrater variability of PTP estimations to be less than excellent (ICC < 0.9), and 2) not statistically different among PTP classes; 3) a significant difference between clinical estimations and estimations made from the referral letters. Methods We studied the 545 patients referred for CCTA from primary care, 1st of June 2021 to 7th of Dec. 2022, with available PTP estimations. The interrater variability, expressed as Intraclass Correlation Coefficients (ICC), was determined for estimations of PTP by the referring physicians (RP) and three external raters (ER). The latter were physicians practising in primary care who rated PTP based on the referral letters to CCTA, independently and blinded. Each rater assessed multiple patients and each patient was assessed by all raters. ICC with a two-way random consistency model for single raters was calculated and evaluated according to a proposed standard(1). Results The ICC for PTP estimations between the RP and the median of three ER was 0.75 (CI 95 % 0.71-0.83, p<0.001). ICC was higher for PTP class > 15% compared to the lower classes: <5% (n = 65, ICC ≈ 0); 5-15% (n = 343, ICC 0.48, CI 95 % [0.39-0.56]); >15% (n = 137, ICC 0.71, CI 95 % [0.62-0.78]) (Figure 1). The ICC for PTP estimations was significantly higher between the three ER (0.88, SE 0.009, CI 95% [0.86-0.89]) than when the RP was added as a rater (ICC 0.80, SE 0.012, CI 95 % [0.77-0.82]). Adding a fixed effect of the difference in ratings between RP and ERs to the ICC model did not change model output (R = 0.80 (SE 0.012, CI 95 % [0.77-0.82]). Conclusions There is a good repeatability, in estimation of PTP based on medical history as described in referral letters, between blinded independent reviewers of CCTA referrals. The repeatability between the external raters and the referring physicians’ compulsory entered PTPs is lower, yet good. The variability of PTP estimations, speculatively from disagreement on main symptom and inconsistency in characterization of chest pain, may impact patient selection and outcomes and is understudied.

EHealth profile and care coordination of primary care physicians

Abstract Background Digital health or eHealth is a vast field encompassing mobile health (mHealth), health information technology, wearable devices, telehealth, and telemedicine, and is changing the practice of medicine. While it holds promise for enhancing care coordination, its adoption is hindered by various barriers, including at the healthcare professional level. We assessed the eHealth profile of primary care physicians and its relationship with care coordination. Methods As part of the Commonwealth Fund 2022 IHP survey of primary care physicians, 1114 physicians in Switzerland completed a questionnaire on their digital health use, and care coordination practices. Based on their responses, we built a digital health score, summarizing physicians’ use of digital health tools, and a care coordination score. Associations between both scores were assessed using stratified analyses and multiple linear regression. Results Among 1114 participants (46% women, mean age 52), 83% used electronic patient records, 96% used teleconsultations for less than 5% of consultations, and 63% never used connected health tools for the monitoring of patients with chronic diseases. A total of 16% allowed for online appointments, 20% for online medical prescriptions, 52% for communicating electronically lists of medications with other healthcare professionals, and 89% the possibility of e-mail or web communications with the patient. The eHealth score was positively associated with the number of weekly working hours, being an internal medicine specialist or practicing physician, the number of full-time equivalents in the practice, and with being in a group practice setting. The higher the eHealth profile score, the higher was the care coordination score. Conclusions Physicians’ use of digital health tools was positively associated with care coordination. This could underscore the potential benefits of digital health in enhancing collaborative and interprofessional care practices. Key messages • In a large survey of primary care physicians, the use of digital health tools and care coordination were correlated. • Digital health could enhance collaborative and interprofessional care practices.

Remnant cholesterol, clinical characteristics and mortality in 41.767 patients from LIPIDOGRAM 2004-2015 studies - the factor analysis for mixed data cluster analysis

Abstract Introduction Remnant cholesterol (remnant-C) contributes to residual cardiovascular risk and is produced by metabolism of triglyceride rich proteins. Aim To assess association between clinical characteristics of patients with elevated remnant-C in a large cohort of patients under the care of primary care physicians. Methods The LIPIDOGRAM studies were carried out in the primary care in Poland in 2004, 2006 and 2015. Patients (n=47,398) recruited in all 16 administrative regions in Poland and physicians were proportionally distributed to the number of inhabitants in each administrative region. Each patient was asked to fill the questionnaire on risk factors, chronic diseases, treatment and lifestyle. In the present analysis we included patients with body mass index (BMI )>18.5 kg/m2 aged 18-75 years. We set the cut-off point of fasting remnant cholesterol at >30 mg/dL (>0.77 mmol/L) that differentiated subjects at high risk of cardiovascular events. We carried out Factor Analysis for Mixed Data (FAMD) cluster analysis to discern groups of patients with similar clinical profiles. Results 41,767 patients, for which we had all relevant data, were included in the analysis. Follow-up rate was 97.8%. Three FAMD-derived clinical characteristics patterns accounted for 47.8% of the total variance and were retained for further analysis. The first pattern was associated with higher prevalence of metabolic syndrome (MetS), higher waist circumference, higher levels of non-HDL-C and remnant-C levels. The second pattern was distinguished by lipid parameters, particularly higher HDL-C levels, and was not significantly associated with comorbid conditions. The third pattern was linked to male sex, previous myocardial infarction, smoking, age, lower remnant-C levels, and reduced prevalence of obesity. All patterns were associated with 5-year mortality. The hazard ratio (HR) for mortality per 1 standard deviation (SD) increase in the first pattern score was 1.18 (95% CI: 1.16-1.22, p<0.001). Patients with clinical characteristics corresponding to second pattern had more favorable outcome HR (per 1SD score increase) – 0.75, 95%CI (0.73-0.78, p<0.001). Patients in third cluster, similarly to patients in cluster 1 had increased mortality HR (per 1SD score) – 1.10, (95%CI:1.06-1.15, p <0.001). Higher (>0.77 mmol/l / 30 mg/dl) remnant-C cholesterol significantly contributed to classification of patients into first and third clusters. It was positively associated with first pattern (r=0.64, p<0.001), but negatively with the third pattern (r=0.39, p<0.001). Conclusions Elevated Remnant-C was associated with clinical pattern typical for metabolic syndrome. Interestingly, lower remnant-C levels in patients with comorbidities and more advanced age may not automatically be indicative of a better prognosis – this requires further investigation.Figure 1.Figure 2.