Primary Care Practice Settings Research Articles

The effectiveness of chronic disease management planning on self-management among patients with diabetes at general practice settings in Australia: a scoping review

BackgroundMedicare provides significant funding to improve, encourage and coordinate better practices in primary care. Medicare-rebated Chronic Disease Management (CDM) plans are a structured approach to managing chronic diseases in Australia. These chronic disease care plans are intended to be a vehicle to deliver guideline-based / evidence-based care.. However, recommended care is not always provided, and health outcomes are often not achieved. This scoping review aimed to identify the specific components of CDM plans that are most effective in promoting self-management, as well as the factors that may hinder or facilitate the implementation of these plans in general practice settings in Australia.MethodA comprehensive search was conducted using multiple electronic databases, considering inclusion and exclusion criteria. Two reviewers independently screened the titles and abstracts of the identified studies via Covidence, and the full texts of eligible studies were reviewed for inclusion. A data extraction template was developed based on the Cochrane Effective Practice and Organization of Care Group (EPOC) to classify the intervention methods and study outcomes. A narrative synthesis approach was used to summarize the findings of the included studies. The quality of the included studies was assessed using the JBI Critical Appraisal Checklist.ResultsSeventeen articles were included in the review for analysis and highlighted the effectiveness of CDM plans on improving patient self-management. The findings demonstrated that the implementation of CDM plans can have a positive impact on patient self-management. However, the current approach is geared towards providing care to patients, but there are limited opportunities for patients to engage in their care actively. Furthermore, the focus is often on achieving the outcomes outlined in the CDM plans, which may not necessarily align with the patient’s needs and preferences. The findings highlighted the significance of mutual obligations and responsibilities of team care for patients and healthcare professionals, interprofessional collaborative practice in primary care settings, and regular CDM plan reviews.ConclusionSelf-management support remains more aligned with a patient-centred collaboration approach and shared decision-making and is yet to be common practice. Identifying influential factors at different levels of patients, healthcare professionals, and services affecting patients’ self-management via CDM plans can be crucial to developing the plans.

Real-world utilization of guideline-directed genetic testing in inherited cardiovascular diseases.

Cardiovascular disease continues to be the leading cause of death globally. Clinical practice guidelines aimed at improving disease management and positively impacting major cardiac adverse events recommend genetic testing for inherited cardiovascular conditions such as dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), long QT syndrome (LQTS), hereditary amyloidosis, and familial hypercholesterolemia (FH); however, little is known about how consistently practitioners order genetic testing for these conditions in routine clinical practice. This study aimed to assess the adoption of guideline-directed genetic testing for patients diagnosed with DCM, HCM, LQTS, hereditary amyloidosis, or FH. This retrospective cohort study captured real-world evidence of genetic testing from ICD-9-CM and ICD-10-CM codes, procedure codes, and structured text fields of de-identified patient records in the Veradigm Health Insights Ambulatory EHR Research Database linked with insurance claims data. Data analysis was conducted using an automated electronic health record analysis engine. Patient records in the Veradigm database were sourced from more than 250,000 clinicians serving over 170 million patients in outpatient primary care and specialty practice settings in the United States and linked insurance claims data from public and private insurance providers. The primary outcome measure was evidence of genetic testing within six months of condition diagnosis. Between January 1, 2017, and December 31, 2021, 224,641 patients were newly diagnosed with DCM, HCM, LQTS, hereditary amyloidosis, or FH and included in this study. Substantial genetic testing care gaps were identified. Only a small percentage of patients newly diagnosed with DCM (827/101,919; 0.8%), HCM (253/15,507; 1.6%), LQTS (650/56,539; 1.2%), hereditary amyloidosis (62/1,026; 6.0%), or FH (718/49,650; 1.5%) received genetic testing. Genetic testing is underutilized across multiple inherited cardiovascular conditions. This real-world data analysis provides insights into the delivery of genomic healthcare in the United States and suggests genetic testing guidelines are rarely followed in practice.

A Narrative Review of Antibiotic Prescribing Practices in Primary Care Settings in South Africa and Potential Ways Forward to Reduce Antimicrobial Resistance.

There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators.

Comparison of Work Patterns Between Physicians and Advanced Practice Practitioners in Primary Care and Specialty Practice Settings

ImportanceDespite the increasing involvement of advanced practice practitioners (APPs; ie, nurse practitioners and physician assistants) in care delivery across specialties, the work patterns of APPs compared with physicians and how they are integrated into care teams have not been well characterized.ObjectiveTo characterize differences between physicians and APPs across specialty types related to days with appointments, visit types seen, and time spent using the electronic health record (EHR).Design, Setting, and ParticipantsThis nationwide, cross-sectional study used EHR data from physicians and APPs (ie, nurse practitioners and physician assistants) at all US institutions that used Epic Systems’ EHR between January and May 2021. Data analysis was performed from March 2022 to April 2023.Main Outcomes and MeasuresAppointment scheduling patterns, percentage of new and established and level of evaluation and management (E/M) visits, and EHR use metrics per day and week.ResultsThe sample consisted of 217 924 clinicians across 389 organizations, including 174 939 physicians and 42 985 APPs. Although primary care physicians were more likely than APPs to have more than 3 days per week with appointments (50 921 physicians [79.5%] vs 17 095 APPs [77.9%]), this trend was reversed for medical (38 645 physicians [64.8%] vs 8124 APPs [74.0%]) and surgical (24 155 physicians [47.1%] vs 5198 APPs [51.7%]) specialties. Medical and surgical specialty physicians saw 6.7 and 7.4 percentage points, respectively, more new patient visits than did their APP counterparts, whereas primary care physicians saw 2.8 percentage points fewer new patient visits than did APPs. Physicians saw a greater percentage of level 4 or 5 visits across all specialties. Medical and surgical physicians spent 34.3 and 45.8 fewer minutes per day, respectively, using the EHR than did APPs in their specialties, whereas primary care physicians spent 17.7 minutes per day more. These differences translated to primary care physicians spending 96.3 minutes more per week using the EHR than APPs, whereas medical and surgical physicians spent 149.9 and 140.7 fewer minutes, respectively, than did their APP counterparts.Conclusions and RelevanceThis cross-sectional, national study of clinicians found significant differences in visit and EHR patterns for physicians compared with APPs across specialty types. By underscoring the different current usage of physicians vs APPs across specialty types, this study helps place into context the work and visit patterns of physicians compared with APPs and serves as a foundation for evaluations of clinical outcomes and quality.

Implementation of an Evidence-Based Clinical Guideline for Depression Screening of the Adolescent

The evidence supports use of a depression screening tool to increase screening completion in the adolescent population. Clinical guidelines include use of the PHQ-9 in the adolescent population (ages 12–18). PHQ-9 screenings are currently lacking in this primary care setting. The aim of this Quality Improvement Project was to improve depression screening in a primary care practice setting located in a rural Appalachian health system. An educational offering with pretest and posttest surveys and a perceived competency scale are utilized. Focus is added to the process and guideline used to complete depression screening. As a result of the QI Project, posttest assessment of knowledge relating to educational offering increased, and use of the screening tool increased by 12.9%. The findings support the importance of education on primary care provider practice and depression screening of adolescents.

A hyperaldosteronism subtypes predictive model using ensemble learning

This study aimed to develop a machine-learning algorithm to diagnose aldosterone-producing adenoma (APA) for predicting APA probabilities. A retrospective cross-sectional analysis of the Japan Rare/Intractable Adrenal Diseases Study dataset was performed using the nationwide PA registry in Japan comprised of 41 centers. Patients treated between January 2006 and December 2019 were included. Forty-six features at screening and 13 features at confirmatory test were used for model development to calculate APA probability. Seven machine-learning programs were combined to develop the ensemble-learning model (ELM), which was externally validated. The strongest predictive factors for APA were serum potassium (s-K) at first visit, s-K after medication, plasma aldosterone concentration, aldosterone-to-renin ratio, and potassium supplementation dose. The average performance of the screening model had an AUC of 0.899; the confirmatory test model had an AUC of 0.913. In the external validation, the AUC was 0.964 in the screening model using an APA probability of 0.17. The clinical findings at screening predicted the diagnosis of APA with high accuracy. This novel algorithm can support the PA practice in primary care settings and prevent potentially curable APA patients from falling outside the PA diagnostic flowchart.

"We're Here to Take Care of Our Community": Lessons Learned From the U.S. Federal Health Center Covid-19 Vaccine Program.

Equitable access to vaccination is crucial to mitigating the disproportionate impact of Covid-19 on low-income communities and people of color in the United States. As primary care clinics for medically underserved patients, Federally Qualified Health Centers (FQHCs) emerged as a success story in the national effort to vaccinate the U.S. public against Covid-19. In February 2021, the Federal Health Center Covid-19 Vaccine Program began allocating vaccine supply directly to FQHCs in an effort to improve vaccine equity. This qualitative study documents how FQHCs in two states successfully mitigated barriers to vaccine access, responded to patient concerns about vaccination, and worked to maintain and grow community trust in a climate of uncertainty and fear during early vaccine roll-out to the general population. Using a socio-ecological model, we show how FQHCs intervened at multiple levels to advance vaccine equity, revealing valuable lessons for health promotion practice in primary care settings or underserved communities. Our findings provide descriptive context for existing quantitative evidence showing FQHCs' greater success in vaccinating people of color, and foreground valuable and innovative strategies for trustworthy health communication practices and equitable resource allocation to medically underserved patients and populations.

PS-C31-1: SIGNIFICANCE OF SCREENING AND DIAGNOSING PRIMARY ALDOSTERONISM (PA) IN GENERAL MEDICINE

Background: Primary aldosteronism (PA) is a frequent secondary hypertension that is more frequently associated with cerebrovascular disease than essential hypertension, and thus requires appropriate diagnosis and treatment. The Japan Endocrine Society has published the new guideline for the diagnosis and treatment of primary aldosteronism, following the change of aldosterone measurement system in 2021. In this presentation, we will discuss a case of PA experienced at a dental school hospital. Case 75 years old male Current medical history: He had been diagnosed as hypertensive more than 10 years ago and had been prescribed antihypertensive medication, but he had stopped taking it. When he visited an oral surgeon for a tooth extraction, hypertension was noted and he was referred to internal medicine. <Physical findings> Blood pressure: 208/120 mmHg, Pulse: 83/min, <Biochemistry> Cre 1.09 mg/dL, Na 139mEq/L, K 3.7mEq/L. <Endocrine metabolism> fT4 0.95ng/dL, TSH 2.58micro-IU/mL, Plasma renin activity: PRA (EIA method) 0.6ng/mL/hr, Plasma aldosterone concentration: PAC (CLEIA method) 130pg/mL. <Abdominal CT> There was a nodule on the right adrenal gland. <Progress and discussion> The patient had a high aldosterone-renin ratio: ARR = PAC/PRA = 130/0.6 = 217 at the time of initial examination, and PA was suspected. CT showed a nodule in the right adrenal gland, raising suspicion of unilateral disease. Because of the high basal plasma aldosterone level and low K level, we referred the patient to a specialized facility because we thought that if PA was confirmed by functional confirmation testing, the case could be aggressively localized and typed by adrenal vein sampling (AVS). In this presentation, we would like to discuss the significance of screening and diagnosis of PA in primary care and general practice settings such as dental school hospitals, based on the results of functional confirmation testing at specialized facilities, and in light of current guidelines.

Enhancing Nurse Roles in Community Health (ENRICH): The Impact of a Primary Care-Based Undergraduate Nursing Fellowship.

Low numbers of new graduate nurses entering careers in primary care settings are insufficient to meet the demand of the current nursing shortage. The Enhancing Nurse Roles in Community Health (ENRICH) Fellowship is aimed at increasing undergraduate nursing students' exposure to population health concepts by providing opportunities to practice in primary care settings. The purpose of this study was to implement and evaluate an undergraduate nursing fellowship program to enhance competency development in the primary care setting. Fellows received targeted exposure to population health content and immersive primary care experiences through participation in 150 dedicated clinical hours in primary clinics, coupled with up to 250 hours of dedicated curriculum. Students who participated in the ENRICH Fellowship showed increased knowledge, improved perception of skills performance, and changed attitudes about population health and primary care nursing. Participation in a population health-based fellowship that includes targeted curricular content and primary care-based clinical experiences during an undergraduate nursing program improves knowledge, attitudes, and competency-based skills related to primary care and population health.

Prevalence of atrial fibrillation in Northern Sri Lanka: a study protocol for a cross-sectional household survey

IntroductionAtrial fibrillation (AF) is the most common arrhythmia globally. It is associated with a fivefold risk in stroke, but early diagnosis and effective treatment can reduce this risk. AF is...

Patient advocates' views of patient roles in interprofessional collaborative practice in primary care: A constructivist grounded theory study.

Interprofessional collaborative practice has been shown to be an appropriate model of care for chronic disease management in primary care. However, how patients play a role in this model is relatively unknown. The aim of this constructivist grounded theory focus group study was to explore the perceptions of patient advocates regarding the role of patients in interprofessional collaborative practice for chronic conditions in primary care. Primary data were collected from patient advocates, from public and private Australian organisations and who represent patients with chronic disease in primary care, through focus groups in July-August 2020. Videoconference focus groups were recorded, transcribed verbatim and inductively, thematically analysed using the five-step approach by Charmaz: (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation and (5) theme and sub-theme development. Three focus groups comprising 17 patient advocates with diverse cultural and professional backgrounds participated. Two themes and five sub-themes relating to interprofessional collaborative practice teams were constructed from the data. In theme 1, patients 'shifted across the spectrum of roles' from 'relinquishing control to the team', 'joining the team' to 'disengaging from the team'. The second theme was the need for 'juggling roles' by 'integrating patient role with life roles', and 'learning about the patient role'. The diversity and variability of patient roles as described by patient advocates highlight the challenges of working with people with chronic conditions. The diverse patient roles described by advocates are an important finding that may better inform communication between patients and health professionals when managing chronic conditions. From the health professional perspective, identification of the role of a patient may be challenging. Therefore, future research should explore the development of a tool to assist both patients and health professionals to identify patient roles as they move across the spectrum, with the support of policy makers. This tool should aim to identify and promote patient engagement in interprofessional collaborative practice in primary care settings.

Using Artificial Intelligence as a Diagnostic Decision Support Tool in Skin Disease: Protocol for an Observational Prospective Cohort Study.

BackgroundDermatological conditions are a relevant health problem. Each person has an average of 1.6 skin diseases per year, and consultations for skin pathology represent 20% of the total annual visits to primary care and around 35% are referred to a dermatology specialist. Machine learning (ML) models can be a good tool to help primary care professionals, as it can analyze and optimize complex sets of data. In addition, ML models are increasingly being applied to dermatology as a diagnostic decision support tool using image analysis, especially for skin cancer detection and classification.ObjectiveThis study aims to perform a prospective validation of an image analysis ML model as a diagnostic decision support tool for the diagnosis of dermatological conditions.MethodsIn this prospective study, 100 consecutive patients who visit a participant general practitioner (GP) with a skin problem in central Catalonia were recruited. Data collection was planned to last 7 months. Anonymized pictures of skin diseases were taken and introduced to the ML model interface (capable of screening for 44 different skin diseases), which returned the top 5 diagnoses by probability. The same image was also sent as a teledermatology consultation following the current stablished workflow. The GP, ML model, and dermatologist’s assessments will be compared to calculate the precision, sensitivity, specificity, and accuracy of the ML model. The results will be represented globally and individually for each skin disease class using a confusion matrix and one-versus-all methodology. The time taken to make the diagnosis will also be taken into consideration.ResultsPatient recruitment began in June 2021 and lasted for 5 months. Currently, all patients have been recruited and the images have been shown to the GPs and dermatologists. The analysis of the results has already started.ConclusionsThis study will provide information about ML models’ effectiveness and limitations. External testing is essential for regulating these diagnostic systems to deploy ML models in a primary care practice setting.

Minimal clinical data sets for spine-related musculoskeletal disorders in primary care and outpatient settings: a scoping review protocol

IntroductionLack of standardised clinical data collection may lead to reduced quality in musculoskeletal (MSK)-related clinical care and research. Little is known about the availability and characteristics of minimal clinical data...

Multilevel Influences on Providers' Delivery of Contraceptive Services: A Qualitative Thematic Analysis.

Introduction:Access to a full range of contraceptive services is essential for quality health care. Contraceptive provision practices of primary care providers play an important role in patients' decision-making about their reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in primary care settings is critical for advancing quality care. This study offers an in-depth examination of influences on providers' delivery of contraceptive services across multiple primary care specialties and practice settings to identify issues and strategies to improve care.Materials and Methods:Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic settings, private practices, and health centers. Interviews were transcribed and analyzed thematically.Results:Providers described a complex set of influences on their provision of contraception across multiple ecological contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on provision of contraception: organizational, individual provider-related, structural and policy, individual patient-related, community, and the lack of influences or barriers. Providers also discussed the sources they access for information about evidence-based contraception counseling.Conclusions:A diverse set of providers described a complex system in which multiple concentric ecological contexts both positively and negatively influence the ways in which they provide contraceptive services to their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barriers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological contexts.

Deep Learning Skin Disease Classifiers: Current Status and Future Prospects

Background Most studies on deep learning skin disease classifiers are done with binary classifications (ie, classifying lesions into malignant and benign). However, dermatology practice involves a large number of inflammatory and infective conditions that are not easily diagnosed by nondermatologist physicians. Objective The aim of this study is to develop a machine learning–based smartphone app for multiclass skin disease classification and evaluate its performance in different levels of dermatology practice. We will also explore similar studies in the literature. Methods We developed an artificial intelligence–driven smartphone app for 40 common skin diseases and tested it in primary care, tertiary care, and private practice settings. Results In the clinical study, the overall top-1 accuracy was 75.07% (95% CI 73.75%-76.36%), top-3 accuracy was 89.62% (95% CI 88.67%-90.52%), and the mean area under the curve was 0.90 (SD 0.07). Multimedia Appendix 1 shows the top-1 positive predictive values and negative predictive values from a clinical study of 35 diseases using the developed mobile health app on patients. In the literature, there are very few studies on image-based deep learning multiclass classification of common skin diseases and none of them included evaluations in actual clinical settings. Conclusions An artificial intelligence–driven smartphone app has the potential to improve the diagnosis and management of skin diseases in patients with skin of color. Nondermatologist, primary care physicians are likely to benefit from having access to such an app. Acknowledgments Nurithm Labs collaborated with the All India Institute Of Medical Science to develop this smartphone app. Other collaborators in this work include Rashi Pangti, Jyoti Mathur, Vikas Chouhan, Sharad Kumar, Lavina Rajput, Sandesh Shah, Atula Gupta, Ambika Dixit, Dhwani Dholakia, Sanjeev Gupta, Savera Gupta, Mariam George, and Vinod Kumar Sharma. Conflicts of Interest None declared.

Introducing a Clinical Summary Template From the Adult Day Center to Support Decision Making by Primary Care Providers.

CareMOBI (Mhealth for Organizations to Bolster Interconnectedness) is a mobile application designed to facilitate information exchange between primary care providers (PCPs) and adult day centers (ADCs). A key function of CareMOBI is to synthesize information collected outside of the provider's office (ie,: in the ADC or at home) and distill the most relevant data points into an exportable clinical summary that can help inform clinical decision making by the PCP with information from outside providers who are not formally embedded within health systems. In this study, we used a qualitative approach to understand the acceptability and utility of the clinical summary template within CareMOBI. Purposive sampling, followed by snowball sampling, was used to recruit PCPs from a variety of primary care practice settings (i.e. home-based, academic). Semi-structured interviews were conducted virtually to elicit feedback on the user-experience after interaction with a prototype template. Interviews were recorded, transcribed, and analyzed using content analysis. Our sample (n = 10) consisted of physicians and nurse practitioners in a variety of settings. Feedback suggested that the summary template facilitates interdisciplinary, bidirectional, succinct, and relevant information exchange across care teams. The summary template effectively integrates observations and assessments from team members, centralizes them, and allows PCPs to hone in on the most salient components to inform clinical decision making for the geriatric patient. The summary gave PCPs "live texture" about what was happening outside the office and represented a significant improvement over other methodologies of information exchange. Prior to implementation into clinical practice, several refinements are necessary based on feedback including integration into the PCP's workflow. The template was viewed by PCPs as a concise and actionable record, in contrast to current communication which is characterized as "bloated"-containing too many pages on nonessential information. The summary could potentially save PCP's time in locating and analyzing historical data to enable rapid patient assessment and prompt more ready and informed action.

Can Understanding Gut-Brain Axis Biopsychosocial Pathways Improve Clinical Reasoning?

Most nurse practitioners (NPs) practice in primary care settings. Cognitive tools to inform and advance NP understanding of biopsychosocial mechanisms can support early recognition, interdisciplinary collaboration, interventions, and prevention of negative outcomes. We describe the development of a model to support NP consideration of gut-brain axis evidence-based pathways, contributing variables, and related health outcomes. The model’s outcomes are factors associated with homeostasis or disruption of biological, psychological, and social systems. This cognitive tool aims to support NP awareness of multidomain gut-brain axis relationships to consider with differential diagnoses and clinical treatment of the “whole body system.”

Identifying key roles of the pharmacy technician in primary care settings.

As the pharmacist's role expands, particularly in primary care practice settings, there is an opportunity for expansion of pharmacy technician duties to aid in administrative and clinical tasks that do not require the pharmacist's professional judgment. Identifying, defining, and expanding the roles of pharmacy technicians has been deemed a key part of the pharmacy practice model. These roles have been shown to enhance pharmacist efficiency and patient outreach; however, examples of the various innovative activities performed by technicians in the primary care setting are lacking in the literature. The duties of primary care pharmacy technicians were compiled and defined in 2 different healthcare systems. The role of the technician was separately implemented at each institution, and study designs and protocols were individually created and executed. One institution utilized a 4-round consensus-building process to systematically refine and codify tasks for a dictionary of duties. The second institution utilized a free-text survey, task documentation data in the electronic medical record, and a telephone discussion with the technicians. Despite a lack of methods- and data-sharing between the 2 institutions, similar tasks were identified, including conducting patient outreach, assisting with medication affordability and access, providing patient education, managing referrals, and scheduling appointments. Differences in technician involvement were noted in areas such as prior authorization, care coordination meetings, and quality improvement projects. Pharmacy technicians are a helpful, yet underutilized, resource in the primary care setting. Further exploration of technician roles is needed to determine the financial and clinical impact of expanding these roles.

Investigating Adverse Childhood Experiences and Nutrition and Physical Activity Behaviors Using the Omaha System.

The aim of the current study was to examine the relationship between adverse childhood experiences (ACEs) and nutrition and physical activity behaviors using the Omaha System. A descriptive cross-sectional design was used with 227 women recruited from three vocational institutes. Measures included Omaha System Knowledge, Behavior, and Status ratings for nutrition and physical activity; sociodemographic information; and the ACE Questionnaire. Results demonstrated that more than one half of participants had a history of at least one ACE (n = 132; 58.1%), and 33 (14.5%) had four or more. ACEs score was significantly associated with nutrition, but not physical activity behavior. Understanding the links between ACEs and health behaviors and including a brief screening for ACEs in primary care practice settings may help nurses holistically customize health promotion interventions and lead to better health outcomes. The Omaha System can efficiently measure health-related behaviors; examine their relationship to risk factors, such as ACEs; and capture individual and population-level changes. [Journal of Psychosocial Nursing and Mental Health Services, 60(3), 23-30.].

Antibiotic Prescribing Practices in Primary Care Settings Using 2019 WHO AWaRe Framework

Background: Bacteria have ability to rapidly evolve, develop strategies to resist antibiotics, and reduce the effectiveness of antibiotics. The emergence and spread of antimicrobial resistance is an important global public health challenge to tackle. Studying antibiotic prescribing practices would allow rational use and preserve effectiveness of antibiotics.
 Objective: To study prescribing practices of antibiotics in out-patients in primary care settings using the WHO AWaRe framework.
 Methodology: A prospective cross-sectional study was conducted to evaluate prescribing practices of antibiotics in the primary care facility of three private hospitals using the WHO ‘core prescribing indicators’ and Access, Watch, and Reserve (AWaRe) classification. A systematic sampling technique was employed to collect the prescriptions at each hospital for three months. Descriptive statistics were applied to the collected data.
 Results: A total of 2685 prescriptions were systematically evaluated. 1280 encounters had at least one antibiotic (47.7%), of which 1041 consist of only one antibiotic (81.5%). Among 1280 antibiotic encounters, the average number of antibiotics per encounter was 1.2 and 14.6% were prescribed with a parenteral antibiotic. 26.6% and 78.6% antibiotics were prescribed using generic names and from the WHO Essential Medicines List, respectively. Amoxicillin/clavulanic acid, ceftriaxone, azithromycin, cefoperazone, and amoxicillin were the five most commonly prescribed antibiotics. According to the WHO AWaRe classification, a total of 27 specific antibiotics (Access 11, Watch 14, and Reserve 2) were prescribed. 38.4%, 53.7%, 0.3%, and 10.5% of antibiotics prescribed were from the ‘Access’, ‘Watch’, ‘Reserve’, and ‘Not Recommended’ categories, respectively. Third generation cephalosporins (24.0%) were prescribed in high rate among ‘Watch’ category. The most commonly prescribed ‘Access’ and ‘Watch’ antibiotics were amoxicillin/clavulanic acid (12.5%) and ceftriaxone (10.6%), respectively. Amoxicillin index was 19.5% and ‘Access-to-Watch’ index was 0.76, which were below the priority values.
 Conclusion: Except few indicators, still better prescribing practices of antibiotics are needed to fully meet the WHO recommendations. Antibiotic prescribing guidelines as per the WHO AWaRe framework, changes in prescription patterns and preference of “Access” over ‘Watch’ antibiotics are crucial to preserve effectiveness and promote rational use of antibiotics.