Primary Care Program Research Articles

Effectiveness and utilization of a cognitive screening program for primary geriatric care

BackgroundEffective detection of cognitive impairment in the primary care setting is limited by lack of time and specialized expertise to conduct detailed objective cognitive testing and few well-validated cognitive screening instruments that can be administered and evaluated quickly without expert supervision. We therefore developed a model cognitive screening program to provide relatively brief, objective assessment of a geriatric patient’s memory and other cognitive abilities in cases where the primary care physician suspects but is unsure of the presence of a deficit.MethodsReferred patients were tested during a 40-min session by a psychometrist or trained nurse in the clinic on a brief battery of neuropsychological tests that assessed multiple cognitive domains. Short questionnaires covering subjective cognitive complaints, symptoms of depression, and medical history were also administered. Results were conveyed to a dementia specialist who reviewed them and returned their judgement of the validity of the cognitive complaint to the primary care provider. Retrospective medical records review was carried out for a random (stratified) half of the sample to determine how screening results were utilized. Screening tests were repeated after two years in a subset of 69 patients.ResultsThe 638 patients screened (mean age = 75.9 years; mean education = 14.9 years; 58% women) were classified by screening as having normal cognition (n = 177), depression (with possible cognitive changes; n = 115), mild cognitive impairment (MCI; n = 107), or dementia (n = 239). Classification accuracy was shown by high agreement with the eventual clinical diagnosis in the medical record (69%; Cohen’s Kappa = .38; p < .001; 77% if MCI and dementia were collapsed; Cohen’s Kappa = .58; p < .001) and longitudinal decline in cognitive test scores only in those initially classified as having MCI or dementia. Medical records documented discussion of screening results with the patient in 69% of cases (80% if MCI or dementia was detected) and often referral to a specialist (62%), new brain imaging (54%), or change in medication (58%) when screening indicated potential cognitive impairment.ConclusionThe cognitive screening program was well accepted by primary care providers as an efficient and effective way to evaluate concerns about cognitive decline in older adults.

Motivation, accountability, and outcomes in a randomized controlled trial of internet weight-loss programs in primary care.

This study explored whether baseline autonomous motivation (AM), controlled motivation (CM), and relative autonomy index (RAI) scores predicted 12-month weight in a three-arm randomized controlled trial of internet weight loss programs in primary care. It also evaluated perceived accountability to a primary care provider for weight loss as a moderator and study engagement (operationalized as weeks logged into the study website) as a mediator of these relationships. Participants with complete data for all model variables (n = 428) were included. Multiple linear regression models controlling for baseline weight and covariates showed that one-unit increases in baseline CM and RAI scores predicted a 0.57 kg increase (p = 0.015; Cohen's f2 = 0.02) and 0.52 kg decrease (p = 0.019; Cohen's f2 = 0.02) in weight, respectively. AM was not associated with 12-month weight. No moderating or mediating effects were found. Findings suggest the need for greater attention to baseline CM in weight loss programs in primary care.

Implementation of a data-driven quality improvement program in primary care for patients with coronary heart disease: a mixed methods evaluation of acceptability, satisfaction, barriers and enablers.

Background The study aimed to understand the acceptability, satisfaction, uptake, utility and feasibility of a quality improvement (QI) intervention to improve care for coronary heart disease (CHD) patients in Australian primary care practices and identify barriers and enablers, including the impact of COVID-19. Methods Within the QUality improvement for Effectiveness of care for people Living with heart disease (QUEL) study, 26 Australian primary care practices, supported by five Primary Health Networks (PHN) participated in a 1-year QI intervention (November 2019 - November 2020). Data were collected from practices and PHNs staff via surveys and semi-structured interviews. Quantitative and qualitative data were analysed with descriptive statistics and thematic analysis, respectively. Results Feedback was received from 64 participants, including practice team members and PHN staff. Surveys were completed after each of six workshops and at the end of the study. Interviews were conducted with a subgroup of participants (n =9). Participants reported positive satisfaction with individual QI features such as learning workshops and monthly feedback reports. Overall, the intervention was well-received, with most participants expressing interest in participating in similar programs in the future. COVID-19 and lack of time were identified as common barriers, whereas team collaboration and effective leadership enabled practices' participation in the QI program. Additionally, 90% of the practices reported COVID-19 effected their participation due to vaccination rollout, telehealth set-up, and continuous operational review shifting their focus from QI. Conclusion Data-driven QI programs in primary care can boost practice staff confidence and foster increased implementation. Barriers and enablers identified can also support other practices in prioritising effective strategies for future implementation.

Clinico-spirometrical correlation of newly detected COPD patients with known tobacco smoking exposure or biomass smoke exposure presenting to a teaching institution in Vadodara, Gujarat

ABSTRACT Introduction: Chronic respiratory symptoms (dyspnoea, coughing, sputum production) associated with abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that result in persistent, frequently progressive airflow obstruction are the hallmarks of COPD, a diverse lung illness. The current investigation aimed to establish a clinical profile of patients with recently diagnosed COPD who present to a healthcare facility in Vadodara. Materials and Methods: The Department of Respiratory Medicine conducted an observational cross-section study on individuals with recently discovered COPD. The study comprised records of 50 participants, from September 2022 to January 2024. Along with the spirometry results, pertinent clinical data were gathered. Results: The study’s patient population presented with an average age of 61.52 years. The fact that every patient in the research was over 40 years old suggests that COPD is becoming more common in people over 40. There was a male majority among the 50 patients, with 40 (80%) male and 10 (20%) female. Most common age group was smokers accounted for 80% of the total cases, suggesting that their incidence of COPD is greater. Average FEV1 at presentation was 41 L/min for 50 patients. Among 50 patients, 6% falls under mild, 28% under moderate, 42% under severe, and 24% under very severe according to GOLD grading and severity of airflow obstruction. Conclusion: Despite the fact that tobacco smoke is thought to be the main cause of COPD. Indoor and outdoor air pollution are major issues in many nations, including India. One of the main risk factors for COPD is smoke from activities such as burning wood or biomass fuels in addition to work exposure. The ageing of the global population and ongoing exposure to COPD risk factors are expected to contribute to a rise in the prevalence and burden of COPD in the ensuing decades. The fact that most newly diagnosed patients in this research were older and more symptomatic and that most identified individuals had moderate to severe COPD, indicates the importance of spirometry programs in primary care for the early detection of COPD. Our findings suggest that a new campaign requiring patients to undergo spirometry and routine follow-up may be able to identify a sizable proportion of patients with undiagnosed COPD and perhaps improve their quality of life.

Characteristics of mortality with Chronic Kidney Disease in Cuba. Trend and forecast. 2011-2020

Mortality due to Chronic Kidney Disease (CKD) has shown a significant increase globally and in Cuba over the past decade. This study analyzes the characteristics of mortality due to CKD in Cuba between 2011 and 2020, aiming to illustrate and determine the trend and prognosis. A longitudinal descriptive study was conducted, using data from 35,031 deaths registered by the Ministry of Public Health of Cuba. The variables analyzed include the year of death, age, sex, province of residence, and cause of death, using the International Classification of Diseases. Mortality rates were calculated and age-adjusted using standard statistical methods and the SPSS version 20.0 program.During the study period, mortality with CKD in Cuba increased from 2,764 cases in 2011 to 4,325 in 2020, an increase of 56.47%. Age-adjusted mortality rates showed a higher increase in men (39.83%) than in women (20.71%). The average age at death was 70.38 years. Potential years of life lost (PYLL) amounted to 263,090.5, with the most affected age groups being 50-59 years. The provinces with the highest age-adjusted mortality rates were Cienfuegos and Sancti Spíritus.Renal diseases represent a growing cause of mortality in Cuba, aligning with trends observed in the Americas region. The implementation of CKD prevention and control programs in primary health care is crucial to mitigate this trend

Short report: Integrated evaluations for autism spectrum disorder in pediatric primary care clinics.

Primary care providers often screen for autism during well child visits in the first few years of life and refer children for diagnostic evaluations when needed. However, most children do not receive a diagnosis until years later which delays access to services. Racism, socioeconomic status, and other systemic inequalities that limit access to health care further delay diagnostic evaluations. Mental health clinicians who work in primary care clinics can help address barriers to accessing diagnostic evaluation services once they are recommended by their primary care provider. However, mental health clinicians who work in primary care typically do not have training in diagnosing autism. The goal of this study was to evaluate a program training mental health professionals working in an urban primary care setting, primarily serving Black and Latinx families insured by Medicaid, to provide autism diagnostic evaluations. Two hundred and fifty children completed evaluations through the Autism in Primary Care (APC) program. The wait time to access an evaluation through APC was significantly shorter than through standard avenues of care (e.g. referring to a separate autism clinic). Referring primary care providers and caregivers endorsed high levels of satisfaction with the program. Conducting autism evaluations in primary care settings offers a promising opportunity to improve earlier diagnosis and treatment access for families, reduce inequities in care, and increase caregiver and child well-being.

Accelerated competency-based education in primary care (ACE-PC): a 3-year UC Davis and Kaiser permanente partnership to meet California’s primary care physician workforce needs

ABSTRACT Problem Our nation faces an urgent need for more primary care (PC) physicians, yet interest in PC careers is dwindling. Students from underrepresented in medicine (UIM) backgrounds are more likely to choose PC and practice in underserved areas yet their representation has declined. Accelerated PC programs have the potential to address workforce needs, lower educational debt, and diversify the physician workforce to advance health equity. Approach With support from Kaiser Permanente Northern California (KPNC) and the American Medical Association’s Accelerating Change in Medical Education initiative, University of California School of Medicine (UC Davis) implemented the Accelerated Competency-based Education in Primary Care (ACE-PC) program – a six-year pathway from medical school to residency for students committed to health equity and careers in family medicine or PC-internal medicine. ACE-PC accepts 6–10 students per year using the same holistic admissions process as the 4-year MD program with an additional panel interview that includes affiliated residency program faculty from UC Davis and KPNC. The undergraduate curriculum features: PC continuity clinic with a single preceptor throughout medical school; a 9-month longitudinal integrated clerkship; supportive PC faculty and culture; markedly reduced student debt with full-tuition scholarships; weekly PC didactics; and clinical rotations in affiliated residency programs with the opportunity to match into specific ACE-PC residency tracks. Outcomes Since 2014, 70 students have matriculated to ACE-PC, 71% from UIM groups, 64% are first-generation college students. Of the graduates, 48% have entered residency in family medicine and 52% in PC-internal medicine. In 2020, the first graduates entered the PC workforce; all are practicing in California, including 66% at federally qualified health centers, key providers of underserved care.

Trends in Maternal Mortality in South America after the Covid-19 Pandemic: A Systematic Review

Introduction: Maternal mortality is a critical indicator of public health, reflecting access to and quality of healthcare. The COVID-19 pandemic exacerbated existing inequalities, negatively affecting maternal mortality in South America. Objectives: The overall objective of the study was to investigate maternal mortality trends in South America during and after the COVID-19 pandemic, with specific objectives to compare maternal mortality rates before, during, and after the pandemic, and to analyze socioeconomic and health factors that influence maternal mortality, with an emphasis on vulnerable populations. Methodology: A systematic review was conducted in academic databases such as PUBMED, SCOPUS, DIALNET, and SCIELO, using specific terms related to maternal mortality and COVID-19. Relevant studies and official data from WHO and PAHO were included. Results: The study revealed a significant increase in maternal mortality in the early years of the pandemic, followed by a gradual decline. The main causes included obstetric hemorrhage and hypertensive disorders. Indigenous and Afro-descendant women were disproportionately affected. Discussion: The pandemic redirected health resources, affecting primary care and reproductive health programs. Structural inequalities and lack of access to quality services were determining factors in the increase in maternal mortality. Conclusions: In conclusion, the COVID-19 pandemic had a devastating impact on maternal mortality in South America, revealing critical failures in health systems and exacerbating pre-existing inequalities. It is crucial to implement robust public policies and comprehensive approaches to reduce maternal mortality and ensure universal access to quality health care.

Medically assisted integrated rehabilitation program for people with opioid dependence: a quasi-experimental evaluation using multi-criteria decision analysis

Abstract Background Opioid use disorders constitute a vast disease burden, need for comprehensive treatment, and substantial costs to individuals, families, and society. The multifaceted needs of people with opioid dependence call for integrated care. The study aims to assess the added value of an integrated medically assisted rehabilitation (MAR) program providing opioid agonist therapy for patients with opioid dependence as compared to the standard of care (SoC) in Norway. Methods The intervention includes a comprehensive tertiary care integrated MAR program in Bergen. SoC is a much less intense primary care program in Oslo. 682 and 609 patients from Bergen, and 864 and 771 patients from Oslo were included in 2017 and 2019, respectively. A multi-criteria decision analysis (MCDA) framework was used where the relative preferences of the importance of the outcomes were obtained from a discrete choice experiment among five different stakeholder-groups. Seven outcomes related to health, well-being, experience of the care process, and cost were measured. The performance scores were measured in a study with a quasi-experimental design. Scores were analyzed using linear mixed methods. Performance scores for the outcomes were standardized and multiplied by their relative preferences to obtain the overall value scores in the MCDA. Results We found similar value scores for both care delivery models regarding physical functioning, psychological well-being, social relationships &amp; participation, enjoyment of life, and total costs. The Bergen-model scored higher on continuity of care (0.733 versus 0.680), while the SoC-model scored higher on person-centeredness (0.772 versus 0.635). Overall value scores were marginally in favor of the MAR-Bergen (0.708 versus 0.705 for patients). Conclusion Acknowledging the significance of different life aspects emphasizes the need for integrated care at a specific level for people with opioid dependence. We conclude that the two highly effective treatment approaches produce promising outcomes in a challenging population and are quite similar. However, further research with more robust longitudinal data is needed.

Exercise in primary care after robot-assisted radical cystectomy for urinary bladder cancer - effects on postoperative complications: a secondary analysis of a randomised controlled trial.

An exercise programme in primary care soon after radical cystectomy for urinary bladder cancer was previously evaluated regarding its effects on physical function. A secondary aim, presented herein, was to evaluate the programme in terms of its effect on postoperative complications. Patients who were planned for robot-assisted radical cystectomy for urinary bladder cancer at Karolinska University Hospital between September 2019 and October 2022 were invited to participate. At discharge from hospital, they were randomised to intervention group including aerobic and resistance exercises with physiotherapist in primary care twice a week for 12 weeks and daily walks, or to unsupervised home-based exercise including daily walks. Readmission rates between 30 and 90 days after discharge, and complications according to Clavien Dindo were collected from the medical records and analysed. Ninety patients were randomised, with a mean (SD) age of 72 (9) years. Readmission rates between 30 and 90 days showed no difference between the groups. For readmitted patients, the intervention group had significantly fewer complications reported as Clavien Dindo grade 2 compared to the control group. Conclusion: An exercise programme in primary care soon after robot-assisted radical cystectomy appears to be safe for patients, as measured by hospital readmission rates. Trial registration: Clinical Trials (NCT03998579).

TEMPORARY REMOVAL: Improving the timeliness and equity of preschool childhood vaccinations: Mixed methods evaluation of a quality improvement programme in primary care

We conducted a mixed methods evaluation to assess whether implementing a primary care quality improvement (QI) programme utilising a digital call-and-recall tool improved timely receipt and equity of first measles, mumps and rubella (MMR) and diphtheria tetanus, pertussis and polio-containing (DTaP /IPV) vaccinations. 138,133 and 136,952 children were eligible to receive first MMR and DTaP/IPV respectively between 1st January 2019 and 31st January 2024 in North East London. We compared proportions with timely first MMR or DTaP/IPV receipt (by ages 18 and six months respectively) pre- and post-implementation using an interrupted time series analysis. We calculated change in the Slope Index of Inequality (SII) by an area-level deprivation measure. We conducted 'Think Aloud' exercises and semi-structured interviews with users. The proportion of children with timely first MMR receipt increased by 5·3% (Rate Ratio [RR]:1·053, 95% confidence interval [CI]:1·033-1·073), equating to an absolute increase in timely MMR receipt of 4·1% - from 77·7% to 81·8% - and for first DTaP/IPV by 0·9% (RR:1·009, 95% CI:1·003-1·015). There was no significant change in SII for either vaccine. Users reported improved recall with tool use, but identified practice-level and systemic barriers, including staff dynamics and unachievable national targets, limiting its consistent use. In a real-world setting, a call-and-recall tool within a primary care QI programme improved timely first MMR receipt. Sustained improvement requires additional support including by incentivising achievable targets and improving staff capacity and training. National Institute of Health and Care Research; Barts Charity.

A new normal in primary care: the rapid normalization of a major eHealth program in public health centers

BackgroundThis study aimed to contribute to a better understanding of the context, mechanisms and outcomes in the implementation process of an eHealth video consultation program in primary care. The study focused on how the program is normalized in the primary care setting. The primary research question for this study is “in what ways is the implementation of video consultation normalized in primary care?”.MethodsThe qualitative design and content analysis of primary data from the transcripts were based on in-depth interviews, complemented with free-text answers to open-ended survey questions and various documents. The study focuses on the large-scale implementation of the public eHealth program Närhälsan Online, which represents more than 100 health centers in Sweden’s largest region of Västra Götaland. Multiagent perspectives on how the program is normalized were drawn from expressed perceptions by professions directly linked to both strategic and functional implementation, as well as administration and clinical operation.ResultsThis study both confirms and enhances the field with a theoretical contribution in six ways to the reviewed previous research, as well as showing practical implications. It also provides multi-agent perspectives on the rapid normalization of the implementation program studied.ConclusionsIn relation to the rapid progression of different initiatives in eHealth, this study contributes to perspectives on specific challenges as expressed by professions directly linked to both strategic and functional implementation as well as administration and clinical operation.

A rural ambulance service in Northern Togo improves access to emergency care for women with obstetric complications.

Maternal mortality remains high in sub-Saharan Africa, with little progress made in the last 20 years. The provision of emergency obstetric care has been shown to have the greatest effect in reducing maternal mortality in countries with high maternal mortality ratios, especially when paired with an emergency transport service. Integrate Health has partnered with the Togolese Ministry of Health to improve maternal and child health via the integration of a free ambulance service into a pre-existing primary care model. In this study, we aim to describe the implementation of this service and assess its effectiveness on access to emergency obstetric care by estimating its coverage of women with obstetric complications. This is a retrospective cross-sectional study using routinely collected data from ambulance logbooks. The study was restricted to pregnant or postpartum woman in four districts of Northern Togo. For each patient transported, the variables collected included date of transport, destination, patient information, kilometres travelled, and reason for transport. Complicated obstetric cases were defined by reason for transport and included maternal haemorrhage, complicated birth, and signs of danger. Estimated coverage of major obstetric complications was calculated using population estimates per fiscal year, the birth rate (3.7%) in Togo, and the assumption that 15% of pregnant women will have a complication. Between July 2020 and June 2023, there were 2926 maternal patients transported by the ambulance service. Of these, 1030 were reported as complicated obstetric cases. Estimated coverage of obstetric complications increased over time and as the programme expanded, from 18% in 2020 to 35.7% in 2021, and 66.5% in 2022. Our findings demonstrate that implementing a rural ambulance service in a region with historically high maternal mortality rates may improve maternal access to emergency obstetric care. The success of our ambulance service was likely due to the fact that it is free, available 24/7, easily accessible, operated by trained staff and community members, and integrated into a pre-existing primary care programme with well-resourced health care centres.

A cluster randomised controlled trial investigating the efficacy of family-centred obesity management program in primary care settings: A study protocol.

The study aims to test the efficacy of a family-centred healthy lifestyle program in primary care health centres among children with overweight or obesity, evaluating the results at 3, 6, and 9 months post-intervention. A single-blind, randomised controlled cluster study where participants will be blinded to group assignment to reduce bias will be followed. The intervention comprises a 6-month program with intensive and maintenance behavioural therapies, including dietary modifications and guidelines for physical activity, administered by a multidisciplinary team. Participants will be assigned to an intervention group or a treatment-as-usual control group. Primary health centres in Seeb Wilayat, serving densely populated areas and willing to participate, will be included. Randomisation will be conducted at the cluster level to improve recruitment efficiency. A sample size calculation will ensure adequate power to detect significant differences. Ethical approval is granted and informed consent/assent will be obtained from all participants. The proposed study focusses on testing the efficacy of a family-centred healthy lifestyle program in primary care centres through a controlled, randomised study. Successful outcomes could lead to informed interventions, improvements in the health system, policy recommendations, positive community impacts, information on behavioural therapies, and improved long-term health outcomes for affected children and their families. This study will contribute to the literature by providing a culturally sensitive and evidence-based solution to a pressing public health issue, which can be adapted to similar contexts in Oman and beyond.

Music to Their Ears: Reducing Antipsychotic Use With a Personalized Music Intervention for Rural Veterans.

Background This project investigates a music intervention to deprescribe antipsychoticsin rural Veterans with dementia. Methods The Veterans Health Administration Home-Based Primary Care Program is care provided in the home by an interdisciplinary team with the goals of decreasing hospitalizations and falls, providing education to patients and caregivers, and improving quality of life. Eighteen Home Based Primary Care Veterans with dementia and active antipsychotic prescriptions were identified with the goal to deprescribe antipsychotics in 50% of them using a music intervention. Individualized playlists and assessments for Veteran quality of life and caregiver burden were evaluated. Phone visits tracked music utilization and captured the voice of the customer. Results Antipsychotic dose reduction occurred in five of eight Veterans, totaling eight dose reductionsand one discontinuation. Veteran quality of life improved; however, caregiver burden increased initially. The caregiver burden did improvewhen an outlier was removed. The voice of the customer favored music intervention. Conclusions A personalized music intervention is a feasible approach for reducing antipsychotic use in rural Veterans, improving quality of life, and potentially reducing caregiver burden.

The American Headache Society First Contact-Headache in Primary Care program: Current metrics, knowledge assessments, and direction for future initiatives.

This study examines the American Headache Society First Contact-Headache in Primary Care program metrics to date in order to assess the program's reach and provide direction for future initiatives. Approximately 4 million primary care office visits annually are headache-specific encounters. Therefore, it is important that primary care providers are knowledgeable about headache management. Recognizing the need, the American Headache Society First Contact designed the comprehensive First Contact-Headache in Primary Care program with input from an advisory board comprised of a diverse group of physicians and advanced practice providers with backgrounds in family and internal medicine, pediatrics, obstetrics and gynecology, and neurology. This is the first study to assess the reach of the program and critically examine how to best meet the needs of clinicians and patients going forward. We report descriptive statistics for the First Contact website metrics from October 2020 to June 2023 and grand rounds program data from May 2020 to December 2023. We also conducted a cross-sectional analysis of survey data from presentations conducted at two large national family medicine symposia, as well as a thematic analysis of the question: "Please indicate what areas of your practice could be enhanced or improved with additional education?" The First Contact program homepage was the second most visited page on the American Headache Society website (>100,000 views). A total of 20 podcast episodes were created for the program (>3500 plays). The First Contact program held 99 events (72 institutional grand rounds, 22 State-level meetings, and five national meetings), reaching >7000 clinicians. The institutional grand rounds and state-level meetings were held across 27 States and Washington D.C. Only 31.9% (30/94) of First Contact program events (excluding national meetings) occurred in the West census region, which has the fewest headache subspecialists and lowest headache subspecialist density in the United States. When examining survey data of participants who attended the two virtual national family medicine symposia (39.3% response rate, N = 636/1620), 85.7% (544/635) reported being "completely confident" or "veryconfident" in their ability to recognize and accurately diagnose patients presenting with a primary complaint of headache and 81.5% (517/634) reported being "completely confident" or "very confident" in their ability to develop evidence-based treatment plans that are tailored to the needs of individual patients. The use of diagnostic tools to recognize patients with migraine (60.4%, 384/636) and translating standards of care to the practice setting (42.5%, 270/636) were the most reported intended changes by participants. Most participants reported that program content was of clinical relevance and would improve their patients' outcomes (90.5% [571/631] and 90.6% [572/631], respectively). Over three-quarters (77.8%, 495/636) of participants reported areas of their practice that can be improved by additional education specifically regarding workflow, diagnosis, and management. This study evaluates one of the first national initiatives for primary care education. Data from the two First Contact Family Medicine national symposia indicate the program is generally well received with most participants reporting improved confidence and intention to implement key changes in practice to improve care for patients with headache; however, there remain areas of exploration for education that could further enhance participant experience and expand the reach of the initiatives. Areas for future programming include continued education on multifactorial approaches to headache treatment and suggestions for addressing cost, insurance, and time constraints. Also, future work may examine where the First Contact program might focus initiatives based on specific areas of need in headache care, such as geographic "desert" areas, racial and ethnic disparities, and uninsured/underinsured populations.

Prediabetes and cardiovascular risk factors: the effectiveness of a guided self-determination counselling approach in primary health care, a randomized controlled trial

BackgroundIdentify individuals who are at risk of Type 2 diabetes, who also are at a greater risk of developing cardiovascular disease is important. The rapid worldwide increase in diabetes prevalence call for Primary Health Care to find feasible prevention strategies, to reduce patient risk factors and promote lifestyle changes. Aim of this randomized controlled trial was to investigate how a nurse-lead Guided Self-Determination counselling approach can assist people at risk of type 2 diabetes to lower their coronary heart disease risk.MethodsIn this randomized controlled study, 81 people at risk of developing type 2 diabetes were assigned into an intervention group (n = 39) receiving Guided Self-Determination counselling from Primary Health Care nurses over three months and a control group (n = 42) that received a diet leaflet only. Measurements included the Finnish Diabetes Risk Score questionnaire and biological measurements of Hemoglobin A1c protein, Body Mass Index, fasting blood glucose, Blood pressure, Cholesterol, High-density lipoprotein, and triglycerides, at baseline (time1), 6 (time2) and 9 months (time 3).ResultsA total of 56 participants, equal number in intervention and control groups, completed all measurements. A significant difference between the intervention and control groups, in coronary heart disease risk was not found at 6 nor 9-months. However, within-group data demonstrated that 55.4% of the participants had lower coronary heart disease risk in the next ten years at the 9-month measurement. Indicating an overall 18% relative risk reduction of coronary heart disease risk by participating in the trial, with the number needed to treat for one to lower their risk to be nine. Within the intervention group a significant difference was found between time 1 and 3 in lower body mass index (p = 0.046), hemoglobin A1c level (p = 0.018) and diastolic blood pressure (p = 0.03).ConclusionsAlthough unable to show significant group differences in change of coronary heart disease risk by this 12-weeks intervention, the process of regular measurements and the guided self-determination counselling seem to be beneficial for within-group measures and the overall reduction of coronary heart disease risk factors.Trial registrationThis study is a part of the registered study ‘Effectiveness of Nurse-coordinated Follow-Up Programme in Primary Care for People at Risk of T2DM’ at www.ClinicalTrials.gov (NCT04688359) (accessed on 30 December 2020).

Where Are They Now? Alumni Outcomes From a Medical School Primary Care Pathway Program.

Many medical schools have implemented primary care tracks to increase the number of medical students pursuing primary care. The Primary Care Program (PCP) at the Keck School of Medicine of University of Southern California is a 4-year primary care pathway that trains medical students to work in urban, underserved communities and has shown high student match rates into primary care residencies. This study evaluates the PCP graduates in residency and after residency, and assesses their career outcomes, their career characteristics, and the impact their PCP experience had on their careers. All PCP alumni who graduated between 2015 and 2022 were invited to complete a 21-item Qualtrics (Qualtrics, LLC) survey. Descriptive data analysis was conducted through Qualtrics, and open-ended data were coded for themes. Seventy percent of PCP alumni (86/122) responded to the survey, with 65% (56/86) in residency/fellowship and 35% (30/86) in practice. Among those who matched into primary care residencies (61/86, 71%), the percentage that practiced or intended to practice general primary care was 70% (43/61). Respondents in practice (30) described their practice characteristics, including locations and payor mix consistent with majority underserved communities. Open-ended responses captured the impact that the PCP had on alumni's careers, with themes including mentorship, friendship/community, educational/service experiences, future career, exposure to types/kinds of practice, and social determinants of health exposure. PCP alumni credit this program with impacting their retention in primary care and their career trajectories. This program can serve as a model for other institutions to help increase the number of medical students who pursue primary care careers.

Implementing a pilot primary care program: Armenia’s steps toward universal health coverage

Abstract Problem Armenia has struggled to transform its ineffective primary healthcare (PHC) system into one that can address the non-communicable disease burden, which causes 93% of mortality. To address this issue, Armenia aims to establish universal health coverage and invest in high-quality primary care. Description In 2023, the Armenian Ministry of Health signed a multisectoral policy to implement a pilot primary care program to trial a multitude of reforms related to diabetes (DM) and hypertension (HTN). Pilot interventions include pathways for screening/diagnosis, provider training, free medications and diagnostics, and new provider financial incentives. The key question to be answered is if these pilot interventions cause DM and HTN health outcomes to improve. Beginning in 2024, the program is being piloted in a primary care clinic in Dsegh. Results As a result of the 2023 Ministerial policy, multisectoral stakeholders designed and implemented this pilot program. Baseline focus groups found that the pilot addresses the financial barriers that community members noted lead to delays in seeking care and that providers perceive the pilot to be beneficial to their patients. Although final results are not yet available, the pilot has already positively changed features in the national EMR and brought together stakeholders in a way never done before. Lessons The pilot’s innovation comes from it being the first time that hypertension and cholesterol medications are provided by the government for free, provider bonuses are based on outcome indicators, indicator targets are set this high, a point-of-care A1c machine is utilized, and a robust monitoring and evaluation (M&amp;E) plan is implemented, all of which are currently shaping discussions on national policy. For countries similarly working on strengthening primary care, it is recommended to pilot specific reforms and establish mechanisms through M&amp;E systems that allow pilots to inform evidence-based decision making. Key messages • To move towards universal health coverage, pilot programs designed with multi-sectoral stakeholders are needed to trial suggested healthcare reforms. • It is essential to invest in monitoring and evaluations systems to generate the data necessary to develop evidence-based policies.

Infographics: A Novel Approach to Improve Faculty-Preceptor Communication.

Communication between preceptors and faculty and the time to teach have been identified as common barriers for preceptors working with nurse practitioner (NP) students. Despite traditional preceptor orientation strategies in school of nursing NP primary care programs, preceptors continued to express uncertainty and lack of clarity regarding the expectations of the precepted experience. Data to support this innovation were obtained through preceptor-faculty interactions through surveys, site visits, and focus groups examining the preceptor's experience with precepting. Infographics were developed for each of the three clinical practicum courses in the NP primary care track, which address expectations for these precepted experiences. Preceptors reported being more likely to review infographics, kept them accessible/available during the semester, and experienced clarity on the expectations for the experience. Preceptors and students expressed a more thorough understanding of the expectations for the NP student's practicums with the implementation of the infographics. [J Nurs Educ. 2024;63(X):XXX-XXX.].