Primary Care Research Articles

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.

What does routine healthcare data tell us about the diagnostic pathway for older people with heart failure in Wales: under-testing, problems with access, or poor coding?

Abstract Background United Kingdom guidelines (NICE, NG106) for suspected chronic heart failure (HF) recommend that NT pro-BNP is performed as a first-line test. The result is also used to triage individuals; when NT pro-BNP is <400ng/L, a diagnosis of HF is less likely, echocardiography (echo) and specialist assessment should be performed within 6 weeks when the result is 400-2000ng/L, and within 2 weeks if >2000ng/L. How accurately this guidance is followed in clinical practice in Wales is not known. Purpose To examine how the current diagnostic pathway is recorded in routinely-collected electronic health record (EHR) data for older people in Wales with a diagnosis of heart failure. Methods We conducted a retrospective, population-level, observational study using linked anonymised EHR data in Wales (2015-22). We included patients aged 65y+ with a HF diagnosis in their primary or secondary care records and with a minimum of 12m pre and post-diagnosis data (for assessment of diagnostic pathway). We looked back from the point of HF diagnosis for codes associated with prior cardiovascular conditions (any time prior), symptoms (within 3 years), and key diagnostic tests (within 90 days). Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of heart failure between 2015-2022. Incidence and prevalence of heart failure increased across the study period (1.4-1.5% and 8.5-9.1% respectively). HF diagnosis was first evident in secondary care records in 54.9%, in primary care 36.3%, and in both data sources on the same day in 8.8%. Preceding cardiovascular diagnoses included hypertension (69.5%), atrial fibrillation (36.7%), myocardial infarction (30.5%), coronary artery disease (25.7%), and valve disease (17.7%). The most common recorded symptoms preceding diagnosis were breathlessness (41.4%), ankle oedema (9.8%), and fatigue (8.8%). Searched for symptoms were not recorded in 43.8%. In the 90 days preceding the diagnosis, 7-30% had recorded NT pro-BNP with the number of tests increasing throughout the study period (Figure 1). In the 90 days prior to HF diagnosis, 28-31% had an echo recorded. NT pro-BNP was >2000ng/L in 51.8%, 400-2000ng/L in 38.6% and <400ng/L in 9.6%. Conclusions In Wales, a greater number of individuals with heart failure appear to be diagnosed during hospital admission, compared with primary care. Many individuals with a code for HF in their records, do not have recorded objective evidence of cardiac dysfunction. The proportion of first-line and definitive tests appears low. It is unclear whether this is because of under-referral, difficulty accessing tests in primary care, or inaccurate coding of test referrals and results. These results are important in evaluating health service delivery and workforce planning.

Cost differences between oral anticoagulation therapies in atrial fibrillation patients

Abstract Background Direct oral anticoagulants (DOACs) have largely replaced warfarin as the primary choice of oral anticoagulation (OAC) in atrial fibrillation (AF) patients. This study uses a nationwide registry data set to compare the health and social care costs of AF patients using different OAC therapies. We studied how these costs were distributed among different care services in the year following AF onset and how the costs develop in time before and after AF diagnosis. Methods This study is a part of the Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) research project, which includes data on patients with AF, combining registry data on primary and secondary care services as well as social services, drug purchases and laboratory data. We included all new-onset AF patients from 2011 to 2017 in Finland with an indication for OAC treatment. Patients were divided based on their first OAC purchase. Time in therapeutic range (TTR) values were assessed for warfarin patients, and they were divided into quartiles based on their TTR value. Standardized costs were determined for different health and social care contacts, accounting for hospital care, primary and ambulatory care, and long-term care. Drug costs were acquired from the Reimbursement for Prescription Medicines registry. Results A total of 130,745 patients (66,610 on warfarin, 32,996 on DOACs) were included. First-year total costs after onset of AF were €10,412 for rivaroxaban (n=13,320), €12,631 for apixaban (n=11,886), €10,706 for dabigatran (n=7,514) and €10,689 for edoxaban (n=366). Costs of care clustered near the diagnosis of AF (Figure 1). Costs for warfarin patients increased inversely with TTR, ranging from €10,945 in the highest TTR quartile (TTR over 82%) to €21,387 in the lowest (TTR under 57%). Average first-year costs for warfarin patients were €15,689, higher than DOAC patients by €3,058-€5,277 (Figure 2). Patients without any OAC had the highest first-year costs, €17,898. Patients with high risk of stroke had higher total costs both in patients using DOACS (€7,271 for patients with a CHA2DS2VA score of 1 vs €11,947 for patients with CHA2DS2VA 2+) and warfarin (€9,933 for CHA2DS2VA 1 vs €16,354 for CHA2DS2VA 2+). Drug costs averaged €1,541 for rivaroxaban, €1,659 for apixaban, €1,495 for dabigatran and €1,540 for edoxaban, and €986 warfarin users. Hospital care was the largest cost driver with 64% of total costs across the whole cohort, followed by primary care (19%), drug purchases (7%), social service costs (6%) and reimbursements for travel and private care (4%). Conclusions DOACs were superior to warfarin in a broad range of social and healthcare cost measures despite higher drug expenses. Patients on warfarin with low TTR and patients without any OAC had the highest cost of care.

Impact of heart failure diagnosis on recorded healthcare resource use by older people in Wales; is primary care shouldering a hidden burden?

Abstract Background Heart failure (HF) is associated with high healthcare resource use and mortality. Most of the evidence focuses on hospital admission data. The impact on primary care interactions and outpatient attendance is less well described, but this information is important in understanding resource utilisation, patient pathways, and in planning services. Purpose To examine how a diagnosis of HF impacts healthcare resource use and outcomes for older people in Wales. Methods We conducted a retrospective, population-level, observational study using linked anonymised electronic health record (EHR) data in Wales (2015-22). 737,230 individuals were aged 65y+ in the study period in primary and secondary care data. Of these, 65,010 had a code for HF in their primary or secondary care records. To evaluate changes in resource use, we excluded 13,990 individuals with fewer than 12 months health data pre- and post-diagnosis. We summarised general practice (GP) interactions, emergency department (ED) attendance, outpatient (OP) attendance, inpatient (IP) episodes and days, time between HF diagnosis and death, and place of death. Results The final cohort comprised 51,020 individuals 65y and over with a diagnosis of HF between 2015-2022. Incidence and prevalence of HF increased across the study period (1.4-1.5% and 8.5-9.1% respectively). Figure 1 shows the percentage change in healthcare resource use for the cohort when HF was diagnosed (12 months pre-and post-diagnosis comparison). Table 1 shows the average number of healthcare utilisation events per person. After a diagnosis of HF, there are fewer ED attendances (-28.2%) and IP admissions (-9.3%) but more OP appointments (31%) and GP interactions (20.3%). When admissions occur, hospital stays tend to be longer (55.4%). Median time (IQR) from HF diagnosis to death from any cause was 247(34-840) days, and with HF listed as a cause 186(25-780) days. In this cohort, the place of death was recorded as NHS establishment (20,379, 67.8%), community (5,450, 18.1%), non-NHS establishment (3,789,12.6%) and unknown (450, 1.5%). Conclusions In Wales, a diagnosis of HF in those 65y+ increases primary care interactions and OP attendances. The change in volume of primary care interactions is considerable (increase from 1,047,920 to 1,315,080). Longer hospital stays may suggest difficulty in managing patients or discharging back to community settings. Majority of those with HF die in NHS establishments. It is unclear whether this reflects deficits in end-of-life care. These results are important in planning effective health service delivery and in establishing baseline data from which to monitor quality improvements.

Health care provider payment schemes in Central and Eastern European countries

Abstract Background Health care provider payment schemes are key elements of the health care system that influence providers behavior, quality of care, and efficient use of resources. In recent decades, Central and Eastern European (CEE) counties have implemented various reforms that have changed payments methods and other elements of the purchasing process. The aim of the study was to provide an overview of the current provider payment schemes within the public health system in selected CEE countries and identify the main directions of their reforming. Methods Based on existing literature, a theoretical framework and data collection form were first developed. Next, desk research was conducted to collect data on provider payment methods and other elements of the purchasing process in primary care, outpatient specialized care, hospital care, and long-term care. The collected information was verified and supplemented though consultations with national experts. Nine countries were included: Bulgaria, Croatia, Czechia, Estonia, Latvia, Lithuania, Hungary, Poland, and Romania. The study was conducted in 2023. Results Capitation, fee-for-service, and case-based payments are the most commonly used methods in the analyzed countries. The countries are increasingly using blended payment methods. Primary and hospital care have the most diverse payment method mix and have experienced the most substantial changes in their payment schemes since 2010. The most common changes focused on modifying existing methods (detailing payment categories, changing the principles of tariff valuation), and introducing additional methods to pay for specific services or performance (fee-for-service, bonus payments). Conclusions CEE countries are following similar directions in reforming provider payment systems, with the goal of strengthening primary health care, shifting emphasis from inpatient to outpatient care and improving cooperation between health care providers. Key messages • CEE countries largely use output-based methods to pay for health care services. • Provider payment systems are becoming more blended as countries look for the most effective payment method mix to meet policy objectives.

10.X.2. Strengthening primary health care through best practice transfer: the CIRCE-JA approach

Abstract Primary health care (PHC) is a fundamental component of resilient, strong, and sustainable health systems. The main aim of PHC is to address people’s health in a high-quality comprehensive system approach, ensuring person-centred and integrated care across their lifespan, which includes their physical, mental and social well-being. Following the COVID-19 pandemic, health systems’ strengthening has become a global public health and European public health priority, and an overarching objective of the EU4Health programme. In Feb 2023, the three-year Joint Action on the transfer of best praCtices In pRimary CarE (CIRCE-JA) was launched. Its overall objective is to effectively transfer and implement six identified PHC best practices (BPs) across EU Member States (MS), with scientifically robust evidence-based approach, to ensure sound transferability methodology. Critically, it aims to increase MS capacity to deploy innovative care models in PHC and to effectively support health system transformation at this level of care. CIRCE-JA is a collaborative effort with 14 MS participating, bringing together 48 entities, to initially transfer the identified BPs into 42 new implementation sites, whilst at the same time generate all the necessary tools to facilitate uptake and evidence-informed decision-making across all MS. This implementation is based on the alignment of key BP characteristics to meet the local healthcare needs and priorities and match them with national and regional policies. It aims to facilitate integration of public health priorities to PHC practice, and to support the reorganization of services, for strong health promotion focus, synergies with community care, and better coordination of care. During this session key aspects will be discussed using the Pecha Kucha style, to inform the audience about current progress and CIRCE-JA using short stories, also on EU policies and priorities, and the EU4Health support for PHC and public health integration. What is urgently needed at EU-level when it comes to health systems’ strengthening in the post-COVID-19 period and why is PHC critical in this respect? How can the CIRCE-JA developments inform the ongoing transfer and future efforts for the selected BPs in terms of a robust scientifically evidence-based approach? How does the policy dialogue CIRCE-JA is establishing locally, nationally, regionally, supports not only the JA’s sustainability, but all future implementation efforts for PHC? Finally, a brief interaction with the audience will take a place to allow attendees to discuss on key priorities and challenges in their own settings and practice, including the barriers and difficulties that they have initially identifies in the implementation efforts. The output of this interaction will also inform the initial steps towards the establishment of the final deliverable of CIRCE-JA, i.e., the European Primary Healthcare Observatory, to sit on the European Commission’s Health Policy Platform. Key messages • Health systems’ strengthening necessitates strong PHC. CIRCE-JA delivers state-of-the-art tools and brokers policy dialogue to achieve it across Europe. • Several barriers and issues that facilitate the transferring process have been identified in the first implementation of this European initiative. Speakers/Panelists Christos Lionis CSFM & HSR-PH Lab, Faculty of Medicine, University of Crete, Heraklion, Greece Ana M Carriazo Regional Ministry of Health and Families of Andalusia, Seville, Spain Alice Borghini National Agency for Regional Health Services AGENAS, Rome, Italy Radivoje Pribakovic NIJZ, Ljubljana, Slovenia

Associations between general practice and outpatient care continuity in people with multimorbidity

Abstract Background Relational continuity in primary and secondary care is linked to better health outcomes for patients, but it is unclear whether metrics of continuity in each setting are associated. Our study examined the association between relational continuity in general practice (GP) and continuity of hospital outpatient specialties in people with clusters of multimorbidity. Methods We used GP records from the Clinical Practice Research Datalink, linked to Hospital Episode Statistics outpatient records. Included were patients ≥18 years, with two or more of 212 Long-Term Conditions (LTCs), registered throughout 2019 and with at least three GP and three outpatient appointments. The Continuity of Care Index (COCI) was calculated separately for visits to the same i) GP and ii) hospital specialty, where 0 represents no continuity and 1 represents all visits to the same GP or specialty. We assessed the association between the indices using univariable and multivariable fractional logit regression. We calculated expected COCI scores for each LTC and assessed variation in the COCI between LTCs assigned to one of 15 clusters of co-occurring diseases derived previously. A sensitivity analysis repeated analysis using the Sequential Continuity (SECON) score, which captures longitudinal continuity. Results Of 1,135,903 patients, 56.2% were ≥60 years. The median (IQR) COCI in GP was 0.22 (0.11-0.40) and in outpatients was 0.33 (0.20-0.52). Although statistically significant (p < 0.001) the relationship between the two measures was clinically insignificant in both univariable and multivariable models. No strong relationships were found between COCI scores and LTC clusters. Similar patterns were found using the SECON score. Conclusions We found no strong association between continuity of care in GP and outpatient settings, and no clear patterns with LTC clusters. This suggests that lack of continuity in secondary care is not compensated for by increased continuity of care in primary care. Key messages • We found no meaningful association between measures of continuity of care in general practice and hospital outpatient settings. • Our findings suggest that lack of continuity of outpatient care is not compensated for by increased continuity in primary care.

How can the detection of AF be improved? Insights from patient journeys and primary care clinicians

Abstract Background Atrial fibrillation (AF) is underdiagnosed and it is estimated that a third of people with AF remain undiagnosed. AF is complex to detect because it can be intermittent and some patients are asymptomatic. When symptoms are present they can be non-specific. In the absence of a screening programme to detect AF it is important to identify ways to improve its detection of AF in order to reduce the risk of AF-related stroke. Purpose We conducted a qualitative study in primary care to explore the patient path to diagnosis of AF and identify ways to improve detection Methods We recruited patients with a recent diagnosis of AF (< 6 months) and interviewed them to understand their path to diagnosis. We interviewed GPs and practice nurses to explore their experience of detecting AF in primary care. The interviews were audio-recorded and transcribed, and the data were analysed using framework analysis. Results Thirty patients and ten primary care clinicians were interviewed. The presence and nature of symptoms experienced by patients and how they interpreted these were significant in the pathways to diagnosis. Patients with acute symptoms presented to A &E and had a quick diagnosis while asymptomatic patients were diagnosed incidentally. Patients with non-specific symptoms generally did not perceive the symptoms as serious, and many delayed seeing a healthcare professional. Their experiences in primary care aligned with findings from interviews with primary care clinicians, who acknowledged AF may not necessarily be the initial suspicion when a patient presents with certain non-specific symptoms. Primary care clinicians described narratives of good practice in the form of opportunistic pulse palpation, as well as challenges of detecting AF in primary care. These included lack of access to 24-hour ambulatory ECG in primary care and limited opportunities to detect AF due to healthcare assistants taking on more responsibilities. Conclusions A number of opportunities to improve the detection of AF can be drawn from these findings. Public education about AF, its signs and symptoms would increase patient knowledge and presentation to healthcare professionals. Standardizing good practice of opportunistic pulse palpation in primary care and training healthcare assistants to perform this is also indicated. Access to 24-hour ambulatory ECG in primary care will reduce delays in diagnosis. Further research on which patients are likely to have undiagnosed AF will facilitate detection in primary care.

Primary eye care service provision ability of mid-level healthcare providers in southern Ethiopia

Background: The provision of eye care services by trained and well-capacitated primary care providers in the rural community will contribute significantly to the reduction of avoidable blindness.Aim: This study aimed to investigate mid-level healthcare providers’ knowledge and skills capacity to provide primary eye care services.Setting: The study was conducted in four districts of southern Ethiopia.Methods: An institution-based descriptive cross-sectional study was conducted among randomly selected mid-level healthcare providers from August to October 2023. A self-administered questionnaire was used to collect data. Data entry and analysis were performed using Epi info version 6 and SPSS version 28 software. Descriptive statistics and logistic regression models were used in the analysis.Results: A total of 103 mid-level healthcare providers were involved in the evaluation with a response rate of 99%. Of the study respondents, less than half (48.5%) were found to have intermediate-level ability to provide primary eye care services. Serving more patients per month (p 0.001), receiving additional training (p 0.005) and having a first degree (p 0.001) were found to have a statistically significant association with the ability to provide primary eye care services.Conclusion: Most primary eye care service providers had a significant knowledge and skill gap. Capacity-building training aimed at enhancing the ability of primary eye care service providers need the appropriate attention.Contribution: This study presents the ability of mid-level healthcare workers to provide primary eye care services to support the elimination of avoidable blindness, resulting in improved quality of life.

Stakeholder involvement in the development of a serious game for and with healthcare professionals

Abstract Increasing pressure on the quality, accessibility and affordability of Dutch health services underlines the need for integrated approaches to healthcare that include lifestyle as preventive measure. Integrated healthcare requires coordinated collaboration between healthcare providers, which is facilitated by the concept of Positive Health as a unifying language. To support primary care providers (PCP) in developing knowledge and skills related to lifestyle as prevention, interdisciplinary collaboration and the concept of Positive Health, we are developing education in the form of a serious game: Game2Connect. Co-creation by active involvement of a consortium of educational institutes, healthcare organisations, a game developer, and PCP as end-users of Game2Connect plays a key role in its development. Data from interviews with PCP (on barriers and facilitators for health-promoting and collaborative behaviours), healthcare recipients (on input for case studies) and consortium meetings were incorporated into an initial version of Game2Connect, which is currently being piloted to assess and improve its utility and usability. Pilot sessions included an observed playthrough, followed by a usability questionnaire and a semi-structured group discussion. So far, 2 pilot sessions were held with consortium members (n = 16), and 3 sessions were held with PCP (n = 22). Learning indicators (e.g. PCP clarifying fellow players’ misconceptions) were observed in all sessions. Usability scores indicate high levels of challenge, content relevance, and positive affect, ranging between 3.3-3.6 on a 4-point scale. Qualitative feedback from group discussions resulted in the development of new case studies to appeal to a broader range of PCP, and the adjustment of a goal-setting exercise as a game component to encourage its use. These results suggest that serious gaming may be a viable and engaging method to educate PCP, especially when developed in active collaboration with stakeholders.

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

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

Oncofertility in primary health care: the role of the Portuguese family doctor

Abstract Background The increasing number of cancer cases diagnosed at young ages and the impact of the disease and treatments on reproductive function have led to the development of Oncofertility. While oncologists typically lead these discussions, family doctors, as primary care providers, also play a crucial role. This study aims to assess family doctors’ knowledge, attitudes, and practices regarding fertility preservation in cancer patients. Methods This cross-sectional study, conducted between April 2023 and March 2024, surveyed 351 General and Family Medicine doctors from the Portuguese Northern Regional Health Administration. The questionnaire, consisting of 15 questions, assessed sociodemographic profiles, knowledge, attitudes, and practices. Data were analyzed using descriptive statistics and multivariate logistic regression. Results Most participants were female (80.5%) and under 40 years old. The majority (91.5%) had treated fewer than 10 cancer patients under 40 in the past two years. Key barriers included lack of knowledge (63.3%), time constraints (57.0%), and patient age (18.5%). Male physicians were more likely to address specific fertility concerns (OR 2.239) and less likely to view patient age as a barrier (OR 0.459). Physicians aged 31-35 were less likely to discuss fertility preservation (OR 0.553) but more likely to address it in the first consultation (OR 2.969). Urban-based physicians were less likely to discuss fertility preservation (OR 2.099). Only 9.1% always discussed fertility preservation before treatment, 27.6% did so sometimes, and 63.3% never discussed it. Conclusions There are significant gaps in the knowledge and practices of family doctors regarding fertility preservation for cancer patients. Targeted training and resources are urgently needed to support family doctors in effectively discussing fertility preservation, crucial for improving the quality of life of young cancer patients wishing to preserve their fertility. Key messages • Empowering Portuguese family doctors to address fertility concerns in cancer patients contributes to comprehensive oncofertility care, improving patient outcomes and quality of life. • Integrating oncofertility support with Portuguese family doctors strengthens primary care, ensuring discussion of fertility preservation is considered as part of cancer treatment planning.

Primary care utilization in Bulgaria: some effects of the COVID-19 pandemic

Abstract Background Disruptions to primary care provision during the pandemic set back prior advancements in screening and chronic disease management. Delays in routine vaccination added to preexisting hesitancy and sustained the downward trend in vaccination rates. The study examines the magnitude and duration of primary care disruptions in Bulgaria between 2020 and 2022. Methods The impact of the pandemic on primary care is assessed using administrative data from the National Health Insurance Fund covering the annual number of primary care services. To evaluate the effect on healthcare utilization, the average number of check-ups per person during the pandemic is compared to a pre-pandemic period (2017-2019). Results After the onset of the pandemic, all visits declined significantly on an annual basis. In 2020, overall prophylactic check-ups dropped by 6-13% and remained lower than the baseline until 2022. Initial figures for 2023 suggest some recovery, while specific services are likely to experience an ongoing decrease. During the pandemic, the average number of prophylactic examinations for children fell between 6.9 and 9.3%. In 2022, there was a modest resumption, although these services did not reach the preceding levels. Adult prophylactic visits declined by approximately 10-12% between 2020 and 2021, but following a U-shaped pattern, they rebounded in 2022. Visits associated with chronic diseases experienced a drop of 7.8% in 2020 and continued to decrease in the next two years. Child vaccination was affected for a shorter period. In 2022, the coverage for most vaccine-preventable diseases was close to the pre-pandemic levels. However, the uptake of MMR and pneumococcal vaccines failed to demonstrate a clear path to recovery. Conclusions During the pandemic, a considerable drop in primary care utilization has been recorded. Effective recovery requires sustained service delivery and a rapid post-lockdown rebound to mitigate the negative impact on health outcomes. Key messages • Primary care needs additional recovery measures to prevent long-term harmful impacts on health outcomes. • Investing in service delivery innovations can boost resilience during disruptive events.

Identifying low-risk chest pain in out-of-hours primary care: the diagnostic performance of preHEAR and preHEART scores based on two European cohorts

Abstract Background Distinguishing cardiac from non-cardiac acute chest pain presents a diagnostic challenge. Risk stratification tools, such as the HEART score, have been developed for decision support for hospital-based settings. For prehospital settings, the preHEART score was developed as an alternative to the HEART score, with refinements made to meet prehospital conditions, as illustrated in Figure 1. While promising for use by emergency medical services, the diagnostic performance in primary care is unknown. Purpose In this study, we aim to evaluate the preHEART score (with and without high-sensitivity cardiac troponin (hs-cTn)) as a risk stratification tool to rule out acute myocardial infarction (MI) in patients evaluated in out-of-hours primary care. Methods We relied on retrospective data from two cohorts, namely, the OUT-ACS study involving 1,711 consecutive patients (47.7% female, median age: 56 (25th-75th percentiles: 45-68)) evaluated at a Norwegian primary care emergency centre from 2016-2018; and the TRACE study involving 664 consecutive patients (56.9% female, median age: 48 (25th-75th percentiles: 32-67) from a Dutch primary care emergency centre in 2017. We evaluated the preHEAR (OUT-ACS & TRACE without hs-cTn) and preHEART scores (OUT-ACS). The threshold of ≤3 points was considered low-risk and previously determined as optimal for rule-out purposes. The primary outcome was the diagnostic performance for ruling out MI at the index episode, and the secondary outcome was the composite of 90-day all-cause death or MI. Results In the OUT-ACS cohort, 61 (3.6%) patients were diagnosed with an MI; for the TRACE study, MI was diagnosed in 20 (3.0%) patients. The percentage of patients deemed at low risk by preHEAR was 49.3% (n=843) and 82.7% (n=549) for OUT-ACS and TRACE, respectively. For preHEART, only 33.6% (n=575) of OUT-ACS patients were deemed low-risk. As shown in Figure 2, the corresponding sensitivity/specificity indices for index MI were 63.9%/49.8% (OUT-ACS) and 65.0%/84.2% (TRACE) for preHEAR and 93.4%/34.6% for preHEART. Positive predictive values were low (preHEAR 5.0-11.3%, preHEART 5.0%), whereas negative predictive values were high (preHEAR 97.4-98.7%, preHEART 99.3%). For the secondary outcome, similar diagnostic performance metrics were found. All missed MI cases (n=4) in the low-risk preHEART group were female. Conclusion The preHEAR and preHEART scores did not result in adequate rule-out safety for an emergency primary care setting despite a low a priori MI risk. Moreover, the score appears to underestimate the risk for MI in females.preHEAR(T) risk scoresPerformance of the risk scores

Delivering remote monitoring, through primary care, to patients with chronic heart failure

Abstract It is estimated that over 90,000 patients in Ireland have a diagnosis of Heart Failure. The HeartCare at Home study was commenced in 2021 as a collaboration between Centric Health and Roche Diagnostic. The study aimed to examine the feasibility of implementing a remote monitoring programme for patients with heart failure, through primary care, and the impact on hospitalisations, A&E attendances, and GP visits. Patients were referred to the study by their GP. Patients were provided with a blood pressure monitor, weighing scales and smart device in line with the study protocol. The remote monitoring app, a CE-certified Medical Device Class IIa, was provided by Luscii Healthtech. Patients were requested to input their weight, blood pressure, heart rate and symptoms for two weeks after a undergoing a clinical onboard to establish a baseline. Thereafter, readings were entered by patients twice weekly. Patients participated for a minimum of 12 months. If measurements fell outside pre-determined parameters or a deterioration was noted, the team was alerted through the Luscii app dashboard. Where clinically appropriate and in line with cardiologist approved protocols, the team supported the patient to titrate their diuretic medication at home for a maximum of 3 days, with continuous daily monitoring. The patient’s GP was informed of all deteriorations and changes in the patient’s condition and of all recommendations made by the HeartCare at Home team. One hundred and sixty-two patients were onboarded to the programme while 120 patients completed one year follow up (42% female; median age 76 years, range 31-100 years). Thirty five percent of patients had a diagnosis of HFrEF, 13% HFpEF, and 6% HFmrEF while 43% were undifferentiated. Seventy five percent of patients had a NYHA I or II classification. Over 95,000 clinical measurements were recorded through the Luscii app over the course of the study. Of the decompensations managed directly by the HeartCare at Home team with medication titration and daily monitoring, 70% were clinically resolved following the HeartCare at Home protocol. Adherence to inputting monitoring data remained strong throughout the intervention period with over 89% of participating patients continuing to upload readings as scheduled at 12 months. Using established and secure communication pathways, such as HealthLink and Healthmail, the clinical team were able to interact with each patients GP to ensure continuity of care and optimised patient treatment. The HeartCare at Home study demonstrates the feasibility of implementing a remote monitoring programme through primary care. Remote monitoring with direct access to clinical support has potential benefits for patients, clinicians, and the health service at large. Further research, in a larger cohort, and examination of the cost of implementation of remote monitoring in primary care, is warranted.

Seeing and believing: behavioural insights from implementing an artificial intelligence-enabled stethoscope in primary care

Abstract Background • Early detection and treatment of cardiovascular disease (CVD) improves survival, quality of life and health economic outcomes (1) • Despite evidence of effectiveness, health systems fail to implement technologies for early detection of CVD sustainably, limiting their public health impact (2). This challenge may limit the full potential of artificial intelligence (AI) in healthcare (3). • An AI-enabled stethoscope can detect reduced left ventricular ejection fraction (LVEF), atrial fibrillation (AF) and structural cardiac murmurs during fifteen seconds of conventional cardiac examination (4) • The determinants of uptake, sustained use and clinical impact of implementing the AI-stethoscope in primary care are unknown. Purpose • To implement the AI-stethoscope in a UK primary care system • To measure rates of utilisation and their association with potential disease detection • To characterise the adoption patterns of an AI technology in primary care Methods • TRICORDER is a cluster randomised controlled trial and implementation study. • Clinicians in the intervention arm receive in-person training in use of the AI-stethoscope and are remunerated for this training time. • Clinicians using the AI-stethoscope in routine care are supported by a clinical guideline and data privacy approvals from the regional health service executive board. • GP practices are not remunerated for using the AI-stethoscope • Anonymised utilisation and AI disease detection rates were extracted from the manufacturer’s cloud database from 31st October 2023 to 25th February 2024. We performed linear regression to characterise use over time. Results • 59 practices were randomised and onboarded to the intervention arm between 31st October and 3rd December 2023, all using the stethoscope at least once, for a total of 1,555 unique patient examinations (3,253 total recordings), over a median of 90 days. • The mean (±SD) number of recordings per practice per week was 5.45 (±5.68). • There were 32 practices with utilisation data for at least 12 weeks. There was a weakly positive utilisation trend (r = 0.042; P= >0.05, Figure 1A), with no significant difference in rates of utilisation at 4, 8 and 12 weeks (Figure 1B). • There were 159 (4.88%), 89 (2.74%) and 102 (3.13%) abnormal AI flags for reduced LVEF, AF and structural murmurs, respectively. • We characterised three groups by patterns of use (Table 1). There were no significant differences between mean rates of abnormal AI findings between groups (ANOVA p = 0.43). Conclusions • Implementation of an AI-stethoscope in primary care is feasible and was associated with stable utilisation. • The proportion of abnormal AI findings are consistent with modelled detection gap of the target conditions in the UK, and would not consequentially overwhelm downstream health services. •The proportion of abnormal AI findings did not significantly differ between low and high-utilisation groups.Table 1Figure 1

Cardiac risk confrontation in primary care as a teachable moment towards improved health outcomes

Abstract Background Urgent life events, such as acute coronary events, can evoke a teachable moment (TM) for lifestyle change. This study aims to investigate whether less urgent events, such as being confronted with an increased risk of cardiovascular disease, can evoke a TM, what psychosocial factors are associated with it, and whether experiencing such a TM predicts improved health outcomes. Methods The study included 114 patients who were informed about their elevated cardiovascular risk during a primary care visit. Participants completed a survey assessing whether they experienced a TM and several psychosocial factors linked to experiencing it: perceived risk, affective impact, changed self-concept. Participants monitored their weight and blood pressure for six months using an at-home self-monitoring device. Univariate and multivariate regression analyses were conducted to examine the associations between the psychosocial factors and the lifestyle change intentions with changes in blood pressure and weight. Results Of the participants, 55.3% experienced increased lifestyle change intentions. Lower risk perception ((B = -0.27; CI = -0.39-(-0.15)) and higher change in self-concept (B = 0.34; CI = 0.23-0.44) were associated with higher intention to change lifestyle. Higher risk perception (B = 0.23; CI = 0.06-0.42) and higher change in self-concept (B = 0.54; CI = 0.37-0.72) predicted a lower weight reduction at six months. A higher change in self-concept predicted a higher blood pressure reduction (B = -3.32; CI = -6.55-(0.09)). Lastly, a higher lifestyle change intention predicted bigger reductions blood pressure (B = -5.04; CI = -9.08-(-0.29)). Conclusions Results suggest that less urgent cardiac events, such as a confrontation with an increased cardiac risk, can be experienced as a TM that urges lifestyle change intentions and affects health outcomes. Risk confrontations in primary care therefore offer a unique opportunity to provide lifestyle counseling at the right moment. Key messages • A confrontation with an increased cardiac risk in primary care can be experienced as a teachable moment. • Experiencing a teachable moment after a cardiac risk confrontation in primary care affects health outcomes.

Needs Assessment for Primary Care for Best Practice Implementation: The CIRCE Joint Action

Abstract Introduction CIRCE is a Joint Action (JA) supporting the transfer of six best practices (BPs) to new primary care settings in Europe. High-quality needs assessment can set the foundation for strong planning and implementation of the CIRCE-JA best practices in these new primary care settings. Methods A needs assessment tool was developed based on the TO-REACH knowledge transfer framework and learnings from a scoping review of international knowledge transfer frameworks. The needs assessment provides structured tool for local sites to self-assess the alignment of the BP with local priorities, readiness of the local site to successfully implement the BP, the availability of necessary leadership, resources and partnerships, and an examination of barriers to local BP implementation and mitigation strategies. Results Twenty-six CIRCE-JA teams completed the needs assessments. Local teams identified the CIRCE-JA BPs were value-adding and aligned with local priorities. Cross-cutting barriers were identified which were common among the six CIRCE-JA best practices across five thematic areas: (1) provider level, (2) intervention level, (3) health system/policy level, (4) partnership and physical resources and (5) information technology. The needs assessment supported primary care sites with a structured approach to planning for transfer of BPs to their local setting that is based on established international best practices and knowledge transfer frameworks including early identification of barriers and mitigating strategies. Conclusions The needs assessment has supported teams with conducting a self-assessment and informing initial planning for adoption of the BP in their local primary care practice. Given the importance of the local needs assessment to high quality implementation of BP the CIRCE-JA experience with local needs assessment may provide learnings for future BP transfer initiatives. Key messages • Local needs assessment supports the transfer of best practices to primary care settings, which is a critical component of service transformation during the post-COVID-19 period. • For successful transfer of best practices in primary care, it is vital to give to examine such as provider capacity, available human resources, health policy, and information technology.

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&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&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.

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

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