Use Of Primary Care Services Research Articles

Use of primary health care services among children and adolescents with cerebral palsy.

Use of primary health care services among children and adolescents with cerebral palsy.

Using electronic health records in assessing the prevalence of hypertension in Kyrgyzstan

Abstract Background Non-communicable diseases are an increasing challenge in Kyrgyzstan as well as in other parts of Central Asia. However, there is very little epidemiological data on disease burden in the country. The development of electronic health records in primary health care provides an opportunity to assess the disease incidence and prevalence among patient population. Methods All patients with hypertension (HT) diagnoses (ICD-10 I10-I15) were identified from electronic health records used in primary health care in Kyrgyzstan from years 2021, 2022 and 2023 from all 7 regions and Bishkek and Osh cities (n = 132621-152743). Each year, all patients diagnosed with HT during that year or in previous years were included, while those who had passed away were excluded. The incidence and prevalence of patients was calculated using as denominator both the patients who had visited the services as well as registered patients. Results The prevalence of patients with hypertension calculated using patients with service use as denominator varied by region between 10.2% to 14.0% and was pretty stable during the observed period. The prevalence was the lowest in Chui region and the highest in Bishkek city. When the prevalence was calculated using the registered patient population the prevalence was only between 1.5% to 3.1%. Conclusions The observed prevalences were notably lower compared with data from WHO Steps surveys, which have reported a hypertension prevalence more than 40% among individuals aged 25 to 64. It is known that only approximately 25% of the population in Kyrgyzstan utilize primary healthcare services, with maternity care comprising the largest portion. This factor, coupled with cases that go undiagnosed, could potentially account for the observed low prevalence in electronic patient data. However, the electronic patient records provide useful information on diagnostics and disease burden in the country that can be used in developing the services. Key messages • Electronic health records have developed quickly in Kyrgyzstan and enable extraction of patient data from primary health care. • The low use of primary health care services complicates the use of register data in assessing the disease prevalences.

Investigating the pattern of prostate specific antigen screening among E-cigarette smokers within the behavioral risk factor surveillance system

Introduction and objectivesE-cigarettes use has recently increased, even among older individuals quitting smoking. Though past studies suggest tobacco smokers may avoid cancer screening, the relationship between e-cigarette uses and preventive health behaviors like prostate specific antigen screening is uncertain. We assessed the relationship between self-reported e-cigarette smoking and prostate specific antigen screening utilization among US adults with a history of e-cigarette use. Materials and methodsWe included men aged 50–69 years, who provided responses regarding PSA screening receipt and smoking status, from Behavioral Risk Factor Surveillance System 2020 and 2022 surveys. Primary outcome was PSA screening receipt. Multivariable regression model was performed to investigate the association between smoking status (never-smokers, current or former e-cigarette smokers, current or former tobacco smokers) and PSA screening. ResultsWe included a weighted population of 8.1 million men aged 50–69. 2.3 million (28.3%) received PSA screening. 3.9 million (48.2%) were never-smokers. 1.3 million (16.6%) were from e-cigarettes smokers group, and 2.9 million (35.2%) were from tobacco smokers group. E-cigarettes smokers were less likely to receive PSA screening within last 2 years (0.76 [0.66–0.88]) than never-smokers. No significant difference in PSA screening was detected between never-smokers and tobacco smokers (0.91 [0.82–1.02]). E-cigarette smokers were less likely to receive PSA screening within the selected time frame (0.84 [0.72–0.97]) than tobacco smokers. When examining potential mediation by primary care visits, e-cigarette smokers were less likely to have had a check-up visit in past 2 years than tobacco smokers (0.77 [0.65–0.92]). ConclusionsE-cigarette smokers were less likely to undergo PSA screening than never-smokers and tobacco smokers, possibly due to reduced use of primary care services.

Digitalised primary care in the UK: a qualitative study of the experiences of minoritised ethnic communities.

Barriers to accessing and using primary care services among minoritised ethnic communities have been extensively evidenced in the UK. However, the impact of the rapid digitalisation of these services on these communities remains under-researched. To explore the impact of digitalisation on access to and use of primary care services among minoritised ethnic communities. Underpinned by a critical realist intersectional approach, and employing qualitative research methods, this study explores minoritised ethnic individuals' experiences of digital primary care in the UK. In total, 100 minoritised ethnic adults who identify as Black African, Black Caribbean, Bangladeshi, Indian, Pakistani, Chinese, and of mixed or multiple ethnic heritage in four sites in the UK were purposively recruited and interviewed. Interviews were thematically analysed to increase understanding of how individuals' ethnicity intersects with other characteristics (for example, language, age, gender, socioeconomic status) to identify constraints and enablements to accessing health care. Minoritised ethnic individuals' access to digital primary care is impeded by factors such as digital precarity (for example, inadequate devices, internet connectivity, and digital literacy skills), a lack of language support, and staff shortcomings in responding to ethnically diverse populations. Intergenerational support and bespoke offerings by general practices in some areas enable some individuals to overcome some of the constraints. The rapid digitalisation of primary care services is replicating and potentially exacerbating barriers to using these services among minoritised ethnic communities, a finding that merits urgent attention by practitioners and policymakers.

A qualitative study of negative sociocultural experiences of accessing primary health care services among Africans from refugee backgrounds in Australia: implications for organisational health literacy

BackgroundPrimary health care is the first point of contact for patients from refugee backgrounds in the Australian health system. Sociocultural factors, including beliefs and value systems, are salient determinants of health literacy and access to primary health care services. Although African refugees in Australia have diverse sociocultural backgrounds, little is known about the influence of sociocultural factors on their experiences of accessing primary health care services. Guided by the theoretical framework of access to health care, this study examined from the perspective of African refugees how culturally and religiously conditioned, constructed and bound health beliefs, knowledge and practices influence their experiences of access to, acceptance and use of primary health care services and information in Australia.MethodsThis exploratory, qualitative study involved 19 African refugees from nine countries living in New South Wales, Australia. Semi-structured interviews were conducted and recorded using Zoom software. The interviews were transcribed verbatim and analysed using a bottom-up thematic analytical approach for theme generation.ResultsFour main themes were identified. The themes included: participants' experiences of services as inaccessible and monocultural and providing information in a culturally unsafe and insensitive manner; the impact of the clinical care environment; meeting expectations and needs; and overcoming access challenges and reclaiming power and autonomy through familiar means. The findings generally support four dimensions in the access to health care framework, including approachability, acceptability, availability and accommodation and appropriateness.ConclusionAfrican refugees experience significant social and cultural challenges in accessing primary health care services. These challenges could be due to a lack of literacy on the part of health services and their providers in servicing the needs of African refugees. This is an important finding that needs to be addressed by the Australian health care system and services. Enhancing organisational health literacy through evidence-informed strategies in primary health systems and services can help reduce disparities in health access and outcomes that may be exacerbated by cultural, linguistic and religious differences.

Comorbidities and use of health services in people with diabetes mellitus according to risk levels by adjusted morbidity groups

BackgroundPeople with diabetes mellitus frequently have other comorbidities and involve greater use of primary and hospital care services. The aim of this study was to describe the comorbidities and use of primary and hospital care services of people with diabetes according to their risk level by adjusted morbidity groups (AMG) and to analyse the factors associated with the utilisation of these services.MethodsCross-sectional study. People with diabetes were identified within the population of patients with chronic conditions of an urban health care centre by the AMG stratification tool integrated into the primary health care electronic clinical record of the Community of Madrid. Sociodemographic, functional, clinical characteristics and annual health care services utilisation variables were collected. Univariate, bivariate and Poisson regression analyses were performed.ResultsA total of 1,063 people with diabetes were identified, representing 10.8% of patients with chronic conditions within the health centre. A total of 51.4% were female, the mean age was 70 years, 94.4% had multimorbidity. According to their risk level, 17.8% were high-risk, 40.6% were medium-risk and 41.6% were low-risk. The most prevalent comorbidities were hypertension (70%), dyslipidaemia (67%) and obesity (32.4%). Almost 50% were polymedicated. Regarding health services utilisation, 94% were users of primary care, and 59.3% were users of hospital care. Among the main factors associated with the utilisation of both primary and hospital care services were AMG risk level and complexity index. In primary care, utilisation was also associated with the need for primary caregivers, palliative care and comorbidities such as chronic heart failure and polymedication, while in hospital care, utilisation was also associated with comorbidities such as cancer, chronic obstructive pulmonary disease or depression.ConclusionsPeople with diabetes were older, with important needs for care, many associated comorbidities and polypharmacy that increased in parallel with the patient’s risk level and complexity. The utilisation of primary and hospital care services was very high, being more frequent in primary care. Health services utilization were principally associated with functional factors related to the need of care and with clinical factors such as AMG medium and high-risk level, more complexity index, some serious comorbidities and polymedication.

Patient and caregiver characteristics associated with differential use of primary care for children and young people in the UK: a scoping review

ObjectiveTo systematically map evidence to answer the research question: What is the relationship between the characteristics of children and young people (CYP) or their caregivers and primary care service use...

What supports are people with intellectual disability living in group homes provided to access health care? A case study

AbstractBackgroundPeople with intellectual disabilities living in group homes often have complex health needs, are high health service users and need support from their service provider to access health services. In Australia, little is known about the types and amounts of these supports.MethodsA case study was conducted on a large Western Australian disability provider of group homes to 160 people with intellectual disability. Over an 18‐month period, including during the COVID‐19 pandemic, the study quantified health service use in hospital‐ and community‐based settings, ways by which the person was supported to access health care and the impact on other people supported by the provider. Economic costs of supporting access to health services were estimated.FindingsOverall, the disability provider supported 160 people in accessing health services an average of 23 times each (n = 3617, median = 20, interquartile range = 10–33) over the 18 months. Support included staff attending with the person (96%), following up with guardian/decision‐maker (50%), additional resourcing via overtime or staff backfills (6%) and transport (94%). The average cost of supporting one health visit was estimated at $78.51 AUD (2021). Impact on the person's household included loss of opportunity for housemates (30%), reduced supervision within the home (79%) and longer timeframes to complete care needs (32%). The impact of COVID‐19 restrictions saw a reduction in allied and mental health service use that did not return to prepandemic levels following the cessation of restrictions. Primary care, specialist, outpatient, pathology and emergency service use was also lower in the postrestriction period compared to the prepandemic period.ConclusionsFor people living in group homes, the disability provider plays an essential role in supporting health service access, primarily through the provision of support staff and transport. The change in health service utilisation following the COVID‐19 restriction period indicates that altered health system priorities can potentially exacerbate access inequality for people with intellectual disability.

A longitudinal cohort study on the use of health and care services by older adults living at home with/without dementia before and during the COVID-19 pandemic: the HUNT study.

Older adults and people with dementia were anticipated to be particularly unable to use health and care services during the lockdown period following the COVID-19 pandemic. To better prepare for future pandemics, we aimed to investigate whether the use of health and care services changed during the pandemic and whether those at older ages and/or dementia experienced a higher degree of change than that observed by their counterparts. Data from the Norwegian Trøndelag Health Study (HUNT4 70 + , 2017-2019) were linked to two national health registries that have individual-level data on the use of primary and specialist health and care services. A multilevel mixed-effects linear regression model was used to calculate changes in the use of services from 18months before the lockdown, (12 March 2020) to 18months after the lockdown. The study sample included 10,607 participants, 54% were women and 11% had dementia. The mean age was 76years (SD: 5.7, range: 68-102years). A decrease in primary health and care service use, except for contact with general practitioners (GPs), was observed during the lockdown period for people with dementia (p < 0.001) and those aged ≥ 80years without dementia (p = 0.006), compared to the 6-month period before the lockdown. The use of specialist health services decreased during the lockdown period for all groups (p ≤ 0.011), except for those aged < 80years with dementia. Service use reached levels comparable to pre-pandemic data within one year after the lockdown. Older adults experienced an immediate reduction in the use of health and care services, other than GP contacts, during the first wave of the COVID-19 pandemic. Within primary care services, people with dementia demonstrated a more pronounced reduction than that observed in people without dementia; otherwise, the variations related to age and dementia status were small. Both groups returned to services levels similar to those during the pre-pandemic period within one year after the lockdown. The increase in GP contacts may indicate a need to reallocate resources to primary health services during future pandemics. The study is registered at ClinicalTrials.gov, with the identification number NCT04792086.

Adolescent and caregiver perceptions of addressing mental health in inflammatory bowel disease.

Adolescents with inflammatory bowel disease (IBD) are at an increased risk of anxiety and depression compared to peers, but availability of mental health services in IBD clinics does not meet patients' needs, and use of primary care services for mental health screening and care is low. This study provides qualitative data regarding adolescent and caregiver perspectives on addressing mental health in IBD. Interviews were conducted with adolescents with IBD and caregivers of adolescents with IBD. Interview transcripts were coded and analyzed for prominent themes. Thirteen adolescents and fourteen caregivers were interviewed. Three primary themes emerged: mental health stigma makes discussing it more difficult, physician-adolescent trust makes conversations about mental health easier, and asking about mental health directly can help adolescents feel comfortable. Adolescents and caregivers highlighted the importance of considering each patient and their family individually when choosing how to discuss mental health. Fostering trust with adolescents with IBD is vital to addressing mental health. While encouraging standardized screening is important, the most patient-centered approach to mental health involves considering families individually to identify and address mental health challenges. Given the increased risk of anxiety and depression in pediatric patients with IBD, all providers encountering these patients should be equipped to discuss mental health non-judgmentally.

Equity and unmet need of non-communicable diseases services in Saudi Arabia using a National Household Survey (2019).

Saudi Arabia is implementing a comprehensive health system transformation in health services provision, governance, and financing. Given the high burden of non-communicable diseases (NCD), a key objective of the transformation is to integrate NCD prevention and treatment into primary care. The study objectives were to assess primary care service use for treatment of NCDs, to quantify existing inequities in preventive services utilization, and to identify regional and sociodemographic factors associated with these inequities. Using the 2019 Kingdom of Saudi Arabia World Health Survey, multivariable logistic regression models were conducted to identify predictors of utilization of primary care services for NCD prevention and treatment, unmet need among those with a diagnosis of diabetes, hypertension, or dyslipidemia, and unmet need in breast and cervical cancer screening. Among those with an NCD diagnosis, living in a high-income household was associated with a lower probability of having an unmet need compared to those in low-income households. Furthermore, rural residents were less likely to have an unmet need compared to urban residents (OR 0.58, p=0.029). Individuals without a perceived need for healthcare within the last 12 months had three times the probability of unmet need in comparison to those with such a perceived need (p<0.001). Women in all regions had a lower probability of ever having a mammogram compared to women in the central regions around Riyadh. Women with an education above a secondary level had five times the odds of undergoing cervical cancer screening and three times the likelihood of ever having a mammogram (P=0.012, p=0.02) than other women. Compared to women in low-income households, those in middle (OR 1.99, P=0.026), upper middle (OR 3.47, p<0.001), or high-income households (OR 2.59, p<0.001) had a higher probability of having had cervical cancer screening. Inequities in NCD treatment and prevention services' utilization in Saudi Arabia are strongly associated with region of living, population density, wealth, income, education and perceived need for health care. More research is needed to better understand the extent of unmet primary care needs for NCD and how to address the underlying contributing factors to access inequities.

Physical health, primary care utilization and long-term quality of life in borderline personality disorder: A 10-year follow-up study in a Spanish sample

ObjectiveWe aimed to study physical health and primary care utilization in the long-term course of borderline personality disorder (BPD) and their impact on quality of life (QOL) in a Spanish clinical sample. MethodsThis study is part of a longitudinal study following a clinical cohort with BPD. A total of 41 participants were re-evaluated at 10-year follow-up, when current medical conditions, primary care utilization, and quality of life were assessed. Comparative population data were extracted from the Catalan Health Survey ESCA. Results68% of BPD patients reported physical health problems, and 32% informed of multiple medical illnesses at follow-up. Higher rates of musculoskeletal disorders and frequent use of general practitioner (GP) consultations were reported by BPD patients compared to the general population. Differences in physical health and use of primary care services between remitted and non-remitted BPD patients were not significant. BPD remission was independently associated with better long-term QOL. Comorbid somatic diseases worsened the long-term QOL of non-remitted BPD patients. ConclusionChronic somatic conditions are prevalent in people with BPD and interact negatively with persistent BPD pathology, worsening their QOL in the long-term. Health care strategies in the assistance of long-lasting BPD patients are recommended.

Use of primary health care services among children and adolescents with cerebral palsy.

To investigate the use of general practitioners and urgent care centres (UCC) among children and adolescents with cerebral palsy (CP) compared to a control group, and per gross motor function level. Data on children with CP born 1996 to 2014 were collected from the Norwegian Quality and Surveillance Registry for Cerebral Palsy. A control group was extracted from Statistics Norway. The date and diagnosis codes for general practitioner and UCC contacts from 2006 to 2015 were collected from the Norwegian Control and Payment of Health Reimbursement Database. Incidence rate ratios (IRR) for the number of contacts per person-year with 95% confidence intervals (CI) were calculated using Poisson regression. Risk differences with 95% CI were used to compare cumulative diagnosis incidences between children with CP and the control group. The study included 2510 children (1457 males; 58.1%) with CP and 12 041 (7003 males; 58.2%) without CP (mean age in both groups 7 years 2 months, SD 4 years 8 months, range 0-19 years), with 336 250 contacts. Children with CP had more general practitioner (IRR 1.47; 95% CI 1.29-1.67) and UCC (IRR 1.30; 95% CI 1.13-1.50) contacts than children without CP, for all ages. IRRs remained unchanged when comparing children with CP in Gross Motor Function Classification System (GMFCS) levels I and II to children without CP. Among children with CP, contact increased as GMFCS levels increased, and they were in contact most often for respiratory and general and unspecified diagnoses. The risk for epilepsy was highest for those in contact with general practitioners. Children with CP, including those with less severe motor impairments, contacted general practitioners and UCCs more than children without CP. However, contact increased as gross motor impairment increased. They had contact for many diagnoses, mostly respiratory.

Primary and secondary care service use and costs associated with frailty in an ageing population: longitudinal analysis of an English primary care cohort of adults aged 50 and over, 2006-2017.

Frailty becomes more prevalent and healthcare needs increase with age. Information on the impact of frailty on population level use of health services and associated costs is needed to plan for ageing populations. To describe primary and secondary care service use and associated costs by electronic Frailty Index (eFI) category. Retrospective cohort using electronic health records. Participants aged ≥50 registered in primary care practices contributing to the Oxford Royal College of General Practitioners Research and Surveillance Centre, 2006-2017. Primary and secondary care use (totals and means) were stratified by eFI category and age group. Standardised 2017 costs were used to calculate primary, secondary and overall costs. Generalised linear models explored associations between frailty, sociodemographic characteristics. Adjusted mean costs and cost ratios were produced. Individual mean annual use of primary and secondary care services increased with increasing frailty severity. Overall cohort care costs for were highest in mild frailty in all 12years, followed by moderate and severe, although the proportion of the population with severe frailty can be expected to increase over time. After adjusting for sociodemographic factors, compared to the fit category, individual annual costs doubled in mild frailty, tripled in moderate and quadrupled in severe. Increasing levels of frailty are associated with an additional burden of individual service use. However, individuals with mild and moderate frailty contribute to higher overall costs. Earlier intervention may have the most potential to reduce service use and costs at population level.

Effectiveness of information and communication technology-based integrated care for older adults: a systematic review and meta-analysis.

Information and communication technology (ICT) is a key factor in advancing the implementation of integrated care for older adults in the context of an aging society and the normalization of epidemics. This systematic review aims to comprehensively evaluate the effectiveness of ICT-based integrated care for older adults to provide input for the construction of intelligent integrated care models suitable for the context of an aging population in China. A systematic review and meta-analysis were conducted using PubMed, Web of Science Core Collection, Scopus, MEDLINE, EBSCO, EMBASE, CINAHL with full text, ProQuest, and Cochrane Library databases, along with the Google Scholar search engine, for papers published between January 1, 2000, and July 25, 2022, to include randomized controlled trials and quasi-experimental studies of ICT-based integrated care for older adults. Two reviewers independently performed literature screening, quality assessment (JBI standardized critical appraisal tool), and data extraction. The results were pooled using a random effects model, and narrative synthesis was used for studies with insufficient outcome data. We included 32 studies (21 interventions) with a total of 30,200 participants (14,289 in the control group and 15,911 in the intervention group). However, the quality of the literature could be improved. The meta-analysis results showed that ICT-based integrated care significantly improved the overall perceived health status of older adults (n=3 studies, MD 1.29 (CI 0.11 to 2.46), no heterogeneity) and reduced the number of emergency department visits (n=11 studies, OR 0.46 (CI 0.25 to 0.86), high heterogeneity) but had no significant effect on improving quality of life, mobility, depression, hospital admissions and readmissions, or mortality in older adults, with a high degree of study heterogeneity. Narrative analysis showed that the overall quality of care, primary care service use, and functional status of older adults in the intervention group improved, but the cost-effectiveness was unclear. ICT-based integrated care is effective in improving health outcomes for older adults, but the quality and homogeneity of the evidence base need to be improved. Researchers should develop intelligent integrated care programs in the context of local health and care welfare provision systems for older adults, along with the preferences and priorities of the older adults.

Missing persons? Men's use of primary care services

Do men really avoid health care professionals and what impact does that have on their health? The author looks at the data and discusses some examples of how to encourage men to engage more with primary care services.

Experiences of primary eye care use among adults in Southern Ethiopia: A qualitative study.

Primary eye care (PEC) is an important component of comprehensive eye care services that allows communities to enjoy basic high-quality services. However, because of various determinants, communities do not use this service. This study aimed to explore and describe the experience of adults who used PEC services in the last 6 months. This study was carried out in four districts in southern Ethiopia from June to September 2023. An exploratory descriptive qualitative study design was used to understand the experiences of adults 40 years and older who had used PEC services. Six focus group discussions were conducted with a total of 48 participants. A nonprobability purposive sampling technique was used to draw participants. Data were analysed thematically using ATLAS.ti software version 23.2.2. Primary eye care service use experiences of adults 40 years and above were discussed in terms of three emerging themes: the experience of community service use, barriers to service and suggestions to improve service. The study identified poor access to services, service provider-related factors and quality and awareness gaps as barriers to the use of PEC services. Attention to PEC services, integration of eye care with other primary health care services, deployment of service providers, awareness creation and expansion of PEC units are needed to improve PEC service use. The findings will guide community-based intervention plans to reduce avoidable blindness and low vision, thus improving quality of life.

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models. To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care. Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices. Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support. The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions). Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures. Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

General practice service use at the end-of-life before and during the COVID-19 pandemic: a population-based cohort study using primary care electronic health records.

Globally, the COVID-19 pandemic has caused unprecedented strain in healthcare systems, but little is known about how it affected patients requiring palliative and end-of-life care from GPs. To evaluate the impact of the pandemic on primary care service use in the last 3 months of life, including consultations and prescribing, and to identify associated factors. A retrospective cohort study in UK, using data from the Clinical Practice Research Datalink. The study cohort included those who died between 2019 and 2020. Poisson regression models using generalised estimation equations were used to examine the association between primary care use and patient characteristics. Adjusted rate ratios (aRRs) and 95% confidence intervals (95% CIs) were estimated. A total of 44 534 patients died during the study period. The pandemic period was associated with an 8.9% increase in the rate of consultations from 966.4 to 1052.9 per 1000 person-months, and 14.3% longer telephone consultation duration (from 10.1 to 11.5 minutes), with a switch from face-to-face to telephone or video consultations. The prescription of end-of-life care medications increased by 6.3%, from 1313.7 to 1396.3 per 1000 person-months. The adjusted rate ratios for consultations (aRR = 1.08, 95% CI = 1.06 to 1.10, P<0.001) and prescriptions (aRR 1.05: 95% CI = 1.03 to 1.07, P<0.001) also increased during the pandemic. The pandemic had a major impact on GP service use, leading to longer consultations, shifts from face-to-face to telephone or video consultations, and increased prescriptions. GP workload-related issues must be addressed urgently to ease the pressure on GPs.

Use of primary health care services and mortality in older patients with type 2 diabetes with or without comorbidities

Objective This study aimed to examine primary health care (PHC) service utilization and mortality in older patients with type 2 diabetes (T2D) with or without comorbidities. Design and setting A cohort study in PHC in the city of Vantaa, Finland. Follow-up period was set between the years 2011 and 2018. Subjects PHC patients aged 60 years or more with a T2D were included. Main outcome measures Service utilization was defined as the number of face-to-face appointments and telephone contacts between a patient and general practitioner (GP) or nurse. The presence of comorbidities was defined using the Charlson Comorbidity Index (CCI). Mortality was assessed using hazard ratio (HR) and standardized mortality ratio (SMR). Results In total, 11,020 patients were included and followed for 71,596 person years. Mean age of the women and men in the beginning of follow-up were 71 and 69 years, respectively. The patients in the study cohort had a mean of eight appointments per person year to the GPs or nurses. Patients with T2D with comorbidities had more appointments than patients with T2D without comorbidities (incidence rate ratio (IRR) 1.44 [95% CI 1.39–1.49]). Increase in the number of all appointments reduced mortality in patients with T2D with and without comorbidities. Between patients with T2D with comorbidities and patients with T2D without comorbidities, the age and sex adjusted HR for death was 1.50 (95% CI 1.39–1.62). The SMR was higher in patients with T2D with comorbidities (1.83 [95% CI 1.74–1.92]) than in patients with T2D without comorbidities (0.91 [95% CI 0.86–0.96]). Conclusions In older patients with T2D, the presence of comorbidities was associated with increased use of PHC services and increased mortality. Increase in the number of appointments was associated with reduced mortality in patients with T2D with or without comorbidities. Key Points In older patients with T2D, it has not been studied whether and to what extend multimorbidity affects use of PHC services and mortality. The presence of comorbidities according to the Charlson Comorbidity Index (CCI) was associated with increased use of PHC services. The number of appointments to GPs or nurses was associated with reduced mortality in patients with T2D with or without comorbidities according to the CCI.