Primary Care Setting Research Articles

Regional variation in health care substitution for intrauterine device insertion: a retrospective cohort study

BackgroundRising health care costs are a major concern in most Western countries. The substitution of healthcare stands as a strategic approach aimed at mitigating costs while offering medical services in proximity to patients’ residences. An illustrative instance involves the migration of outpatient hospital care to primary care settings. Notably, the insertion of intrauterine devices (IUDs) can be safely executed within primary care contexts. In order to establish a pragmatic objective for the rate of IUD substitution, we conducted an evaluation of regional disparities in healthcare substitution pertaining to the insertion of intrauterine devices. Furthermore, we investigated disparities in the follow-up ultrasound and reinsertion of IUDs between primary and secondary healthcare environments.MethodsAll women who underwent IUD insertion in Dutch primary care (by general practitioners and midwives) and secondary care (by hospital physicians) between January 1, 2016, and December 31, 2020 were included. The main outcome measures were the case-mix adjusted IUD insertion rates at the regional level by care setting and the proportions requiring follow-up ultrasound and IUD reinsertion within three months.ResultsOf the 840,766 IUD placements, 74% were inserted in primary care and 26% in secondary care. The proportion inserted in primary care increased from 70% in 2016 to 77% in 2020. The observed substitution rate ranged from 58 to 82% between regions. Compared with health care professionals in primary care, those in secondary care performed more ultrasounds to verify IUD placement (23% vs. 3%; p-value < 0.01) and more IUD reinsertions within three months (6% vs. 2%; p-value < 0.01).ConclusionsIUDs are increasingly being inserted in Dutch primary care, with peak regional IUD insertion care substitution rates at ≥ 80%. IUD insertion care substitution to primary care appears to be associated with significantly fewer women having follow-up ultrasound or IUD reinsertion within three months.

Editorial comment on: Urinary Incontinence Care in the Academic and Safety-Net Primary Care Settings: Opportunities to Improve Quality of Care"

Editorial comment on: Urinary Incontinence Care in the Academic and Safety-Net Primary Care Settings: Opportunities to Improve Quality of Care"

Practice Recommendations for the Management of MASLD in Primary Care: Consensus Results.

Despite its high prevalence and impact on health, metabolic dysfunction-associated steatotic liver disease (MASLD) is inadequately addressed in European primary care (PC), with a large proportion of cases going undiagnosed or diagnosed too late. A multi-country European research consortium led a project to design and evaluate a patient-centered, integrated model for MASLD screening, diagnosis, and linkage to specialty care for European PC settings. Based on the lessons from this project, the latest research evidence, and existing guidelines for the management of MASLD, we sought to develop a set of practice recommendations for screening, referral, and management of MASLD in PC. The Rand/UCLA modified Delphi panel method, with two rounds, was used to reach consensus on practice recommendations. The international panel consisted of experts from six countries, representing family medicine, gastroenterology, hepatology, cardiology, and public health. Initially, fifteen statements were drafted based on a synthesis of evidence from the literature and earlier findings from our consortium. Prior to the consensus meeting, the statements were rated by the experts in the first round. Then, in a hybrid meeting, the experts discussed findings from round one, adjusted the statements, and reassessed the updated recommendations in a second round. In round one, there was already a high level of consensus on 10 out of 15 statements. After round 2, there were fourteen statements with a high degree of agreement (>90%). One statement was not endorsed. The approved recommendations addressed the following practice areas: risk screening and diagnosis, management of MASLD-lifestyle interventions, pharmacological treatment of MASLD/MASH, pharmacological treatment for co-morbidity, integrated care, surgical management, and other referrals to specialists. The final set of 14 recommendations focuses on increasing comprehensive care for MASLD in PC. The recommendations provide practical evidence-based guidance tailored to PC practitioners. We expect that these recommendations will contribute to the ongoing discussion on systematic approaches to tackling MASLD and supporting European PC providers by integrating the latest evidence into practice.

The Dexcom Community Glucose Monitoring Project: 6-Month Results Using Continuous Glucose Monitoring in Type 2 Diabetes.

The Dexcom Community Glucose Monitoring Project is a collaborative, ongoing, primary care-driven public health initiative designed to provide continuous glucose monitoring (CGM) systems to adults with type 2 diabetes who lack health insurance coverage for CGM. After 6 months of program participation, mean A1C decreased by 2.4 ± 1.9% from baseline to 6-month follow-up (from 9.4 ± 1.7 to 7.1 ± 1.2%, P <0.001). There was a clinically meaningful and statistically significant improvement in CGM metrics as well. Greater CGM use in the primary care setting among people with type 2 diabetes may help patients successfully manage their diabetes.

Quality improvement initiative to reduce URI-associated antibiotic prescriptions among adult primary care providers

ImportanceDespite evidence that most upper respiratory infections (URIs) are due to viruses, antibiotics are frequently prescribed for this indication in the outpatient setting. Antibiotic stewardship strategies are needed to reduce...

A Brief Review on Normal Pressure Hydrocephalus Diagnosis in Primary Neuropsychiatric Care Settings

Normal pressure hydrocephalus (NPH) is clinically characterized by the triad of mental deterioration, gait disturbance, and urinary incontinence. Correct diagnosis and referral of patients is important because NPH is a potentially treatable cause of cognitive decline and should be distinguished from more common forms of irreversible dementia. Unfortunately, it remains to be a rather underdiagnosed and controversial neuropsychiatric entity even in countries with modern healthcare systems. The diagnostic process is complicated by diverse clinical presentations, especially when the classical triad is incomplete or atypical such as with psychiatric symptoms. This manuscript aims to briefly review atypical clinical presentations of NPH and basic radiologic findings associated with it, and outline some recommendations to primary care physicians for diagnosis and referral.

The Perceived Usefulness of Patient Narrative Feedback in Primary Care Settings

The Perceived Usefulness of Patient Narrative Feedback in Primary Care Settings

2247 Clinical pharmacists working in primary care supporting people living with dementia: a UK survey

Abstract Background Clinical pharmacists are increasingly working as part of primary care teams in UK. Many people living with dementia live at home with the support of primary care. Given the complexity of their health problems and their use of several medications, clinical pharmacists may potentially play a crucial role in their support. Aims To explore clinical pharmacists’ experiences of working in primary care with people living with dementia and identify any specific training needs to provide effective support for this patient group. Methods An online survey sent via email in 2023 through professional organisations, social media, and utilising research team contacts. The survey covered topics including clinical pharmacists’ background, experience of working with people with dementia, and training needs. Results 57 clinical pharmacists responded to the survey; the mean time working as a clinical pharmacist was 9.6 years (standard deviation 8.6) and within a primary care setting was 6.1 years (standard deviation 6.1). Just over three-quarters of respondents (n = 31, 77%) work with people living with dementia. While almost two thirds (n = 35, 61%) had undertaken training for dementia care, such training often lasted a few hours (less than a day) (n = 17, 49%). Most respondents (n = 39, 89%) wanted further information or training; including non-pharmacological interventions to improve quality of life in dementia and how to support carers and relatives. Practice challenges reported included a lack of face-to-face consultations and getting assurance that the patient could safely take medications. Conclusions These findings indicate an interest in dementia care, a willingness to undertake further training but practice uncertainties that suggest a system approach might be beneficial.

Pharmacist-led primary care interventions to promote medicines optimisation and reduce overprescribing: a systematic review of UK studies and initiatives

ObjectivesTo systematically review and synthesise evidence on the effectiveness and implementation barriers/facilitators of pharmacist-led interventions to promote medicines optimisation and reduce overprescribing in UK primary care.DesignSystematic review.SettingUK primary care.MethodsWe searched...

Intra-rater and Inter-rater Reliability of the Commander Pressure Algometer in Greek Patients With Chronic Neck Pain.

Introduction Non-specific chronic neck pain (NSCNP) is a musculoskeletal disorder that affects 45%-54% of the general population. There is a strong correlation between patient-reported pain and mechanical pain pressure threshold (PPT) measured with an algometer. Purpose This study aims to investigate the intra- and inter-rater reliability of the Commanderalgometer in Greek NSCNP patients, in an urban primary care setting. Methods Thirty-three patients (22 women and 11 men) suffering from NSCNP (>3 months), the majority (42.4%) between the ages of 50 years and 59 years and overweight, were measured bilaterally both at the neck (mastoid, trapezius head-insertion and mid-portion, C5-C6 facet, insertion of levator scapula) and at the control areas (mid-deltoid and tibialis anterior) using the Commanderalgometer. Measurements were taken twice over a span of six days, by two raters, in a primary care setting. Intraclass correlation coefficient (ICC) statistics were used asmeasures of reliability (p = 0.05). Results Intra-rater reliability was "moderate to good" for both raters. ICCvalues for PPT at the seven bilaterally measured sites varied between 0.67 and 0.86 for the first rater (p ≤ 0.001) and 0.64 and 0.82 for the second rater (p ≤ 0.003). The inter-rater reliability was "moderate to excellent" (ICC = 0.68-0.92) in the first measurement (T1) and "moderate to good" (ICC = 0.68 to 0.89) in the second measurement (T2). Conclusion This study supports the intra- and inter-rater reliability of the Commander algometer in detecting reliably the mechanical PPT, in Greek NSCNP patients, as measured according to the procedures and methodology followed throughout this study.

Prevalence of steatotic liver disease, advanced fibrosis and cirrhosis among community-dwelling overweight and obese individuals in the USA

BackgroundThere are limited prospective data among overweight and obese individuals on the prevalence of advanced fibrosis, and cirrhosis using advanced MRI-based methods in the USA. The aim of this study...

The Prescription and Safety of Oral Antidiabetic Drugs in Outpatients with Type 2 Diabetes Mellitus: An Observational, Retrospective, Multicenter Study on the Role of Adherence in a Real-Life Primary Care Setting

Introduction: Type 2 diabetes mellitus (T2DM) is a common disease burdened with significant morbidity and mortality. Despite the substantial number of new available drug treatments, adherence to therapy and adverse drug reactions (ADRs) are the major constraint in the management of this disease. We evaluated the use, the adherence, and the safety of antidiabetic drugs in patients with T2DM. Methods: We performed an observational, retrospective, multicenter study on medical records of outpatients referred to general practitioners in Catanzaro (Calabria, Italy). Drug adherence was measured considering the packages of antidiabetic drugs prescribed at the time of admission, after three months, and 1 year later. ADRs were evaluated using the Naranjo probability scale. Collected data were analyzed using the Statistical Package for the Social Sciences. Results: During the study, we evaluated 12,170 medical records of seven general practitioners. The most prescribed drug was metformin alone (28.4%) or with other oral antidiabetics (19.6%) and then insulin (n: 354; men 190, women 164). Logistic regression showed an association between T2DM less than or equal to 5 years and low adherence (p = 0.023). During the study, we recorded 26 ADRs that were correlated with sex (women) and insulin treatment. Conclusions: this real-life study shows that patients with T2DM have a high adherence, probably related to their having a low number of ADRs.

Implementing virtual primary care: experiences, perspectives and identification of improvement opportunities in an academic primary care setting

BackgroundOne of the biggest changes to primary care triggered by the COVID-19 pandemic was the rapid integration of virtual care (VC). VC offers benefits to patients and providers but implementation...

Breaking down barriers to COPD management in primary care: applying the updated 2023 Canadian Thoracic Society guideline for pharmacotherapy.

Chronic obstructive pulmonary disease (COPD) is a highly prevalent yet under-recognized and sub-optimally managed disease that is associated with substantial morbidity and mortality. Primary care providers (PCPs) are at the frontlines of COPD management, and they play a critical role across the full spectrum of the COPD patient journey from initial recognition and diagnosis to treatment optimization and referral to specialty care. The Canadian Thoracic Society (CTS) recently updated their guideline on pharmacotherapy in patients with stable COPD, and there are several key changes that have a direct impact on COPD management in the primary care setting. Notably, it is the first guideline to formally make recommendations on mortality reduction in COPD, which elevates this disease to the same league as other chronic diseases that are commonly managed in primary care and where optimized pharmacotherapy can reduce all-cause mortality. It also recommends earlier and more aggressive initial maintenance inhaler therapy across all severities of COPD, and preferentially favors the use of single inhaler therapies over multiple inhaler regimens. This review summarizes some of the key guideline changes and offers practical tips on how to implement the new recommendations in primary care. It also addresses other barriers to optimal COPD management in the primary care setting that are not addressed by the guideline update and suggests strategies on how they could be overcome.

The Feasibility of the Diabetes Self-Management Coaching Program in Primary Care: A Mixed-Methods Randomized Controlled Feasibility Trial.

Diabetes mellitus, a chronic metabolic disorder associated with elevated blood sugar levels, is a significant cause of morbidity, mortality, and disability globally. The rampant rise in the prevalence of diabetes presents a public health burden and a challenge to the primary care setting. Diabetes self-management coaching is an emergent, client-centered, solution-focused approach to enhance self-efficacy and self-care behavior, control glycemia, and prevent acute and chronic complications. Currently, there is no diabetes self-management support strategy in the primary care setting in Ethiopia. Therefore, this study assessed the feasibility, acceptability, and fidelity of implementing the Diabetes Self-Management Coaching Program in primary care in Ethiopia. A single-center, single-blinded, parallel group mixed-methods feasibility randomized control design was applied to assess the feasibility, acceptability, and fidelity of the Diabetes Self-Management Coaching Program in primary care. Adult patients with type 2 diabetes with HbA1c ≥ 7%, taking diabetic medication, and living in Gondar town were included in the study. A block randomization technique with a block size of four was used to allocate participants into the treatment and control groups. The treatment group attended a 12-week Diabetes Self-Management Coaching Program in addition to undergoing usual care, while the control group received the usual care for the same period. Data were collected at baseline, at the end of the intervention, and after the follow-up period. Descriptive statistics such as the frequency, mean, median, and standard deviations were computed. Based on the normality assessment, the baseline group difference was examined using the independent sample Student's t-test, the Mann-Whitney U test, and the chi-square test. This study's eligibility, recruitment, retention, and adherence rates were 23%, 70%, 90%, and 85%, respectively. Both the qualitative and quantitative findings show that the program was feasible to implement in primary care and acceptable to the participants. The fidelity assessment of the Diabetes Self-Management Coaching Program indicates an appropriate intervention implementation. This study demonstrated remarkable recruitment, retention, and adherence rates. The Diabetes Self-Management Coaching Program was feasible, acceptable, and implementable in primary care in Ethiopia. As a result, we recommend that a large-scale multi-center cluster randomized controlled trial with an adequate sample can be designed to evaluate the effect of the DSM Coaching Program on clinical and behavioral outcomes.

Use of telehealth simulation to teach the enhanced primary care RN role through community/public health-focused simulations.

America is facing a primary care provider shortage. Enhanced primary care RNs (EPC-RNs), registered nurses working at the top of their practice scope, can be an important part of community-based primary care provision. Typically, community health nursing education has not included primary care-based clinical experiences, and there is a clinical site shortage. Teaching students about EPC-RN roles can be an important domain of community/public health nursing education. Simulation is a creative pedagogical approach to learning about the EPC-RN role. The purpose of this manuscript is to 1) describe EPC-RN Telehealth Simulation development; and 2) describe student simulation feedback. Nursing faculty and simulation experts designed five simulations for community health students to teach about the EPC-RN role, incorporating recommendations from the Quad Council Coalition of Public Health Nursing Organizations community/public health nursing competencies and the National Competencies for Registered Nurses in Primary Care. Retrospective, descriptive quantitative, and qualitative student feedback data (n=519) was collected through QuestionPro over multiple semesters. Student feedback data demonstrated support of the use of the simulations in community/public health nursing education. The EPC-RN Telehealth Simulations prepared pre-licensure nursing students to practice in community-based primary care settings. Innovative, sustainable experiences such as this can improve community/public health nursing education.

Competing in the "war for talent" in nursing homes: A quantitative investigation.

This study explores the characteristics of primary care organizations that are likely to attract and retain highly skilled professionals, meeting their expectations and increasing Person-Organization fit. Both "hard" dimensions (ownership) and organizational/managerial traits under the span of control of management are investigated. The objective is to raise awareness on how to mitigate unpopular features of primary healthcare organizations so to effectively compete in the war for talent. This study has been carried out based on data extrapolated from a broader study conducted by the Italian National Agency for Regional Health Services and commissioned by the Italian Ministry of Health. Data deriving from Italian nursing homes was extrapolated from the broader public dataset and multiple regressions were carried out to detect associations between managerial variables and staff seniority. Several significant associations were detected, suggesting that both physicians and nurses are affected by some investigated variables when deciding where to work and for how long. While some of these are common to the two categories of professionals (e.g., the presence of a nursing director), others are not (e.g., the presence of internal training programs). The implications of this study are related to the need of increasing awareness of managers of nursing homes on those features that are likely to increase their attractiveness and long-lasting appeal to professionals. This is a paramount topic in times in which the war for talent is strong. A lack of attention on this field may lead to the inability to attract and retain staff in primary care settings and, in turn, to implement strategic trends of change healthcare systems are facing in Italy and worldwide.

"Life with Diabetes": A Pilot Study on an Experiential Continuous Glucose Monitoring Curriculum for Resident Physicians.

The use of technology in diabetes mellitus (DM) management has been growing. The indications and coverage for continuous glucose monitoring (CGM) have increased. Primary care (PC) clinics, including resident continuity clinics, are the frontline for DM management; however, they struggle to adopt CGM. To implement a CGM curriculum to resident physicians to improve knowledge and confidence. An internal medicine (IM) resident PC clinic in an urban academic medical institution. Twenty-four IM residents. We designed a curriculum that included a lecture about CGM indications, interpretation, ordering, and insurance consideration; and a voluntary, experiential learning module in which the residents wore a CGM. We conducted a retrospective pre-post survey with a 4-point Likert scale. Average self-reported scores in knowledge increased for CGM (1) indications from 1.85 to 3.45, (2) ordering from 1.35 to 3.05, (3) functioning from 2.20 to 3.50, and (4) data interpretation from 1.85 to 3.25 (all p < 0.0001). Confidence for "describing CGM monitoring" and "fielding questions about CGM" increased from 2.25 to 3.65 (p < 0.0001) and 1.90 to 3.30 (p < 0.0001). Given the demand for DM management in the PC setting, this targeted CGM curriculum has promise to help residents adopt CGM into their practice.

Transformation of primary care settings implementing a co-located team-based care model: a scoping review

BackgroundIn Canada, primary care reforms led to the implementation of various team-based care models to improve access and provide more comprehensive care for patients. Despite these advances, ongoing challenges remain. The aim of this scoping review is to explore current understanding of the functioning of these care models as well as the contexts in which they have emerged and their impact on the population, providers and healthcare costs.MethodsThe Medline and CINAHL databases were consulted. To be included, team-based care models had to be co-located, involve a family physician, specify the other professionals included, and provide information about their organization, their relevance and their impact within a primary care context. Models based on inter-professional intervention programs were excluded. The organization and coordination of services, the emerging contexts and the impact on the population, providers and healthcare costs were analysed.ResultsA total of 5952 studies were screened after removing duplicates; 15 articles were selected for final analysis. There was considerable variation in the information available as well as the terms used to describe the models. They are operationalized in various ways, generally consistent with the Patient’s Medical Home vision. Except for nurses, the inclusion of other types of professionals is variable and tends to be associated with the specific nature of the services offered. The models primarily focus on individuals with mental health conditions and chronic diseases. They appear to generally satisfy the expectations of the overarching framework of a high-performing team-based primary care model at patient and provider levels. However, economic factors are seldom integrated in their evaluations.ConclusionsThe studies rarely provide an overarching view that permits an understanding of the specific contexts, service organization, their impacts, and the broader context of implementation, making it difficult to establish universal guidelines for the operationalization of effective models. Negotiating the inherent complexity associated with implementing models requires a collaborative approach between various stakeholders, including patients, to tailor the models to the specific needs and characteristics of populations in given areas, and reflection about the professionals to be included in delivering these services.

Prevalence of Depression and Its Associated Factors among Adult Libyan Diabetic Patients Attending Golden Polyclinic, Al-Badri, Tripoli

Background and aims: Depression is a significant public health concern and a common comorbid condition among patients with diabetes mellitus. This study aims to assess the prevalence of depression and its associated factors among patients with diabetes in the Al-Badri polyclinic. Methods: A descriptive cross-sectional study was conducted at Al-Badri Polyclinic from February to April 2024. The presence of depression among diabetes patients was assessed using the 9-item Patient Health Questionnaire (PHQ-9) scale. Data was entered and analyzed by using SPSS software version 26. Results: A total of two hundred and forty-seven participants were enrolled in the study, with 142 (57.5%) being female and 168 (68.0%) aged between 41 and 60 years. The majority of participants (71.7%) were married, and 40.5% were employed. Additionally, 78% had a positive family history of diabetes mellitus. Among the participants, 43.3% were smokers. The duration of diabetes mellitus was more than 10 years for 52.2% of the patients. Approximately two-thirds of the patients (61.5%) were taking tablets for the treatment of DM. The majoring of the patients (98.8%) had an HbA1c level of 6.5 or higher. Approximately one-third of the patients had hypertension as a comorbidity with DM, and 12.1% had heart disease as a complication of diabetes. The overall prevalence of moderate depression among the diabetes patients at the clinic was 24.7%. The majority (70.4%) exhibited mild depression, and 4.9% experienced minimal depression. No cases of severe depression were identified. Factors independently associated with depression included being on age, marital status, insulin therapy, and comorbidities. Conclusion: Depression was prevalent in our diabetic patients. Factors independently associated with this included being on age, marital status, insulin therapy, and comorbidities. The study emphasizes and recommends the importance of identifying and managing depression among diabetes patients. It is also recommended to increase awareness of the benefits of early diagnosis of patients to prevent major forms of depression and cost saving for the health system. Programs for screening depression should be implemented in primary care settings.