Primary Care Resources Research Articles

The Use of the TARGET Antibiotic Checklist to Support Antimicrobial Stewardship in England's Community Pharmacies.

Antimicrobial Stewardship (AMS) requires effective teamwork between healthcare professionals, with patients receiving consistent messages from all healthcare professionals on the appropriate antimicrobial use. Patient education may reduce patients' expectations to receive antibiotics for self-limiting conditions and reduce the pressure on primary care clinicians to prescribe antibiotics. The TARGET Antibiotic Checklist is part of the national AMS resources for primary care and aims to support interaction between community pharmacy teams and patients prescribed antibiotics. The Checklist, completed by the pharmacy staff with patients, invites patients to report on their infection, risk factors, allergies, and knowledge of antibiotics. The TARGET antibiotic checklist was part of the AMS criteria of England's Pharmacy Quality Scheme for patients presenting with an antibiotic prescription from September 2021 to May 2022. A total of 9950 community pharmacies claimed for the AMS criteria and 8374 of these collectively submitted data from 213,105 TARGET Antibiotic Checklists. In total, 69,861 patient information leaflets were provided to patients to aid in the knowledge about their condition and treatment. 62,544 (30%) checklists were completed for patients with an RTI; 43,093 (21%) for UTI; and 30,764 (15%) for tooth/dental infections. An additional 16,625 (8%) influenza vaccinations were delivered by community pharmacies prompted by discussions whilst using the antibiotic checklist. Community pharmacy teams promoted AMS using the TARGET Antibiotic Checklist, providing indication-specific education and positively impacting the uptake of influenza vaccinations.

Association of Primary Care Visit Length With Potentially Inappropriate Prescribing

Time is a valuable resource in primary care, and physicians and patients consistently raise concerns about inadequate time during visits. However, there is little evidence on whether shorter visits translate into lower-quality care. To investigate variations in primary care visit length and quantify the association between visit length and potentially inappropriate prescribing decisions by primary care physicians. This cross-sectional study used data from electronic health record systems in primary care offices across the US to analyze adult primary care visits occurring in calendar year 2017. Analysis was conducted from March 2022 through January 2023. Regression analyses quantified the association between patient visit characteristics and visit length (measured using time stamp data) and the association between visit length and potentially inappropriate prescribing decisions, including inappropriate antibiotic prescriptions for upper respiratory tract infections, coprescribing of opioids and benzodiazepines for painful conditions, and prescriptions that were potentially inappropriate for older adults (based on the Beers criteria). All rates were estimated using physician fixed effects and were adjusted for patient and visit characteristics. This study included 8 119 161 primary care visits by 4 360 445 patients (56.6% women) with 8091 primary care physicians; 7.7% of patients were Hispanic, 10.4% were non-Hispanic Black, 68.2% were non-Hispanic White, 5.5% were other race and ethnicity, and 8.3% had missing race and ethnicity. Longer visits were more complex (ie, more diagnoses recorded and/or more chronic conditions coded). After controlling for scheduled visit duration and measures of visit complexity, younger, publicly insured, Hispanic, and non-Hispanic Black patients had shorter visits. For each additional minute of visit length, the likelihood that a visit resulted in an inappropriate antibiotic prescription changed by -0.11 percentage points (95% CI, -0.14 to -0.09 percentage points) and the likelihood of opioid and benzodiazepine coprescribing changed by -0.01 percentage points (95% CI, -0.01 to -0.009 percentage points). Visit length had a positive association with potentially inappropriate prescribing among older adults (0.004 percentage points; 95% CI, 0.003-0.006 percentage points). In this cross-sectional study, shorter visit length was associated with a higher likelihood of inappropriate antibiotic prescribing for patients with upper respiratory tract infections and coprescribing of opioids and benzodiazepines for patients with painful conditions. These findings suggest opportunities for additional research and operational improvements to visit scheduling and quality of prescribing decisions in primary care.

Supply-demand balance and spatial distribution optimization of primary care facilities in highland cities from a resilience perspective: A study of Lhasa, China.

The development of urban resilience, which is fundamentally a balance between the supply capacity of primary care resources and the demand from urban residents, includes an appropriate architecture of primary care facilities. Resilient city construction in highland areas is hampered by the physical environment and transportation constraints and frequently encounters issues like poor accessibility and unequal distribution of primary care facilities. To optimize the supply and demand of primary care resources in highland cities and effectively improve the resilience of urban public health, this paper assesses the distribution of primary care facilities within the built-up area of Lhasa (China) through a spatial network analysis method based on GIS, combined with population distribution data, and employs a location-allocation model to optimize the distribution. Firstly, the overall supply of primary care exceeds the overall demand, but the facilities' service area can only accommodate 59% of the residences. Secondly, there is a clear spatial variation in the accessibility of primary care facilities, and the time cost of healthcare is too high in some residences. Thirdly, the supply-demand relationship of primary care facilities is unbalanced, with both over-saturated and over-deficient areas. After distribution optimization, the coverage and accessibility of primary care facilities have increased significantly, and the spatial imbalance of supply and demand has been alleviated. This paper proposes a research method to evaluate and optimize the spatial distribution of primary care facilities from multiple perspectives based on the resilience theory. The results of the study and visualization analysis methods can be used as an invaluable reference for planning the distribution of urban healthcare facilities and urban resilience construction in highland areas and other underdeveloped areas.

Population-based evaluation of the impact of socioeconomic status on clinical outcomes in patients with heart failure in integrated care settings

Introduction and objectivesLow socioeconomic status (SES) is associated with poor outcomes in patients with heart failure (HF). We aimed to examine the influence of SES on health outcomes after a quality of care improvement intervention for the management of HF integrating hospital and primary care resources in a health care area of 209 255 inhabitants. MethodsWe conducted a population-based pragmatic evaluation of the implementation of an integrated HF program by conducting a natural experiment using health care data. We included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January 1, 2015 and December 31, 2019. We compared outcomes between patients exposed to the new HF program and those in the remaining health care areas, globally and stratified by SES. ResultsA total of 77 554 patients were included in the study. Death occurred in 37 469 (48.3%), clinically-related hospitalization in 41 709 (53.8%) and HF readmission in 29 755 (38.4%). On multivariate analysis, low or very low SES was associated with an increased risk of all-cause death and clinically-related hospitalization (all Ps <.05). The multivariate models showed a significant reduction in the risk of all-cause death (HR, 0.812; 95%CI, 0.723-0.912), clinically-related hospitalization (HR, 0.886; 95%CI, 0.805-0.976) and HF hospitalization (HR, 0.838; 95%CI, 0.745-0.944) in patients exposed to the new HF program compared with patients exposed to the remaining health care areas and this effect was independent of SES. ConclusionsAn intensive transitional HF management program improved clinical outcomes, both overall and across SES strata.

Forecasting upper respiratory tract infection burden using high-dimensional time series data and forecast combinations.

Upper respiratory tract infections (URTIs) represent a large strain on primary health resources. To mitigate URTI transmission and public health burdens, it is important to pre-empt and provide forward guidance on URTI burden, while taking into account various facets which influence URTI transmission. This is so that appropriate public health measures can be taken to mitigate strain on primary care resources. This study describes a new approach to forecasting URTIs which can be used for national public health resource planning. Specifically, using environmental and disease data comprising more than 1000 dimensions, we developed sub-models which optimizes model explainability, in-sample model fit, predictive accuracy and combines many weaker predictors over a 2-month time horizon to generate direct, point forecasts over a 1-8 week ahead forecast horizon. Predictive performance was evaluated using rolling out-of-sample forecast assessment within both periods with/without structural breaks in transmission over the period of 2012-2022. We showed that forecast combinations of 5 other forecasting models had better and more consistent predictive performance than other modelling approaches, over periods with and without structural breaks in transmission dynamics. Furthermore, epidemiological analysis on high dimensional data was enabled using post-selection inference, to show the dynamic association between lower temperature, increases in past relative humidity and absolute humidity and increased URTIs attendance. The methods proposed can be used for outbreak preparedness and guide healthcare resource planning, in both stable periods of transmission and periods where structural breaks in data occur.

The role of community pharmacists in optimising patient self-management of constipation: an inter-disciplinary consensus view

Constipation is a common gastrointestinal disorder that may occur as occasional (acute) episodes, but can also persist over longer periods of time. Patients usually self-diagnose and self-manage constipation with over-the-counter (OTC) medications, so in terms of medical advice/consultation, the pharmacist is often the first point of contact. Patients’ self-management of constipation helps to free up primary care resources to focus on more complex conditions. However, there is no clear guidance on the appropriate, practice-oriented approach to, and the limitations of, self-management of constipation. The objective of this article is to provide up-to-date clinical practice guidance for healthcare professionals, particularly community pharmacists, to assist in the day-to-day management of patients who present with constipation. Here, we discuss typical clinical factors (e.g. symptom duration, warning symptoms and treatment response) that help to distinguish whether constipation can be self-managed or if further medical assessment is required. We have also developed screening questions and a patient management algorithm to help pharmacists and pharmacy technicians make appropriate decisions when a patient presents with symptoms of constipation or requests advice after initiation of OTC medications.

Patterns of Healthcare Resource Utilisation of Critical Care Survivors between 2006 and 2017 in Wales: A Population-Based Study.

In this retrospective cohort study, we used the Secure Anonymised Information Linkage (SAIL) Databank to characterise and identify predictors of the one-year post-discharge healthcare resource utilisation (HRU) of adults who were admitted to critical care units in Wales between 1 April 2006 and 31 December 2017. We modelled one-year post-critical-care HRU using negative binomial models and used linear models for the difference from one-year pre-critical-care HRU. We estimated the association between critical illness and post-hospitalisation HRU using multilevel negative binomial models among people hospitalised in 2015. We studied 55,151 patients. Post-critical-care HRU was 11-87% greater than pre-critical-care levels, whereas emergency department (ED) attendances decreased by 30%. Age ≥50 years was generally associated with greater post-critical-care HRU; those over 80 had three times longer hospital readmissions than those younger than 50 (incidence rate ratio (IRR): 2.96, 95% CI: 2.84, 3.09). However, ED attendances were higher in those younger than 50. High comorbidity was associated with 22-62% greater post-critical-care HRU than no or low comorbidity. The most socioeconomically deprived quintile was associated with 24% more ED attendances (IRR: 1.24 [1.16, 1.32]) and 13% longer hospital stays (IRR: 1.13 [1.09, 1.17]) than the least deprived quintile. Critical care survivors had greater 1-year post-discharge HRU than non-critical inpatients, including 68% longer hospital stays (IRR: 1.68 [1.63, 1.74]). Critical care survivors, particularly those with older ages, high comorbidity, and socioeconomic deprivation, used significantly more primary and secondary care resources after discharge compared with their baseline and non-critical inpatients. Interventions are needed to ensure that key subgroups are identified and adequately supported.

How health care professionals handle limited resources in primary care – an interview study

IntroductionHealth care systems around the world are struggling with limited resources, in relation to the prevailing health care need. An accessible primary care is an important part of the solution for how to provide affordable care for the population and reduce pressure on the overall health care system such as unnecessary hospital stays and associated costs. As primary care constitutes an important first line of healthcare, the task of prioritising and deciding what to do and for whom lies in practice, primarily with the primary care professionals. Thus, the decisions and behaviour of primary care professionals have a central role in achieving good and equal health in the population. The aim of this study is to explore how primary health care professionals handle situations with limited resources and enhance our knowledge of priorities in practice. MethodsSemi-structured interviews with 14 health care professionals (7 nurses, 7 physicians) working in Swedish primary care were interviewed. Data were analysed inductively with content analysis.FindingsThree main categories were found: Influx of patients; Structural conditions; and Actions. Each category illustrates an important aspect for what primary care professionals do to achieve good and equal care. The influx of patients concerned what the professionals handled in terms of patients’ healthcare needs and patient behaviour. Structural conditions consisted of policies and goals set for primary care, competence availability, technical systems, and organisational culture. To handle situations due to limited resources, professionals performed different actions: matching health care needs with professionals’ competency, defining care needs to suit booking systems appointments, giving care at the inappropriate health care level, rearranging workhours, and passing on the decision making.ConclusionPriorities in primary care are not, “one fits all” solution. Our study shows that priorities in primary care comprise of ongoing daily processes that are adapted to the situation, context of patient influx, and structural conditions. Healthcare professional’s actions for how influx of patients’ is handled in relation to limited resources, are created, and shaped within this context which also sets the boundaries for their actions.

Access to episodic primary care: a cross-sectional comparison of walk-in clinics and urgent primary care centers in British Columbia.

This study aimed to identify publicly reported access characteristics for episodic primary care in BC and provided a clinic-level comparison between walk-in clinics and UPCCs. Walk-in clinics are non-hospital-based primary care facilities that are designed to operate without appointments and provide increased healthcare access with extended hours. Urgent and Primary Care Centres (UPCCs) were introduced to British Columbia (BC) in 2018 as an additional primary care resource that provided urgent, but not emergent care during extended hours. This cross-sectional study used publicly available data from all walk-in clinics and UPCCs in BC. A structured data collection form was used to record access characteristics from clinic websites, including business hours, weekend availability, attachment to a longitudinal family practice, and provision of virtual services. In total, 268 clinics were included in the analysis (243 walk-in clinics, 25 UPCCs). Of those, 225 walk-in clinics (92.6%) and two UPCCs (8.0%) were attached to a longitudinal family practice. Only 153 (63%) walk-in clinics offered weekend services, compared to 24 (96%) of UPCCs. Walk-in clinics offered the majority (8,968.6/ 78.4%) of their service hours between 08:00 and 17:00, Monday to Friday. UPCCs offered the majority (889.3/ 53.7%) of their service hours after 17:00. Most walk-in clinics were associated with a longitudinal family practice and provided the majority of clinic services during typical business hours. More research that includes patient characteristics and care outcomes, analyzed at the clinic level, may be useful to support the optimization of episodic primary healthcare delivery.

Optimization of physician resources in primary care during a pandemic: A ‘hot’ and ‘cold’ team approach

Healthcare in rural localities has faced unique pressures in the midst of the COVID-19 (coronavirus disease 2019) pandemic. The Marathon Family Health Team physicians created a novel pandemic model that divides active physicians into 'hot' and 'cold' teams with a "sideline" reserve based on physician infectious status and ongoing exposure risk, in order to address the potential instability of small medical groups in isolated situations. Implemented in stages, the model maximizes group agility and healthcare provisions, while minimizing the risk of physicians as vectors for transmission or a possible healthcare system collapse from simultaneous physician incapacitation. The hot/cold pandemic model can be applied to various healthcare facilities, including but not limited to hospitals and assessment centres, and the model's scale can be further adjusted for larger settings. By making use of incapacitated physicians who have been "sidelined" due to illness or burnout but still able to work from home, this model is integrative, efficient and innovative.

Indigenous Plant-Derived Medical Applications for Primary Health Care

Traditional medicine is an important primary health care resource for many people and has been acknowledged as a necessary component of reaching universal health. The purpose of this research is to offer an overview of indigenous plant-derived medicinal applications administered to treat current human ailments. The data were collected via a mixed-methods research in four Bapedi communities in South Africa's Limpopo Province. The research documented six different techniques for administering indigenous plant-derived medications, including decoction, infusion, steam bath, incense, poultice, and powder. These uses are determined by the kind of plant material employed and the type of illness being treated. For instance, a leaf poultice is applied directly to wounds to promote healing, while decoctions and infusions of the root, bark, and bulb are used as purgatives and enemas to treat gastrointestinal diseases and as emetics to alleviate cough. Steam baths and incense inhalation increase sweat, which is beneficial in the treatment of fever and cough. The standard dose for decoctions and infusions is a teacup, but there are no accounts of particular dosages for poultices, steam, ash, burned root, or leaf sap. This research advises hastening the process of authenticating traditional medicine in order to assure optimal practices, such as accurate dosage uses for medications.

Effect on mortality and hospitalization of real-world implementation of transitional care heart failure programmes in patients with heart failure: a population-based study in 77,554 patients

Abstract Background The efficacy of heart failure programs has been demonstrated in clinical trials but their applicability in the real-world practice setting is more controversial. Purpose This study evaluates the efficacy of a comprehensive, transitional-care nurse-based HF programme integrating hospital and primary care resources in a healthcare area covering a population of 209,255 (implementation area). Methods We designed a pragmatic, population-based evaluation of the implementation of the program conducting a natural experiment. Study periods were: pre-implementation period (years 2015 and 2016), transition period (year 2017) and consolidation of implementation period (years 2018 and 2019). For the purposes of this study, we included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as the primary diagnosis and discharged alive in Catalonia between January, the 1st, 2015 and December, the 31st of 2019. Efficacy of the implementation of the program was measured at two levels: first, comparing the outcomes of patients exposed to the HF program between periods of implementation taking 2015–2016 as the reference period and, second, comparing outcomes between patients of the implementation area with patients of the remaining areas of the Catalonia at each predefined period. Results We included 77,554 patients in the study: 3,396 exposed to the implementation area and 74,158 exposed to the rest of healthcare areas in Catalonia. During the period of the study, 55,886 (72.1%) patients experienced at least one major adverse event. Death occurred in 37,469 (48.3%), clinically related hospitalisation in 41,709 (53.8%) and HF readmission in 29,755 (38.4%). As shown in Table 1, multivariate Cox proportional hazards models adjusted for age, gender, previous hospitalisation, co-morbidities, socioeconomic status, and time since HF diagnosis showed there was a significant (all p-values &amp;lt;0.001) relative risk reduction of the risk of all-cause death (5%), clinically related hospitalisation (13%) and HF hospitalisation (14%) in the consolidation period (2018–2019) compared to the pre-programme period (2015–2016). Similarly, as shown in Table 1 and Figure 1, while in the pre-programme period (2015–2016) the risk of adverse outcomes was significantly higher in patients exposed to the implementation area compared to the rest of Catalonia, this association was inverted during the consolidation period (2018–2019) where the risk of mortality, clinically-related readmission and HF re-hospitalisation was significantly reduced (all p-values &amp;lt;0.025) by 19%, 11% and 16%, respectively, among patients exposed to the implementation area compared with patients of the remaining areas of Catalonia. Conclusions The implementation of multidisciplinary transitional-care nurse-based heart failure programmes integrating hospital and primary care reduce mortality and hospitalisation in vulnerable patients with heart-failure. Funding Acknowledgement Type of funding sources: None.

Informal Providers-Ground Realities in South Asian Association for Regional Cooperation Nations: Toward Better Cancer Primary Care: A Narrative Review.

South Asian Association for Regional Cooperation (SAARC) nations are a group of eight countries with low to medium Human Development Index values. They lack trained human resources in primary health care to achieve the WHO-stated goal of Universal Health Coverage. An unregulated service sector of informal health care providers (IPs) has been serving these underserved communities. The aim is to summarize the role of IPs in primary cancer care, compare quality with formal providers, quantify distribution in urban and rural settings, and present the socioeconomic milieu that sustains their existence. A narrative review of the published literature in English from January 2000 to December 2021 was performed using MeSH Terms Informal Health Care Provider/Informal Provider and Primary Health Care across databases such as Medline (PubMed), Google Scholar, and Cochrane database of systematic reviews, as well as World Bank, Center for Global Development, American Economic Review, Journal Storage, and Web of Science. In addition, citation lists from the primary articles, gray literature in English, and policy blogs were included. We present a descriptive overview of our findings as applicable to SAARC. IPs across the rural landscape often comprise more than 75% of primary caregivers. They provide accessible and affordable, but often substandard quality of care. However, their network would be suitable for prompt cancer referrals. Care delivery and accountability correlate with prevalent standards of formal health care. Acknowledgment and upskilling of IPs could be a cost-effective bridge toward universal health coverage and early cancer diagnosis in SAARC nations, whereas state capacity for training formal health care providers is ramped up simultaneously. This must be achieved without compromising investment in the critical resource of qualified doctors and allied health professionals who form the core of the rural public primary health care system.

Priorities for improvement across cancer and non-cancer related preventive services among rural and non-rural clinicians

IntroductionIt is not realistic for most clinicians to perform the multitude of recommended preventive primary care services. This is especially true in low resource and rural settings, creating challenges to delivering high-quality care. This study collected stakeholder input from clinicians on which services they most need to improve.MethodsThe authors conducted a survey of primary care physicians 9–12/2021, with an emphasis on rural practices, to assess areas in which clinicians felt the greatest needs for improvement. The survey focused on primary prevention (behavior change counseling) and cancer screening, and contrasted needs for improvement for these services vs. other types of screening, and between clinicians in rural vs. non-rural practices.ResultsThere were 326 respondents from 4 different practice-based research networks, a wide range of practice types, 49 states and included 177 clinicians in rural settings. Respondents rated the need to improve delivery of primary prevention counseling services highest, with needs for nutrition and dietary assessment and counseling rated highest followed by physical activity and with almost no differences between rural and nonrural. Needs for improvement in cancer screenings were rated higher than non-cancer screenings, except for blood pressure screening.ConclusionsBoth rural and nonrural primary care clinicians feel a need for improvement, especially with primary prevention activities. Although future research is needed to replicate these findings with different populations and other types of preventive service activities, greater priority should be given to development of practical, stakeholder informed assistance and resources for primary care to conduct primary prevention.

Informal Caregivers' Health Literacy in Lisbon, Portugal: A Profile for Health Promotion Prioritization.

Health literacy (HL) allows people to access, understand and evaluate health information. Informal caregivers’ levels of HL may impact long-term care outcomes. ‘Informal caregivers’ profile in Lisbon county: a health community approach’ is a nurse-led research project aiming to assess informal caregivers’ health literacy and associated factors in Lisbon county, as well as to foster the development of a local-specific health literacy strategy. A survey to identify a health/social caregiver profile, including questions about HL (HLS-EU-PT), was submitted to a representative sample of carers. Descriptive and bivariate inferential analysis was developed. Informal caregivers’ level of HL was mostly sufficient (n = 99, 38%). More than 60% of caregivers have limited HL regarding health promotion. ‘Access’, ‘Appraisal’ and ‘Use’ are the information processing stages with lower mean scores of HL. Carers with low HL levels appear to be older and to have less education, low knowledge of community resources and decreased wellbeing (p < 0.05). A strategy focused on health promotion-related HL through primary care resources can potentially improve caregivers’ knowledge, competencies and motivation, as well as health system sustainability. Reported HLS-EU-PT scores deserve special attention. Future work should emphasize the role of HL-associated factors and health outcomes for caregivers and cared-for persons.

Ups and downs of hypertension control in Canada: critical factors and lessons learned.

ABSTRACTAs the leading risk for death, population control of increased blood pressure represents a major challenge for all countries of the Americas. In the early 1990’s, Canada had a hypertension control rate of 13%. The control rate increased to 68% in 2010, accompanied by a sharp decline in cardiovascular disease. The unprecedented improvement in hypertension control started around the year 2000 when a comprehensive program to implement annually updated hypertension treatment recommendations started. The program included a comprehensive monitoring system for hypertension control. After 2011, there was a marked decrease in emphasis on implementation and evaluation and the hypertension control rate declined, driven by a reduction in control in women from 69% to 49%. A coalition of health and scientific organizations formed in 2011 with a priority to develop advocacy positions for dietary policies to prevent and control hypertension. By 2015, the positions were adopted by most federal political parties, but implementation has been slow.This manuscript reviews key success factors and learnings. Some key success factors included having broad representation on the program steering committee, multidisciplinary engagement with substantive primary care involvement, unbiased up to date credible recommendations, development and active adaptation of education resources based on field experience, extensive implementation of primary care resources, annual review of the program and hypertension indicators and developing and emphasizing the few interventions important for hypertension control. Learnings included the need for having strong national and provincial government engagement and support, and retaining primary care organizations and clinicians in the implementation and evaluation.

Quality of chronic care for patients with type 2 diabetes in practices with and without a Clinical Specialized Medical Assistant (CSMA) - a cross-sectional study from Switzerland.

Due to Switzerland's shortage of general practitioners (GPs), task shifting through interprofessional collaboration is needed to relieve GPs' workload and allow the continued provision of quality care. The profession of specialized medical assistant (SMA) was created in Switzerland several years ago to provide a career advancement opportunity for medical practice assistants (MPAs) and intended to counteract the increasing scarcity of resources in primary care. Clinical specialized medical assistants (CSMAs) are trained to care for a set of chronic conditions, such as diabetes. We aimed to compare the quality of care for patients with type 2 diabetes in practices with and without CSMAs. Further, we aimed to investigate whether evidence exists that CSMA care models may allow for task shifting and the provision of interprofessional care while maintaining a high quality of care and to assess patient experiences with diabetes care in both care models. The present study was a paper-based cross-sectional survey of patient data. A total of 171 patients with type 2 diabetes who had been under the care of either a GP with CSMA (91 patients) or a GP without CSMA (80 patients) for at least one year were consecutively recruited for the study. Data were collected from mid-September 2020 to mid-June 2021. For the statistical analyses, we used descriptive statistics and t-tests. Patients from both practice types were comparable in age, gender and diabetes-relevant factors such as Body Mass Index, smoking status and blood pressure. Overall, patients in both models received a high quality of care (Diabetes Treatment Satisfaction Questionnaire, DTSQ >32/36 points, SGED >75 points) and a low treatment burden (Treatment Burden Questionnaire, TBQ <20/150 points). When comparing patients' DTSQ, SGED and TBQ in both groups, we found no significant differences in diabetes-specific satisfaction (32.1 [SD 3.6] vs. 32.4 [SD 3.8], p = 0.7), SGED score (80.2 [SD 8.5] vs. 75.9 [SD 4.8], p = 0.18) or treatment burden (19.2 [SD 15.6] vs. 18.8 [SD 21.4], p = 0.89). Our comparison of patient-reported outcomes and SGED criteria of patients with type 2 diabetes in practices with and without CSMAs showed an equally high quality of care and a low treatment burden. More research is needed on the long-term effects and benefits of the care provided by CSMAs and which other tasks could be shifted to CSMAs to reduce the burden on GPs in the future. At the same time, an increasing number of patients with type 2 diabetes will require high-quality primary care.

Rheumatology Clinic Staff Needs: Barriers and Strategies to Addressing High Blood Pressure and Smoking Risk.

Patients with rheumatologic conditions are at elevated risk of cardiovascular disease (CVD) due to inflammatory and traditional risk factors, such as high blood pressure (BP) and smoking. However, rheumatology clinics rarely address traditional risk factors, although they are routinely assessed and modifiable in primary care. The present study sought to (1) characterize rheumatology clinic staff's work process for addressing high BP and smoking and (2) identify barriers and strategies for effective management of these risk factors. We conducted 7 focus groups with medical assistants, nurses, and scheduling staff from 4 adult rheumatology clinics across 2 health systems (BP focus groups, n = 23; smoking, n = 20). Transcripts were analyzed using thematic analysis to elucidate barriers and strategies. We found 3 clinic work processes for the management of high BP and smoking risk: (1) risk identification, (2) follow-up within the clinic, and (3) follow-up with primary care and community resources. Within these processes, we identified barriers and strategies grouped into themes: (1) time, (2) clinic workflows, (3) technology and resources, (4) staff's attitudes and knowledge, and (5) staff's perceptions of patients. The most pervasive barriers were (1) no structured system for follow-up and (2) staff confidence and skill in initiating conversations about health-related behavior change. Our study identified generalizable gaps in rheumatology staff's work processes and competencies for addressing high BP and smoking in patients. Future efforts to support staff needs should target (1) systems for follow-up within and outside the clinic and (2) conversation support tools.

Research on Disparities in Primary Health Care in Rural versus Urban Areas: Select Perspectives

Much of the differences in health care outcomes can be attributed to the differential rates of primary health care utilization and resource allocation across population subgroups [...].

An Effective Gender-Affirming Care and Hormone Prescribing Standardized Patient Case for Residents.

IntroductionIt is estimated that at least 700,000 individuals in the United States identify as transgender or gender expansive. Many have confronted marginalization within the health care system, leading to suboptimal care and inequitable health outcomes. Health sciences trainees do not receive adequate training in gender-affirming care. The authors therefore created, piloted, and evaluated a formative standardized patient case for gender-affirming care for family medicine resident learners that could be given with limited resources in primary care and health professional education.MethodsThe curriculum for the case was developed with patient input and with family medicine physicians skilled in education, simulation, and gender-affirming care. The first case was held for 20 residents in a 4-year family medicine program in the Pacific Northwest. Nineteen participants completed pre/post case surveys delineating knowledge, awareness, attitudes, and intended behavior regarding providing gender-affirming care.ResultsSelf-reported knowledge and awareness increased after standardized patient case participation in multiple skill areas related to providing gender-affirming care. Faculty observers informally reported that the session increased their knowledge and comfort as well.DiscussionImplementation of this gender-affirming standardized patient case inclusive of community input was associated with successful improvements in self-reported measurements of resident knowledge and awareness of providing gender-affirming care. Additional institutions should consider such training to improve health care equity for this population.