Primary Care Setting Research Articles

Epidemiology of skin diseases among children attending the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu State: a retrospective observational study

Background: Numerous studies have examined skin disease trends in Nigeria, revealing a shift towards increased allergic dermatoses. This research assessed the patient landscape at a clinic and satellite site in Obukpa, Nigeria. Methods: A retrospective study of patients seen in the skin clinic of the university of Nigeria teaching hospital (UNTH), Ituku Ozalla, and the rural outpost in Obukpa between November 2009 and 2018 was carried out. A total of 1851 patients' data were analyzed. Diagnosis was based on clinical findings. Results: There were more females (n=1007 [54.4%]) than males (n=844 [45.6%]). Most of the patients were of school age (6-12 years), and the most typical skin disease category was infectious disorders (32.5%), another categories/miscellaneous group (27.7%). Nearly all patients that presented to the rural outpost in Obukpa resided in the surrounding area of Nsukka (93.4%). Conclusions: Comparing the study findings with an earlier one from the same center, there is no change in pattern, with infectious disorders being the most common skin disease category. However, these are largely preventable and emphasize the need for public enlightenment campaigns and policies to discourage the over-the-counter purchase of prescription-strength corticosteroid creams and antibiotics by parents and caregivers, a prevalent practice before seeking medical attention for their children. In addition, there is an urgent need to strengthen dermatologic training in primary health care settings, especially among pediatricians in Nigeria, to improve access to care.

Managing an adolescent with Type 1 Diabetes and socioeconomic deprivation in a remote primary care setting — Ethical challenges

This case study discusses the ethical challenges encountered by a primary care team in managing a 17-year-old girl with Type 1 diabetes in a socio-economically deprived tribal area. The case highlights critical issues such as justice in access to essential medicines, ethical dilemmas arising from complex family dynamics, and systemic failures within the public health system. By examining these challenges, this case study underscores the importance of addressing broader social determinants of health to ensure just and effective healthcare delivery in rural and tribal settings.

Co-designing a blueprint for spreading person-centered, Whole Health care to HIV specialty care settings: a mixed methods protocol

BackgroundSince 2013, the Veterans Health Administration (VHA) has advanced a person-centered, Whole Health (WH) System of Care, a shift from a disease-oriented system to one that prioritizes “what matters most” to patients in their lives. Whole Health is predicated on patient-provider interactions marked by a multi-level understanding of health and trusted relationships that promote well-being. Presently, WH implementation has been focused largely in primary care settings, yet the goal is to effect a system-wide transformation of care so that Veterans receive WH across VHA clinical settings, including specialty care. This sort of system-wide cultural transformation is difficult to implement.MethodsThis three-aim mixed methods study will result in a co-designed implementation blueprint for spreading WH from primary to specialty care settings. Taking HIV specialty care as an illustrative case- because of its diverse models of relationships to primary care - to explore how to spread WH through specialty care settings. We will use the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to organize quantitative and qualitative data and identify key determinants of WH receipt among Veterans living with HIV. Through a co-design process, we develop an adaptable implementation blueprint that identifies and matches implementation strategies to different HIV specialty care configurations.DiscussionThis study will co-design a flexible implementation blueprint for spreading WH from VHA primary care throughout HIV specialty care settings. This protocol contributes to the science of end-user engagement while also answering calls for greater transparency in how implementation strategies are identified, tailored, and spread.

The Acceptability and Feasibility of a Mobile Phone Delivered Brief Intervention for Hazardous Drinking in India

Abstract The effectiveness of Brief Interventions (BIs) for hazardous drinking is well established. However the implementation of BIs at scale in LMICs such as India is rare, primarily due to human resource related barriers. This paper describes the testing of acceptability and feasibility, and the preliminary impact, of a mobile phone delivered BI in an uncontrolled treatment cohort and nested qualitative study. Consenting adult (≥18 years) participants with an Alcohol Use Disorder Identification Test (AUDIT) score between 8 to 15 were recruited from educational institutions, workplaces, and primary care settings. The TLFB (Time-Line Follow Back) was administered to participants at baseline and 3 months post recruitment. All participants received the BI through text messages or IVR (Interactive Voice Response) over eight weeks; and in-depth interviews (IDIs) were conducted with some participants. The mean pre and post outcomes were compared using paired t-test. Qualitative data was analysed using thematic analyses. 29 participants received the intervention and 16 (55%) completed the outcome assessments. Some key qualitative findings indicated the desire from participants for fewer messages and messages that did not require interaction; and more messages with motivational content and information on practical skills to reduce drinking. The percentage days abstinent (PDA) was significantly higher at follow up than baseline in all those who had completed the TLFB at baseline and follow up. Feasibility and acceptability testing is an important component of the intervention development process to ensure that the resulting intervention is suitable for the context.

Exploring methodologies and frameworks for best practice transfer at the primary care level

Abstract Background In Feb 2023, the EU’s Joint Action on the transfer of best praCtices In pRimary CarE (CIRCE-JA) was launched with the objective of effectively transferring and implementing six best practices (BPs) among Member States (MS). Transferability from one primary care (PC) setting to another can be challenging given organizational, legal, cultural, social, economic, and environmental factors, requiring robust a methodological framework to guide the transfer process. A scoping review was conducted to identify conceptual models and methodological frameworks for context-relevant and evidence-informed BP transfer in PC settings. Methods The study aimed to identify models or frameworks to guide BP transfer in PC settings, whilst maximizing transferability. The JBI methodology was used, and an extensive search was conducted in PubMed (time limit: Jan ‘13-May ‘23). All publications of original research, systematic reviews, and text and opinion papers in English were eligible for inclusion. Key exclusion criteria were set, i.e., intervention type, level of care and reporting quality. The search was supplemented by gray literature review. Results From a total of 369 publications, 9 met eligibility criteria, reporting on 10 conceptual and methodological models/framework largely varying. These included transfer models applicable to all BPs as well as elements specific to some BPs, i.e., addressing integration, patient-centered care, care coordination, and health promotion. Strengths and weaknesses were identified for all. Conclusions Transferability of health interventions is complex, requiring systematic consideration of setting and intervention characteristics to inform and support local adaptation, implementation, and decision-making. Key elements identified can support the CIRCE-JA BP transfer and are largely relevant for further BP transfer across PC settings in EU MS, incl. for local adaptation, stakeholder engagement and effective implementation monitoring. Key messages • Innovative BPs are successfully deployed in many EU MS. To best support transformation for strong EU primary care and resilient health systems, it is important to ensure evidence-informed BP transfer. • This review reports on the selection of appropriate frameworks and models, and key elements thereof, to allow successful transfer of CIRCE-JA BPs and other BP transfer across PC settings in Europe.

Primary clinics achieving regular follow-up of patients: Teamwork aspects among healthcare staff

Abstract Backgrounds Studies have shown that more temporally regular primary care visits, or visits more evenly spaced in time, are associated with improved patient outcomes. However, no study has examined what clinic staff can do to encourage greater temporal regularity (TR). We aimed to understand factors related to healthcare staff dynamics that contribute to higher TR for adults with chronic conditions. Methods The study is part of a two-stage mixed methods project. In the first stage, we ranked clinics according to their TR level. In this qualitative stage, we interviewed staff at 6 clinics with extremely high TR (regular follow-up with primary care physician, or PCP), and 6 clinics with extremely low TR. Interviews were conducted with 15 PCPs, 12 nurses, 15 administrative staff, and 4 pharmacists between July 2022- September 2023. Interviews were audiotaped, transcribed, and analyzed using Atlas qualitative analysis software. Findings Themes emerged regarding best ways to promote regular follow-up of patients with chronic conditions. Strategies included having a defined system to reach out to no-show patients, having routine staff meetings to discuss no-shows, adapting workflow to meet the needs of challenging patients, dealing with bureaucracy on patients’ behalf, informal channels of communication with patients, and consulting social workers more often. Relational aspects among staff members at high TR clinics emphasized flat as opposed to hierarchical relationships, as well as high levels of teamwork. Conclusions Teamwork between staff members in primary care settings can contribute to more proactive care delivery, with greater potential to prevent long-term complications. The findings suggest that a high-functioning multidisciplinary care team that focuses on creating the right sorts of interactions and teamwork among staff members, and uses proactive strategies to help engage patients, can contribute to more temporally regular care and thus improved outcomes. Key messages • Stronger teamwork and flat relationships between staff members in primary care settings can result in proactive medicine and developing strategies that improve patients’ regular follow-ups. • Programs focusing on how medical staff utilize their dynamics/relations to improve health outcomes and how doctors’ role align with the staff, can facilitate regular follow-ups of challenging patients.

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

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

Primary health care models for refugees and the involvement of nurses: A systematic review

Abstract Background Primary health care is key to address the health and social needs of refugees. Nurses are often part of multidisciplinary teams in primary health care, but little is known about their roles and responsibilities in refugee health. Our systematic review aimed to synthesise the existing knowledge about models of care (MoC) for refugees in primary care settings and the involvement of nurses in these models. Methods We searched PubMed, CINAHL and Web of Science for literature published in English, Spanish, French and German. For grey literature, we additionally searched Google Search and Scholar, Microsoft Bing and DuckDuckGo. Eligible publications reported on MoC for refugees in a primary care setting and the involvement of nurses. We extracted and synthesised information about the structure of these models as well as the roles and responsibilities of nurses within these. Results 112 publications met our inclusion criteria. Our narrative synthesis focuses on 61 publications with in-depth insights into existing MoC and nurse involvement. We identified 45 MoC, mainly originating from high-income-countries and with almost a third from Australia. The majority of MoC set up a parallel health care structure that refugees could access for a limited period of time. In most MoC, the role of the nurse is described with a relatively high degree of autonomy and with clear areas of responsibility. Clinical and administrative tasks are only part of the nurse’s role, while educational and coordinating activities are often equally important. Conclusions Despite the significant number of refugees in European countries we identified only few reports on MoC specifically addressing their needs. While parallel care structures may be an appropriate approach for a short period of time, integration of refugees into the regular health system is key. Specially trained nurses are well placed to support refugees through a range of measures, including health education and case management. Key messages • Models of Care for refugees could help to navigate within a new healthcare system and ensure that no one is left behind. However, development of and research on such structures are still scarce. • Specially trained nurses are well placed to care for refugees and to support their integration into regular health systems through a range of measures, including health education and case management.

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

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

Improving the functional detection of sarcopenic obesity: prevalence and handgrip scoring in the OBESAR cohort.

The study objectives were: 1) to detect early signs of low muscle function and assess sarcopenic obesity (SO) prevalence in patients with obesity; and 2) to introduce a new online diagnostic tool for scoring handgrip strength (HGS), adjusted for age and sex. Patients from the OBESAR cohort (184 men and 499 women) were tested for body composition and functional testing (chair stand test or HGS based on the cutoffs from the European Society for Clinical Nutrition and Metabolism [ESPEN]/European Association for the Study of Obesity [EASO] or adjusted HGS [adHGS] based on reference values), and SO prevalence was calculated accordingly. Among the 683 patients (mean [SD], age 42.6 [12.8]years; BMI 44.4 [6.3] kg/m2), HGS averaged 25.6 (6.8) kg for women and 43.2 (10.4) kg for men. A total of 25.2% of patients had adHGS lower than the 10th percentile, but this was true for only 5.6% using ESPEN/EASO cutoffs of HGS. SO prevalence rates were different according to functional tests: 5.4%, 24.5%, and 3.2% for HGS, adHGS, and the chair stand test, respectively. Using adHGS through a scoring process considering age and sex may help to detect early signs of SO in a primary care setting in order to better prevent SO through a personalized approach in adults with obesity. A free online application, "GRip And Sarcopenia Prediction" (GRASP), is proposed to diagnose probable SO.

ValveVision AI - a multimodal language model for qualitative reporting of the aortic valve in echocardiography

Abstract Background The precise assessment of the aortic valve via echocardiography is critical for early detection and management of aortic valve diseases. Until recently, previous studies have examined machine learning models to estimate individual measurements and severity of aortic stenosis (AS) from echocardiographic images. These image processing algorithms, while precise in their narrow focus, fall short in mirroring the holistic and interconnected clinical judgment typical of human echocardiographers in producing a qualitative report. Large language models (LLMs), particularly image-to-text multi-modal LLMs, are a fundamental advance in the field of deep learning with implications for a host of applications in medical imaging. They promise to encapsulate not just discrete data points typical in traditional machine learning, but also the complex contextual interrelations in clinical diagnosis. Methods In this study, a large-scale heterogeneous database of echocardiographic images containing over 90,681 studies with textual descriptors of the aortic valve was used to train a single, image-to-text multimodal LLM called ValveVision AI. The ground truth textual summaries were drafted by level III echocardiographers in a clinical setting between 2015-2020. BLEU and ROUGE score was calculated. The models were retrospectively assessed on a holdout dataset. Reviewing physicians compared the generated summary to the ground truth and binarily agreed or rejected it. Receiver Operating Characteristics (ROC) for distinct pathologies were also assessed (Figure I). Results ValveVision AI performed with a BLEU score of 0.45 and a ROUGE score of 0.49. The performance of the model in reporting on classification of moderate/severe vs none/mild AS in concordance with the validation protocol described above achieved a specificity of 91.98% and a sensitivity of 83.89%, along with more precise qualitative description. Qualitatively, the model exhibited the capability of zero-shot learning in certain instances, however, this result remains an area of exploration. Conclusion This study represents to our knowledge, the first attempt at an image-representation to text-tokenizer deep learning model architecture to mimic the thought and subtlety of echocardiographic qualitative analysis of the aortic valve. The results suggest that this multimodal LLM has sufficient accuracy to create a preliminary textual summary of the aortic valve that, if paired with a point of care ultrasound (POCUS) device in a primary care setting, may facilitate case triage, increase efficiency, and determine a more precise care pathway for patients.

Pharmacologic treatment of hypertension guided by non-invasive haemodynamics in primary care improves blood pressure control

Abstract Background Current guidelines on hypertension (HTN) provide blood pressure (BP) targets and therapeutic algorithms but ignore the potential to treat individual patients according to their haemodynamic profile. We have shown that use of non-invasive haemodynamic information obtained by impedance cardiography (ICG) can improve BP control in the primary care setting. Purpose To investigate whether improved rates of BP control by matching patients’ non-invasive haemodynamics to specific pharmacologic treatments and increasing patient engagement translates into improved clinical outcome measures. Methods Electronic medical records (EMR) were obtained for 14,698 patients from two US primary care groups between 2014 and 2023. ICG was done when BP exceeded 140/90 mmHg. Haemodynamic measurements included mean arterial pressure (MAP), cardiac index (CI), cardiac power index (CPI), total peripheral resistance index (TPRI), stroke index (SI) and heart rate (HR) (Figure 1). Haemodynamic ICG profiles were classified as: Vasoconstriction, Hyperdynamic, or Mixed pattern. Printed clinical decision support (CDS) tools and later an EMR integrated CDS application were used to communicate recommendations to physicians. Printed reports were shared with patients to increase their engagement. Pharmacological therapy was tailored based on haemodynamic information. Rates of successful BP treatment and the occurrence of myocardial infarction (MI) or stroke were tracked through the EMR. Results Of 14,698 patients, 50% were women, 17% were Black and 17% were aged 18-49 years, 45% aged 50-69 years, and 38% age ≥ 70 years. A total of 21,246 ICGs were performed classifying patients as Vasoconstriction 47%, Hyperdynamic with high heart rate (HR) or high stroke index (SI) 24%, and Mixed Haemodynamic (combination of Vasoconstriction and Hyperdynamic) 29% (Figure 1). Demographic features were not strongly associated with haemodynamic classification. Within 2-3 years of inclusion, >85% of patient achieved BP control (<140/90 mmHg), which was sustained during follow-up. Over a median (IQR) follow-up of 8 (2016-2023) years, there were 14 (5) MI and 34 (16) strokes. These event rates appear to be lower than those reported in other large cohorts of patients with HTN. Conclusions Treating patients with HTN according to their individual haemodynamic profile is associated with high rates of BP control. Further analysis will determine whether the rates of MI, stroke and death are lower than expected based on the patients baseline risk profile.Haemodynamic Status (ICG Test Results)

Identification and optimisation of a risk stratified cohort of patients with type 2 diabetes through the delivery of a enhanced pharmacist-led service

Abstract Introduction Cardio-renal metabolic (CRM) diseases are each associated with significant morbidity and mortality, and due to their shared pathology, the benefit of managing these diseases holistically is becoming increasingly evident. The East Belfast Federation practices have sought to review patients living with type 2 diabetes (T2D), prioritising those not meeting their 3 Treatment Targets (3TT, HbA1c, blood pressure [BP] and cholesterol) to optimise treatment through a pharmacist-led model of care. Aims and Objectives 1. Improve adherence to latest update of NICE T2D [NG28, 2022], with a focus on patients with Cardiovascular Disease (CVD) & Chronic Kidney Disease (CKD). 2. Upskill diabetes teams, to create a legacy effect and ensure improved holistic management will continue beyond the project period. 3. Use a clinical audit tool to identify, stratify and optimise T2D patients not meeting their 3TTs. 4. Improve identification, coding and recall of patients with non-diabetic hyperglycaemia (NDH) as per QOF Indicator NDH001NI [QOF 2022/23]. 5. Enhanced focus on review of sulphonylureas (SU) in relation to frailty and risk of hypoglycaemia [Strain, 2021]. Method Patients not meeting their 3TTs (HbA1c>58 mmol/mol, BP>140/80mmHg, total cholesterol>5mmol/L) were identified from October 2022 to July 2023. Primary care based clinics created which we tailored to the specific needs of the practices with a focus on optimising patients with CVD & CKD co-morbidities. Dedicated specialist education and clinical support was provided to existing diabetes teams in CRM patient management. Additional searches were created and patients identified to review patients experiencing NDH and on a SU. Results At 9 months from baseline, there was a statistically significant improvement of 8.9% in patients achieving all 3TTs (n=373, P=0.013). This was accompanied by an increase in the number of patients optimised for CV risk reduction, with a 39% and 42% increase in patient receiving sodium glucose co-transporter-2 (SGLT2) inhibitors (n=542) and Glucagon-like peptide-1 receptor agonists (GLP1RA) (n=190), respectively. A 5.5% (n=28) reduction in the number of patients on a SU was observed, as well as a 44% (n=76) increase in the number of referrals into the Diabetes Prevention Programme (DPP). 151 statins and 51 BP medications were started/optimised. Discussion and Conclusion The project further exemplifies the feasibility of a pharmacist-led T2D service in a primary care setting. In addition to improvement in established T2D markers, the role promoted collaboration and facilitated best-practice sharing across multiple diabetes teams. This approach allows for more co-ordinated care for patients who may otherwise be referred to multiple specialists, which often results in fragmented care. Future work should focus on promoting CRM protection as early as possible to reduce disease progression and improve outcomes.Number of patients on antidiabetic meds% attainment of 3TT

The identification, referral and management of patients with cardiac-related distress: a new model to support psychological recovery after a cardiac event

Abstract Background Identification, referral and management of patients with psychological distress is an important component of cardiac rehabilitation (CR). We developed a protocol to identify patients in hospital, CR and primary care settings, and refer them to a specialist psychocardiology clinic. Using the newly developed Cardiac Distress Inventory (CDI), we demonstrated that counselling resulted in reduced rates of cardiac-related distress. This study demonstrates the importance of having a clear pathway from screening to referral to intervention to support cardiac patients in their recovery. Purpose The team identified a dearth of high-quality research on distress in cardiac patients, including a lack of data on the resolution of cardiac-related distress after psychotherapeutic intervention. This was due to the lack of appropriate measurement of cardiac distress, and the absence of clear pathways for identification, referral and management of cardiac distress. Methods The Cardiac Emotions Study is a multi-site, multi-component study of cardiac-related distress. The team first developed the 55-item Cardiac Distress Inventory (CDI), a comprehensive clinical assessment tool. A brief screening version, the 12-item Cardiac Distress Inventory Short Form (CDI-SF), was then developed. Patients referred to the specialist psychocardiology clinic over a 6-month period (N=113) were administered the CDI-SF, together with the Generalised Anxiety Disorder 7 (GAD7) and the Patient Health Questionnaire (PHQ9), with all measures re-administered at discharge. Results More than half the clients presented to the Clinic within the first 3 months post-event (58%), while 84% presented within the first year. At presentation, over half the clients were anxious (GAD7>10; 53%), depressed (PHQ9>10; 57%), or distressed (CDI-SF>13; 56.4%). Levels of particular aspects of cardiac distress are shown in the Figure. On completion of counselling, distress had resolved for the majority of clients, with the distress rate of 18.6% at discharge equivalent to that seen in a normative sample of cardiac patients. Rates of anxiety and depression also significantly decreased after counselling. Conclusion This study demonstrated that distressed cardiac patients could be appropriately identified in settings such as hospital, CR and primary care and referred for counselling, and that counselling resulted in significant reductions in rates of cardiac distress, anxiety and depression. Undergoing counselling through a specialist psychocardiology clinic assisted clients in obtaining normative rates of post-cardiac event distress. The analysis showed the necessity of having a clear clinical pathway from screening to psychological treatment, and the utility of having a validated measure of cardiac distress that is sensitive to change after intervention.

Electrocardiogram-based artificial intelligence to identify prevalent coronary artery disease

Abstract Background Coronary artery disease (CAD) often goes undetected for years before it manifests and results in substantial morbidity and mortality. Some patients have neither typical risk factors nor symptomatic angina despite progressive disease. Purpose Develop a deep-learning model to detect prevalent CAD and identify people at risk for adverse events using electrocardiograms (ECG) in a primary care setting. Methods We developed a convolutional neural network using 12-lead ECG waveforms to discriminate the presence of CAD defined using diagnostic codes ("ECG2CAD"). ECG2CAD was trained on 764,670 ECGs from 137,199 individuals at the Massachusetts General Hospital (MGH). Model performance for discrimination of prevalent CAD was measured using AUROC and AUPRC, and compared against a model comprising age and sex, as well as the Pooled Cohort Equations (PCE), in three test sets independent of model training: MGH, Brigham and Women’s Hospital (BWH) and UK Biobank. ECG2CAD was assessed across subgroups of age, sex and self-reported ethnicity and for incident CAD-related events in the BWH primary care subset. Results ECG2CAD was evaluated in MGH (N=18,706 [N=6,051 cases], age 57±16 years), BWH (N=88,270 [N=27,898 cases], age 57±16 years), and UK Biobank (N=42,147 [N=1,509 cases], age 65±8 years). ECG2CAD consistently discriminated prevalent CAD (MGH: AUROC 0.782, AUPRC 0.639; BWH: AUROC 0.747, AUPRC 0.588; UK Biobank: AUROC 0.760, AUPRC 0.155) and incrementally improved upon both a model based on age and sex (p<0.01) and the PCE (p<0.01) in MGH and BWH. In the BWH primary care subset (N=51,808), model performance was consistent in subgroups defined by age, sex and self-reported ethnicity/race. The incorporation of ECG2CAD in addition to age and sex consistently improved discrimination (AUROC delta of 0.011-0.086) in all subgroups. In the BWH primary care subset with over 10 years of follow-up, we observed that either the presence of ECG2CAD-predicted CAD (HR 2.18, 95% CI 2.00-2.38, P<0.001) and ICD-based known CAD (HR 2.13, 95% CI 1.86-2.45, P<0.001) were associated with increased risk for incident myocardial infarction. The presence of both definitions was associated with an almost five-fold increase in risk (HR 4.97, 95% CI 4.51-5.48, P<0.001). The risk of incident adverse events was highest among people in the top quintile of ECG-based predicted risk (high risk) compared with people from quintile 4-2 (intermediate risk) or the lowest quintile (low risk), even when excluding those with known prevalent CAD at baseline. Conclusions Artificial intelligence-enabled analysis of the 12-lead ECG may facilitate efficient identification of individuals with possible undiagnosed CAD and inform downstream testing and preventive measures.

Real-world evaluation of a lipid transformation project in primary care settings

Abstract Background The National Health Service England Long-Term Plan (2019) highlights the need to optimise lipid management to reduce cardiovascular disease (CVD) risk. A collaborative project was funded between a local health service and an industry partner to review current practice and improve outcomes in a UK region through introduction of lipid management pathways, primary care education and patient-focused reviews to optimise lipid-lowering therapies among high-risk patient groups. Purpose The project aimed to increase prescribing of CVD risk reduction therapies such as high-intensity statins (HIST), escalation of therapy to achieve lipid-lowering treatment targets, to improve clinician knowledge and confidence in lipid management and provide benefits for local populations in reducing CVD risk. Methods Systematic patient searches across six Primary Care Networks (PCNs) prioritised high-risk patients for review. Community of Practice sessions were held to facilitate shared learning and problem-solving. A pragmatic, real-world evaluation was conducted to explore the impact of the new pathways and tools on prescribing outcomes and optimisation of lipid-lowering therapies. To examine the changes in HIST prescriptions, a statistical analysis of open-source prescribing data was undertaken between baseline (December 2021) and follow-up (December 2022) on over 39,000 eligible patient records. Qualitative interviews with clinicians from all participating PCNs and a thematic analysis of emerging themes was conducted in 2023. Results A paired sample t-test demonstrated a significant increase in the percentage of HIST prescribed, of the total number of statins prescribed, across the six PCNs between baseline and follow-up t(5) = -3.38, p = 0.01. Table 1 illustrates the changes at individual PCN level. Four of the six PCNs reached the National Institute for Health and Care Excellence minimum threshold of 65% target for HIST prescribing in statin prescriptions and three of these PCNs exceeded the optimal target of 75% HIST. An additional 600 patients were prescribed Ezetimibe (as therapy escalation or for statin intolerance). Through qualitative data, clinicians reported development of new skills and knowledge, leading to increased confidence in optimising lipid management with medication and lifestyle interventions. Conclusion The lipid transformation project demonstrated significant improvements in prescribing of lipid-lowering therapies and improved clinician competence in lipid management pathways and guidance. This has enabled sustainable improvements in lipid management and cardiovascular disease reduction in local populations.

A comparative analysis of conventional echocardiographic findings among different heart failure stages and phenotypes: insights from the national echocardiographic society registry

Abstract Background The contemporary conceptualization of heart failure (HF) encompasses four developmental stages (at risk for HF, pre-HF, symptomatic HF, and advanced HF) and three distinct HF phenotypes categorized by left ventricular ejection fraction (LVEF) (HFpEF, HFmrEF, HFrEF). However, there is a need for a more comprehensive understanding of echocardiographic similarities and differences among pre-HF stages and various HF phenotypes. Material and Methods Our national echocardiographic society conducted a multicenter HF screening initiative. General practitioners in 13 primary care centers utilized the original mobile phone app to determine referrals for transthoracic echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing in individuals without a prior HF diagnosis. The 2021 ESC guidelines' algorithms were used to diagnose HF phenotypes and 2016 EACVI/ASA recommendation² to assess diastolic function. This study defined "heart stress" (elevated NT-proBNP in asymptomatic individuals with risk factors, regardless of structural heart disease or cardiac dysfunction) and "patients at risk for HF" (normal NTproBNP and at least one HF risk factor). All patients were categorized into six groups: (I) no HF, no risk, (II) at risk for HF, (III) heart stress, (IV) HFpEF, (V) HFmrEF, and (VI) HFrEF. Echocardiographic findings were compared among groups (II) to (VI), using ANOVA, Kruskal-Wallis and Chi-squared test, when needed. Results In a cohort of 930 outpatients (mean age 66±11 years, 61% female), 34.2% were diagnosed with HF, 22.3% experienced heart stress, 37.8% were at risk for HF, and 12.8% had neither HF nor risk factors (Figure). While NT pro BNP showed progressive increase, LVEF showed a progressive decline across the groups, reaching its lowest in HFrEF patients (Table). Simultaneously, left ventricular mass index (LVMi), left atrial volume index (LAVi), and maximal velocity of tricuspid regurgitation (TR Vmax) significantly increased in a stepwise manner. Variations in predominant LV geometry were significant across groups (p<0.001): normal LV geometry in those without HF (60.8%), concentric LV remodeling in at-risk patients (38.6%), normal LV geometry in heart stress (49%), concentric LV hypertrophy (LVH) in HFpEF (27.7%), eccentric LVH in HFmrEF (42.3%), and both concentric and eccentric LVH in HFrEF (43.3% each). Diastolic dysfunction increased prevalence across the groups (12.9% vs 24.7% vs 37.6% vs 19.6% vs 51.1%, p<0.001). Remarkably, HFmrEF group had the highest proportion of undetermined diastolic function (14.7% vs 23.1% vs 27.9% vs 50% vs 26.7%, p<0.001). Conclusions The mobile phone app used in primary care setting allowed identification of significant number of individuals in the pre-HF stages, warranting further investigation. Distinct echocardiographic differences in pre-HF stages and HF phenotypes provide valuable insights for early detection and tailored treatments.

Interprofessional Education Simulation Project Using the Collaborative Care Model.

Integrated behavioral health care (IBH), a team-based approach to care, involves behavioral health providers (BHP) to be utilized in primary care settings. Unfortunately, many BHP and primary care advanced practice nursing students do not receive IBH content in their educational curriculum. This article describes an innovative interprofessional simulation project (ISP) in a virtual IBH setting with primary care nurse practitioner and master's level counseling students. The ISP involved students role-playing using case studies while enacting the roles exemplified in the Collaborative Care model (CoCM). Interprofessional faculty collaborated in developing the project and training facilitators and interprofessional students. Of the students and faculty who completed a postsurvey, 87.7% reported an increase in preparedness in learning the CoCM, and 92.6% responded the preparation time for the project was "appropriate." The ISP project resulted in high satisfaction and perceived increased preparedness for students and faculty to practice and teach IBH. [J Nurs Educ. 2024;63(X):XXX-XXX.].

Promoting Equity: Child & Adolescent Health Service

Abstract The health and well-being of children and adolescents face significant challenges, particularly in times of social instability. In response to these challenges, the Norwegian government allocated funding in 2021 to establish a national center for Child and Adolescent Health Promotion Services. Situated within the Norwegian Institute of Public Health, this center focuses on enhancing expertise, professional development, and research within municipal maternity and child health clinics, school health services, and youth health clinics. This presentation delves into the crucial role of Universal Health Promoting Services (UHPS) in mitigating the adverse effects of social inequality on child and adolescent health. By leveraging evidence-based practices and identifying knowledge gaps in health promotion and disease prevention in primary care settings, UHPS serve as catalysts for reducing health disparities and enhancing outcomes among expecting parents, children, and adolescents. Moreover, UHPS plays a vital role in addressing the underlying determinants of health inequality, including social network, lifestyle factors, promotion of health literacy and ensuring accessible health care services for all. UHPS empowers individuals and communities to actively participate in health promotion efforts, fostering a culture of health equity and resilience. Through targeted health education programs, early intervention strategies, and community empowerment initiatives the UHPS work both at a systems and individual level to address social inequality in health. This presentation contextualizes UHPS within a broader picture aimed at promoting child and adolescent health while addressing social inequality in health. By highlighting effective approaches and areas requiring further research, it aims to contribute to the ongoing discourse on optimizing health outcomes for young populations.

6.H. Round table: Harnessing Patient-Reported Data for Health Innovation: Insights from the OECD PaRIS Initiative

Abstract Summary This round table will disseminate knowledge and foster discussions on data reported by patients with a chronic disease in primary care settings in 20 countries for enhancing health system responsiveness and effectiveness. By delving into the OECD’s Patient-Reported Indicator Surveys (PaRIS) survey’s development, adaptation, and analytical strategies, participants will leave with a richer understanding of how patient-reported data can inform and transform health policy and practice in Europe and beyond. Rationale The round table aligns with the Conference theme by focusing on the transformative potential of patient-reported data in health systems. OECD PaRIS provide a unique lens through which to examine patient-centered care, showcasing innovative methods to capture and utilize data across diverse health system contexts. This round table will explore the development, adaptation, and analysis of this flagship survey, revealing its critical role in shaping health policies and practices that are attuned to patient needs and experiences. Objectives 1. Understanding Development and Testing Processes: To gain insights into the systematic approaches used in developing patient-reported instruments that are both robust and sensitive across multiple healthcare settings; 2. Exploring Co-development and Adaptation: To discuss the challenges and strategies involved in adapting health surveys to various national contexts while ensuring stakeholder engagement and data relevancy; 3. Analyzing Data for Policy Making: To comprehend the analytical frameworks used in processing patient-reported data for crafting effective health policies and identifying factors that influence patient outcomes. Key messages • Patient reported data on experiences and outcomes provide essential information for health systems performance. • Unique insights into the systematic collection of such information can be gathered through the proposed discussion on the experience of designing and implementing the PaRIS Survey.