Family practice最新文献

Background: Multimorbidity-the co-existence of two or more chronic health conditions in the same individual, without reference to an index condition-has become a global health issue and creates enormous pressure on the healthcare system. This review aimed to summarize evidence on the effectiveness of interventions used to manage people with multimorbidity.

Methods: MEDLINE, EMBASE, CINAHL, Cochrane Library, two trials registers, and grey literature were searched for studies of adults with multimorbidity receiving care in primary or community care settings up to 30 September 2024. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias and study certainty. Interventions were categorized as medicines management (MM), support for self-management (SSM), or care coordination plus support for self-management (CC + SSM). Meta-analyses for primary outcomes (health-related quality of life, healthcare utilization, and healthcare costs) were conducted.

Results: From 10 272 titles screened, 33 eligible studies (this review: 18, previous review: 15; MM: 6, SSM: 9, CC + SSM: 18) were identified, of which 26 studies with 9449 participants were included in meta-analysis. Overall, there was little significant evidence of benefit of the interventions compared with usual care for most outcomes. SSM was associated with lower hospitalization risk and medication costs, but slightly more emergency department (ED) visits; and CC + SSM with better SF-12 PCS score, lower hospitalization risk and fewer ED visits, but more outpatient and general practitioner visits.

Conclusion: This review found some suggestions of improved outcomes and reduced healthcare utilization (especially hospitalization) for these interventions. There is a paucity of evidence reporting on health outcomes, especially healthcare costs, in the management of multimorbidity.

Introduction: Family physicians spend approximately half their professional time on indirect patient care activities (IPCA). Essential to patient care, inbox IPCA includes renewing prescriptions, checking lab results, and reviewing messages. However, IPCA detracts time from direct patient care and has been linked to burnout, potentially contributing to the family medicine crisis in Canada. Our objective was to understand the range of family physicians' experiences and perspectives regarding electronic inbox management.

Methods: We conducted a systematic review of peer-reviewed articles, published in English between 1 January 2012, and 22 April 2024, that addressed family physicians' perspectives on tasks related to the electronic inbox and used any method of primary data collection and analysis. Data analysis used a constant comparative method.

Results: Fifty-four articles were included. The combination of fragmented technical systems and an overwhelming volume of complex tasks has created a system where family physicians struggle to manage the administrative work of patient care. Selected impacts include excessive time spent on duplicated or unnecessary tasks, inadvertently making uninformed clinical decisions, and perceived tension between patient accessibility and workload. Strategies for management were described, including the re-design of electronic medical record systems, task delegation, and synchronizing prescription renewals with patient visits.

Conclusions: The intersection of inefficient systems and high workloads makes inbox management labour-intensive and frustrating, lowering job satisfaction and efficacy. Downloading administrative tasks to family physicians, combined with the growing complexity of patient management, has generated a tremendous burden. Solutions are needed to improve the sustainability and appeal of family medicine.

Introduction: In 2023, cardiovascular disease was the leading cause of death worldwide. Various risk calculation tools based on risk factors can be used to estimate this risk. Calculating the coronary calcium score should allow us to assess this risk at an individual level. There is no consensus in the various good clinical practice guidelines (CPG) on the use of this score. The aim of this study was to assess the reliability of the various CPGs for the use of the calcium score in primary prevention.

Methods: CPGs published between 2018 and 2023 whose recommendations included advice on the use of CSC in primary prevention cardiovascular risk assessment for the general population was searched via Pubmed. The G-TRUST evaluation grid was then applied to the CPGs to determine which fell into the "reliable and relevant" category.

Results: 467 publications were identified via Pubmed. Only seven met the inclusion criteria. Of these seven CPGs, only two obtained an overall score of "reliable and relevant." The other five were assessed as "not usable" because of the risk of conflicts of interest, the absence of a systematic review, or the absence of patients' opinions and wishes.

Discussion: The two CPGs selected as reliable and relevant recommended that the CSC should not be used to assess cardiovascular risk, while the five classified as "not usable" recommended its use. G-TRUST is a tool which assesses the quality of the design of a recommendation and not the quality of the guidelines they propose.

Background: The growing aging population and chronic diseases underscore the need for sustainable healthcare, with expanding South Korean pharmacies' roles beyond dispensing medicines offering a solution to fragmented care. This study assesses public acceptance and perceived need for implementing a "Family Pharmacy" model in South Korea by examining public perceptions, functional needs, and policy implications.

Methods: A cross-sectional, web-based survey was conducted among 1000 South Korean adults aged 19 years and older (response rate: 15.19%). Participants were categorized into three groups based on their pharmacy usage patterns: non-regular users, prescription-focused users, and comprehensive service users. Satisfaction levels, functional needs, and factors influencing "Family Pharmacy" selection were assessed. Logistic regression analysis identified predictors of willingness to use family pharmacies.

Results: The comprehensive service user group reported significantly higher satisfaction across items such as pharmacist communication skills, adequacy of consultation time, and comprehensive health consultations. Functional needs like proper medication use education, adverse drug reaction monitoring, and consultation on new prescriptions were broadly supported. Critical selection factors included geographical accessibility, pharmacist expertise, and sufficient consultation time. Logistic regression analysis indicated higher odds of willingness to adopt the "Family Pharmacy" model among the comprehensive service user group (OR: 3.521) and participants with chronic diseases (OR: 2.033).

Conclusion: The "Family Pharmacy" model demonstrates the potential for implementation in South Korea, with public interest and functional needs aligning with its patient-centered approach. The successful introduction and expansion of a "Family Pharmacy" model requires a phased and coordinated approach.

Background: Over the past decade, there have been rapid advancements in genomic medicine that have improved the clinical utility of genetic testing and counseling. Although theoretically, primary care is an ideal locations for the delivery of genomic medicine, physicians lack training, confidence, and time to implement these services. Though it has been suggested that genetic counselors could be integrated into the primary care setting to fill this gap in care, such integration has not yet been widely implemented. Decision makers' perceptions are foundational in the implementation of this model, but have yet to be explored.

Methods: We conducted a qualitative interview-based study with individuals holding key administrative roles in primary care systems to elicit opinions on a model of care that integrates genetic counselors into primary care. Interviews were analyzed using interpretive description involving thematic coding and iterative discussions among the research team to develop a comprehensive conceptual model.

Results: Barriers included team integration difficulties, a perceived lack of buy-in at the institutional, physician, and patient levels, and a lack of resources. Participants felt that integrating genetics into primary care is most feasible when one genetic counselor is contracted as a resource to multiple different clinics and is able to provide remote or hybrid care.

Conclusion: Despite the growing evidence supporting the integration of genetic counselors into primary care settings, decision makers have concerns about how this integration will occur, and feel that more buy in is needed from patients, providers, and administration to make this model of care a reality.

Background: Shoulder pain often results in functional limitations leading to substantial societal and healthcare costs. Guidelines recommend a corticosteroid injection or exercise therapy, but long-term comparative cost-effectiveness remains unclear. This study examined the cost-effectiveness of these two treatments over 12 months in patients with shoulder pain presenting in Dutch primary care.

Methods: A randomized controlled trial was conducted with patients consulting for a new episode of shoulder pain. Participants were randomly assigned to a corticosteroid injection or a 12-week physiotherapist-led exercise therapy program. Participants completed questionnaires at baseline, 6 weeks, and 3, 6, 9, and 12 months. The primary outcome was incremental costs per quality-adjusted life year (QALY) gained over 12 months, analyzed with the incremental cost-effectiveness ratio (ICER). QALY was measured using the EuroQol Five-Dimensional Questionnaire (EQ-5D-5L) score.

Results: A total of 183 participants were included, with 91 participants in the injection group and 92 in the exercise therapy group. The incremental costs and QALY for the exercise group were, respectively, €428 (95% CI: -1825 to 2682) and 0.02957 (95% CI: -0.0299 to 0.0891), resulting in an ICER of €14 489 (95% CI: -1 698 053 to 1 727 032) per QALY gained. With a willingness-to-pay threshold of 50 000 the cost-effectiveness acceptability curve showed a probability of 70% of cost-effectiveness for exercise therapy.

Conclusions: For patients with shoulder pain, the exercise therapy group has a probability of 70% to be cost-effective compared to the injection group over a 12-month follow-up with an ICER of €14 489 (95% CI: -1 698 053 to 1 727 032) at a willingness-to-pay threshold of €50 000 per QALY.

Clinical trial registration: registered in the Netherlands Trial Registry (NL-OMON52854).

Background: Emergency care systems worldwide are increasingly facing capacity challenges. A significant number of people are using emergency care, including the use of emergency departments and ambulance services, for conditions that could be managed in primary care settings, potentially creating unnecessary strains on the already heavily burdened emergency care systems, leading to overcrowding, inefficient use of healthcare resources, and inadequate access to emergency care for those in need.

Objectives: This scoping review of the literature aimed to explore existing evidence considering the multifaceted factors contributing to patients' decisions to seek emergency care for conditions manageable in primary care.

Methods: A comprehensive search of "PubMed", "Embase", "MEDLINE", "CINAHL" and "the Cochrane Library" was conducted, including peer-reviewed articles published from Jan 1st 2004, until June 15th 2024. This review was conducted following the methodological framework presented by Arksey and O'Malley.

Results: A total of 44 studies conducted in 21 countries worldwide were included in the final analysis. Key data were extracted and analysed using thematic analysis, and the following themes have been identified: (1) accessibility and convenience, (2) health anxiety, (3) uncertainty and knowledge gaps in healthcare services, (4) external advice and encouragement, and (5) personal influences.

Conclusion: Our study maps the existing international literature to inform researchers and policymakers on possible future development of efficient alternative care frameworks and pathways designed to alter emergency care utilisation behaviours, ultimately reducing unnecessary visits and ensuring efficient care is provided for true emergencies.

Background: One of the major challenges of the rural family medicine program is the retention of doctors in rural areas, which is significantly influenced by their experience of living in these regions. This study aims to explore physicians' experiences regarding the challenges and opportunities of living in rural areas.

Methods: This qualitative study was conducted in 2024 in Fars Province. Sixteen physicians were selected using purposive sampling until data saturation was reached. Data were collected through semi-structured interviews and analyzed using Graneheim and Lundman's conventional content analysis method. Data management was carried out using MAXQDA software, version 20. Lincoln and Guba's trustworthiness criteria were applied to ensure the validity and reliability of the findings.

Results: Nine main challenge themes and three main opportunity themes were identified, including financial constraints, inadequate infrastructure, professional isolation, family-related barriers, inadequate incentives, poor living conditions, security concerns, cultural differences, and limited career growth as challenges, and strong patient-physician relationships, lower living costs, and gaining comprehensive primary care experience as opportunities.

Conclusion: Addressing these challenges while leveraging the identified opportunities provides policymakers with practical implications for designing effective strategies to retain family physicians in rural areas of Iran.

Background: Ontario's primary care reforms have introduced three blended physician payment models: (i) blended fee-for-service (BFFS), (ii) blended capitation without interprofessional teams, and (iii) blended capitation with teams. Each model includes the same pay-for-performance incentives, yet their impact on cancer screening, including that during the COVID-19 pandemic, remains unclear.

Methods: We used linked administrative data (2018-23) to examine the associations between these models and colorectal, cervical, and breast cancer screening rates. Fractional probit regression models, adjusting for physician and patient characteristics, estimated the effects of each payment model relative to the BFFS. Stratified analyses explored heterogeneity by physician sex, age, practice size, rurality, and socioeconomic deprivation.

Results: Compared with the BFFS model, the blended capitation models were associated with higher screening rates, although initial differences were modest. By 2022, nonteam and team capitation models had colorectal screening rates 3.0% and 3.6% higher, respectively, than those of the BFFS. Similar but smaller increases were observed for cervical and breast cancer screening. These advantages persisted through COVID-19 disruptions and were most pronounced among physicians serving rural or socioeconomically disadvantaged populations. Stratified analyses indicated that female, younger, and higher-volume physicians performed better in capitation-based models.

Conclusions: Blended capitation arrangements, especially those integrating interprofessional teams, appear more effective than the BFFS in delivering preventive cancer screening. Strengthening team-based primary care and targeted incentives could bolster preventable cancer screening rates in the population, even under pandemic-related challenges. These findings can inform policy decisions aimed at improving population health through optimized primary care provisions.

Background: The global diabetes epidemic necessitates self-management strategies, and traditional patient education faces challenges in personalization, continuity, and monitoring. This study evaluates the efficacy of the collection-assessment-plan-do-check-aggrandizement (CAPDCA) model, which is a personalized patient education framework for improving glycemic control and self-management.

Methods: A multicenter, two-stage cluster randomized controlled trial was conducted across six community health centers in Beijing. Eligible participants were randomized into intervention (CAPDCA model, n = 90) or control (traditional education, n = 90) groups. Primary outcomes were HbA1c reduction and target achievement; secondary outcomes included fasting blood glucose (FBG) and 2-h postprandial blood glucose (2h-PPG), medication adherence (MMAS-8), and quality of life (SF-36). Follow-ups occurred over 18 months (11 visits). Generalized estimating equations (GEE) analyzed longitudinal trends.

Results: 178 participants completed the trial (90 in the intervention group and 88 in the control group). Compared to the control group, the intervention group demonstrated ​a significantly lower final HbA1c level​ (t = 6.356, P < .01) and ​a greater reduction in HbA1c​ (t = -6.117, P < .01). Target achievement rate of HbA1c is 83.3% in intervention and 25.0% in controls (risk ratio = 3.33, 95% CI: 2.29-4.84, P < .01). FBG (odds ratio (OR) = 0.663, 95% CI: 0.468-0.938) and 2h-PPG (OR = 0.218, 95% CI: 0.138-0.345) in intervention reductions were significantly greater (P < .05). MMAS-8 scores improved to 7.0 (inter-quartile range: 6.75-7.5) better than control group (Z = 5.912, P < .01). SF-36 scores is higher in the intervention group (t = 9.497, P < .01).

Conclusions: The CAPDCA model enhances glycemic control, medication adherence, and quality of life in patients with diabetes through structured and personalized iterative education. Its scalability and adaptability address critical gaps in personalized diabetes education, offering a feasible framework for global implementation in primary healthcare institutions.