Family practice最新文献

Background: Prescribing high-potency opioids for chronic non-cancer pain has increased in Germany, despite limited evidence of long-term efficacy. General practitioners write approximately 87% of all opioid prescriptions. The guideline "Long-term use of opioids for chronic non-cancer pain" (LONTS) provides recommendations for responsible opioid management, but its uptake in primary care remains unclear.

Objective: This study investigates how general practitioners apply LONTS guideline recommendations and identifies barriers to implementation.

Methods: A mixed-methods study was conducted, including an online questionnaire to detect deviations from LONTS recommendations, followed by semi-structured telephone interviews to explore barriers for guideline adherence.

Results: A total of 131 questionnaires and 21 interviews with general practitioners were analyzed. 45% of questionnaire participants were unfamiliar with the LONTS guideline. Four key gaps were identified: (i) Nearly 40% of general practitioners rarely or never set individualized treatment goals for chronic pain patients; (ii) 49% preferred combining long-acting opioids at fixed intervals with short-acting opioids on demand; (iii) 17% used short-acting opioid monotherapy, considered a treatment error; (iv) 44% did not discuss opioid reduction or discontinuation after 6 months of effective pain relief. Qualitative analysis identified key barriers: lack of integration into daily routines, anticipating patients' fear of pain recurrence, and preference for personal experience over evidence.

Conclusion: General practitioners in Germany may struggle to implement LONTS recommendations for opioid use in chronic non-cancer pain. Targeted strategies are needed to promote and improve the adoption of these guidelines in primary care.

Background: The 2024 Final Rule for physician fee schedule under the Medicare Prospective Centers for Medicare & Medicaid Services (CMS) has sunset and combined seven screening and quality measures for traditional Medicare Merit-Based Incentive Payment System (MIPS) reporting with a single composite clinical quality process measure, Preventive Care and Wellness (PCW). While composites offer benefits including statistical efficiency and increased stability over time, the contextless nature of composite scores may result in disadvantaging low-resource primary care health centers ("health centers") serving medically underserved communities that face healthcare access and outcome challenges.

Objective: Evaluate the CMS composite score metric in health centers to identify characteristics that are associated with higher versus lower composite scores.

Methods: We conducted a 4-year (2019-2022) retrospective data analysis with more than 1.5 million patients from 191 primary care health centers within the OCHIN national network of community health organizations (CHOs). The primary outcome is a modified version of the PCW. Generalized linear mixed models assessed clinic factors associated with score variation, accounting for repeated measures.

Results: Our analysis demonstrated that prepandemic scores started to recover by the end of 2022 (0.6644 vs. 0.6153) and that five factors (pediatric or 65+ patients, Hispanic adults, uninsured patients, and clinic encounter volumes in Q2 and Q4) significantly affected clinic score variation over time.

Conclusions: Our analyses show that preventive service delivery in health centers has nearly recovered from pandemic declines. Differences in subpopulations highlight the importance of context in interpreting health centers' score variation.

Background: Causal mediation, a quantitative analysis method, has the potential to be a valuable addition to any primary care provider, researcher, or student's toolbox.

Objective: This manuscript describes the theory behind causal mediation, provides a running example to help understand the application of this method in research, and explains how the results may be applied practically to help design appropriate interventions.

Methods and application: Causal mediation allows an exploration of the mechanism of action of a primary care intervention on an outcome that may pass through a third variable that is on the causal pathway, a mediator. Causal mediation analysis allows the decomposition of the total effect of an intervention on an outcome into both direct and indirect effects. Careful interpretation of generated results can guide decision-makers when devising or refining interventions or policies that affect patient health outcomes in primary care.

Conclusion: Causal mediation has been used in many disciplines and is well-positioned to answer varied research questions. However, the full extent of its potential has yet to be realized.

Background: In primary health care (PHC), telemedicine consultations ensure access to current treatments and provide real-time feedback, promoting continuous education and training for future scenarios.

Objective: This study aimed to evaluate the behavioral change intentions of PHC physicians regarding the application of knowledge gained from teleconsultations in their clinical practice.

Methods: We conducted a cross-sectional study involving PHC physicians from northeastern Brazil who engaged in telemedicine consultations with specialists. Data were collected between May and December 2023. The continuing professional development-Reaction questionnaire was used to assess behavior change intentions among the physicians.

Results: According to median responses, PHC physicians demonstrated high individual motivation to apply the information discussed. Their positive perception of facilitators and barriers, along with the perceived approval or disapproval from key individuals, influenced their adoption of knowledge from the teleconsultations. Univariate linear modeling, used to assess the impact of demographic and professional variables, identified female physicians as statistically significant (P = .030) in Factor 1. Participating physicians showed a strong intention to apply knowledge acquired through teleconsultations in their clinical practice, regardless of their academic background, professional experience, age, workload, or demographic characteristics.

Conclusion: Telemedicine consultations offer valuable learning opportunities by providing access to standardized information, facilitating the adoption of evidence-based practices, and enhancing physicians' confidence in applying new knowledge.

Background: The World Health Organisation's Medication Without Harm campaign aims to reduce severe avoidable medication-related harm by 50%. This systematic review explored the characteristics of interventions that provide visual and longitudinal feedback on prescribing (interactive dashboards), in general practice and the effect of these interventions on prescribing-related outcomes.

Methods: This systematic review was registered prospectively and reported in line with PRISMA guidelines. Multiple databases and grey literature were searched in November 2023 to identify interventional studies that explored the effect of interactive dashboards on prescribing-related outcomes in general practice. Two independent researchers conducted screening, data extraction, and risk of bias assessment. Interventions were described narratively, and a random-effects meta-analysis was performed for comparable studies.

Results: Ten randomized controlled trials, one controlled before-and-after study, and three interrupted time series were included. Seven studies reported a significant positive effect on prescribing-related outcomes, with an effect seen more often for studies focussing on potentially inappropriate prescribing (PIP) (four out of six). Three of the eight studies that focussed on antibiotic prescribing demonstrated a significant effect. A meta-analysis of three RCTs involving 160 general practices and 198 135 patients demonstrated the overall odds of PIP was 0.92 (95%CI: 0.78-1.06, I2 = 70.1%) in the intervention compared to the control group.

Conclusion: Interactive dashboards show promise for supporting safe and effective prescribing in general practice, but current evidence is inconclusive. Future research should focus on developing core outcome sets to facilitate future meta-analyses of effectiveness as well as optimizing their implementation and understanding how to sustain user engagement.

Background: Sex workers face significant barriers to accessing health services, including stigma, economic constraints, and safety concerns. In Turkey, this group is often subjected to discrimination and prejudiced approaches when accessing sexual health services, which reduces the uptake of health services. This study aims to analyze the health care experiences of sex workers in depth.

Methods: The study conducted semi-structured in-depth interviews with 16 women working as sex workers in Adana brothel in July-October 2024, and the data were analyzed through thematic analysis. Participants were selected through purposive sampling to ensure socio-demographic diversity.

Results: Four main themes were identified through the analysis: Barriers to Access and Use of Health Services, Health Service Experiences and Satisfaction, Information and Awareness, and Emotional Situations. Participants indicated that they often preferred private health facilities due to difficulties in accessing public health services and long waiting times, but that these preferences were limited by cost.

Conclusions: Improving the quality of public health services and reducing costs may improve public health by encouraging this group to use health services.

Background: Appropriate medication behavior is important to ensure patients receive optimal health benefits from interacting with their healthcare providers. Communication between patients and providers is essential in ensuring patients take prescribed medication appropriately.

Objective: To investigate the available evidence on the effectiveness of bi-directional communication interventions that focus on both patients and clinicians in outpatient settings aimed at changing how patients take their medications. The desired patient medication behavior changes included initiation, adherence, dose escalation, dose reduction, and discontinuation.

Methods: We performed a systematic review of research studies assessing bi-directional patient-provider communication interventions targeting patient medication behavior change in the outpatient setting. We identified the types of interventions used in each study and the components of successful trials.

Results: We included eight randomized controlled trials and two quasi-experimental trial with a total of 2,911 adult participants. Among the 10 studies, 9 reported statistically significant improvement in the desired direction of medication behavior change in the intervention group compared to control group.

Conclusion: This scoping review shows the promise of bi-directional patient-provider communication tools in impacting behavior related to how patients take their prescribed medications. More randomized controlled trials with standardized outcomes are needed to better assess the utility of patient-provider communication tools.

Practice implications: Including both patient and provider in an effort to improve desired patient medication behavior change should be considered when educational interventions are designed.

Background and aim: Large language models (LLMs) have shown promise in specialized medical exams but remain less explored in family medicine and primary care. This study evaluated eight state-of-the-art LLMs on the official Israeli primary care licensing exam, focusing on prompt design and explanation quality.

Methods: Two hundred multiple-choice questions were tested using simple and few-shot Chain-of-Thought prompts (prompts that include examples which illustrate reasoning). Performance differences were assessed with Cochran's Q and pairwise McNemar tests. A stress test of the top performer (openAI's o1-preview) examined 30 selected questions, with two physicians scoring explanations for accuracy, logic, and hallucinations (extra or fabricated information not supported by the question).

Results: Five models exceeded the 65% passing threshold under simple prompts; seven did so with few-shot prompts. o1-preview reached 85.5%. In the stress test, explanations were generally coherent and accurate, with 5 of 120 flagged for hallucinations. Inter-rater agreement on explanation scoring was high (weighted kappa 0.773; Intraclass Correlation Coefficient (ICC) 0.776).

Conclusions: Most tested models performed well on an official family medicine exam, especially with structured prompts. Nonetheless, multiple-choice formats cannot address broader clinical competencies such as physical exams and patient rapport. Future efforts should refine these models to eliminate hallucinations, test for socio-demographic biases, and ensure alignment with real-world demands.

Background: The 2021 Royal Commission into Aged Care Quality and Safety proposed a new primary care model to address the growing healthcare needs of Australia's aging population.This study explored the views of general practitioners (GPs) working in residential aged care homes on the proposed model and identified potential implementation challenges.

Methods: A cross-sectional survey was conducted between December 2023 and April 2024, recruiting GPs through professional networks and social media. The survey used a 5-point Likert scale to gauge agreement with the proposed model and an open-ended question to explore potential implementation barriers.

Results: One hundred and fifteen GPs (48.7% male; 59.2% aged 30-49) with an average of 12.2 ± 10.4 years' experience in aged care participated. Respondants indicated broad support for extending practice accreditation to aged care-focused practices, with strong endorsement for criteria such as formal accreditation and telehealth integration. Yet, GPs expressed substantial concerns about the practical implementation of capitation payments and other systemic changes, citing underfunding and increased administrative burdens as major obstacles. Reservations were also raised about the adequacy of support for managing increasingly complex aged care needs. Notably, 46% doubted the feasibility of implementing the recommendations, highlighting challenges in funding, after-hours care, and collaboration.

Conclusions: This study highlights key factors influencing the feasibility of implementing the proposed primary care model in aged care, offering valuable insights applicable globally. Addressing GP concerns and fostering collaboration appear crucial, while further stakeholder consultation involving GPs, practice nurses, patients, and their families should guide the implementation of proposed reforms.