Family practice最新文献

Background: Family physicians (FPs) endorse the value of spiritual care (SC) as part of comprehensive, patient-centered care. However, a mismatch exists between patients' desire to have spiritual needs addressed and physicians' SC provision. Studies explore physician barriers, but few examine workplace barriers/facilitators. Qualitative and longitudinal studies are rare. The objective is to gain an in-depth understanding of how workplace factors affect FPs' SC provision.

Methods: This was a longitudinal, qualitative, and individual interview study; a secondary analysis of a dataset collected over 20 years. All 38 residents in a USA FM residency were invited to participate; the longitudinal study-group (PGY-1 subset) was interviewed four times over 20 years. The data were collected through semi-structured interviews, audio-recorded, and transcribed. Researchers analyzed interviews, using grounded theory, with workplace factors as the central topic of interest. Iterative analysis cycles involved researchers individually coding transcripts followed by group analysis meetings until they reached consensus.

Results: Thirty-four FPs participated with 13 interviewed longitudinally; 66 interviews analyzed. While diverse in personal importance of spirituality, all FPs endorsed SC as part of whole-person care. Workplace SC facilitators/barriers include: practice setting/patient population; doctor-patient relationships; resources available; workplace demands; and workplace culture. Throughout 20 years, FPs readily identified patients needing SC. Workplaces that lacked SC referral resources or undervalued comprehensive care and/or physician wellness negatively impacted SC provision for patients and physician job satisfaction.

Conclusions: While FPs value SC provision as part of whole-person care, workplace factors have a profound impact on physicians' SC provision. Misalignment of physician and workplace values could contribute to physician burnout.

Background: Kidney function declines with age, increasing risk of harm from raised blood levels of many medicines. Prescribing is often inappropriate for older people with reduced creatinine clearance (CrCl).

Objective: To examine the feasibility and acceptability of providing performance feedback to increase CrCl calculation and coding and reduce potentially inappropriate prescribing.

Methods: We delivered evidence-based feedback on CrCl coding and prescribing for common medicines requiring dose adjustment in renal impairment. This mixed-methods study in seven UK general practices collected data at three time points for evidence-based feedback (October 2021, December 2021, February 2022) and additionally pre-/post-feedback intervention. An institutional ethnography explored responses. We observed and conducted semi-structured interviews with primary care clinicians. We thematically analysed qualitative data, guided by Clinical Performance Feedback Intervention Theory.

Results: Mean CrCl coding for ≥75s rose from 46% to 50.4% (difference 4.4%; range -10.5% to 14.7%). The number of patients with CrCl-associated inappropriate prescribing fell. We observed in 6 settings and interviewed 11 clinicians. Feedback engaged practices, was seen as important and allowed flexible action. All feedback cycle components were evident. Participants mentioned difficulties in remembering to consider kidney function, calculating and coding CrCl, recalling relevant medicines, and deciding appropriate dosing. Pharmacy teams were considered important facilitators in the response.

Conclusions: Feedback on prescribing in reduced kidney function can encourage improvement but is not sufficient alone. Systematized CrCl calculation and coding may improve patient safety by facilitating decision support for prescribing, review, and audit/research. A rigorous, larger-scale effectiveness evaluation is likely to be feasible and acceptable.

Objective: To conduct a systematic review of the literature on the impact of team-based primary care on downstream health care utilization (all-cause or mental health-specific emergency department (ED) visits and hospitalizations) among people with mental or substance use disorders.

Methods: A literature search was conducted using the Scopus, MEDLINE, and Web of Science databases. Gray literature and forward and backward citation searches yielded additional results. Two independent reviewers screened the abstracts and full texts. Both reviewers performed a critical appraisal of the methodological quality using a modified Downs and Black checklist. The data were extracted using a standardized data extraction spreadsheet, and the effect sizes of studies were synthesized.

Results: A total of 18 studies were included (16 in the USA and 2 in Canada). Seven of the 15 studies that assessed the effect of team-based care on all-cause ED visits found they were associated with a lower number or odds of visits. Of the 15 studies that assessed the effect of team-based approaches on all-cause hospitalizations, 8 found that they were associated with an overall decrease. Very few studies assessed mental health-related ED visits (n = 2) or hospitalizations (n = 4), and the findings varied. All included studies were of fair quality (mean score ± standard deviation: 17.4 ± 1.3).

Conclusion: Team-based care is likely associated with a decrease in all-cause ED visits and hospitalizations. A team-based primary care approach has the potential to reduce downstream healthcare utilization for patients with mental or substance use disorders and improve health outcomes.

Background: Patient preferences about their role in decision-making in medical practice are a very important phenomenon, especially since patient participation allows decision-making to be more responsive to their needs and improves the quality of care.

Objective: To evaluate the proportion of patients with preferences toward an active, passive, or shared role in medical consultation in a sample of patients with chronic diseases who attend family medicine and general hospital level of care and to explore the relationship of preferences with sociodemographic and clinical variables.

Methods: Participants were recruited from their scheduled consultation in August, 2019, at one family medicine and one general hospital of the Mexican Institute of Social Security. People >18 years of age with different chronic disease diagnoses were surveyed. The Control Preferences Scale was applied to identify the participants' preferred role in decision-making related to medical care. The evaluation of health status and health-related quality of life was included. Multivariate analyses determined the predictors of participation preferences in decision-making.

Results: A total of 530 patients participated. Most preferred the passive role (47.7%), followed by the shared role (27.7%) and the active role (24.5%). Age influenced preferences; participants ≥45 years preferred a shared role. Patients who reported poorer quality of life preferred the shared role in decision-making.

Conclusion: The study showed that patients with chronic diseases prefer to leave the decisions to doctors. Only patients <45 years with a good quality of life had a greater preference for participation in decision-making.

Background: The aim of the study was to assess the effect of an interdisciplinary, digital consultation platform on the proportion of appropriate referrals from general practitioners (GPs) to an orthopaedic outpatient hospital.

Methods: We performed a stepped wedge, cluster, randomized controlled trial. Sixty GP practices in the catchment area of a large teaching hospital in the Netherlands were randomized. Groups of GP practices entered the trial in four steps at 13-week intervals, at which point they received access to the Prisma platform. The platform allowed them to post questions about anonymized cases to a multidisciplinary group of specialists. During the control condition, GPs did not receive platform access. In both conditions, GPs provided care as usual. The proportion of appropriate referrals, defined as referrals for which a patient had either (i) more than one consultation with an orthopaedic surgeon or (ii) one consultation with additional diagnostics or interventions, was the primary outcome.

Results: Participating GPs referred 4928 patients to hospital. Intention-to-treat analysis showed a 4.4% estimated increase in the proportion of appropriate referrals among GP practices randomized to have access to the platform compared to the control group, with an odds ratio (OR) of 1.22 [95% confidence interval (CI), 1.01-1.46; P = 0.037]. Per-protocol analysis showed a smaller, but non-significant, 2.2% difference between interventions, with an OR of 1.11 (95% CI, of 0.96%-1.28%; P = 0.178).

Conclusions: We observed a modest increase in appropriate referrals for orthopaedic review among GP practices randomized to the platform. On a larger scale, this could contribute to more sustainable access to specialist care.

Background: In Canada, primary care manages most diabetes care. The COVID-19 pandemic disrupted primary care, reducing access to care and monitoring.

Objectives: We aim to describe changes in diabetes monitoring during the first 21 months of the pandemic, patients' experiences with these changes, and impact on HbA1c and blood pressure (BP) control.

Methods: We conducted a two-phase mixed methods study: (i) A retrospective pre-post cohort study using de-identified electronic medical record data to compare HbA1c and BP measurement frequency and results in diabetic patients prepandemic (22 June 2018 to 12 March 2020) and during the pandemic (13 March 2020 to 3 December 2021); (ii) A qualitative descriptive analysis using semistructured interviews to understand patient experiences navigating diabetes care during the pandemic.

Results: The cohort included 84 617 patients with validated diabetes case definition. Proportion of patients with <1 HbA1c test increased by 10% during the pandemic. For those with ≥1 test, mean HbA1c remained unchanged [mean (SD) HbA1cPre: 7.2 (1.3); HbA1cDuring: 7.2 (1.3); P = .51]. Proportion of patients with <1 BP measurement increased by 23%. For those with ≥1 measurement, mean BP remained clinically similar [mean (SD) sBPPre: 131.8 (13.7); sBPDuring: 132.9 (15.2); P < .01. Mean dBPPre: 74.9 (8.6); dBPDuring: 75.1 (9.1); P = .63]. Nineteen participants were interviewed, discussing virtual care, challenges with self-monitoring, and self-management strategies.

Conclusions: Mean HbA1c and BP values remained clinically stable during the pandemic despite reductions in monitoring frequency, likely due to continuity of care and patient self-management. Future research should evaluate a de-intensified frequency of diabetes monitoring and address care gaps.

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.