Family practice最新文献

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.

Background: Musculoskeletal (MSK) pain is known to influence health-related quality of life (HRQoL), but the role of co-occurring chronic diseases in HRQoL in a MSK pain population has been less studied. This study aimed to evaluate (i) whether chronic disease clusters are related to HRQoL and (ii) whether these relationships differ in magnitude from those between the number of chronic diseases and HRQoL among people with MSK pain.

Material and methods: The Northern Finland Birth Cohort 1966 and its 46-year data collection point were used. The chronic disease clusters for individuals reporting any MSK pain within the past year were previously formulated using latent class analysis and consisted of: Psychiatric (co-existing mental health disorder, substance use disorder, and asthma), Metabolic (referring to the burden of metabolic diseases), and Relatively healthy. HRQoL was measured with a 15-dimension questionnaire. General linear regression model was used.

Results: Among 4490 participants, both the Psychiatric and Metabolic clusters associated with clinically significantly reduced HRQoL, when contrasted with the Relatively healthy cluster, but the association was stronger for the Psychiatric cluster. Similarly, the adjusted mean difference in HRQoL was higher for the Psychiatric cluster than for the multimorbidity (two or more diseases) category when compared with the reference categories (Relatively healthy cluster and no chronic diseases, respectively).

Conclusions: The present findings imply the clinical relevance of the previously identified chronic disease clusters and suggest that pure counts of chronic diseases may not be enough to describe the role of chronic diseases in HRQoL in MSK pain.

Background: Multimorbidity guidelines recommend tailoring care to patients' priorities. The Supporting Prescribing in Multimorbidity in Primary Care (SPPiRE) trial focused on optimizing medicines use in older adults with significant polypharmacy and tailoring prescribing and deprescribing to individual priorities. This study aimed to compare self-reported and general practitioner (GP)-recorded patient priorities and examine the impact of prioritizing pain on analgesic prescribing.

Methods: This secondary cohort analysis of the SPPIRE trial and process evaluation assessed baseline participant-identified priorities and intervention group GP-recorded priorities during medication reviews with agreement assessed using Cohen's kappa. Analgesic prescribing patterns and daily morphine milligram equivalents changes during the study period were summarized. The impact of pain (self-reported, GP-recorded, and severe or extreme pain on the baseline EQ5D) on opioid intensification was analysed using multi-level models accounting for GP practice clustering and intervention effects.

Results: A total of 403 patients (mean age 76.5 years) were included; 178 (44.2%) reported pain as a priority at baseline. Agreement between self-reported and GP-recorded pain was poor (kappa 0.118, P = 0.05). Most analgesic prescriptions decreased during the study, except for potent opioids, which increased in both trial arms. All three pain variables were associated with increased odds of opioid intensification at follow-up.

Conclusion: In this older population of patients with significant polypharmacy, identifying pain as a priority was associated with an increased likelihood of opioid intensification, despite guidelines advising against their use for chronic pain. This study highlights the challenges faced by GPs treating pain in older adults with multimorbidity.