Family Medicine and Community Health最新文献

Objective: Decision fatigue (DF) can lead to impaired judgement, decreased diagnostic accuracy and increased likelihood of medical errors. Research on DF is scarce, and little is known about its nature in the clinical context. The objective of the present review was to provide a comprehensive framework to understand how the construct of DF in medical settings has been defined and measured. This review aimed to understand DF determinants and consequences and capture motivational factors overlooked in the existing reviews.

Design: Systematic and scoping review (ScR) with meta-synthesis.

Eligibility criteria: Empirical and non-empirical papers on clinical DF or related constructs directly impacting clinical decision-making were considered, with doctors of all ages, sexes and nationalities as participants. The Preferred Reporting Item for Systematic Reviews and Meta-analyses scoping review checklist has been applied and checked.

Information sources: Six databases were systematically searched by two independent researchers according to a predefined set of keywords.

Results: 43 papers were included, of which 25 were empirical. The quantitative studies outnumber the qualitative ones and primarily involved residents in Europe/UK and North America. Internal medicine and primary care were the most studied disciplines. Only one sequential cross-sectional study measured DF in the medical setting, and all other studies addressed the construct indirectly. A conceptual analysis of clinical DF, including narrative contributions, a thematic analysis of the data extracted and a meta-synthesis, is provided. Clinical DF was investigated mostly by individual risk factors analysed through multiple intertwined determinants involving cognitive, emotional, behavioural, social and ethical aspects. Relevant risks, protective factors and negative outcomes circularly increasing DF are outlined.

Conclusions: The review gives solid arguments for developing a clear and coherent definition of clinical DF that allows the implementation of preventive targeted intervention.

Prospero registration number: This systematic review was pre-registered in PROSPERO on 8 November 2023 (available online at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023476190, registration number CRD4202347619).

Objective: The scope of practice (SOP) of primary care physicians (PCPs) has been narrowing, with declining comprehensiveness leading to fragmented care. Identifying SOP-associated factors can help improve comprehensiveness. This study aimed to describe the SOP of PCPs working in clinics and to identify SOP-associated factors.

Design: A cross-sectional study using a self-administered questionnaire.

Setting: Shizuoka, Japan.

Participants: PCPs working in clinics offering internal medicine.

Main outcome measures: The total number of services provided, covering 109 items, was categorised into 8 clinical areas, 78 clinical activities and 23 procedures.

Results: Questionnaires were mailed to 1191 clinics, and 389 valid responses were included in the analysis. Of the 389 physicians, 254 (65.3%) were internal medicine specialists, and 382 (98.2%) worked in their own private clinics. The mean number of services provided was 60.4±17.4. Clinical activities were provided less frequently in the areas of paediatric and adolescent care, women's health, home healthcare, palliative care and mental health. Physician-related factors were more significantly associated with SOP than practice or environmental factors. Preference for broad practice was the strongest factor associated with a broader SOP, followed by completion of the Japan Medical Association (JMA) primary care training programme and rotational training experience. Additionally, younger physician age, rural practice experience, surgical specialisation, a larger number of physicians in the clinic, higher patient volume and a more rural setting were associated with broader SOP.

Conclusion: Physician preference regarding SOP, completion of the JMA primary care training programme and rotational training are key factors influencing SOP. These findings suggest that postgraduate clinical training with a broad scope not limited to internal medicine and continuing medical education after establishing a private clinic, particularly for physicians who prefer broad practice, may be important in expanding the SOP of PCPs.

Objectives: Primary care attachment represents an inclusive, equitable and cost-effective way of enhancing health outcomes globally. However, the growing shortage of family physicians threatens to disrupt patient-provider relationships. Understanding the consequences of these disruptions is essential for guiding future research and policy. The objectives of this study were to map the existing evidence on the impacts of changes in primary care attachment, identify research gaps and recommend areas for further investigation.

Design: Scoping review following Joanna Briggs Institute (JBI) guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. Two researchers conducted all stages of screening, and study quality was assessed using JBI critical appraisal tools. Key themes included causes of attachment change, direction of change and outcomes aligned with the quintuple aim framework. Both qualitative and quantitative findings were synthesised narratively.

Eligibility criteria: Peer-reviewed, English-language articles published between 1999 and 2024 on primary care attachment changes.

Information sources: PubMed, Scopus and Web of Science.

Results: Of 2045 studies screened, 31 met inclusion criteria, with 60% published after 2020. Most studies originated from high-income countries, particularly the USA (35%) and Canada (29%). Attachment losses and transfers were the most frequently studied, while attachment and unattachment durations were less explored. These changes in attachment were consistently shown to impact patients, providers, clinics and the healthcare system, influencing all aims of the quintuple aim framework, including clinical outcomes, healthcare utilisation, costs, equity and patient experience. Commonly assessed outcomes included clinical impact (68%), health equity (48%), patient experience (32%) and costs (23%), with no study assessing provider experience.

Conclusions: This scoping review maps the published literature on changes in primary care attachment and introduces clarifying terminology. Key research gaps include geographical diversity (lack of studies from low- and middle-income countries), attachment gain (limited research on strategies to reconnect unattached patients), attachment duration (insufficient evidence on long-term health outcomes), economic implications (underexplored costs of physician turnover and disruption), provider experiences (lack of studies on how changes in primary care attachment impact provider burnout, job satisfaction and workload) and patient health outcomes (focus on healthcare utilisation rather than direct health outcomes). These findings underscore the need for further research and offer valuable insights for future studies and policy development.

The need for effective primary healthcare to address social and structural determinants of health and to mitigate health inequalities has been well established. Here, we report on the international forum of the 2023 NAPCRG (formerly known as North American Primary Care Research Group) Annual Meeting. The aim of the forum was to develop principles for action for the primary healthcare research community on addressing social and structural determinants of health. From this forum, 10 key recommendations for the primary care research community were identified.

Objective: Several research gaps affect the improvement of care for healthy ageing. Their identification is crucial to developing a specific research prioritisation agenda supporting progress at the micro (clinical), meso (service delivery) and macro (system) levels. To achieve this, a scoping review was carried out to describe the most significant gaps impeding the improvement of care for healthy ageing.

Design: A scoping review of the literature was conducted according to the Joanna Briggs Institute methodology. The selected articles were analysed to identify topics or areas essential for improving care for healthy ageing but requiring further support from research.

Eligibility criteria: Every type of scientific article, except for randomised controlled trials, was considered of potential interest without restrictions on publication date, type of publication and methodology.

Information sources: A systematic search (last search: 6 December 2023) was conducted using PubMed, MEDLINE and Scopus.

Results: Overall, 1558 articles were retrieved from the literature. Of these, 310 were finally retained for this work. A total of 1195 research gaps were identified (average: 3.85 per article) and clustered into the 13 primary areas: ageing, care approach, caregivers, health economics, health, interventions, policies, research, settings, training, technology, specific populations and understanding the older person. In particular, research for improving the person-centred approach (n=38), better considering cultural diversities (n=27), implementing integrated care (n=25) and ensuring access to care (n=25) were the most prevalent priorities reported in the literature.

Conclusions: A wide range of factors spanning multiple disciplines, from clinical to policy levels, require special consideration, exploration and resolution. The findings of this scoping review represent an essential step in identifying gaps for developing a research prioritisation agenda to improve care for healthy ageing.

Objective: The primary objective was to investigate temporal trends and between-practice variability of paediatric test use in primary care.

Methods and analysis: This was a descriptive study of population-based data from Clinical Practice Research Datalink Aurum primary care consultation records from 1 January 2007 to 31 December 2019. Children aged 0-15 who were registered to one of the eligible 1464 general practices and had a diagnostic test code in their clinical record were included. The primary outcome measures were (1) temporal changes in test rates measured by the average annual percent change, stratified by test type, gender, age group and deprivation level and (2) practice variability in test use, measured by the coefficient of variation.

Results: 14 299 598 diagnostic tests were requested over 27.8 million child-years of observation for 2 542 101 children. Overall test use increased by 3.6%/year (95% CI 3.4 to 3.8%) from 399/1000 child-years to 608/1000 child-years, driven by increases in blood tests (8.0%/year, 95% CI 7.7 to 8.4), females aged 11-15 (4.0%/year, 95% CI 3.7 to 4.3), and children from the most socioeconomically deprived group (4.4% /year, 95% CI 4.1 to 4.8). Tests subject to the greatest temporal increases were faecal calprotectin, fractional exhaled nitric oxide and vitamin D. Tests classified as high-use and high-practice variability were iron studies, coeliac testing, vitamin B₁₂, folate, and vitamin D.

Conclusions: In this first nationwide study of paediatric test use in primary care, we observed significant temporal increases and practice variability in testing. This reflects inconsistency in practice and diagnosis rates and a scarcity of evidence-based guidance. Increased test use generates more clinical activity with significant resource implications but conversely may improve clinical outcomes. Future research should evaluate whether increased test use and variability are warranted by exploring test indications and test results and directly examine how increased test use impacts on quality of care.

Transitions are a period and a process, through which there is a longitudinal adaptation in response to changing circumstances in clinical practice and responsibilities. While the experience of the transition in medical student learning and in hospital-based specialty training programmes are well described and researched, the experience of the transition in community-based postgraduate general practitioner (GP) training has not been described comprehensively.

Objective: We aimed to identify, and categorise, the formative experiences of transitions in GP training and their impacts on personal and professional development.

Design: We adopted Levac et al's scoping review methodology. Of 1543 retrieved records, 76 were selected for data extraction. Based on a combined model of the socioecological and multiple and multi-dimensional theories of transitions, data relating to the experiences of transitions were organised into contextual themes: being physical, psychosocial, organisational culture and chronological.

Eligibility criteria: Empirical studies focused on general practice trainees or training, that discussed the transitions experienced in general practice training and that were published in English were included.

Information sources: PubMed, MEDLINE and Web of Science databases were searched in January 2024 with no date limits for empirical studies on the transition experiences of GP into, and through, training.

Results: Our findings describe context-dependent formative experiences which advance, or impede, learning and development. Time is a significant modulator of the factors contributing to more negative experiences, with some initially adverse experiences becoming more positive. Identification of the inflection point that represents a shift from initially adverse to more positive experiences of transitions may help moderate expectations for learning and performance at different stages of training.

Conclusion: Challenges in training can either advance development and contribute positively to professional identity formation and clinical competency, or detract from learning and potentially contribute to burnout and attrition from training programmes. These findings will assist future research in identifying predictive factors of positive and adverse experiences of transitions and may strengthen existing and nascent GP training programmes. The findings are transferable to other community-based specialty training programmes.

Objectives: To evaluate the longitudinal impact of introducing a national, direct access physiotherapy model of care on the rates of primary and secondary care consultations for musculoskeletal (MSK) conditions.

Design: Interrupted time series analysis using segmented linear regression.

Setting: Norway primary care PARTICIPANTS: A cohort of 82 072 participants was derived from 3 population-based health surveys conducted across separate geographical regions in Norway. All participants surveyed were eligible for inclusion as a national representative sample of the Norwegian population. Registered MSK consultations were linked to the Norwegian Control and Payment of Health Reimbursement database and the Norwegian Patient Register using the International Classification of Primary Care diagnostic medical codes L-chapter for MSK conditions and spine related International Classification of Diseases, 10th Revision, codes.

Intervention: Direct access to physiotherapy model of care introduced nationally in Norway in 2018. This model allowed Norwegians to consult directly with qualified physiotherapists for MSK conditions (eg, back pain, knee osteoarthritis) without the need for a medical referral in order to claim a social security reimbursement.

Main outcomes measured: Rates of primary care consultations per 10 000 population (general practitioner (GP) and physiotherapist consultations) and secondary care (specialist consultations and surgical procedures) measured from 2014 to 2021.

Results: The introduction of the direct access physiotherapy model was associated with an immediate stepped reduction of 391 general practice consultations per 10 000 population, (95% CI: -564 to -216), without an associated change in physiotherapy consultations. Subgroup analyses suggested there was an associated reduction in physiotherapy consultations for those in the lowest education group of 150 consultations per quarter (95% CI:-203 to -97), 70 consultations per quarter in the intermediate education group (95% CI:-115 to -27) and a stepped reduction of 2 spinal surgical procedures per 10 000 population, for those aged between 40 and 60 years (95% CI: -3 to -1) following the introduction of the direct access physiotherapy model.

Conclusion: The national introduction of a direct access to physiotherapy model of care was associated with a reduction in the workload of GPs for the management of MSK conditions. The use of physiotherapists in direct contact roles is a potential strategic model to reduce the burden on the GP workforce in primary care worldwide.