Family Medicine and Community Health最新文献

Objective: Diabetes remission has emerged as an achievable treatment goal, shifting the focus of care from increasing medication use to restoring metabolic health. While clinical trials show that remission is possible in controlled settings, evidence remains limited regarding its implementation in routine care within middle-income, rice-based dietary contexts. This study aims to explore healthcare provider experiences with implementing diabetes remission services in Thailand, focusing on dietary strategies, deprescription practices and patient management in routine care settings.

Design: Qualitative study using semi-structured, in-depth interviews, supplemented by structured questionnaires and programme documents.

Setting: Thirteen healthcare facilities across six Thai regions and two national-level professional or policy organisations.

Participants: 17 key informants purposively sampled for regional, institutional and professional diversity, including physicians, nurses, dietitians and national programme leaders. Data were collected and analysed iteratively until no new insights emerged. Thematic content analysis was conducted in QDA Miner Lite v3.0 with investigator triangulation.

Result: Five major themes emerged: key strengths, success factors, nutritional approaches and lifestyle modification, implementation challenges, and development strategies. Multidisciplinary teamwork, personalised care plans and regular monitoring facilitated service delivery. Culturally adapted dietary strategies, such as low-carbohydrate Thai-style meals and intermittent fasting, were widely used. Challenges included unclear clinical guidelines, limited staffing and technological disparities. Medication deprescription varied across sites due to the absence of standardised protocols. Healthcare providers emphasised the need for community engagement and policy support to enable scale-up. Real-world implementation of diabetes remission services is feasible but challenged by systemic constraints and contextual variability. Flexible, culturally tailored approaches, empowered care teams and supportive policy frameworks are essential for sustainability.

Conclusion: These findings provide practical insights for scaling remission programmes in other middle-income settings. Flexible, culturally tailored clinical pathways, empowered teams and supportive policy and financing are required to sustain outcomes and expand coverage.

Objective: Demographic changes, increasing prevalence of chronically ill and multimorbid patients and the ongoing shortage of general practitioners (GPs) collectively present significant challenges for European general practice. Task delegation from GP to practice nurse (PN)-led patient consultations could be a potential solution to tackle those challenges.Therefore, this study aimed to examine the attitudes of GPs and PNs towards PN-led consultations in general and for specific conditions.

Design: Cross-sectional survey using a self-developed, pretested questionnaire, conducted between September 2023 and November 2024. The questionnaire assessed attitudes towards PN-led consultations, conditions within PN-led consultations, possible benefits and concerns regarding PN-led consultations, sociodemographic characteristics and characteristics on GP offices (GPOs). We performed descriptive statistics, univariable and multivariable regression analyses using SPSS V.27.

Setting: GPOs located in the German federal states of Saxony-Anhalt and Saxony.

Participant: From 2071 contacted GPOs, 437 GPs and 339 PNs participated (GP response rate: 21.1%).

Results: The majority of GPs (61.7%) and PNs (61.2%) were open towards PN-led consultations. In multivariable analysis, GPs showed greater openness if they had prior positive delegation experiences (OR=5.88, 95% CI (3.01 to 11.48)) or already delegated special tasks (OR= 5.34, 95% CI (2.29 to 12.46)). GPs were less open if they worked in urban GPOs (OR=0.44, 95% CI (0.22 to 0.88)) or owned a single GPO (OR=0.41, 95% CI (0.20 to 0.83)). In multivariable analysis, PNs were more open towards PN-led consultations if they had prior positive delegation experiences (OR=3.03, 95% CI (1.12 to 8.18)) and advanced PN training (OR=3.50, 95% CI (1.44; 8.51)).The three most accepted conditions by GPs and PNs for PN-led consultations were chronic wounds, diabetes mellitus and arterial hypertension.

Conclusion: Our findings demonstrate broad openness among both GPs and PNs towards PN-led consultations in German GPOs in general, and for various acute and chronic conditions. PN-led consultations are already partially practised. The results indicate considerable potential for further delegation beyond current national agreements.Future pilot studies should further develop PN roles and provide evidence of feasibility and non-inferiority of PN-led consultations compared to GP-led consultations. Conditions and participant characteristics investigated may serve as a foundation for study design and participant recruitment.

Objective: The primary objective was to evaluate the impact of clinical decision support (CDS) tool integration into primary care visits on depression screening and follow-up rates and to assess whether CDS use improves adherence to Health Resources and Services Administration (HRSA) guidelines for depression screening and follow-up.

Design: This quality improvement evaluation study employed quantitative and qualitative components conducted in parallel to provide complementary insights. Modified Poisson regression with generalised estimating equation (GEE) was used to assess the association between CDS tool use and meeting HRSA criteria for depression screening and follow-up. In addition, semi-structured interviews explored perspectives on the implementation and utility of CDS tools.

Setting: This study was conducted at a federally qualified health centre in Minnesota.

Participant: The dataset included 12 338 patient encounters attributed to 8647 unique patients, covering 2 years of data. Five care providers were recruited through purposive sampling for the semi-structured interviews.

Result: CDS use was significantly associated with an increased likelihood of meeting HRSA depression screening and follow-up criteria (relative risk 1.44, 95% CI 1.34 to 1.55; p<0.001). Qualitative findings suggested that while providers found CDS tools useful, workflow challenges and human-centred practices shaped their effectiveness.

Conclusion: Integrating CDS tools into primary care workflows can enhance adherence to depression screening and follow-up guidelines. However, their effectiveness relies on supportive person-centred approaches, including collaboration and previsit preparation. These findings highlight the need for a balanced approach that integrates technological interventions with human interaction to enhance clinical practices. Future research should investigate how CDS tools are used in practice, address barriers to their adoption and develop strategies to promote their broader use while fostering continued learning among providers.

Background: Well child visits (WCV) are fundamental to preventive primary care. We examined trends in WCV attendance during the COVID-19 pandemic and characterised variation by patient and provider characteristics.

Methods: Deidentified electronic medical records from two academic practice-based research networks in Ontario were used to create age-specific cohorts of children under age six attending WCVs from 2015 to 2022. Patients' residential postal codes were linked to neighbourhood-level measures to estimate socioeconomic status. Monthly visit rates were modelled using segmented linear regression with autoregressive residuals. Changes associated with COVID-19 were assessed using level change and trend change of monthly visit rates.

Findings: For the 53 256 included children, WCV attendance increased from 2015 to 2020 for cohorts aged 15 months and younger and was stable for 18-month, 2-3-year and 4-6-year visits. The COVID-19 pandemic was associated with decreased WCV attendance in all ages except ages 1-2 weeks, 1 month, 12 months, 15 months and 18 months, in whom attendance was unchanged. The rate of change in WCV attendance rates pre-COVID-19 compared with post-COVID-19 was unchanged, with the exception of increased rate of change for the 1-2 weeks and 2-3 years old cohorts. Lower attendance rates were observed in children residing in neighbourhoods with the highest material deprivation, rural regions and those whose family physicians were men or older than 65 years.

Interpretation: Prepandemic gains in WCV attendance were stable or improved after the initial reductions observed at the pandemic onset, suggesting that WCVs were prioritised by family physicians and families. Targeted strategies are needed to improve WCV attendance for vulnerable groups.

Background/objective: Patients often expect antibiotics for self-limiting diseases, pressuring providers to prescribe antibiotics unnecessarily. These expectations also contribute to the unsafe practice of taking antibiotics without a prescription (non-prescription use), such as pills retained from prior prescriptions or antibiotics from non-medical sources. Previous work shows that non-prescription use is due to strong, widely held misconceptions regarding the curative power of antibiotics. To reduce unnecessary use of antibiotics, we developed and pilot-tested a patient-focused, bilingual (English and Spanish) educational tool with patient and provider stakeholder input. The tool, a trifold brochure, included information on safe antibiotic use, potential antibiotic harms and symptom management with over-the-counter medications.

Design: Using a qualitative design, we conducted a two-phase study to (1) develop a provider-patient communication tool and (2) pilot-test the tool in primary care clinics. Development of the tool involved patient advisory board meetings and healthcare professional (HCP) focus groups. Pilot-testing of the tool was done through semistructured interviews of randomly recruited patients from primary clinic waiting rooms and their providers.

Setting: Publicly funded safety net primary care clinics in Texas.

Participants: Patients (n=18) and HCPs (nurses, medical assistants, pharmacists, nurse practitioners and physicians) (n=14) from participating clinics.

Result: Themes were extracted from the qualitative data. Main themes from the development phase highlighted the need to create a simple tool to make it clear that antibiotics are not used to treat viral infections, pain or allergies and that using antibiotics without consulting a medical professional is not safe. During pilot-testing, providers noted the tool helped adjust patients' antibiotic expectations. Providers felt that the tool gave them credibility in scenarios where antibiotics were not indicated. Patients felt that the tool provided alternatives to antibiotics for symptom relief. Patients and providers found the tool useful in supporting patient-provider communication around antibiotic use.

Conclusions: A stakeholder-driven, patient-focused educational tool addressing inappropriate antibiotic use facilitated patient-provider communication around antibiotic usage and helped manage patients' antibiotic expectations. Embedding this tool into a community-facing intervention may reduce use of antibiotics without a prescription.

Background: Limited evidence has investigated the effect of a healthy lifestyle on mortality in patients with inflammatory bowel disease (IBD). We aimed to assess the relationship between a healthy lifestyle and all-cause mortality in IBD, as well as the underlying metabolic mechanisms in a prospective cohort.

Methods: Overall, 5052 IBD patients free of cancer (aged 57.0±8.0 years, 48.5% men) were included from UK Biobank cohort. A healthy lifestyle was defined as a normal body mass index, never smoking, moderate alcohol consumption, regular physical activity, adequate sleep duration and healthy diet. The primary outcome was all-cause mortality. Lifestyle-related metabolic signatures were constructed by linear regression and elastic net regression in patients with metabolomics data. A multivariable Cox proportional hazards model was used to assess associations between lifestyle, metabolic signature and all-cause mortality. The mediation effect of lifestyle-related metabolic signatures was estimated through the Cox marginal structural model.

Results: During a median of 14.6 years' follow-up, 583 deaths were identified. Compared with unfavourable lifestyle, those with favourable lifestyle showed significantly lower risk of all-cause mortality in IBD (HR=0.56, 95% CI 0.46 to 0.68), ulcerative colitis (UC) (HR=0.61, 95% CI 0.48 to 0.79) and Crohn's disease (HR=0.49, 95% CI 0.36 to 0.67), and 18.9% of the reduced risk was mediated by metabolic signature. Metabolic signature was significantly associated with lower all-cause mortality, with HR of 0.65 (95%CI 0.49 to 0.85) for values above versus below the median and 0.73 (95%CI 0.64 to 0.83) for per SD increase. Subgroup and sensitivity analyses demonstrated similar results.

Conclusion: A healthy lifestyle is associated with lower mortality in IBD patients. This beneficial effect may be mediated by metabolic signatures and related to favourable metabolic alterations.

Objective: As populations age, multimorbidity and frailty have emerged as major health challenges. While their associations with disability and mortality are well documented, their impact on quality of life (QoL) in sub-Saharan Africa remains underexplored. We examined the associations between frailty, multimorbidity and QoL among older adults in Rwanda.

Design: A cross-sectional population-based study. Multimorbidity was defined as having two or more chronic conditions, including hypertension, diabetes, heart disease and mental health conditions. Frailty scores were derived using the Fried phenotype, and QoL was measured using the European Health Instrument Survey-Quality of Life index (scaled 0%-100%). Sequential linear regression models were used to examine independent associations.

Setting: Rural and urban settings of Rwanda.

Participant: We analysed data from 4369 adults (≥40 years).

Results: The mean QoL score was 48.2% (±15.6). Frailty and multimorbidity prevalence were 14.5% (95% CI 13.5 to 15.6) and 55.2% (95% CI 53.7 to 56.6), respectively, while 55.0% (95% CI 53.3 to 56.3) were classified as prefrail. Frailty and multimorbidity are independently associated with poorer QoL. Compared with robust individuals, prefrail and frail individuals experienced a 3.66 (95% CI -4.63 to -2.70) and 7.30 (95% CI -8.76 to -5.83) percentage point reduction in QoL, respectively. Multimorbidity was associated with a 4.66% (95% CI -5.54 to -3.79) point decrease in QoL. Impairments in activities of daily living partly mediated these associations.

Conclusions: Frailty and multimorbidity showed a strong negative association with QoL, with frailty having a stronger effect. These findings underscore the need for age-responsive healthcare strategies, including frailty screening and integrated chronic care, to enhance QoL among older adults in Rwanda.

Objective: To examine general practitioners' (GPs) referral patterns to allied health services for people with dementia compared with those without dementia across two large Australian Primary Health Networks (PHNs).

Design: A retrospective cohort study using routinely collected general practice data. Logistic regression was used to compare odds of allied health referrals, adjusting for age, sex and socioeconomic status.

Setting: De-identified patient and episode activity data from 537 GP practices across two PHNs in Australia between 2018 and 2023.

Participants: Data from 1 153 304 patients and 28 667 517 GP episodes of care were analysed. After merging records, 693 328 unique patients were identified, including 16 610 patients with dementia. Subcohorts included patients with dementia, stroke, Parkinson's disease and combinations of these conditions.

Results: The dementia cohort (n=16 610) had a similar overall allied health referral rate (36.1%) to the control cohort (n=48 977) (35.4%). Patients with dementia only were significantly less likely to receive any allied health referral compared with those with stroke (adjusted OR (aOR) 0.76, 95% CI 0.72 to 0.80; p<0.001) or Parkinson's disease (aOR 0.72, 95% CI 0.66 to 0.78; p<0.001). Those with dementia and stroke were also less likely to receive referrals than those with stroke only (aOR 0.71, 95% CI 0.61 to 0.82; p<0.001). No significant difference was found between dementia with Parkinson's and Parkinson's only groups (p=0.48). Patients with dementia were consistently less likely to be referred to key allied health services (p<0.05).

Conclusion: Despite strong evidence supporting allied health interventions for dementia, referral rates remain comparatively low. Enhancing GP referral resources and education, integrating dementia-specific care pathways and implementing supportive policy changes are needed to improve access and equity in dementia care.