Family Medicine and Community Health最新文献

Objective: To describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO).

Design: This study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation.

Setting: The study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5-9, in one ACO in the Midwestern United States.

Participants: Providers, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators.

Results: With integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process.

Conclusions: Joining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.

Objective: WHO recommends that every pregnant woman and newborn receive quality care throughout the pregnancy, delivery and postnatal periods. However, Maternal Mortality Ratio in Indonesia for 2015 reached 305 per 100 000 live births, which exceeds the target of Sustainable Development Goals (<70 per 100 000 live births). Receiving at least four times antenatal care (ANC4+) and skilled birth attendant (SBA) during childbirth is crucial for preventing maternal and neonatal deaths. The study aims to assess the determinants of ANC4 +and SBA independently, evaluate the distribution of utilisation of ANC4 + and SBA services, and further investigate the associations of two levels of continuity of services utilisation in Indonesia DESIGN: Data from the Indonesia Demographic and Health Survey, a cross-sectional and large-scale national survey conducted in 2017 were used.

Setting: This study was set in Indonesia.

Participants: The study involved ever-married women of reproductive age (15-49 years) and had given birth in the last 5 years prior to the survey (n=15 288). The dependent variables are the use of ANC4 + and SBA. Individual, family and community factors, such as age, age at first birth, level of education, employment status, parity, autonomy in healthcare decision-making, level of education, employment status of spouses, household income, mass media consumption residence and distance from health facilities were also measured.

Results: Results showed that 11 632 (76.1%) women received ANC4 + and SBA during childbirth. Multivariate analysis revealed that age, age at first birth, and parity have a statistically significant association with continuity of services utilisation. The odds of using continuity of services were higher among women older than 34 years (adjusted OR (aOR) 1.54; 95% CI 1.31 to 1.80) compared with women aged 15-24 years. Women with a favourable distance from health facilities were more likely to receive continuity of services utilisation (aOR 1.39; 95% CI 1.24 to 1.57).

Conclusions: The continuity of services utilisation is associated with age, reproductive status, family influence and accessibility-related factors. Findings demonstrated the importance of enhancing early reproductive health education for men and women. The health system reinforcement, community empowerment and multisectoral engagement enhance accessibility to health facilities, reduce financial and geographical barriers, and produce strong quality care.

Objectives: Dizziness is a common and challenging clinical presentation in general practice. Failure to determine specific aetiologies can lead to significant morbidity and mortality. We aimed to establish frequency and associations of general practitioner (GP) trainees' (registrars') specific vertigo provisional diagnoses and their non-specific symptomatic problem formulations.

Design: A cross-sectional analysis of Registrar Clinical Encounters in Training (ReCEnT) cohort study data between 2010 and 2018. ReCEnT is an ongoing, prospective cohort study of registrars in general practice training in Australia. Data collection occurs once every 6 months midtraining term (for three terms) and entails recording details of 60 consecutive clinical consultations on hardcopy case report forms. The outcome factor was whether dizziness-related or vertigo-related presentations resulted in a specific vertigo provisional diagnosis versus a non-specific symptomatic problem formulation. Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.

Setting: Australian general practice training programme. The training is regionalised and delivered by regional training providers (RTPs) (2010-2015) and regional training organisations (RTOs) (2016-2018) across Australia (from five states and one territory).

Participants: All general practice registrars enrolled with participating RTPs or RTOs undertaking GP training terms.

Results: 2333 registrars (96% response rate) recorded 1734 new problems related to dizziness or vertigo. Of these, 546 (31.5%) involved a specific vertigo diagnosis and 1188 (68.5%) a non-specific symptom diagnosis. Variables associated with a non-specific symptom diagnosis on multivariable analysis were lower socioeconomic status of the practice location (OR 0.94 for each decile of disadvantage, 95% CIs 0.90 to 0.98) and longer consultation duration (OR 1.02, 95% CIs 1.00 to 1.04). A specific vertigo diagnosis was associated with performing a procedure (OR 0.52, 95% CIs 0.27 to 1.00), with some evidence for seeking information from a supervisor being associated with a non-specific symptom diagnosis (OR 1.39, 95% CIs 0.92 to 2.09; p=0.12).

Conclusions: Australian GP registrars see dizzy patients as frequently as established GPs. The frequency and associations of a non-specific diagnosis are consistent with the acknowledged difficulty of making diagnoses in vertigo/dizziness presentations. Continuing emphasis on this area in GP training and encouragement of supervisor involvement in registrars' diagnostic processes is indicated.

Recent guidelines restricted aspirin (ASA) in primary prevention of cardiovascular disease (CVD) to patients <70 years old and more recent guidance to <60.In the most comprehensive prior meta-analysis, the Antithrombotic Trialists Collaboration reported a significant 12% reduction in CVD with similar benefit-risk ratios at older ages. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, four trials were added to an updated meta-analysis.ASA produced a statistically significant 13% reduction in CVD with 95% confidence limits (0.83 to 0.92) with similar benefits at older ages in each of the trials.Primary care providers should make individual decisions whether to prescribe ASA based on benefit-risk ratio, not simply age. When the absolute risk of CVD is >10%, benefits of ASA will generally outweigh risks of significant bleeding. ASA should be considered only after implementation of therapeutic lifestyle changes and other drugs of proven benefit such as statins, which are, at the very least, additive to ASA. Our perspective is that individual clinical judgements by primary care providers about prescription of ASA in primary prevention of CVD should be based on our evidence-based solution of weighing all the absolute benefits and risks rather than age. This strategy would do far more good for far more patients as well as far more good than harm in both developed and developing countries. This new and novel strategy for primary care providers to consider in prescribing ASA in primary prevention of CVD is the same as the general approach suggested by Professor Geoffrey Rose decades ago.

Objectives: Explore (1) associations between maternal body mass index (BMI), demographic and clinical characteristics, (2) longitudinal trends in BMI, (3) geographical distributions in prevalence of maternal overweight and obesity.

Design: Retrospective population-based study.

Setting: Linked, anonymised, routinely collected healthcare data and official statistics from Northern Ireland.

Participants: All pregnancies in Northern Ireland (2011-2017) with BMI measured at ≤16 weeks gestation.

Methods: Analysis of variance and χ² tests were used to explore associations. Multiple linear regression was used to explore longitudinal trends and spatial visualisation illustrated geographical distribution. Main outcomes are prevalence of overweight (BMI ≥25 kg/m²) and obesity (BMI ≥30 kg/m²).

Results: 152 961 singleton and 2362 multiple pregnancies were included. A high prevalence of maternal overweight and obesity in Northern Ireland is apparent (singleton: 52.4%; multiple: 48.3%) and is increasing. Obesity was positively associated with older age, larger numbers of previous pregnancies and unplanned pregnancy (p<0.001). BMI category was also positively associated with unemployment (35% in obese class III vs 22% in normal BMI category) (p<0.001). Higher BMI categories were associated with increased rate of comorbidities, including hypertension (normal BMI: 1.8% vs obese III: 12.4%), diabetes mellitus (normal BMI: 0.04% vs obese III: 1.29%) and mental ill-health (normal BMI: 5.0% vs obese III: 11.8%) (p<0.001). Prevalence of maternal obesity varied with deprivation (most deprived: 22.8% vs least deprived: 15.7%) (p<0.001). Low BMI was associated with age <20 years, nulliparity, unemployment and mental ill-health (p<0.001).

Conclusions: The prevalence of maternal BMI >25 kg/m² is increasing over time in Northern Ireland. Women are entering pregnancy with additional comorbidities likely to impact their life course beyond pregnancy. This highlights the need for prioritisation of preconception and inter-pregnancy support for management of weight and chronic conditions.

Qualitative research remains underused, in part due to the time and cost of annotating qualitative data (coding). Artificial intelligence (AI) has been suggested as a means to reduce those burdens, and has been used in exploratory studies to reduce the burden of coding. However, methods to date use AI analytical techniques that lack transparency, potentially limiting acceptance of results. We developed an automated qualitative assistant (AQUA) using a semiclassical approach, replacing Latent Semantic Indexing/Latent Dirichlet Allocation with a more transparent graph-theoretic topic extraction and clustering method. Applied to a large dataset of free-text survey responses, AQUA generated unsupervised topic categories and circle hierarchical representations of free-text responses, enabling rapid interpretation of data. When tasked with coding a subset of free-text data into user-defined qualitative categories, AQUA demonstrated intercoder reliability in several multicategory combinations with a Cohen's kappa comparable to human coders (0.62-0.72), enabling researchers to automate coding on those categories for the entire dataset. The aim of this manuscript is to describe pertinent components of best practices of AI/machine learning (ML)-assisted qualitative methods, illustrating how primary care researchers may use AQUA to rapidly and accurately code large text datasets. The contribution of this article is providing guidance that should increase AI/ML transparency and reproducibility.

Objective: The purpose of this study is to examine the association between delivery of healthcare provider's advice about lifestyle management and lifestyle behavioural change in pre-diabetes management in adults who were overweight or obese.

Design: This cross-sectional study included adults with body mass index (BMI) ≥25 kg/m² and reporting pre-diabetes in USA. Outcomes included the prevalence of receiving provider's advice on lifestyle management and patterns of practicing lifestyle change. The association between delivery of provider's advice and lifestyle-related behavioural change in pre-diabetes management was examined.

Setting: US Continuous National Health and Nutrition Examination Survey (2013-2018).

Participants: A total of 1039 adults with BMI ≥25 kg/m² reported pre-diabetes.

Results: Of eligible adults with pre-diabetes, 76.8% received provider's advice about lifestyle change. The advice group showed higher proportions of ongoing lifestyle change than no advice group, including weight reduction/control (80.1% vs 70.9%, p=0.018), exercise (70.9% vs 60.9%, p=0.013) and diet modifications (83.8% vs 61.8%, p<0.001). After adjustment, those receiving provider's advice were more likely to increase exercise (OR 1.63, 95% CI 1.12 to 2.38) and modify diet (OR 3.0, 95% CI 1.82 to 4.96).

Conclusion: Over 75% of US adults who were overweight or obese and reported pre-diabetes received healthcare provider's advice about reducing the risk of diabetes through lifestyle change. Provider's advice increased the likelihood of lifestyle-related behavioural change to exercise and diet.

Objective: To identify factors that likely contribute to potentially inappropriate prescriptions (PIPs) among older adults in primary care settings, as well as barriers to medicines optimisation and recommended potential solutions.

Design: Systematic review.

Eligibility criteria: Quantitative studies that analysed the factors associated with PIPs among older adults (≥65 years) in primary care settings, and qualitative studies that explored perceived barriers and potential solutions to medicines optimisation for this population.

Information sources: PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, CNKI and Wanfang.

Results: Of the 13 167 studies identified, 50 were included (14 qualitative, 34 cross-sectional and 2 cohort). Nearly all quantitative studies examined patient-related non-clinical factors (eg, age) and clinical factors (eg, number of medications) and nine studies examined prescriber-related factors (eg, physician age). A greater number of medications were identified as positively associated with PIPs in 25 quantitative studies, and a higher number of comorbidities, physical comorbidities and psychiatric comorbidities were identified as patient-related clinical risk factors for PIPs. However, other factors showed inconsistent associations with the PIPs. Barriers to medicines optimisation emerged within four analytical themes: prescriber related (eg, inadequate knowledge, concerns of adverse consequences, clinical inertia, lack of communication), patient related (eg, limited understanding, patient non-adherence, drug dependency), environment related (eg, lack of integrated care, insufficient investment, time constraints) and technology related (eg, complexity of implementation and inapplicable guidance). Recommended potential solutions were based on each theme of the barriers identified accordingly (eg, prescriber-related factors: incorporating training courses into continuing medical education).

Conclusions: Older adults with more drugs prescribed and comorbidities may have a greater risk of receiving PIPs in the primary care setting, but it remains unclear whether other factors are related. Barriers to medicines optimisation among primary care older adults comprise multiple factors, and evidence-based and targeted interventions are needed to address these difficulties.

Prospero registration number: CRD42020216258.