Family Medicine and Community Health最新文献

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.

In recent years, significant insights have been gathered into the effectiveness of lifestyle interventions in the treatment of chronic non-communicable diseases (NCD). To speed up the implementation of evidence-based lifestyle medicine, we developed a research agenda in collaboration with Dutch experts in treating NCD, using a hybrid Delphi approach. The research agenda focuses on four key themes: (1) promoting sustainable behavioural change at patient, healthcare professional and organisational levels; (2) optimising research designs, methodology and outcomes for the evaluation of effectiveness and implementation of lifestyle medicine modalities in healthcare practice; (3) elucidating biological mechanisms underlying successful lifestyle interventions and (4) advancing data infrastructure to ensure accessible data for citizens, healthcare professionals, researchers and health insurers for monitoring and evaluation of health and lifestyle outcomes. Collectively, the identified knowledge questions across these four themes provide guidance for (applied) research towards lifestyle medicine in healthcare.

Objective: This systematic review assessed trial-based economic evaluations to provide empirical evidence on the cost-effectiveness of non-drug interventions (NDIs) that are currently recommended within the Royal Australian College of General Practitioners Handbook of Non-Drug Interventions (HANDI).

Methods: Medline, CINAHL and PsycINFO along with clinical trial registries (clinicaltrials.gov and WHO International Clinical Trials Registry Platform) were searched from inception to 1 July 2025. Randomised controlled trials (RCTs) that reported cost effectiveness for a prescribed non-drug intervention (NDI) from HANDI were included in the study. The primary outcome was the incremental cost-utility ratio (ICUR) derived from cost-utility analyses (CUAs).

Results: A total of 11 187 citations were identified, from which 156 RCTs were included. These RCTs enrolled a total of 66 926 participants (median=214, IQR 139-342), with a median follow-up duration of 12 months (IQR 6-12 months). Over half of the CUA NDIs were for mental health conditions (n=81; 54.0%), one-third were for were for musculoskeletal conditions (n=44; 29.3%), while only 16.0% (n=24) were for those with cardiovascular/metabolic conditions. Out of the 150 NDIs that reported CUAs, 40% were deemed to be in the south-east (SE) quadrant (cheaper and more effective) and 49.3% fell in the north-east (NE) quadrant (more costly but more effective), with 70% considered cost effective against a £25 000/quality-adjusted life-year (QALY) willingness to pay threshold. The overall median ICUR was £2400/QALY (IQR -18 986 to 20 027).

Conclusions: Most of the HANDI NDIs that were included within this systematic review are cost-effective compared with a variety of alternatives including usual care or waiting list controls. HANDI NDIs warrant use as a first line of treatment when clinically appropriate.

Introduction: Family physicians (FPs) provide essential support during life's most challenging moments, including experiences of grief and loss. After a patient's death, FPs are expected to provide information and emotional support to bereaved family members. Prior research suggests that bereaved relatives expect follow-up contact from their FP, acknowledging it as part of the physician's role. This study aims to explore the practices and attitudes of FPs towards bereaved family members.

Methods: A cross-sectional, descriptive study was conducted through an online questionnaire, exploring participants' perceived role in bereavement care, the type of support offered to families, available resources in primary care, as well as personal knowledge and approach on grief. This questionnaire was distributed via digital platforms to general and family medicine doctors.

Results: A total of 210 physicians participated (84.3% female; 53.8% in residency), with a median age of 32 years old. On average, each FP experienced five patient deaths, most often reported by family members. More than half (53.3%) contacted bereaved families in fewer than 25% of cases, typically within 7 days of the death, most commonly by phone (76.5%).

Conclusion: This study highlights significant gaps in the bereavement follow-up practices of FPs in Portugal. Findings emphasise the need for integrated bereavement care guidelines in primary care, institutional policies and investment in targeted training programmes to enhance grief's approach. The reported lack of grief training reinforces the need to integrate grief education into medical curriculum and continuous professional development. Structural improvements, such as the implementation of automatic death notifications within the healthcare system, are also critical for enabling timely and effective support.

Introduction: Tobacco and other substance co-use has not been examined in adolescent and young adult (AYA) cancer survivors. We compared the prevalence of past-month co-use of tobacco+cannabis, alcohol and illicit drugs between AYAs with and without a cancer history and considered associations between co-use and nicotine dependence in AYA cancer survivors who use tobacco, exploring if past-year major depression moderates this relationship.

Methods: 2015-2019 National Survey on Drug Use and Health data were used to analyse past-month co-use in 7793 AYAs (228 with cancer; 7565 without cancer). Weighted univariable and multivariable logistic regression models estimated associations between cancer history and co-use and co-use with nicotine dependence (among AYA cancer survivors) incorporating moderation by major depression.

Results: AYA cancer survivors had lower reported past-month cannabis co-use than those without cancer (29% vs 39%), but cancer history was not associated with cannabis co-use in multivariable models (adjusted OR (aOR): 0.83, 95% CI=0.54, 1.28). When AYA cancer survivors who use tobacco had major depression, alcohol co-use was associated with lower rates of nicotine dependence (aOR=0.08, 95% CI=0.01, 0.53).

Conclusions: There are high rates of substance co-use among AYAs who use tobacco, consistent across cancer history. Unlike previous research, alcohol co-use was associated with lower rates of nicotine dependence, but only for those with major depression. This finding could be related to neurochemical dysregulation due to co-use and warrants further exploration. Future research should also examine more nuanced definitions of substance use including modes, patterns and initiation of use, and explore motivation to change tobacco behaviour in AYA cancer survivor populations.