Family Medicine and Community Health最新文献

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.

Introduction: This study aimed to either identify or develop and validate a patient-reported outcome measure (PROM) to assess treatment burden related to general practice for patients with multimorbidity, which can be used alongside the MultiMorbidity Questionnaire part 1 (MMQ1) without overwhelming the target population with redundant items.

Methods: We conducted a systematic literature review to identify all existing PROMs measuring treatment burden. If no suitable PROM was found, our plan was to: (1) develop a draft PROM using items from existing instruments, (2) carry out group and individual interviews with patients with multimorbidity to ensure the PROM's understandability, clarity, completeness and relevance and (3) undertake psychometric validation with a diverse sample of primary care patients with chronic conditions.

Results: We did not identify an eligible PROM in the literature review. The draft PROM consisted of 30 items divided into six domains; Information about treatment, Challenges with medication, Medical appointments, Self-monitoring, Health behaviour and Challenges in the contact to the health system. In the psychometric validation, neither these domains nor any other theoretical constellation of items had adequate psychometric properties. Individual items had good criterion validity and sensitivity to change.

Conclusions: In this study, we developed a 30-item PROM with high content validity where various individual items showed adequate criterion validity and sensitivity to change, making these items useful as a supplemental measure to the MMQ1.

Trial registration number: NCT05676541 Registration Date: 16 December 2022.

Introduction: Advances in clinical genomics have raised the importance of integrating genomic medicine across healthcare systems, including primary care. Primary care presents an ideal environment to offer equitable and efficient access to genetic services. Familial hypercholesterolaemia (FH) is a preventable and treatable cause of premature heart disease and represents a health condition that can be successfully diagnosed and managed in primary care. This study describes a process for tailoring a primary-tertiary shared care model for FH to optimise health professional and patient engagement.

Methods: Data were collected through semistructured interviews (n=10) with stakeholders in New South Wales, Australia. Interviews gathered feedback on how to tailor a shared care model for FH between tertiary and primary care services. Reflexive thematic analysis was used to analyse interview transcripts.

Results: Analysis generated three main themes: (1) current process for genetic testing and management, (2) challenges with genetic testing for FH in primary care and (3) components needed to enable a tertiary-initiated shared care model. Participants considered the model of care acceptable and could be successfully implemented, provided key supports were in place to assist general practitioners. Based on these results, a process model for integrating genetic testing for other conditions into primary care settings was developed, using FH as an exemplar.

Conclusion: The process model for tailoring of a primary-tertiary model of care for FH can be applied across a range of primary care services and treatable genetic conditions.

Introduction: Task-shifting and task-sharing strategies show promise for managing chronic diseases especially in low-income and middle-income countries (LMICs), though their effectiveness in multimorbidity management remains unclear. This study synthesised evidence on task-shifting and task-sharing strategies globally and assessed the impact on core health outcomes in multimorbidity management.

Methods: We conducted a systematic review and meta-analysis of global studies evaluating task-shifting and sharing interventions for individuals with multimorbidity. Six databases, including PubMed, Embase, Web of Science, Ovid (Medline), CINAHL and Cochrane Library, were searched for studies reporting the core outcomes of multimorbidity management in quality of life, mortality, hospitalisation, emergency department visits and symptoms of depression and anxiety. Random-effects models were used to calculate pooled effect sizes with heterogeneity assessed through subgroup and meta-regression analyses.

Results: From 8471 records, 36 studies from 14 countries were included, with only 5 conducted in LMICs. Twenty-one studies, encompassing 20 989 participants, were eligible for meta-analysis. More than half of the studies involved nurses as delegates, with some sharing the tasks with health professionals and about 10% of studies involved non-health professionals, including community healthcare workers as delegates to share the responsibility in caring for individuals with multimorbidity. Most studies were multicomponent, with 16.7% addressing all guideline-recommended aspects of multimorbidity management. By pooling the findings, task-shifting and task-sharing interventions were associated with a 27% reduction in mortality (OR: 0.73, 95% CI: 0.55 to 0.97, I²=0%), a modest improvement in quality of life (standardised mean difference (SMD): 0.1, 95% CI: 0.03 to 0.17, I²=47%) and reduced symptoms of depression (SMD: 0.27, 95% CI: -0.52 to -0.02, I²=90%), but showed no significant effect on hospitalisation, emergency visits or anxiety-related symptoms.

Conclusions: Some evidence, although limited in existing research, indicates the great potential of task-shifting and task-sharing strategies in supporting management of multimorbidity. Further research is needed to optimise and adopt these interventions, particularly in LMICs where evidence remains scarce.

Prospero registration number: CRD42024526845.

Objective: This study describes acceptance and attitudes towards genetic cancer testing among German primary care patients.

Design: Cross-sectional survey.

Setting: Primary care.

Participant: Systematically recruited patients aged ≥18 years from six general practices in Mecklenburg-Western Pomerania participated in an anonymous self-administered survey on familial cancer prevention (n=479 and 67.0% participation rate). Those with complete data were analysed (n=424; mean age 53.7, SD 16.6 years; men 34.4%). Linear regression analyses were used to examine potential disparities in general acceptance of genetic testing and attitudes towards genetic cancer testing according to sociodemographics and familial cancer knowledge.

Result: General acceptance of genetic testing was high, particularly among younger, higher-educated individuals and those with a family history of cancer and higher familial cancer knowledge. For example, 83.3% either agreed or strongly agreed that it should be available to anybody. The most important benefits of genetic cancer testing were to guide check-up frequency (81.4%), to inform medical decision-making (80.2%) and to understand children's risk (75.2%). The most important concerns included the potential burden on the family (44.6%) and the belief that cancer cannot be prevented (39.2%). More favourable attitudes were found among younger, higher-educated individuals, those with a personal history of cancer and those with fewer children or no partner. For example, higher age was linked to lower benefit (regression coefficient (RC) -0.01, 95% CI -0.01 to -0.001) and higher concern ratings (RC 0.01, 95% CI 0.002 to 0.01). About a third (34.7%) rated not wanting to know about genetic alterations that increase their cancer risk as a (very) important reason against testing. Information avoidance was higher among older individuals (RC 0.02, 95% CI 0.01 to 0.02), women (RC 0.40, 95% CI 0.11 to 0.69), those with lower education (RC -0.64, 95% CI -0.91 to -0.36) and those with more children (RC 0.21, 95% CI 0.09 to 0.33).

Conclusion: Acceptance of genetic testing was high, but barriers remain, particularly among older adults, women, the less educated and those with more children. Targeted educational efforts to improve health literacy, emphasise the preventive potential of genetic testing and emotional support through genetic counselling are essential to overcome these barriers and promote informed decision-making.

Introduction: Long-term use of benzodiazepines (BZD) triggers health problems. Although Spain leads European use of BZD, the number of long-term users (LTUs) remains unknown.

Objective: The aim of the study is to estimate the proportion of primary care (PC) patients who initiate a BDZ prescription that subsequently become LTU and to identify its associated factors.

Design: Retrospective real-world data cohort.

Setting and participant: It included the population over 15 years with a new prescription of BZD in PC in Catalonia. Users were considered LTU if they had been dispensed at least three prescriptions within 3 months. Sociodemographic characteristics of patients and prescribers, pathologies, previous BZD use, number and type of visits, and prescription quality standard were considered. We estimated the proportion of LTU among patients with a new prescription, stratified by age and sex, and estimated risk factors by multivariate generalised linear models.

Result: 100 638 users with a new BZD prescription were included. 27.1% were LTU at 3 months and 14.5% at 6 months. LTU increases with age and is higher in women. Predictors of LTU are Spanish nationality, living in rural areas, having a mental illness, having used BZD, having virtual visits or not meeting pharmacy-therapeutic quality standards.

Conclusion: The number of patients who develop LTU is high, especially in the elderly. Exploring the causes of this phenomenon could contribute to the development of future interventions.

Background: The Registrar Clinical Encounters in Training (ReCEnT) project is an Australian general practice vocational training programme with integrated and interdependent education and research functions. Trainees (registrars) contemporaneously document in-consultation clinical experience and actions.

Objectives: Using a realist lens, we elucidate the mechanisms underpinning project outcomes to answer questions around programme effectiveness, impacts, sustainability and the lessons and findings that are translatable to other primary care training programmes.

Methods: The context, input, process and product framework was used. As a means to understand the interactions between each of the interdependent components, it allows for inferences regarding causal mechanisms for specific outcomes.

Results: Context: ReCEnT occurs within an apprenticeship-like model of general practice vocational training entailing a central supervisor/apprentice relationship. ReCEnT has demystified the content and characteristics of registrar consultations. Input: multiple stakeholder involvement is both advantageous and a logistical challenge, with the programme's success dependent on registrars, practices and training providers providing detailed and accurate data, with prompt subsequent processing.

Process: contemporaneous consultation data collection in different stages of training constitutes a component of registrars' programmatic assessment. Product: individualised feedback provides educational benefit through reflection. Clinical and educational research questions can be addressed with resulting research translation feeding back into the programme model and government policy. Clinical behaviour change is also evaluated.

Conclusion: ReCEnT is unique, globally, in its scope and longevity (2010-present). Creation of meaningful, individualised feedback facilitates reflection and provides both immediate educational benefits and the substrate for further research, programme and policy design and targeted formal teaching and learning.

Background: To investigate the relationship of age at first separation from parents (AFSP) with suicidal ideation (SI), suicide planning (SP) and suicide attempts (SA) among left-behind children (LBC) in China and the mediating effect of traumatic events (TEs).

Methods: This cross-sectional study employed a multistage sampling method to conduct questionnaire surveys in six high-concentrated LBC provinces. Logistic regression and restricted cubic splines were performed to investigate the association of AFSP with SI, SP and SA, and meta-analysis (I²) was used to assess the heterogeneity. Causal mediation analysis (structural equation modelling) was used to evaluate the mediating effect of TEs, and bootstrap resampling was employed to assess the robustness of the causal mediation analysis.

Results: A total of 12 162 (6269 LBC) participants were included in this study; the prevalence rates of SI, SP and SA among LBC were 30.7%, 18.6% and 11.9%; and LBC had a higher risk of SI (OR: 1.32), SP (OR: 1.40) and SA (OR: 1.25) than non-LBC, all p<0.001. AFSP was negatively associated with SI, SP and SA, particularly peaking before 2 years old. LBC with AFSP <2 years old had a higher risk of SI (OR 2.65; 95% CI 2.17 to 3.24; p<0.001), SP (OR 2.63; 95% CI 3.36 to 4.29; p<0.001) and SA (OR 2.04; 95% CI 2.73 to 3.63; p<0.001). TEs mediated the increased risk of SI (average causal mediation effect (ACME) 0.03-0.07; proportion (Prop) 40-54%; all p<0.001), SP (ACME 0.03-0.06; Prop 39-61%; all p<0.001) and SA (ACME 0.02-0.04; Prop 53-80%; all p<0.01).

Conclusions: We found that AFSP was associated with SI, SP and SA, mediated by TEs. Our findings supported the necessity of reducing SI, SP and SA risks among LBC and highlighted the need to consider AFSPs and TEs in intervention strategies.

Background and objective: The WHO emphasises the importance of integrating advice on physical activity (PA) into primary care of patients with chronic ischaemic heart disease (IHD). Similarly, the German treatment guideline 'Chronic Coronary Heart Disease' recommends that general practitioners (GPs) provide advice on PA to IHD patients. However, the provision of PA advice seems to be inadequately implemented in general practice. One reason is the lack of medical training in providing PA advice effectively and efficiently. International guidelines recommend such training for health professionals. This study aims to explore experiences, perceptions and attitudes, including barriers and facilitators of GPs towards the routine delivery of PA advice to IHD patients.

Methods: Between March and June 2023, 12 face-to-face problem-centred interviews and six focus group discussions (n=37) with GPs were conducted. Interview and discussion guides were developed and pilot tested by the multi-professional study team. We used a purposive sampling strategy, and data were collected in an iterative process. Audio-recorded data were transcribed verbatim and analysed using a content structuring procedure (deductive and inductive approach). GPs were involved throughout the entire research process, for example, in multi-professional analysis groups.

Results: Although GPs are mostly aware of the health benefits of PA for patients with IHD, PA advice is not routinely provided. Conversations on PA tend to be rather unstructured, and advice is often addressed more generally than customised to the patients' needs and preferences. Priority is given to other lifestyle issues, such as smoking cessation. PA advice is perceived as time-consuming and rather ineffective with regard to the target behaviour. GPs frequently express frustration in this context. GPs express a lack of and simultaneously a need for communication strategies (structure and tools) that can be integrated into everyday GP practice to motivate patients to PA.

Conclusion: The results provide relevant insights into the current practice of GPs with regard to their attitudes on, experiences with, and requirements for the provision of PA advice to IHD patients. These results are helpful to inform the development of appropriate GP training in the provision of very brief PA advice to IHD patients.