Family Medicine and Community Health最新文献

Background: Clinical guidelines recommend frailty screening for the aged population, given that frailty is frequently reversible. However, little is known about frailty and prefrailty reversal rates in the general population if no specific interventions have been implemented.

Aim: To assess real-world frailty and prefrailty reversal rates in the general population aged ≥65 years, the main contributing clinical conditions and the main risk factors for reversing frailty and prefrailty.

Methods: Observational longitudinal 12-month study (2019) of all 1·5 million persons aged ≥65 years in Catalonia. Data were retrospectively collected from various health databases through the Catalan Public Data Analysis for Health Research and Innovation (PADRIS) V.2022 programme. Frailty status according to the electronic Screening Index for Frailty (e-SIF) was determined for 31 December 2018 and for 31 December 2019.

Results: The study included 1 465 312 Catalan inhabitants (mean age 75.8 years, 57.0% women). The annual frailty and pre-frailty reversal rates were 7.1% and 4.6%, respectively. Both rates were higher in men and decreased with age. The e-SIF components with the greatest impact on frailty reversal were non-planned hospitalisations, polypharmacy, orthostatic hypotension or syncope, anaemia and visual impairment. Female sex, age, dependency, ≥2 comorbidities and polypharmacy had an independent protective effect on 12-month frailty and pre-frailty reversals.

Conclusions: Prefrailty and frailty are reversible, but reversal is unlikely in cases of multimorbidity, polypharmacy and functional dependency in older and severely frail individuals. Interventions that mainly target the avoidance of non-planned hospitalisations, polypharmacy and falls would have the greatest impact on reversing frailty and pre-frailty.

Objective: The purpose of this study was to determine if the COVID-19 pandemic had differential effects on individuals with chemical intolerances (CI). CI is characterised by multisystem symptoms initiated by a one-time high dose or persistent low-dose exposure to environmental toxins including chemicals, foods and drugs. With an estimated 20% US prevalence, symptoms include fatigue, headache, weakness, rash, mood changes, musculoskeletal pain, gastrointestinal issues, difficulties with memory, concentration and respiratory problems, which are similar to COVID-19 and its sequelae.

Design: A US population-based survey involving 7500 respondents was asked if they ever had COVID-19, what the severity was, and if they had long COVID-19. CI was assessed using the Quick Environmental Exposure and Sensitivity Inventory.

Setting: The Center for Disease Control estimates that over 24 million have been infected with COVID-19 in the USA with over 6 700 000 being hospitalised and over 1 174 000 deaths. Other industrialised countries show similar numbers.

Results: Those in the High CI class reported a greater COVID-19 prevalence, symptom severity and long COVID-19 than in the medium and low CI groups (p<0.0001). These associations were independent of race, ethnicity, income, age and sex. However, there were significantly increased odds of COVID-19 severity among women and those over 45 years old. Asian individuals were least likely to have severe symptoms compared with white individuals (OR=0.53; 95% CI 0.35 to 0.79). Black/African American individuals reported a lower prevalence of COVID-19 than non-Hispanic whites. However, one interaction between CI and race was significant, African Americans with high CI reported greater odds (OR=2.2; 95% CI 1.15 to 3.16) of reporting COVID-19 prevalence. Furthermore, African American individuals had significantly greater odds of increased symptom severity.

Conclusion: Prior studies show higher risk for COVID-19 among older age groups, male sex, those with pre-existing comorbidities (eg, challenged immunities) and those from minoritised racial/ethnic groups. The results of this study suggest that those with CI be included in a high-risk group. Various risk subsets may exist and future investigations could identify different risk subsets. Understanding these subgroups would be helpful in mounting targeted prevention efforts.

Objective: To measure the impact of each type of exercise on sleep quality and identify the exercise that enhances sleep quality the most.

Study selection: Eligible randomised controlled trials that compare physical exercise to routine activities, usual care, non-physical activity, or health education to measure the Pittsburgh Sleep Quality Index.

Data source: Studies retrieved from Medline, Embase, CINAHL, Scopus, ClinicalTrial.gov and ThaiJo from the database's inception to October 2022.

Data extraction and synthesis: Two reviewers independently identified studies, collected data and assessed bias. In the absence of heterogeneity, a fixed effect model was used for pairwise meta-analysis. Alternatively, a random effect model was used. A two-stage network meta-analysis used the surface under the cumulative ranking curve (SUCRA) to compare exercise efficacy.

Main outcome: Global Pittsburgh Sleep Quality Index (GPSQI) and subdomain score.

Results: This review comprised 2170 people from 25 trials. Direct meta-analysis revealed significant improvement in GPSQI with combined exercise (unstandardised mean difference (USMD) -2.35, 95% CI-3.13 to -1.57, p<0.001, I²=69.13%). GPSQI decreased considerably with aerobic activity (USMD -4.36, 95% CI -7.86 to -0.86, p=0.01, I²=97.83%). For the network meta-analysis, strengthening, aerobic and combination exercise significantly lowered GPSQI (USMD-5.75, -3.76 and -2.54, respectively). Strength training improved GPSQI scores most effectively (SUCRA 94.6%).

Conclusion: Exercise that strengthens muscles, rather than aerobic or combination exercises, is the most effective way to enhance sleep quality.

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.