Family Medicine and Community Health最新文献

Objective: The primary objective was to investigate temporal trends and between-practice variability of paediatric test use in primary care.

Methods and analysis: This was a descriptive study of population-based data from Clinical Practice Research Datalink Aurum primary care consultation records from 1 January 2007 to 31 December 2019. Children aged 0-15 who were registered to one of the eligible 1464 general practices and had a diagnostic test code in their clinical record were included. The primary outcome measures were (1) temporal changes in test rates measured by the average annual percent change, stratified by test type, gender, age group and deprivation level and (2) practice variability in test use, measured by the coefficient of variation.

Results: 14 299 598 diagnostic tests were requested over 27.8 million child-years of observation for 2 542 101 children. Overall test use increased by 3.6%/year (95% CI 3.4 to 3.8%) from 399/1000 child-years to 608/1000 child-years, driven by increases in blood tests (8.0%/year, 95% CI 7.7 to 8.4), females aged 11-15 (4.0%/year, 95% CI 3.7 to 4.3), and children from the most socioeconomically deprived group (4.4% /year, 95% CI 4.1 to 4.8). Tests subject to the greatest temporal increases were faecal calprotectin, fractional exhaled nitric oxide and vitamin D. Tests classified as high-use and high-practice variability were iron studies, coeliac testing, vitamin B₁₂, folate, and vitamin D.

Conclusions: In this first nationwide study of paediatric test use in primary care, we observed significant temporal increases and practice variability in testing. This reflects inconsistency in practice and diagnosis rates and a scarcity of evidence-based guidance. Increased test use generates more clinical activity with significant resource implications but conversely may improve clinical outcomes. Future research should evaluate whether increased test use and variability are warranted by exploring test indications and test results and directly examine how increased test use impacts on quality of care.

Transitions are a period and a process, through which there is a longitudinal adaptation in response to changing circumstances in clinical practice and responsibilities. While the experience of the transition in medical student learning and in hospital-based specialty training programmes are well described and researched, the experience of the transition in community-based postgraduate general practitioner (GP) training has not been described comprehensively.

Objective: We aimed to identify, and categorise, the formative experiences of transitions in GP training and their impacts on personal and professional development.

Design: We adopted Levac et al's scoping review methodology. Of 1543 retrieved records, 76 were selected for data extraction. Based on a combined model of the socioecological and multiple and multi-dimensional theories of transitions, data relating to the experiences of transitions were organised into contextual themes: being physical, psychosocial, organisational culture and chronological.

Eligibility criteria: Empirical studies focused on general practice trainees or training, that discussed the transitions experienced in general practice training and that were published in English were included.

Information sources: PubMed, MEDLINE and Web of Science databases were searched in January 2024 with no date limits for empirical studies on the transition experiences of GP into, and through, training.

Results: Our findings describe context-dependent formative experiences which advance, or impede, learning and development. Time is a significant modulator of the factors contributing to more negative experiences, with some initially adverse experiences becoming more positive. Identification of the inflection point that represents a shift from initially adverse to more positive experiences of transitions may help moderate expectations for learning and performance at different stages of training.

Conclusion: Challenges in training can either advance development and contribute positively to professional identity formation and clinical competency, or detract from learning and potentially contribute to burnout and attrition from training programmes. These findings will assist future research in identifying predictive factors of positive and adverse experiences of transitions and may strengthen existing and nascent GP training programmes. The findings are transferable to other community-based specialty training programmes.

Objectives: To evaluate the longitudinal impact of introducing a national, direct access physiotherapy model of care on the rates of primary and secondary care consultations for musculoskeletal (MSK) conditions.

Design: Interrupted time series analysis using segmented linear regression.

Setting: Norway primary care PARTICIPANTS: A cohort of 82 072 participants was derived from 3 population-based health surveys conducted across separate geographical regions in Norway. All participants surveyed were eligible for inclusion as a national representative sample of the Norwegian population. Registered MSK consultations were linked to the Norwegian Control and Payment of Health Reimbursement database and the Norwegian Patient Register using the International Classification of Primary Care diagnostic medical codes L-chapter for MSK conditions and spine related International Classification of Diseases, 10th Revision, codes.

Intervention: Direct access to physiotherapy model of care introduced nationally in Norway in 2018. This model allowed Norwegians to consult directly with qualified physiotherapists for MSK conditions (eg, back pain, knee osteoarthritis) without the need for a medical referral in order to claim a social security reimbursement.

Main outcomes measured: Rates of primary care consultations per 10 000 population (general practitioner (GP) and physiotherapist consultations) and secondary care (specialist consultations and surgical procedures) measured from 2014 to 2021.

Results: The introduction of the direct access physiotherapy model was associated with an immediate stepped reduction of 391 general practice consultations per 10 000 population, (95% CI: -564 to -216), without an associated change in physiotherapy consultations. Subgroup analyses suggested there was an associated reduction in physiotherapy consultations for those in the lowest education group of 150 consultations per quarter (95% CI:-203 to -97), 70 consultations per quarter in the intermediate education group (95% CI:-115 to -27) and a stepped reduction of 2 spinal surgical procedures per 10 000 population, for those aged between 40 and 60 years (95% CI: -3 to -1) following the introduction of the direct access physiotherapy model.

Conclusion: The national introduction of a direct access to physiotherapy model of care was associated with a reduction in the workload of GPs for the management of MSK conditions. The use of physiotherapists in direct contact roles is a potential strategic model to reduce the burden on the GP workforce in primary care worldwide.

Objective: 'Sludge' refers to administrative burdens or frictions that preclude people from getting what they want or need (eg, duplicative forms, complicated instructions, long waiting times). This mixed methods study evaluated patients' perceptions of sludge in the colorectal cancer (CRC) screening process and some impacts of this sludge.

Design: We employed an exploratory sequential mixed methods study design that comprised patient interviews and a patient survey. The interviews informed final survey revisions and captured contextual data about patients' experiences with sludge. Interview transcripts were inductively and deductively analysed to identify overarching themes. The survey quantified sludge, delayed or forgone screenings, screening experience (Net Promoter Score) and health system distrust (Health System Distrust Scale). We used χ² or t-tests for univariable comparisons and logistic or linear regressions to evaluate the association between cumulative sludge score and delayed or forgone screenings, screening experience and health system distrust. Results were integrated for interpretation.

Setting: Southeastern United States.

Participants: Patients who were 45-75 years of age, at average risk for CRC and had either completed or been referred for CRC screening (colonoscopy or stool-based test) within the previous 12 months.

Results: 22 interview participants and 255 survey participants completed the study. 38 (15%) survey participants rated their screening experience as poor (Net Promoter Score=0-7 out of 10). The mean (SD) Health System Distrust Scale score was 22.4 (6.3) out of 45 possible points (higher score=greater distrust). Perceptions of sludge in the CRC screening process varied, with long waiting times and burdensome communication being the most common sources (58% and 35% of participants, respectively). Sludge was positively associated with delayed or forgone screenings (OR=1.42, 95% CI 1.28, 1.57, p<0.001), poor screening experience (OR=1.15, 95% CI 1.04, 1.28, p=0.009) and health system distrust (β=0.47, p<0.001). Qualitative findings add descriptive detail about sludge encountered, context to impacts experienced, and illustrate the heavy emotional impact of sludge: 'it just isn't worth it'.

Conclusion: Efforts to reduce sludge in the CRC screening process may improve timely completion of CRC screening, enhance patient experience and restore trust in the health system.

focused Rapid Assessment Process (fRAP) 2.0 is a community engagement approach combining geospatial mapping with rapid qualitative assessment in cyclical fashion within communities to capture multifactorial and multilevel features impacting primary care problems. fRAP 2.0 offers primary care researchers a methodology framework for exploring complex community features that impact primary healthcare delivery and outcomes. The fRAP 2.0 study design expands the fRAP from a sequential design to a cyclical process of geospatial mapping and rapid qualitative assessment in search of modifiable contextual factors. Research participants are stakeholders from various socioecological levels whose perspectives inform study outcomes that they may use to then become the agents of change for the very problems they helped explore. Here, we present a proof-of-concept study for fRAP 2.0 examining disparities in cervical cancer mortality rates among Hispanic women in Texas. The primary outcomes of interest are features at the community level, medical health system level and regional government policy levels that offer opportunities for collaborative interventions to improve cervical cancer outcomes. In this study, geospatial mapping of county and ZIP code-level variables impacting postdiagnosis cervical cancer care at community, medical and policy levels were created using publicly available data and then overlaid with maps created with Texas Cancer Registry data for cervical cancer cases in three of the largest population counties. Geographically disparate areas were then qualitatively explored using participant observation and ethnographic field work, alongside 39 key informant interviews. Roundtable discussion groups and stakeholder engagement existed at every phase of the study. Applying the fRAP 2.0 method, we created an action-oriented roadmap of next steps to improve cervical cancer care disparities in the three Texas counties with emphasis on the high disparity county. We identified local change targets for advocacy and the results helped convene a stakeholder group that continues to actively create on-the-ground change in the high-disparity county to improve cervical cancer outcomes for Hispanic women.

Objective: To extract key lessons on primary healthcare (PHC) service delivery strategies for non-communicable diseases (NCD) from the work of researchers funded by the Global Alliance for Chronic Diseases (GACD).

Design: A convergent mixed methods study that extracted data using a standardised template from research projects funded by the GACD that focused on PHC. The strategies implemented in these studies were mapped onto the PHC Performance Initiative framework. Semistructured qualitative interviews were conducted with researchers from purposefully selected projects to understand the strategies and contextual factors in more depth.

Setting: PHC contexts from low or middle-income countries (LMIC) as well as vulnerable groups within high-income countries. Projects came from all regions of the world, particularly East Asia and Pacific, sub-Saharan Africa, South Asia, Latin America and Caribbean.

Participants: The study extracted data on 84 research projects and interviewed researchers from 16 research projects.

Results: Research projects came from all regions of the world, and mainly focused on diabetes (35.3%), hypertension (28.3%) and mental health (27.6%). Mapped onto the PHC Performance Initiative framework: 49.4% focused on high-quality PHC (particularly the comprehensiveness of NCD care, 41.2%); 41.2% on the availability of PHC services (particularly the competence of healthcare workers, 36.5%); 35.3% on population health management (particularly community-based services, 35.3%); 34.1% on facility organisation and management (particularly team-based care, 20.0%) and 31.8% on access (particularly digital technology, 23.5%). Most common strategies were task shifting and training to improve the comprehensiveness of NCD care through community-based services. Contextual factors related to inputs: infrastructure, equipment and medication, workforce (particularly community health workers), finances, health information systems and digital technology.

Conclusion: Key strategies and contextual factors to improve PHC service delivery for NCDs in LMICs were identified. These strategies should combine with other strategies to strengthen the PHC system as a whole, while improving care for NCDs.

Background: Colorectal cancer (CRC) is the second leading cause of cancer death in US adults but can be reduced by screening. The roles of individual and contextual factors, and especially physician supply, in attaining universal CRC screening remains uncertain.

Methods: We used data from adults 50-75 years old participating in the 2018 New York (NY) Behavioural Risk Factor Surveillance System linked to county-level covariates, including primary care physician (PCP) density and gastroenterologist (GI) density. Data were analysed in 2023-2024. Our analyses included (1) ecological and geospatial analyses of county-level CRC screening prevalence and (2) individual-level Poisson regression models of receipt of screening, adjusted for socioeconomic and county-level contextual variables.

Results: Mean prevalence of up-to-date CRC screening was 71% (95% CI 70% to 73%) across NY's 62 counties. County-level CRC screening demonstrated significant spatial patterning (Global Moran's I=0.14, p=0.04), consistent with the existence of county-level contextual factors. In both county-level and individual-level analyses, lack of health insurance was associated with lower likelihood of up-to-date screening (ß=-1.09 (95% CI -2.00 to -0.19); adjusted prevalence ratio 0.68 (95% CI 0.60 to 0.77)), even accounting for age, race/ethnicity and education. In contrast, county-level densities of both PCPs and GIs were completely unassociated with screening at either the county or individual level. As expected, other determinants at the individual level included education status and age.

Conclusion: In this state-wide representative analysis, physician density was completely unassociated with CRC screening, although health insurance status remains strongly related. In similar screening environments, broadened insurance coverage for CRC screening is likely to improve screening far more effectively than increased physician supply.

Objective: Neighbourhood deprivation increases the risk of colorectal neoplasia and contributes to racial disparities observed in this disease. Developing race-specific advanced colorectal neoplasia (ACN) prediction models that include neighbourhood socioeconomic status has the potential to improve the accuracy of prediction.

Methods: The study includes 1457 European Americans (EAs) and 936 African Americans (AAs) aged 50-80 years undergoing screening colonoscopy. Race-specific ACN risk prediction models were developed for EAs and AAs, respectively. Area Deprivation Index (ADI), derived from 17 variables of neighbourhood socioeconomic status, was evaluated by adding it to the ACN risk prediction models. Prediction accuracy was evaluated by concordance statistic (C-statistic) for discrimination and Hosmer-Lemeshow goodness-of-fit test for calibration.

Results: With fewer predictors, the EA-specific and AA-specific prediction models had better prediction accuracy in the corresponding race/ethnic subpopulation than the overall model. Compared with the overall model which had poor calibration (P _Calibration=0.053 in the whole population and P _Calibration=0.011 in AAs), the EA model had C-statistic of 0.655 (95% CI 0.594 to 0.717) and P _Calibration=0.663; and the AA model had C-statistic of 0.637 ((95% CI 0.572 to 0.702) and P _Calibration=0.810. ADI was a significant predictor of ACN in EAs (OR=1.24 ((95% CI 1.03 to 1.50), P=0.029), but not in AAs (OR=1.07 ((95% CI 0.89 to 1.28), P=0.487). Adding ADI to the EA-specific ACN prediction model substantially improved ACN calibration accuracy of the prediction across area deprivation groups (P _Calibration=0.924 with ADI vs P _Calibration=0.140 without ADI) in EAs.

Conclusions: Neighbourhood socioeconomic status is an important factor to consider in ACN risk prediction modeling. Moreover, non-race-specific prediction models have poor generalisability. Race-specific prediction models incorporating neighbourhood socioeconomic factors are needed to improve ACN prediction accuracy.