Journal of Primary Care and Community Health最新文献

Background: Primary care physicians' (PCPs) prescription of oral anti-diabetic drugs (OADs) is pivotal to optimise glycaemic control of patients with type 2 diabetes mellitus (T2DM). Their decision-making process is not well-understood and is postulated to be multi-factorial. The study aimed to explore the factors influencing the prescribing behaviour of PCPs managing patients with T2DM in an urban setting.

Methods: A qualitative methodology using a descriptive-interpretive approach was employed for this study. Qualitative data from 23 PCPs was collected via 3 focus group discussions and 10 in-depth interviews using a semi-structured topic guide. PCPs with various experiences, qualifications and backgrounds were purposively recruited from public and private primary care clinics in Singapore. The audio-recorded interviews were transcribed verbatim and audited for accuracy. Thematic analysis was conducted and the emergent themes were grouped under the domains of the 'Generalist Wheel of Knowledge, Understanding and Inquiry' framework. The data was managed using Nvivo qualitative management software.

Results: The 4 main themes identified were clinician experience and knowledge, patient clinical risk stratification and preference, diabetes severity and drug factors, and healthcare system. PCPs' prior experience with OADs, years of practice, academic roles and knowledge resources influenced their decision-making when prescribing OADs. Their prescription was guided by patient preferences and comorbidities, such as selecting sodium-glucose cotransporter-2 inhibitors for patients with proteinuria. Disease severity, OADs safety profile, efficacy, stipulations in the drug formulary, cost and availability of OADs in their pharmacy, and social worker support were other factors affecting PCPs' prescribing habits of OADs. Clinical decision support functionality in the electronic medical record (EMR) system prompted PCPs to select the type of OADs during the consultation.

Conclusions: The study highlights the multifaceted factors influencing PCPs' prescribing of OADs, including clinical experience, patient preferences, drug formulary limitations, medication costs and EMR utilisation. To enhance prescribing habits, interventions should focus on continuous education for PCPs, expanding drug formularies, addressing patients' preferences, cost and access barriers through subsidies and promoting the adoption of EMRs with clinical decision support systems in both public and private sectors.

Objective: This conceptual paper explores the transition from apomediation to AIMediation, allowing patients or users to independently seek and access health information on their own, often using the internet and social networks, rather than relying exclusively on the intermediation of health professionals. It examines how generative artificial intelligence (GAI) reconfigures the dynamics of informational authority, access, and user autonomy in digital health environments in light of the increasing use of generative AI tools in healthcare contexts.

Method: This study examined how mediation models in health information have changed over time. It uses Eysenbach's framework and new developments in large language models (LLMs). A new model was created to compare intermediation, apomediation, and AImediation.

Results: AImediation emerges as a new paradigm in which patients or users interact directly with AI tools such as ChatGPT, Claude, Perplexity, or Gemini to access compiled multi-source health information. While this model retains the user autonomy characteristic of apomediation, it centralizes information flows and removes peer-based social layers. Key challenges include algorithmic opacity, prompt dependence, and the risk of misinformation due to hallucinations or biased outputs.

Conclusion: AImediation redefines how individuals access and evaluate health information, requiring critical engagement from users and responsible development by technology providers. This framework calls for more research to determine how it affects patient actions, the roles of professionals, and the ethical use of AI in healthcare.

Purpose: Type 2 diabetes is a global pandemic, with 1 in 6 people expected to be diagnosed by 2050. The Diabetes Prevention Program (DPP) is an evidence-based program that has been shown to reduce A1c and bolster health outcomes in people with type 2 diabetes and prediabetes, but implementation has been varied, with lower uptake in rural and economically underserved communities. The study assessed whether there are geographic and socioeconomic disparities in the availability of hospital-supported DPPs in the US.

Methods: We assessed DPPs in 3204 general medical hospitals. Data on hospital and county characteristics came from the American Hospital Association (AHA) Annual Survey, the Area Health Resource File, and County Health Rankings. We assessed geographic and socioeconomic differences between hospitals with and without DPPs using t-tests and chi-square tests. Rurality was determined based on the 2013 Rural-Urban Continuum Codes (RUCC). We then conducted a multivariable analysis to assess the relationship between geographic location, socioeconomic characteristics and the presence of a DPP, independent of hospital factors.

Findings: Nearly half (49.3%, n = 1580) of hospitals in the U.S. reported having a DPP in 2021. DPPs were less commonly found in rural counties as well as micropolitan counties when compared to their urban counterparts. After controlling for hospital size and other community characteristics, these disparities disappeared. When including the interaction of hospital size and geographic location, the odds of offering DPPs was higher among large, rural hospitals. DPPs were also less commonly available in counties with more limited food access and in health professions shortage areas.

Conclusions: DPP implementation is less common in rural and underserved areas. The interaction between hospital size and location is helpful for understanding barriers to DPP availability.

Background: The increasing prevalence of opioid use coupled with the emergence of the Coronavirus Disease-19 (COVID-19) pandemic impacted opioid overdoses and death rates. People with opioid use disorder (OUD) are particularly vulnerable to the pandemic's consequences. Although Medications for Opioid Use Disorder (MOUD) are the most well supported treatment for OUD, they remain underutilized by clinicians, particularly in the primary care setting, emphasizing the importance of examining factors that impact prescribing.

Objective: To assess clinicians' prescribing practices for MOUD and assess the pandemic's effect on MOUD prescription. To determine whether there is an association between patient-specific factors, such as mental health diagnoses and substance use disorder (SUD), and MOUD prescription practices prior to and during the COVID-19 pandemic.

Methods: A retrospective chart review assessed 500 patient charts with a diagnosis of OUD to assess demographics, MOUD prescribing, substance use, and co-morbid mental health conditions.

Results: 312 charts met inclusion criteria. There was no significant difference in the percentage of new MOUD prescriptions among the selected cohort between the 2 selected timeframes, nor was there a significant difference in the prescriber/setting of new prescriptions. Cumulative analysis revealed that greater than 2/3 of the selected patients had concurrent mental health diagnoses. Greater than 50% of patients reported active non-opioid substance use. The odds of having a co-occurring SUD were significantly higher among patients treated in the emergency department and various treatment settings-including urgent care and non-primary care clinics-as compared to the primary care outpatient setting.

Conclusions: Strong evidence supports the efficacy of using MOUD in primary care, yet it is underutilized in the mid-Michigan region. Overall prevalence of mental health diagnoses, SUD, MOUD prescriber practices were similar prior to and during the COVID-19 pandemic. There was a high occurrence of co-occurring SUD especially among patients treated outside of the primary care setting. Future initiatives to increase clinician education around MOUD and address patient barriers to treatment are warranted.

Objective: Multicancer Detection (MCD) tests, such as the GRAIL Galleri, offer a novel approach to cancer screening by detecting cancer-specific methylation patterns in cell-free DNA through a single blood sample. This study evaluated an 18-month implementation of MCD testing in a tertiary ambulatory internal medicine clinic.

Patients and methods: Between June 2022 and November 2023, 2244 asymptomatic (without symptoms attributed to cancer) patients underwent MCD testing. The study focused on operational workflows, patient and physician education, and diagnostic follow-up of positive results. Standardized materials, including electronic health record (EHR) workflows, FAQs, and diagnostic pathways, were developed to facilitate implementation. Challenges included managing false positives, patient anxiety, costs, and ethical considerations.

Results: Of the 2244 patients tested, 17 (0.76%) had positive results, and 15 underwent further diagnostic evaluation. Cancer was confirmed in 11 (73.3%) patients, including cases of breast, colon, esophageal, lymphoma, ovarian, and pancreatic cancers. Four patients had no identifiable malignancy despite comprehensive work-up.

Conclusions: MCD testing is feasible in routine clinical workflows, with 73% of positive cases yielding cancer diagnoses. While promising, further research is required to assess long-term outcomes, cost-effectiveness, and optimal implementation strategies of cancer interception in broader healthcare settings.

Introduction: One of the most effective measures for the reduction and prevention of healthcare-associated infections (HAI) is hand hygiene (HH). Covert direct observation of HH is difficult to realize in general practice office (GPO). The World Health Organization recognizes electronic monitoring as a form of measuring product use and estimating compliance. This is the first study to monitor HH performance electronically in Dutch GPOs.

Objectives: The main aim of this study was to evaluate HH compliance in general practice offices.

Methods: An observational study was conducted at 4 Dutch GPOs between 2019 and 2021. We measured HH compliance using data on HH events (HHE) from alcohol-based hand rub (ABHR) dispensers with a built-in electronic counter. Daily HH opportunities were calculated according to the 'Five Moments for Hand Hygiene' based on the continuously documented activities using general practitioners (GPs) patient electronic dossier systems.

Results: In total, hand hygiene was performed during 1786 of the estimated 4322 opportunities (41%). HH compliance for the general practitioners, practice assistants, and nurse practitioners was 38%, 51%, and 43%, respectively. The overall HH compliance within the same GPOs was 42% pre-pandemic and rose to 56% during the pandemic. The overall mean volume of ABHR was 2.44 ml, varying per HHE between 1.91 to 2.55 ml. The mean volume of ABHR measured before and during the pandemic rose from 2.55 ml to 2.81 ml. The overall self-reported compliance was 86% and was highest among nurse practitioners.

Conclusions: Hand hygiene compliance among HCWs in Dutch GPOs was found to be 41%, with general practitioners having the lowest compliance and practice assistants the highest compliance. While the mean volume of ABHR used per HHE seems appropriate, directed observations would be needed to ensure that an adequate hand-rub technique was used to cover the whole hand. Multi-modal interventions are needed to improve HH-compliance and stimulate the switch to ABHR with in the Dutch general practice office.

Background: Hypertension and obesity are major public health problems in the United States and Maryland.

Objectives: To assess the impact of Medication Therapy Management (MTM) on controlling hypertension and obesity in a sample in Southern Maryland: Prince George's, Calvert, Charles, and St. Mary's counties.

Methods: 171 patients with high blood pressure were enrolled in an MTM program for 12 months. Patients received at least one pharmacist consultation between September 2021 and September 2023. We employed a pre-post prospective study design to assess the impact of MTM on patients' blood pressure management. We examined the association between MTM and systolic blood pressure (SBP) and diastolic BP (DBP) as the primary outcome, and weight and body mass index (BMI) as secondary outcomes. We used descriptive analysis and fixed effect regression models to present the association between outcome variables and enrollment time in the program.

Results: Our findings showed that the MTM reduced uncontrolled hypertension by 17.5 percentage points, weight by 3.6lbs (10.2), and BMI by 0.6 kg/m² (2.1). The regression model showed that the MTM intervention reduced the prevalence of uncontrolled hypertension (-1.81, CI: [-3.11, -0.51]), and obesity (BMI > 30, -1.85 (CI: [-3.12, -0.57]), by 12 months of enrolling in the program. During this time SBP reduced to -10.37 mmHg (CI: [-19.62, 1.2]).

Conclusions: Our results suggest that policymakers should prioritize promoting MTM services as an effective means of blood pressure control. Combining a community health worker (CHW) model with community-based pharmacists can further improve health outcomes for patients with hypertension.

Introduction: This study aimed to test the introduction of Community Appointment Days (CADs) for patients on the Musculoskeletal (MSK) Physiotherapy waiting list in Lanarkshire, UK.

Methods: A multi-professional team developed, implemented, and evaluated the first 2 CADs on 16th and 17th April, 2024. The mixed-methods design involved patients completing a "passport" (which included a survey) on the day and being followed up 4 weeks later by survey or interview. The patient management system was interrogated for waiting times and numbers returning to the service within 6 months. Structured thematic analysis was used to create a conceptual model from the qualitative data.

Results: More than 3 times as many patients were booked into a CAD appointment (n = 443) compared to routine outpatient clinics (n = 133), and the vast majority reported positive outcomes. A total of 52 attendees (12%) were discharged on the day and a further 202 (46%) with Patient Initiated Review (PIR). Only 126 (28%) were given a follow-up 1:1 Physiotherapy appointment, although 63 (14%) did not attend on the day. Of the 443 booked, 26 (6%) returned for an additional review MSK outpatient appointment within 6 months.

Conclusions: The CADs had positive outcomes for patients and were successful in reducing waiting times.

Introduction: A broad range of studies have associated spirituality with health outcomes. However, the integration of spiritual care in primary and community care has substantially lagged behind. Chaplains, as specialist spiritual caregivers, are increasingly employed in primary and community care to fill the gap. To investigate the implementation of chaplains in these settings from the perspective of clients, this study focused on the following research question: what are primary and community care clients' reasons to seek chaplaincy care, their ideas of care goals, and what outcomes of care do they report?

Methods: 24 Dutch chaplaincy clients were interviewed.

Results: Clients sought support from a chaplain for existential concerns, or an existential struggle encompassing several areas of life. They described goals and outcomes of care in 3 domains: (1) the relationship with the chaplain, which included being seen, heard and acknowledged; (2) meaning-making, where they gained insight into and/or processed life-events, and connected more with themselves, others and/or the sacred; and (3) well-being, which included feeling better and finding peace.

Conclusions: This study provides novel insights into clients perspective on chaplains' contributions in primary and community care. Their experiences are key to further shaping the implementation of chaplaincy in these settings.