Journal of Primary Care and Community Health最新文献

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.

Poor dietary habits are a major contributor to chronic disease burden, yet nutrition counseling remains underutilized in primary care settings despite proven effectiveness. This article presents a novel adaptation of the 5 A's framework (Assess, Advise, Agree, Assist, Arrange) titled 'The 5 A's Approach to Promoting Nutrition Counseling in Primary Care', by incorporating validated assessment tools and evidence-based strategies to support implementation in clinical settings. To address practical challenges, implementation approaches are proposed including alternative delivery and payment models. The 5 A's adaptation can be a tool used to address the critical need for standardized nutrition counseling in primary care.

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.

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.

Background: The hypertriglyceridemic-waist phenotype (HTWP), defined by concurrent hypertriglyceridemia and increased waist circumference, is a recognized marker of metabolic and cardiovascular risk. While extensively studied across populations, data on Amerindian communities remain scarce. This study examines HTWP prevalence and its association with type 2 diabetes mellitus in middle-aged and older adults of Amerindian ancestry in rural Ecuador.

Methods: This population-based cross-sectional study was conducted in 3 ethnically homogeneous villages. Participants aged ≥40 years underwent standardized assessments, including structured interviews and fasting blood tests. HTWP was defined using serum triglyceride levels ≥150 mg/dL together with increased waist circumference determined by 2 criteria: Amerindian-specific (men ≥ 89 cm, women ≥83 cm) and NCEP-ATP III (men ≥102 cm, women ≥88 cm). Logistic regression models assessed associations between HTWP and diabetes indicators, adjusting for demographics and cardiovascular risk factors.

Results: Among 1354 participants, HTWP prevalence was 47% by Amerindian-specific, and 30% using NCEP-ATP III criteria. Hypertriglyceridemia was frequent (55%), particularly in men. In multivariate models, HTWP was associated with fasting glucose ≥126 mg/dL under both Amerindian-specific (OR 1.32, 95% CI 1.02-1.71) and NCEP-ATP III (OR 1.50, 95% CI 1.12-2.01) criteria. When HTWP components were separately included in the models, only hypertriglyceridemia remained significantly associated with diabetes risk. No significant association was observed between HTWP and HbA1c levels.

Conclusion: HTWP prevalence is high in this population. Hypertriglyceridemia drives diabetes risk more than waist circumference. Findings underscore the need for ethnicity-specific cardiovascular risk assessments and targeted health interventions for indigenous communities.