Journal of Primary Care and Community Health最新文献

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: Type 2 Diabetes Mellitus (T2DM) presents a significant public health challenge, particularly in developing countries, where healthcare resources are limited. Community-Based Interventions (CBIs) have been explored as a strategy to improve glycemic control, yet evidence regarding their efficacy in reducing HbA1c levels in these settings remains limited.

Aim: This study aimed to evaluate the efficacy of community-based interventions in improving HbA1c levels among patients with T2DM in developing countries.

Methods: A systematic review and meta-analysis were performed following PRISMA guidelines. A comprehensive literature search was conducted in PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Ovid-Medline, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for full-text randomized controlled trials (RCTs) published between 2015 and 2024. Studies conducted in developing countries focusing on community-based interventions targeting HbA1c outcomes were included. Quality appraisal was conducted using the Joanna Briggs Institute (JBI) critical appraisal tools. Statistical analysis employed a random-effects model to calculate the pooled mean difference (MD) with 95% confidence intervals (CI). Heterogeneity was assessed using the I² statistic. Potential publication bias was assessed using Egger's test, the Trim-and-Fill method, and a funnel plot.

Results: Twenty RCTs involving 4914 participants across developing countries were included. CBIs significantly reduced HbA1c levels compared to usual care, with a pooled MD of -0.54 (95% CI = -0.71, -0.36; P < .00001; I² = 92%). Subgroup analysis showed that education-focused interventions (MD = -0.67; 95% CI = -1.02, -0.31) and physical activity-focused interventions (MD = -0.67; 95% CI = -1.14, -0.20) were the most effective. Analysis by income level revealed no significant differences in efficacy between lower-middle-income and upper-middle-income countries (P = .29). The greatest HbA1c reduction was observed during the 0- to 3-month measurement period (MD = -0.56; 95% CI = -0.90, -0.23).

Conclusion: CBIs are an effective strategy for reducing HbA1c levels among patients with T2DM in developing countries, with significant benefits across diverse economic contexts and intervention models. These findings highlight the adaptability and scalability of CBIs, underscoring their potential to enhance diabetes management in resource-limited settings.

Objective: To identify competencies required for effective collaborative working within Primary Care Networks (PCNs).

Methods: An online questionnaire about roles within PCN teams, importance of collaboration and experiences of connection and conflict within teams, was sent to Mental Health Practitioners (MHPs) and PCN/Practice Managers from several teams across Lancashire. Semi-structured interviews with similarly themed questions were conducted with MHPs, General Practitioners (GPs), and PCN/Practice Managers and analysed using reflexive thematic analysis. Questionnaire and interview data were combined, and themes were mapped onto 3 competency constructs (knowledge, skills and abilities, and personal characteristics).

Results: Subthemes that were considered important to effective collaborative working in PCNs included: knowledge around shared goals, expectations, and role clarity; skills in communication and relationship building; embodiment of personal characteristics such as being engaged, accepting, and supportive.

Conclusion: Clinical implications for promoting collaboration between staff working within PCN settings include meetings and joint training between PCN and NHS Trusts to establish network goals and expectations, regular team meetings and opportunities for face-to face activity to promote understanding of different roles and relationship building.

Arkansas faces significant health disparities, including high rates of chronic diseases and limited healthcare access, especially in rural and underserved communities. Community Health Workers (CHWs) serve as essential links between the healthcare system and these communities and address the state's significant health disparities through culturally appropriate care. This article describes the development of CHW programs in Arkansas, including early CHW training initiatives, the formation of the Arkansas Community Health Workers Association (ARCHWA), the state's adoption of standardized CHW training, the establishment of a CHW certification process, including an apprenticeship program and college credit, and the introduction of upskilling opportunities. The article describes both failed and successful legislative efforts. By detailing how collaborative efforts among healthcare organizations, community stakeholders, and public health entities have supported ongoing education, career development, and policy advocacy, this article may provide an example for other states striving to enhance their CHW workforce.

Background: Identifying circulating biomarkers that reflect cerebrovascular health may help clarify underlying mechanisms associated with brain damage. Serum albumin, a multifunctional protein with antioxidant, anti-inflammatory, and endothelial-stabilizing properties, could serve as a marker of cerebral integrity. We examined the association between albumin levels and neuroimaging markers of cerebral small vessel disease (cSVD) in a rural population of older adults.

Methods: We conducted a cross-sectional study among community-dwelling individuals aged ≥ 60 years in rural Ecuador. Participants were invited to undergo brain MRI and laboratory testing as part of the study protocol. Inclusion was based on completion of these procedures and serum albumin levels within the physiological range of 3.0-5.0 g/dL. Logistic regression models were fitted to assess the association between serum albumin and cSVD markers, adjusting for demographics and cardiovascular health metrics .

Results: Among 409 participants (mean age: 66.2 ± 6.1 years; 60% women), moderate-to-severe white matter hyperintensities (WMH) were present in 34% of participants. Serum albumin showed a non-linear inverse association with WMH. Only participants in the highest albumin quartile (4.42-5.0 g/dL) showed significantly lower odds of moderate-to-severe WMH (adjusted OR: 0.48; 95% CI: 0.25-0.93). No significant associations emerged with other cSVD markers.

Conclusion: Higher physiological albumin levels were associated with a lower burden of WMH, consistent with a threshold-dependent protective effect on the cerebral microvasculature. These findings support serum albumin as a candidate biomarker of brain health in aging populations. Albumin may capture systemic processes - such as endothelial integrity and vascular inflammation - that contribute to cSVD. Its accessibility and affordability underscore its potential utility in community-based aging research and population-level screening.

Background: While biopsychosocial interventions are recommended for treatment of patients with chronic pain, outcome measurement frequently does not take a multifaceted approach to assessing patient outcomes. As primary care settings increasingly implement chronic pain approaches such as Integrative Group Medical Visits (IGMV), a comprehensive yet pragmatic measurement approach is needed to capture biopsychosocial outcomes.

Methods: We recruited 21 clinicians, administrators, and staff with direct experience implementing IGMV in safety-net settings to participate in semi-structured qualitative interviews. Participants were recruited from 6 Federally-Qualified Health Centers and 4 Safety-Net Hospital outpatient clinics representing 6 states across the U.S. We first analyzed interview transcripts using the Consolidated Framework of Implementation Research, then used inductive thematic content analysis to identify themes related to what participants currently measure and the outcomes they view as important to be measuring.

Results: Thematic content analysis revealed 3 themes: variability of measures chosen, rationale for measures chosen, and desire for biopsychosocial outcome measurement tailored to IGMV for chronic pain. Thirteen different measures were used across 9 sites. The choice of measures was driven by clinical utility and/or administrative incentives. Interviewees described that as patients progressed through IGMV they demonstrated improved health through improvements in social support, self-efficacy in pain management, self-management behaviors, and improved physical function. The measures currently used address most but not all these outcomes.

Conclusion: We recommend developing and refining a biopsychosocial outcome measurement tool that addresses unique aspects of IGMV. These findings contribute to a growing consensus on how to measure actionable, patient-centered data on biopsychosocial interventions for chronic pain.

Background: Direct Primary Care (DPC) offers an alternative healthcare delivery model with potential benefits for patient-centered care. However, concerns remain about its equity and accessibility, particularly in urban settings. This study examines the utilization patterns and patient engagement within a DPC clinic in Houston, Texas, and whether subscription duration impacts patient-provider interactions in an urban healthcare environment.

Methods: Deidentified data from a Houston-based DPC clinic (January 2023-January 2024) were analyzed. Patient demographics, subscription details, and interaction data (including in-person appointments and audio-visual calls) were collected. Descriptive statistics summarized utilization patterns, while logistic regression models assessed relationships between demographic factors and DPC utilization.

Results: The sample included 71% Non-Hispanic Black patients, 21% Non-Hispanic White, and 77% females. Most patients resided in urban areas (79%) and paid over $125 monthly (44%). Subscription duration positively correlated with engagement: patients subscribed for ≥21 months had higher yearly averages for chart interactions and appointments compared to those who subscribed for ≤5 months. Regression analysis revealed significant dose-response increases in patient engagement among those with longer subscription durations across all interaction types. No other demographic characteristics were significant predictors of DPC utilization.

Conclusion: Subscription duration strongly influences DPC utilization, suggesting sustained enrollment fosters deeper patient engagement and more frequent provider interactions. While DPC may enhance patient-provider relationships, cost and urban-centric accessibility may pose barriers to equity.

Sociodemographic factors are critical determinants of health outcomes and disparities, yet their documentation in electronic medical records is often sparse and confined to unstructured clinical text. This poses substantial challenges for automated extraction and integration into clinical decision-making. In this study, we systematically evaluate and compare 6 convolutional neural network architectures, including hybrid models that integrate traditional classifiers, for binary classification of multiple sociodemographic characteristics from EMR text using data from 4375 patients across 96 primary care clinics. The goal was to assess how model complexity and lexical diversity influence classification performance. Manual annotation achieved high inter-rater reliability (kappa: 0.98 for documentation status, 0.96 for documented information). We report performance using F1 score, precision, recall, area under the precision-recall curve, and Matthews correlation coefficient. Results showed that simpler architectures, particularly a single-layer CNN, consistently outperform deeper or hybrid models across most characteristics (F1 score: 90.99%), especially under conditions of data imbalance and varied documentation patterns. While hybrid models offered gains for well-documented factors like marital status, they were less effective for sparse or diverse characteristics. These findings provide a practical framework for developing efficient, interpretable clinical NLP pipelines and inform model selection strategies for real-world health equity and EMR research applications.

Purpose: This pilot study tested the feasibility and acceptability of a pragmatic randomized trial evaluating group-based non-pharmacologic approaches to increase access in primary care and improve pain-related outcomes.

Methods: This 2 × 2 factorial trial assessed two 12-week interventions: group acupuncture and integrative group medical visits (IGMVs). Adults with chronic pain lasting ≥3 months were enrolled from safety-net primary care clinics. Participants were randomized to group acupuncture, IGMVs, both, or neither (usual care). We analyzed data using linear mixed models, ANCOVA, and abductive qualitative analysis.

Results: Overall, 44 participants were randomized (25 English-speaking and 19 Spanish-speaking); 59% were female (mean age = 55 years), 21% African American or Black, 52% Latine, 21% non-Latine White, and 5% more than 1 race; and 78% had annual income <$25 000. At baseline, the average duration of chronic pain was 13.0 years, and the mean pain impact score was 36.0 (SD = 6.4). Participants randomized to interventions attended 6 of 12 sessions on average; 89% would participate again; and 86% reported clinically relevant pain improvements versus 20% in usual care (P < .001). Qualitative data revealed substantial barriers to accessing multimodal care and social benefits of group-based models.

Conclusion: Group-based integrative pain management is feasible and acceptable when co-located within safety-net primary care.Clinicaltrials.gov Registration Number: NCT05906784 (http://clinicaltrials.gov/study/NCT05906784).

Objectives: This qualitative study explored the beliefs and values influencing healthcare providers' delivery of gender-affirming care (GAC) to transgender and gender-diverse (TGD) youth amidst current social and political dynamics.

Methods: The study PI conducted 43 semi-structured interviews with providers across states with varying GAC legislation. Responses from 41 providers were analyzed in this paper. A thematic approach to data analysis was employed using qualitative coding.

Results: Key themes emerged: criteria for treatment, ethical and moral considerations, and professional and personal responsibility. Providers widely endorsed GAC as evidence-based and essential for alleviating distress and promoting autonomy. They emphasized the importance of respecting patients' gender identities and viewing GAC as life-saving.

Conclusion: Despite legislative challenges, the study highlights a strong consensus among providers on the medical necessity of GAC for TGD youth.