Journal of Primary Care and Community Health最新文献

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).

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: Chronic Kidney disease (CKD) accounts for approximately 82 billion dollars of Medicare spend. Implementing culturally competent, community-based programs may be a strategy for changing utilization behaviors and lowering cost while maintaining quality in this population.

Methods: A longitudinal claims based study was carried out from April 2023 to August 2024 in the state of CA to assess the impact of the program on cost, utilization, and quality metrics. A propensity matched approach was leveraged yielding of 203 pairs of CKD Medicare Advantage (MA) enrollees. A comparison of the difference of differences was performed between utilization, and available claims-based quality metrics.

Results: Enrollees in the peer support program, Connect For Life (CFL) generated significantly lower costs of $461 pmpm (95% CI = -1037 to -10 037; P = .016) significantly lower inpatient utilization of 172 per 1000 (95% CI = -10 to -330; P = .037) and significantly higher outpatient utilization of 1212 per 1000 (95% CI = 90 to 2340; P = .035). No differences were found in available quality metrics.

Conclusions: For CKD MA enrollees in the intervention population, more efficient utilization patterns and lower costs while maintaining quality were observed. The tight propensity match left the study underpowered to detect significant changes for other care settings or individual stages of CKD.

Background: Burnout among Community Health Center (CHC) providers has worsened post-COVID-19, exacerbated by understaffing and heightened recruitment challenges due to competition from higher-paying hospitals and private practices.

Objective: This exploratory qualitative study investigates strategies used by four leading CHCs to address perceived drivers of burnout among their providers.

Methods: The study used qualitative interviews with CHC staff to explore approaches to mitigating burnout. Focus was placed on organizational strategies, staff engagement, and operational changes aimed at enhancing provider wellbeing.

Results: Key challenges included low funding and rapid growth, leading to staffing shortages and strained relationships between staff and leadership. Common strategies to combat burnout involved: (1) emphasizing the CHC mission of supporting staff wellbeing, (2) creating onboarding and workforce development programs focused on support, (3) implementing operational changes to reduce workloads and maximize patient care time, (4) fostering staff involvement in decision-making, and (5) using wellness surveys with the expectation of visible changes based on feedback.

Conclusion: The study found that employee voice is crucial in addressing burnout, contrasting with wellness approaches that focus solely on individual staff members. Involving staff in decision-making and addressing systemic issues are viewed by participants as essential strategies for mitigating burnout in CHCs.

Introduction: During catastrophes, physicians face significant stress and emotional challenges. This review explored existing evidence about the challenges family physicians face during infectious catastrophes, and their perceived well-being needs.

Materials and methods: We conducted a mixed studies literature review using 2 databases, Ovid MEDLINE ALL (1946 to February 2023) and PsycInfo on Ovid (1806 to February 2023). To assess methodological quality, we used Mixed Methods Appraisal Tool. The extracted data were analyzed employing a data-based convergent mixed methods design.

Results: Thirty-four (34) studies met the criteria for data extraction. Line-by-line coding for thematic analysis was applied to Result and Discussion sections of included articles. Findings were categorized into 4 levels: Societal, Institutional, Organizational, and Individual. Seven themes were identified in total.

Discussion: Public health authorities should focus on systemic changes, including organizational development to improve coordination within and across organizations. Clinician involvement in decision-making, clear communication, mental health support, and adequate resources are crucial. Policy implications underscore the necessity for healthcare policies prioritizing physician well-being, and organizational support during infectious catastrophes. Improving work conditions extends beyond personal protective equipment (PPE) access, requiring swift betterment of service innovations, with ongoing reassessment for sustainable care planning, financing, and delivery beyond emergencies.

Introduction/objectives: Individually rare, rare diseases are collectively common resulting in frequent health system use. Navigating the health system persists as a challenge. Primary care provides longitudinal contact with the health system and is placed to provide integrated rare-disease-care.

Methods: This scoping review used Joanna Briggs Institute and PRISMA methods with a Consolidated Framework for Implementation Research based data extraction tool to find how integrated rare-disease-care is delivered, enablers and barriers to the same, in primary care settings in contemporary literature in OECD countries.

Results: The Primary Care Provider (PCP) role varies from routine primary care to shared-rare-disease-care models. In the 26 papers, the most frequently cited PCP roles included involvement in diagnosis (n = 14), care coordination (n = 16), primary and preventative care (n = 18), management of components of rare-disease-care (n = 13), and treatment monitoring (n = 10). Individuals whose PCP was actively involved in their care were reported to have shortened diagnostic delay, improved transitions of care across the lifespan, reduced unplanned utilization of emergency and hospital services, comprehensive psychosocial care, improved quality of life across environments including home, school and work and improved palliative care experiences.

Conclusions: Sufficient communication from specialists, information, resources, time and reimbursement for complex care are still needed. Future integrated-rare-disease-care models should be developed by, or with, PCPs.

Introduction/objectives: Patients returning to the community from incarceration (ie, reentry) are at heightened risk of experiencing trauma when interacting with the healthcare system. Healthcare professionals may not recognize patients' trauma reactions or know how to effectively respond. This paper describes the development and pilot evaluation of a single-session training to prepare primary care teams to deliver trauma-informed care (TIC) to patients experiencing reentry.

Methods: A multidisciplinary team including community members with lived experience engaged in a multiphase human-centered design process that incorporated interviews, discussions, and a participatory process to design and evaluate a single-session interactive pilot training targeting providers' attitudes toward formerly incarcerated patients and confidence to deliver TIC.

Results: Both pre- and post-training surveys were completed by 12 TIC training attendees, which included primary care providers and staff. Trainees reported significant increases in confidence to reduce potentially re-traumatizing practices and improved attitudes toward formerly incarcerated individuals. They also expressed interest in receiving additional TIC training and learning how best to care for and meet the needs of persons with a history of incarceration. Trainees described the panel of community members with lived experience as one of the most rewarding aspects of the training.

Conclusion: Centering people with lived experience in the training design and delivery produced a single-session TIC training that was both well-received and effective. Our TIC training helped primary care providers and staff move from being merely informed on trauma to having the self-efficacy to prevent and respond to trauma reactions during encounters with all patients, particularly those with a history of incarceration.

Background: Readmission can be be related to the work of several stakeholders involved in the care of individuals throughout the community, including, for example, primary care and social care providers. A narrative review was performed to assess definitions and frequency of readmission for older adults found in previous research. In addition, a dataset for a cohort of older adults in Stockholm, Sweden, was used to quantify how different definitions of readmission affect frequency.

Materials and methods: The review was based on pre-specified search criteria within PubMed and Embase databases. All studies based on a cohort of older adults with a primary objective to assess readmission to inpatient care, were included for the assessment of readmission criteria. The dataset was based on a cohort of older adults treated at a geriatric department in Stockholm during 2016. Estimations of readmission were performed with the most common criteria found in the narrative review.

Results: The narrative review showed that definitions of readmission included predominantly time-based criteria, either alone or combined with additional criteria such as medical condition or readmitting department. Frequency of readmission based on different definitions varied substantially; a 14-day time interval implied a rate of 8.0% whilst a 30-day interval-more commonly used-rendered a rate of 12.6%. The density of readmissions per day was higher during the first weeks after discharge, and then dropped continuously.

Conclusion: Transparency on definitions is imperative in studies that include rates of readmission. The levels of readmission rates are highly dependent on the study population and its context. Furthermore, the actual value of readmission monitoring is dependent on what purpose it is supposed to fulfill, and it is essential to put it into context of all relevant stakeholders including, for example, the primary care providers and different social care providers throughout the community.

Introduction: This study determined the clinic prevalence and compared the quality of care of allergic diseases in urban, rural, and remote primary care sites.

Methods: This was a retrospective review of electronic health records of all adult patients who consulted in the 3 sites from May 2019 to April 2022. Data of adult patients with allergic diseases was extracted from the 3 EHR systems operating across the participating sites using standardized Structured Query Language queries across the 3 systems. We computed the prevalence of allergic diseases among adults who consulted in primary care health facilities by dividing the number of patients diagnosed to have an allergic disease over the total number of adult patients who consulted within the 3-year study period. We compared the quality of care of patients across the 3 sites based on clinical practice guidelines using Chi-square test, Fisher's exact test, or 1-way analysis of variance, as appropriate.

Results: The prevalence of allergic disease among adults who consulted in primary care health facilities was 1.3% for the urban site, 2.2% for the rural site, and 2.1% for the remote site. The most common allergic disease was asthma (59.0%). First-line medications based on recommendations in clinical practice guidelines were prescribed more often in the urban site, including inhaled corticosteroids with long-acting beta-agonists for asthma patients (P < .001) and topical corticosteroids for atopic dermatitis (P < .001). In contrast, there was more frequent prescription of medications that were not recommended in clinical practice guidelines in the rural and remote sites.

Conclusion: Health inequity was observed in this study, with results demonstrating that the rural and remote sites had greater allergic disease prevalence, greater underutilization of first-line medications, and more frequent overutilization of non-essential medications.