Annals of Family Medicine最新文献

Purpose: Vitreous floaters are often considered harmless. However, floaters might be the first and only alarm symptom for a retinal tear or early retinal detachment (RD). Data from ophthalmology practices show that experiencing new-onset floaters is more strongly associated with retinal tears than experiencing flashes, but these associations have not been studied in primary care. We aimed to calculate the absolute risk (AR) and relative risk (RR) of floaters for RD in primary care.

Methods: We performed a retrospective cohort study of patients (aged ≥18 years) with new-onset floaters or flashes during the period 2012 to 2021 among 7 family practices in the Netherlands. Based on electronic health record reviews, cases (n = 1,181) were categorized into floaters, flashes and floaters, and flashes. The duration (acute, defined as ≤14 days) and number of floaters (many, defined as ≥10 floaters or a cloud/haze/curtain) were used as subgroups. We calculated the RR for flashes alone as the reference group.

Results: The incidence (1,000 patient-years) of floaters and flashes was 5.5 and 2.7, respectively. The AR of RD was 6.1% for floaters alone, 4.7% for flashes alone, and 8.4% for floaters and flashes. Both acute and many floaters increased AR. The RRs for acute floaters and flashes (2.39; 95% CI, 1.11-5.15), many floaters (4.20; 95% CI, 1.87-9.40), and many floaters and flashes (6.20; 95% CI, 2.47-15.55) were significantly increased compared with flashes alone.

Conclusions: Data from primary care confirm that new-onset floaters confer increased risk of RD. Currently, family physicians use vision loss and flashes as important alarm symptoms for RD. Our primary care data revealed that floaters confer a greater risk of RD than flashes. This enables family physicians to make an evidence-based risk assessment for patients with floaters or flashes.

Genomic tests can illuminate and mislead. I cared for a school-aged boy with short stature whose copy-number variant at 1q21.1-typically associated with variable neurodevelopmental and cardiac features rather than isolated short stature-seduced me into a syndromic label. I told his family that a "pathogenic" deletion likely explained his growth. Months later, family segregation testing contradicted the story: some short relatives lacked the deletion; a taller cousin carried it. His excellent response to growth hormone pointed to treatable growth hormone deficiency, not a genetic syndrome. I returned to the family to revise-both the diagnosis and my words. This reflection traces how the promise of precision medicine can eclipse bedside sense, and how apology, delabeling, and a new clinic script helped me re-center care on phenotype, family context, and uncertainty handled with humility.

Purpose: We aimed to evaluate the effectiveness and safety of Care Anywhere with Community Paramedics (CACP), a mobile community paramedic intervention delivering a broad range of clinical services in the home, in preventing or shortening hospitalizations.

Methods: In this multicenter, pragmatic, randomized controlled trial, we randomized 240 adults from ambulatory, emergency department (ED), or hospital settings requiring acute care-administered services to CACP or usual care. The trial was conducted from January 2022 to March 2023. The primary outcome was days alive out of hospital/ED within 30 days. Secondary outcomes were 30-day ED and unplanned hospital use, death, health-related quality of life, program satisfaction, medication errors, and falls with injury.

Results: A total of 119 patients were randomized to CACP and 121 to usual care. Mean (SD) age was 68 (14) and 69 (15) years, respectively, 37% and 46% lived in rural areas, the mean (SD) Elixhauser comorbidity index was 10.0 (4.4) and 8.9 (3.7), and 84% and 86% had an unplanned hospitalization in the past 6 months. There was no difference between the CACP and usual care arms in the primary outcome (26.7 [6.6] vs 27.9 [4.2] days; P = .1) or secondary outcomes. The mean satisfaction score was greater for CACP (4.2 [0.8] vs 3.9 [0.9]; P = .02), and 94% were very/extremely likely to recommend CACP to others.

Conclusions: The CACP program, which enrolled highly complex patients with heterogeneous care needs, did not decrease 30-day acute care use compared with alternative usual care pathways, but it improved patient satisfaction and was preferred by most participants. Future research is needed to better tailor community paramedic services to those most likely to benefit.

Purpose: Growing numbers of people live with multimorbidity, defined as 2 or more long-term health conditions. Health care delivery must adapt to manage the growing workload and complexity associated with multimorbidity. Research, practice, and policy have called for a shift to whole-person tailored primary care management of multimorbidity but have yet to adequately describe how this should be implemented. Here, we systematically identify the enablers and barriers to delivery of tailored care for people living with multimorbidity to develop a new model for implementation.

Methods: We collected data across 5 UK general practitioner (GP) sites through 2 methods: ethnography and focus group discussions. Ethnographers observed 25 consultation sessions, 5 per site. Focus groups were held among primary care staff (n = 16, across 4 sessions) and patients and carers (n = 8, across 2 sessions). We analyzed integrated data using inductive thematic analysis to describe enablers/barriers to delivery of tailored care.

Results: We identified 3 elements needed to enable tailored management: (1) resources for tailored assessment of, and practical support for, tailored management of multimorbidities, (2) engagement of patients/carers with professional collaboration to cocreate tailored management plans, and (3) evaluation and development of the professional skills required to confidently work beyond traditional condition-focused models.

Conclusions: Whole-person tailored care needs inclusion of more services in routine primary care and change of culture toward shared decision making among multidisciplinary health care teams, patients, and carers. Such approach needs flexible consultation models and data sources enforced through monitoring and continual learning.

Purpose: We sought to describe the current state of data governance principles in Canadian practice-based research and learning networks (PBRLNs) and to examine opportunities and challenges in applying Indigenous data sovereignty frameworks.

Methods: We conducted a cross-sectional survey of Canadian PBRLN leaders. Survey results were described using summary statistics and directed content analysis of open-text responses. Indigenous data sovereignty frameworks were identified through a scan of recent publications. We identified and synthesized the main principles presented in each framework and assessed their relevance to PBRLNs.

Results: Eleven of 15 Canadian PBRLN leaders participated in the survey. The respondents noted several activities to be important for Indigenous data sovereignty: building knowledge of Indigenous data sovereignty within PBRLNs, having resources specifically dedicated to advance Indigenous data sovereignty, and understanding ways in which PBRLNs can advance this sovereignty. We identified 9 frameworks addressing Indigenous data sovereignty. Common principles among the frameworks were fostering relationships; ensuring collective benefits and action; respecting Indigenous ways of knowing and space for co-learning; prioritizing relevance to communities and places; ensuring data governance; building capacity; and striving for ethical sustainability.

Conclusions: Our survey suggests that improving knowledge of Indigenous data sovereignty within PBRLNs is a necessary step in Canada. We identified a set of principles in Indigenous data sovereignty frameworks that should be applied in PBRLNs. Networks and learning health systems need to adopt "wise practices" that focus on place-based and relational learning to advance Indigenous reconciliation.

Purpose: Health care systems increasingly incorporate social risk data into electronic health records (EHRs) to address needs like food, housing, and transportation insecurity. This study evaluated whether EHR-integrated social clinical decision support (SCDS) tools improved control of blood pressure (BP) and hemoglobin A_1c (HbA_1c) and increased social risk-informed care and documentation in community-based clinics.

Methods: We conducted a cluster randomized trial in a large primary care network. This pragmatic trial was designed to assess tool impact in real-world clinic conditions. Six clinics received SCDS tools embedded in the EHR; 44 clinics served as controls. The tools supported clinic-wide workflows and targeted decision support. A screening alert was triggered for adult patients lacking up-to-date social risk screening. Additional components were activated for patients with uncontrolled hypertension or diabetes, or with a diagnosis of either condition combined with a visit no-show rate of at least 50%. Primary outcomes were BP and HbA_1c control. Secondary outcomes included social risk screening and documentation. Generalized linear mixed models accounted for patient clustering. We also examined use patterns of individual tool components.

Results: Blood pressure control improved over 12 months in both arms, with significantly greater improvement in intervention clinics. Control of HbA_1c showed no significant differences. Intervention clinics had significantly greater odds of social risk screening and documentation. Use of individual SCDS tool components varied widely across clinics.

Conclusion: Access to EHR-integrated SCDS tools was associated with increased documentation of social risks and greater improvements in BP control. These findings support embedding social risk data into clinical workflows to enhance chronic disease management in primary care.

Purpose: It is unclear whether patients with cancer continue to benefit from antithrombotic therapy (ATT) during the last phase of life. We estimated the incidences of ATT discontinuation, bleeding, and venous thromboembolic (VTE) and arterial thromboembolic (ATE) events among patients with cancer during the last phase of life.

Methods: We included patients aged ≥18 years with cancer during the period 2018 to 2022 at the time a reimbursement claim for general practitioner (GP) palliative care was made. We manually identified ATT discontinuation, along with reasons, and the incidences of bleeding events, VTE events, and ATE events in free-text reports of routine primary care consultations until death.

Results: Among the 2,860 included patients, 32.5% used ATT at the index date. The median follow-up was 43 (interquartile range [IQR] 14-190) days for ATT users and 42 (IQR 13-149) days for nonusers. During follow-up, 22.1% of ATT users discontinued ATT, with a median of 8 (IQR 3-26) days before death. The most common reason for discontinuation was recognition of the terminal phase (22.9%). Bleeding occurred for 28.5% (95% CI, 25.7%-31.5%) of ATT users and 22.0% (95% CI, 20.2%-23.9%) of nonusers. Venous thromboembolic events occurred for 3.1% (95% CI, 2.2%-4.4%) of ATT users and 3.0% (95% CI, 2.3%-3.9%) of nonusers, and ATE events occurred for 2.5% (95% CI, 1.7%-3.7%) of ATT users and 1.9% (95% CI, 1.4%-2.6%) nonusers.

Discussion: One-third of patients with cancer used ATT at the initiation of GP palliative care, with most continuing treatment until death or discontinuing shortly before death. Bleeding events largely outnumbered ATE and VTE events among both ATT users and non-users. These findings provide new insights into ATT management by GPs and inform future research on optimizing ATT use for patients with cancer during the last phase of life.