BMC primary care最新文献

Background: As the COVID-19 pandemic accelerated the uptake of virtual primary care (VPC) in Canada, debates over how it ought to be encouraged or discouraged, governed and paid for have intensified. Within these debates there has been little attention paid to the details of which technologies are being deployed to deliver VPC and how those technologies interact with non-technical factors to ensure efficiency and effectiveness.

Methods: The aims of the study included drawing out pragmatic considerations for policy makers by identifying the various constellations of VPC technology that are being deployed; characterizing how key informants see them working and to what purpose; and describing how those technologies are interacting with non-technical factors to shape success. 29 qualitative interviews were conducted with mid-level VPC experts from the provinces of Alberta, Nova Scotia, and Ontario.

Results: Key informants saw a broad range of VPC technologies as improving access to primary care by increasing efficiency and coordination. They deployed VPC to improve the accessibility, availability, and accommodativeness of care. They described VPC technologies interacting with and relying on: human efforts, funding models, and the institutional contexts for their success.

Conclusions: Policy-makers seeking to optimize VPC will want to consider ways to support not just purchases of technology, but: the human effort required to choose and manage technology; the funding mechanisms that incentivize the efficient use technology; and the institutional contexts and cultures that underpin access improvements through technology.

Background: Less than one in five eligible adults has received lung cancer screening (LCS) with low dose computed tomography in the U.S. We aimed to determine factors associated with intentions to undergo LCS.

Methods: Cross-sectional survey of LCS-eligible English and Spanish speaking adults in two primary care systems in Massachusetts and Oklahoma from 02/2023-05/2024. Surveys assessed smoking, lung cancer and LCS history, attitudes, beliefs, and psychological factors. Associations between these factors and screening intentions were assessed with multivariable logistic regression using bootstrap sampling to select model variables, and latent class analysis plus chi-square tests to measure associations between classes and intentions.

Results: Of 292 LCS eligible survey respondents, most were currently smoking (n = 174, 59.6%), some had previously undergone LCS (n = 115, 39.5%), and 29.5% (n = 86) were 'extremely likely' to screen in the next 12 months. In regression models, having a healthcare provider recommend LCS (odds ratio [OR]: 4.22, 95% confidence interval (CL) 2.40-7.44), being 'somewhat' or 'extremely worried' about getting lung cancer (OR 2.45, 95%CI 1.40-4.32), and speaking English at home (OR 3.54, 95% CI 1.74-7.17) were associated with intention to screen. Four latent classes emerged that varied by age, race, ethnicity, smoking status, screening self-efficacy, perceived risks, and cancer worry. Classes were significantly associated with screening intentions (p < .0001).

Conclusions: Factors associated with LCS intentions highlight opportunities to expand screening. Attending to content for Hispanic adults, increasing discussions of LCS by health care providers, and tailoring communications to incorporate cancer worry could increase use of this life-saving intervention.

Background: Changes in healthcare governance and the rise of evidence-based medicine (EBM) have over the last decades contributed to an increase in guideline-driven management of general practice. There is a lack of recent studies investigating how this continuous development affects the practice of Swedish general practitioners (GPs) from a broad perspective. Thus, this study aims to explore how Swedish GPs relate to management control through guidelines, how it affects their daily practice and work environment, and how they reflect on its consequences.

Methods: We conducted semi-structured, face-to-face interviews during 2024 with 11 GPs from all across Sweden. The transcribed interview data were analysed using thematic analysis.

Results: We constructed three themes, each representing a field of tension created by guidelines: (1) Torn between high ambitions and their resulting negative side effects, (2) Guidelines promote measurable over unmeasurable knowledge, and (3) Although autonomy in relation to guidelines is highly valued, there are compelling reasons to submit. The first theme reflects a broad agreement on the benefits of guidelines and support of the growing ambitions they reflect. However, guidelines also result in increasing work-load and reduce flexibility in healthcare collaboration. The second theme highlights that because guidelines tend to prioritise measurable over non-measurable knowledge, other aspects of GPs' professional skills risk being underused and underdeveloped. The third theme captures how GPs exercise a high degree of autonomy in relation to guidelines, yet occasionally relinquish their clinical discretion. These tensions may result in side-effects such as a deteriorating work environment, crowding-out effects, fragmented healthcare, and potentially reduced quality in areas of general practice that are difficult to measure.

Conclusions: While management control through guidelines entails many benefits, the participants in this study also reported several adverse effects on both the quality of care and the work environment. Promoting quality by organizing healthcare through increasingly complex guidelines may seem like a natural approach in a system that focuses strongly on measuring outcomes, but it is also important for healthcare decisionmakers and guideline developers to acknowledge its potential side effects.

Background: Although support for tobacco smoking cessation provided by general practitioners (GP) has proven effective, such an approach remains quite rare. We designed a behavioural science-based intervention to improve GP support for patients to quit smoking. The present study aimed to evaluate the effectiveness of this in-office paper-based intervention by comparing it with a no-intervention control group.

Methods: We conducted an online randomised controlled trial between January and May 2024 among GPs in France. The intervention consisted in sending a kit containing an information sheet for GPs outlining the main stages of brief advice for smoking cessation, questionnaires for patients asking them about their smoking status and, for those who smoked, their motivation to quit, as well as a poster to be displayed in each GP's waiting room to encourage people who smoke tobacco to complete the questionnaire. The primary outcome was the proportion of people who smoke with whom GPs had discussed smoking cessation on their last full working day five weeks after the kit had been sent out. The secondary outcome was the likelihood that GPs provided cessation support (e.g., prescribed nicotine replacement therapy (NRT), proposed a follow-up consultation, and/or referred patients to other professionals) on the same day.

Results: Of the 800 GPs recruited, 641 fully completed the final survey (333 in the intervention group and 308 in the control group). The proportion of people who smoke with whom GPs had discussed cessation was significantly higher in the intervention group (59.0% vs. 52.3%, p < 0.05). The likelihood of a follow-up consultation being offered to patients who smoke was also significantly higher in the intervention group (73.8% vs. 60.3%, p < 0.05). The likelihood of NRT prescription or referral were not significantly different between groups (82.4% vs. 77.9%, and 23.3% vs. 21.5%, respectively).

Conclusions: Providing simple paper-based tools was associated with a greater likelihood of GPs discussing smoking cessation with their patients. This kind of intervention could usefully complement other primary care interventions, for example training, remuneration and financial incentives or care pathway reorganisation, with a view to significantly decreasing smoking prevalence.

Trial registration: The study was retrospectively registered on 25 November 2024 (ISRCTN10207960).

Background: Primary care physicians face multiple challenges in integrating clinical cancer genetics into routine care. Most studies of genomic medicine come from countries with well-developed primary healthcare systems, while research on the integration of clinical genetics in primary care remains limited in Japan and Asia. In Japan, where family medicine is still emerging as a specialty, no prior studies have examined Japanese family physicians' engagement with clinical cancer genetics, including genetic counseling and referral. This study investigates Japanese family physicians' knowledge, attitudes and practices regarding hereditary cancer syndromes.

Methods: This is mixed methods research employing an explanatory sequential design with survey data collection followed by qualitative interviews. First, a quantitative survey assessed Japanese family physicians' knowledge, attitudes, and practices regarding genetic counseling and referrals for hereditary cancer syndromes. We then explored their practices and perspectives in relation to the quantitative findings through semi-structured individual interviews with a subset of the family physicians. Finally, we integrated both findings in a joint display table and generated conclusions or metainferences.

Results: A total of 149 family physicians completed a survey (response rate: 26.7%), with 11 who did not have experience in genetic counseling or referrals participating in follow-up qualitative interviews. Survey responses found that only 6% of respondents provided genetic counseling, and 5% referred patients to genetic professionals. Most family physicians (64-73%) demonstrated limited knowledge of hereditary cancer syndrome, leading to difficulty interpreting family history and assessing cancer risk in clinical practice. While many family physicians (71-94%) conceptually acknowledged the benefits of clinical genetics in the survey, interviews highlighted concerns about the potential harm of genetic testing. Interviews helped explain the reasons for low engagement rates. Family physicians were uncertain about the clinical utility of genetic interventions and about the psychological impact discussing cancer genetics might have on patients. Further, the term "heredity" carries negative connotations, which made family physicians hesitant to initiate such conversations.

Conclusion: Japanese family physicians encounter challenges in applying clinical cancer genetics. Further research is needed to explore effective approaches that support family physicians in addressing these challenges while enhancing their role in clinical cancer genetics.

Background: Depression in older adults is common in general practice, but the optimal approach for identification and treatment is not entirely clear.

Aim: To explore physicians' experiences with a structured collaborative model involving joint consultations between patients, general practitioners (GPs), and geriatric psychiatrists for managing depression in adults aged 65 years and older.

Methods: Three focus group discussions were conducted with 13 physicians (10 GPs and 3 psychiatrists) who had participated in a structured collaboration model as part of a recent cluster randomized intervention study. Data were analyzed using Systematic Text Condensation.

Results: Five themes emerged: (1) diagnostic challenges; (2) perceived advantages; (3) feasibility; (4) concerns about overdiagnosis and overtreatment; and (5) suggested adjustments to the model. Somatic presentations often overshadowed depressive symptoms, particularly under GPs time constraints. Joint consultations strengthened the GP-patient relationship and enabled mutual learning. The presence of the GP was viewed as essential for patient engagement. The model addressed a treatment gap for GPs and was considered by psychiatrists to be highly cost-effective. All participants supported broader implementation in clinical practice.

Conclusion: The GPs' enthusiasm for this collaborative approach indicates an unmet need in the treatment of older patients with depression. By strengthening both the doctor-patient relationship and interdisciplinary collaboration between GPs and psychiatrists in a cost-effective manner, the use of such joint consultations should be further investigated.