BMC primary care最新文献

Background: As part of the ongoing overhaul of the Moroccan health-care system, clinical coordination between primary level physicians (PLP) and referral level specialists (RLS) remains crucial but under documented, especially in North Africa and the Eastern Mediterranean Region. This study aimed to assess clinical coordination levels in the Casablanca-Settat region and identify influencing factors.

Methods: An analytical cross-sectional survey was conducted from April to May 2024 among a random sample of 329 public-sector physicians (186 PLP; 143 RLS) from a pool of 1637 eligible practitioners. The COORDENA-CAT questionnaire, adapted from the original COORDENA instrument developed in Latin America and refined in Catalonia, was translated into French, culturally adapted, and psychometrically validated in four steps: forward-back translation, expert review, cognitive interviews, and a pilot study confirming construct validity and reliability. Fourteen items evaluated experiences of information-sharing and clinical-management coordination, whereas one summary item captured overall perception. Sociodemographic, organizational, and interactional data were collected. A multivariable logistic regression was performed to identify factors associated with a high perception of coordination (α = 0.05).

Results: Only 30.7% respondents (18.8% of PLP vs. 46.2% of RLS) reported regularly sharing clinical information. Therapeutic coherence was limited, with just 24.3% stating that care plans were jointly defined. While 97.3% of the PLP considered referrals appropriate, only 59.4% of the RLS agreed. Overall, 27.7% of the physicians (17.2% PLP and 41.3% RLS) judged coordination "often or always" satisfactory. Independent determinants of a high perception of coordination included working at the referral level (adjusted OR (aOR) = 3.34; 95% CI: 1.60-6.97), having personal ties with the other level (aOR = 3.05; 1.54-6.04), perceiving mutual influence on practice (aOR = 2.39; 1.24-4.58), and working in an institution that facilitates coordination (aOR = 2.66; 1.37-5.17).

Conclusion: Clinical coordination in the study region is limited, especially among PLP, due to inadequate feedback, weak formal mechanisms, and restricted specialist access. Strengthening local governance, providing secure digital tools (such as shared electronic health record and tele-expertise), organizing regular clinical meetings, and granting PLP formal recognition as care coordinators are priority strategies to enhance the continuity and efficiency of care pathways.

Background: Atherosclerotic cardiovascular diseases (ASCVD) account for 85% of all cardiovascular diseases and put a substantial burden on healthcare systems. General practitioners play an important role in managing ASCVD. The management of ASCVD could be improved by audit and feedback (A&F) based on quality indicators (QIs) derived from the electronic health record (EHR) of the general practitioner. This study aimed to define a set of validated and EHR extractable QIs for ASCVD to support A&F in primary care.

Methods: A RAND-modified Delphi method was employed to define QIs. Recommendations were selected based on the SMART principle from international guidelines, selected following the AGREE II evaluation. After assessment by a multidisciplinary expert panel, the recommendations were analyzed using the median Likert Scale score, prioritization, and degree of agreement. They were preliminary classified as having high, uncertain or low potential to measure the quality of ASCVD care. These recommendations were further discussed in a consensus meeting. Upon final validation, high-potential recommendations were converted into QIs.

Results: A questionnaire composed of 92 recommendations, selected from 12 international guidelines, were presented to the panel, resulting in a set of 50 high-potential recommendations. These were merged and modified into 41 recommendations after the consensus meeting. This resulted in a final set of 41 QIs classified into four categories: follow-up (N = 4), pharmacological treatment (N = 22), patient education (N = 10), and referral (N = 5).

Conclusions: This study defines a set of 41 EHR extractable QIs for ASCVD in primary care, supporting A&F in primary care.

Social concordance is a facilitator of key dimensions of healthcare engagement and may mitigate effects of systemic oppression. Given social hierarchies disadvantage marginalized patients in medical encounters, social concordance can strengthen the patient-clinician therapeutic alliance and increase communication and epistemic justice, necessary precursors to patient empowerment and improved health outcomes.

Background: Addressing the complex health and wellbeing challenges of older adults is a critical public health priority as populations age. Social Prescribing (SP) represents a promising strategy, connecting patients to non-clinical, community-based resources to enhance physical, mental, and social wellbeing.

Methods: To develop a SP theory of change, this study used cross-sectional data from 2,450 community-dwelling older adults who participated in a population survey. Factor analyses identified four factors of comfort with primary care discussions (general, mental, physical, and social wellness) and three factors of openness to SP (effectiveness, meaningfulness, and supportiveness). Path analysis was conducted for each set of mediators separately.

Results: Path analyses revealed that comfort with primary care discussions about social wellness (β = 0.08**) is associated with better wellbeing. People who report social loneliness are most comfortable with primary care discussions about general wellness (β = - 0.17***) and least comfortable with primary care discussions about mental wellness (β = - 0.24***), whereas people who report emotional loneliness are more likely to have similar levels of comfort to discuss general wellness and mental wellness (β = - 0.18***; - 0.18***). In addition, social loneliness is associated with less comfort with primary care discussions about social wellness (β = - 0.19***) and mental wellness (β = - 0.19***), whereas association is not found for emotional loneliness. These suggest that addressing the SP needs of people who experience emotional loneliness requires a different strategy. Reporting emotional loneliness is associated with expressing support for SP (β = 0.14***), which may be key to improving wellbeing (β = 0.10***) among this population. Overall, social loneliness has a total effect size of β_total = - 0.19, whereas emotional loneliness has a total effect size of β_total = - 0.45, more than 2.3 times larger.

Conclusions: While SP may be acceptable to those who need it, some may experience greater difficulties accessing SP through primary care providers without interventions tailored to their loneliness status that could elicit buy-in and enrolment. Primary care providers may wish to pay closer attention to people with emotional loneliness. Other considerations, such as trust and motivational interviewing for positive self-beliefs may explain potential changes from loneliness to wellbeing.

Background: Social prescribing is gaining traction globally as a means to achieve global goals for health and wellbeing. In 2023, we launched a social prescribing program in a comprehensive, pediatric integrated health and social service hub in an underserved inner city neighbourhood in Ottawa, Ontario, Canada. The program targeted children and youth with poor social health, including social isolation and loneliness. Program participants were paired with a connector, who worked with them to explore their individual needs, strengths, and interests. Together, they created a social prescription for a child and youth-friendly community activity. The connector then provided a supported referral to aid the program participant in successfully completing their social prescription. The program was piloted at the hub over a period of ten months, during which time a program evaluation took place. As part of our program evaluation, we sought to explore the concept of self-determination, which is thought to be one of the guiding principles of social prescribing. While self-determination has been explored in adult social prescribing, it has not yet been examined in child and youth social prescribing. Thus, the aim of this evaluation was to explore the ways in which our social prescribing program may foster self-determination in children and youth.

Methods: A qualitative descriptive design was employed. Between November 2023 and February 2024, semi-structured interviews were conducted with 33 program participants and 30 caregivers at the six-month mark of enrollment in the program. Interview questions centered around program participants' and caregivers' experiences of the program. Interviews were audio recorded, transcribed verbatim, and anonymized. Using the Circle of Courage - a child and youth-focused theory on self-determination, we conducted deductive thematic analysis.

Results: The findings indicated that the program may foster self-determination through each component of the Circle of Courage: (1) Independence: The child's free will is nurtured by increased responsibility; (2) Belonging: The universal longing for human bonds is nurtured by relationships of trust; (3) Mastery: The child's inborn thirst for learning is nurtured; and (4) Generosity: The child's character is nurtured by concern for others.

Conclusion: This evaluation has shed light on the ways in which social prescribing may foster self-determination in children and youth. The Circle of Courage may be a useful framework to explore the impact of other child and youth social prescribing programs.

Context: Artificial intelligence (AI) technologies are increasingly used for image recognition, especially for skin lesions. Due to what may be long wait times for dermatology appointments, general practitioners (GPs) are the gatekeepers when it comes to skin diseases requiring rapid treatments.

Objective: This study aims to examine the diagnostic accuracy of AI in diagnosing skin lesions encountered in primary care and to perform a meta-analysis of AI's in diagnostic accuracy for melanoma detection.

Methodology: This systematic review and meta-analysis, conducted according to the 2020 PRISMA guidelines, included diagnostic accuracy studies using any type of AI applied to photographs or dermoscopy images to diagnose skin lesions encountered in primary care settings. The reference standard was dermatologist consensus or histopathological examination. Searches were conducted in PubMed, Web of Science and Cochrane in December 2023. Risk of bias and concerns of applicability were assessed using the QUADAS-2 tool. Data extraction was conducted by two investigators and meta-analysis was performed using a bivariate random effects model.

Results: Between 2013 and 2023, 382 studies were found and 38 met the inclusion criteria.AI's accuracy was reported as non-inferior or superior to that of dermatologists in 30 studies, while 4 studies reported that AI was less accurate than dermatologists. Similarly, AI's accuracy was reported as non-inferior or superior to that of GPs in 8 studies, and one study indicated that AI was less accurate than GPs. The meta-analysis showed that AI for the diagnosis of melanoma had a pooled sensitivity of 0.86 (95% CI: 0.80-0.90) and a specificity of 0.94 (95% CI: 0.89-0.97). The diagnostic odds ratio was 44.36 (95% CI: 29.28; 67.1), with an AUC of 0.922 for the SROC curve. Of the 38 included studies, 25 were at high risk of bias, primarily due to patient selection. Datasets were frequently not representative of the outpatient population, as malignant conditions were often overestimated.

Conclusion: AI appears to perform at a similar level to dermatologists, and the same is true when comparing AI to GPs. This is especially true for serious conditions like melanoma, suggesting that AI could be a valuable tool for GPs in improving patient care.

Background: Clinical pharmacists are the principal profession reviewing polypharmacy in English general practice. Pharmacists reviewing polypharmacy can encounter clinical uncertainty, thus affecting decision-making and the utility of medication reviews. Understanding factors and interventions that mitigate clinical uncertainty could improve polypharmacy medication reviews. This review's objective was to explore how primary care clinical pharmacist decision-making can be improved when reviewing polypharmacy in the context of clinical uncertainty.

Methods: A critical literature review was undertaken in key databases. Included articles explored polypharmacy, clinical uncertainty and medication review by primary care clinical pharmacists. Exclusion criteria included community pharmacy and monotherapy management. Quality assurance was conducted using Lincoln and Guba's evaluative criteria. Contents of included papers were thematically analysed and conceptual models produced.

Results: 647 titles/abstracts were screened and 11 full-text articles included, encompassing focus group, interview, ethnography and intervention-development studies. Pharmacists expressed feelings of self-competence occurring alongside apprehension when reviewing polypharmacy. Relationships with patients, including shared decision-making, continuity of care and engagement can support medication reviews. Decision-making is impacted by environmental factors, with poor working relationships within organisations, working across several sites and time pressures hindering deprescribing. The absence of clinical and deprescribing guidelines for multimorbid patients contributes to clinical uncertainty. Multidisciplinary working mitigates clinical uncertainty and training interventions can support pharmacists to proactively deprescribe.

Conclusion: Pharmacist, patient and environmental factors can influence pharmacists' decision-making when experiencing clinical uncertainty during polypharmacy review. Clinical education, peer support and multidisciplinary working have roles in reducing clinical uncertainty and therefore optimising pharmacists' reviews of polypharmacy.