A grounded theory research protocol on an attempt to practice interprofessional collaborative care by a primary care clinic health professional fresh graduate in diabetes care.

Interprofessional collaborative care (IPCC) can improve the quality of care in patients with chronic diseases in primary care settings. In Malaysia, many medical and healthcare universities have adopted the concept of the interprofessional collaborative practice (IPCP) framework by the World Health Organization (WHO) and implemented interprofessional learning (IPL) in their curriculum to prepare fresh graduates for interprofessional collaboration (IPC) in the health workforce albeit in various degrees. However, there are potential challenges in putting what they have learned into practice, especially in managing chronic diseases due to the complexity of behavior changes required. Diabetes care is a classic example of such chronic disease management. This article presents a qualitative research protocol exploring the processes and challenges of fresh graduates attempting to practice IPC when managing diabetes mellitus (DM) in primary care clinics. A grounded theory (GT) approach will be adopted.

Increasing the adoption of evidence-based communication practices for HPV vaccination in primary care clinics: The HPV ECHO study protocol for a cluster randomized controlled trial.

BACKGROUND: The safe, highly-effective human papillomavirus (HPV) vaccine remains underused in the US. The Announcement Approach Training (AAT) has been shown to effectively increase HPV vaccine uptake by training providers to make strong vaccine recommendations and answer parents' common questions. Systems communications, like recall notices, can further improve HPV vaccination by reducing missed clinical opportunities for vaccination. Never tested in supporting HPV vaccination, the ECHO (Extension for Community Healthcare Outcomes) model is a proven implementation strategy to increase best practices among healthcare providers. This trial uses a hybrid effectiveness-implementation design (type II) to evaluate two ECHO-delivered interventions intended to increase HPV vaccination rates. METHODS: This 3-arm cluster randomized controlled trial will be conducted in 36 primary care clinics in Pennsylvania. Aim 1 evaluates the impact of HPV ECHO (AAT to providers) and HPV ECHO+ (AAT to providers plus recall notices to vaccine-declining parents) versus control on HPV vaccination (≥1 dose) among adolescents, ages 11-14, between baseline and 12-month follow-up (primary outcome). Using a convergent mixed-methods approach, Aim 2 evaluates the implementation of the HPV ECHO and HPV ECHO+ interventions. Aim 3 explores exposure to and impact of vaccine information from providers and other sources (e.g., social media) on secondary acceptance among 200 HPV vaccine-declining parents within 12 months. DISCUSSION: We expect to demonstrate the effectiveness and evaluate the implementation of two highly scalable interventions to increase HPV vaccination in primary care clinics. Our study seeks to address the communication needs of both providers and parents, increase HPV vaccination, and, eventually, prevent HPV-related cancers. TRIAL REGISTRATION: ClinicalTrials.govNCT04587167. Registered on October 14, 2020.

Evaluation of Self-Medication with Antibiotics in Primary Care Clinics in Palestine.

Background: Antibiotics are highly effective medications and essential in curing infectious diseases; however, their inappropriate use, such as self-medication, is a significant factor in developing antimicrobial resistance. Objective: This study aimed to evaluate the level of antibiotic self-medication among patients who visited primary care clinics in Palestine. Methods: Data were collected via a self-administered questionnaire, either printed or electronically, using google forms (Google Inc., USA). The sample size needed to provide a 95% confidence level and 5% margin error and assuming a prevalence of 50% of SM with antibiotics was 377 patients. A total of 700 questionnaires were randomly distributed to patients aged 18 years or older. However, 87 were excluded due to duplication, incomplete responses, or participants under 18 years old. Finally, 423 patients were included in this study, with 254 patients completing the electronic Google Forms and 181 completing the written survey. The questionnaire consists of patients' demographics, antibiotics knowledge, and self-medication behavior. In addition, descriptive statistics and knowledge scales were performed using SPSS 22 IBM to measure and assess the scope of the problem and find the association between self-medication demographics, education, and socioeconomic status. Results: Approximately 50% of participants reported self-medication with antibiotics, with a very high use among participants with medical knowledge. Most people have adequate awareness of antibiotics, whereas out of 423 respondents, (40.2%, n = 170) had GKL, (50.4%, n= 213) had AKL, and only (9.5%, n=40) presented PKL. The primary source for self-treatment with antibiotics was community pharmacies (87.1%, n=223), whereas (14.1%, n=36) got antibiotics from family and friends. Convenience, easy access, and experience with community pharmacists contributed to self-medications. The most commonly used antibiotic for self-medication was amoxicillin/clavulanic acid. Conclusion: Self-medication with antibiotics is a common practice in Palestine, regardless of socioeconomic or educational status. Patients' educations about complications from inappropriate use and the possibility of side effects are essential steps to decrease patients' demands for antibiotics. Furthermore, compliance and adherence of community pharmacists in dispensing antibiotics only with a prescription is necessary.

Multi-component interventions and change in screening rates in primary care clinics in the Colorectal Cancer Control Program.

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Implementation of evidence-based interventions (EBIs) increases CRC screening. The purpose of this analysis is to determine which combinations of EBIs or strategies led to increases in clinic-level screening rates among clinics participating in CDC's Colorectal Cancer Control Program (CRCCP). Data were collected from CRCCP clinics between 2015 and 2018 and the analysis was conducted in 2020. The outcome variable was the annual change in clinic level CRC screening rate in percentage points. We used first difference (FD) estimator of linear panel data regression model to estimate the associations of outcome with independent variables, which include different combinations of EBIs and intervention strategies. The study sample included 486 unique clinics with 1156 clinic years of total observations. The average baseline screening rate was 41 % with average annual increase of 4.6 percentage points. Only two out of six combinations of any two EBIs were associated with increases in screening rate (largest was 6.5 percentage points, P < 0.001). Any combinations involving three EBIs or all four EBIs were significantly associated with the outcome with largest increase of 7.2 percentage points (P < 0.001). All interventions involving 2-3 strategies led to increases in rate with largest increase associated with the combination of increasing community demand and access (6.1 percentage points, P < 0.001). Clinics implementing combinations of these EBIs, particularly those including three or more EBIs, often were more likely to have impact on screening rate change than those implementing none.

Pharmacist-led transitions of care between hospitals, primary care clinics, and community pharmacies.

BACKGROUND: Pharmacist-led transitions of care (TOC) interventions have been described as some of the most promising interventions to reduce medication-related harm (MRH) in older adults. This study analyzed the feasibility of pharmacist-led TOC interventions between hospitals, multidisciplinary primary care clinics (PCC), and community pharmacies. METHODS: Adults aged 65 years and older at risk of MRH in three regions of Quebec, Canada, with contrasting contexts of care based on university affiliation were recruited in this multicenter, single arm, and prospective intervention cohort. The hospital pharmacist developed the pharmaceutical care plan in collaboration with the hospital physician and transferred this plan with the hospitalization summary, at hospital discharge, to the PCC family physician and to the community and PCC pharmacists. A consultation with the community pharmacist was scheduled within seven days of hospital discharge and with the PCC pharmacist when appropriate. Feasibility outcomes included the time to complete the interventions and their location. RESULTS: The 123 eligible patients had a mean age of 78.5 years, and 63.4% were females. The most frequent inclusion criterion was 10 medications or more, including one high-risk medication for 90 patients (73%). Recruitment in one region was stopped after three months due to unsuccessful recruitment of key PCC. The hospital pharmacist interventions took a median of 165 min. The first consultations of the PCC and community pharmacists took a median of 15 and 50 min. Among the 96 patients with a post-discharge pharmacist follow-up, 23 (24.0%) had a consultation with a PCC pharmacist, with 65.2% of the consultations conducted at the PCC. The community pharmacists conducted a consultation with 88 patients (93%), with more than 70% of consultations conducted by phone. CONCLUSION: Our study showed the feasibility of pharmacist-led TOC interventions between hospitals, PCC, and community pharmacies and detailed the novel role that PCC pharmacists played in optimizing TOC interventions.

Association of family function, demographic and clinical characteristics with Glycemic control among patients with Type 2 Diabetes Mellitus seen at primary care clinics in Las Piñas City

Background and Objective@#The family plays an important role in the management of patients with Diabetes Mellitus. In this study, the authors determined the association between family function using the APGAR questionnaire with glycemic control among Type 2 diabetic patients. Association between demographic and clinical characteristics with glycemic control was also assessed.@*Methods@#This was a cross-sectional study of 237 adults ages 18 years old and above with Type 2 Diabetes Mellitus seen in Healthway clinics in Las Piñas between April 2021 to May 2021. Data from participants were obtained through a self-administered questionnaire and review of recent HbA1c results. The questionnaire contained 3 sections which included sociodemographic and clinical characteristics of the participants, their recent HbA1c result, and Family APGAR score. Multiple logistic regression analysis was done to determine the association of glycemic control with family function, demographic, and clinical factors. @*Results@#Four variables were noted to be significantly associated with glycemic control- family function (p<0.0001), duration of being diabetic (p=0.021), diabetes regimen (p=0.013), and comorbidity status (p=0.021). Respondents with functional families as evaluated from their Family APGAR scores were 6 times more likely to have good glycemic control (OR 6.204) compared to those with dysfunctional families. Respondents with ≤10 years duration of diabetes (OR 4.051) and on both oral and insulin therapy (OR 9.639) are more likely to have good glycemic control. Respondents with comorbidities (OR 0.465) are less likely to achieve good glycemic control@*Conclusion@#Family APGAR score, duration of diabetes, type of diabetes regimen, and presence of comorbidities should be highlighted in diabetic management as they may influence glycemic control. This supports the need to include family assessment (especially family function) in the routine care of diabetic patients, and to address family issues which may hinder achievement of glycemic targets.

Factors associated with willingness of parents to vaccinate their children against COVID-19 in primary care clinics in Cavite: A cross-sectional study

Background@#The recent inclusion of the pediatric population aged 12-17 years old in the rollout of COVID-19 vaccines in the country is necessary in order to increase vaccine coverage, and eventually achieve herd immunity. Vaccination of those in this age group is dependent on the vaccine acceptance of their parents or respective caregivers.@*Objective@#The study’s primary aim was to determine factors associated with parents’ intent to vaccinate their children against COVID-19. Specifically, this study aims to determine: 1. parent and child factors that influence the parents willingness to have their children vaccinated, 2. external factors in the decision to vaccinate their children, that is, if it is recommended by the doctor or school, and 3. concerns of parents regarding vaccination@*Methods@#A multi-clinic cross-sectional analytic study design was used. Respondents were parents in select Healthway Family Clinics in Cavite. Data were gathered via self-administered questionnaires, adapted and modified with permission from the authors of The COVID States Project. Data were analyzed using Epi Info 7.@*Results@#Among 350 respondents, 73.71% are most likely to vaccinate their children against COVID-19 once the vaccine becomes available to them. The major parental concerns are: long term health effects (56.29%), whether it has been tested enough (54.86%), immediate side effects (54.57%), and whether the vaccine actually works (54%). There is an association between the willingness of parents to vaccinate their children with the age and COVID-19 vaccination status of parent, and age and EPI immunization status of the child. Parents consider doctors’ and school’s recommendations to be very important factors in their decision to vaccinate their children@*Conclusion@#Majority of participants are likely to have their children vaccinated. Knowledge of associated factors and parental concerns gives the researchers better understanding of vaccine hesitancy amongst parents. This is vital to promote vaccination in the clinic setting, and on a much larger scale, in the local and national government’s public health strategies.

Quality of life among type II diabetic patients attending the primary health centers of King Saud Medical City in Riyadh, Saudi Arabia.

BACKGROUND/AIM: Type 2 diabetic patients (T2DM) have lower quality of life (QoL) compared to the general population. This study was conducted to determine QoL of T2DM patients and analyze factors that affect patients' QoL. METHODS: We conducted this cross-sectional study in January to February of 2019 at several primary care health centers (PCHC) in Riyadh, Saudi Arabia. All adult T2DM patients were invited to participate in the study. We used the EQ-5D-3L and EQ VAS tools to determine the patients' health state and their self-rated overall health. RESULTS: A total of 274 T2DM patients were surveyed, 149 (54.4%) were males. The mean age was 59.7 ± 10.4 years. Of the five EQ-5D-5L domains, self-care had the highest proportion that reported no problem (n = 183, 66.8%). The mobility domain had the highest proportion of reported severe problems (n = 37, 13.5%) and extreme problems (n = 7, 2.6%). Nineteen (6.9%) patients reported with a full state of health. The mean EQVAS was 65.9 ± 22.1, with only 24.1% reported as between 81-100%. Females, patients above 75 years old, those who are in the low socioeconomic income, unemployed, widow had lower EQ VAS. CONCLUSION: Males, with higher socioeconomic status, employed, married and younger patients experience better QoL compared to their counterparts. The overall health related QoL among our diabetic patients is low. These findings suggest improvement of health-related QoL, and more efforts should be invested in patient education particularly among patients who are in the low socioeconomic status, the elderly, females and the unemployed.

Predictors of Quality of Life among Older People with Mild Cognitive Impairment Attending Urban Primary Care Clinics.

OBJECTIVES: To study the prevalence of Mild Cognitive Impairment (MCI) among older people attending primary care clinics and its predictors of QOL. METHODS: A cross-sectional study was conducted at two primary care clinics in Kuala Lumpur, Malaysia, recruiting 271 participants by utilizing the universal sampling method. Every patient who attended both the clinics during the study period and met the inclusion and exclusion criteria were approached and briefed about the study. Patients who gave consent were recruited as study participants. Information on sociodemographic, medical condition, and lifestyle behaviors were obtained. The Montreal Cognitive Assessment (MoCA) was used to screen for MCI at a score < 23. The World Health Organization Quality of Life-BREF (WHOQOL-BREF) questionnaire was used to evaluate QOL. RESULTS: Prevalence of MCI was 27.3%. Lower QOL scores were found in the physical (67.3 ± 1.4), psychological (67.3 ± 1.4), social (66.9 ± 1.6) and environmental (71.3 ± 1.3) domains among participants with MCI. Among them, predictors of QOL were depression in the physical domain, age and stroke in the psychological domain, presence of other types of disorders in the social domain and diabetes and stroke in the environmental domain. CONCLUSIONS: MCI was prevalent among study participants and were associated with poorer QOL in all domains of QOL. A better understanding of predictors of QOL in older people with MCI is deemed important. CLINICAL IMPLICATION: Routine cognitive screening at primary care clinics will facilitate early recognition of MCI and facilitates referral to memory clinics for further assessment and treatment.

Enhancing learning in longitudinal clinical placements in community primary care clinics: undergraduate medical students' voices.

Longitudinal clinical placements are increasingly adopted by medical training institutions. However, there seems to be little evidence regarding their implementation in primary care settings in the developing world. This paper explored medical students' perceptions of their learning experiences in longitudinal placements in primary care clinics. The Manchester clinical placement index (MCPI) survey was offered to second-year medical students at the University of Botswana to determine perceptions of their 16 weeks clinical placement in primary care clinics. The MCPI provided data on eight aspects of clinical placements which were analysed to gain insight into students learning experiences while on placement. The eight items in the tool were grouped into four themes, namely, teaching and learning, learning environment, relationships and organisation of placements. Students cited the feedback they received whilst on placement and the learning environment in primary care clinics as aspects of clinical placements which could be improved to enhance their learning experience. For an enriched learning experience in primary care settings in a developing world context, there are critical aspects to be considered. Based on the students' perspective we suggest an approach of how learning in such placements could be enhanced.

Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populations.

INTRODUCTION: Screening for colorectal cancer (CRC) is effective in reducing CRC burden. Primary care clinics have an important role in increasing screening. We investigated associations between clinic-level CRC screening rates of the clinics serving low income, medically underserved population, and clinic-level screening interventions, clinic characteristics and community contexts. METHODS: Using data (2015-16) from the Centers for Disease Control and Prevention's (CDC) Colorectal Cancer Control Program, we linked clinic-level data with county-level contextual data from external sources. Analysis variables included clinic-level CRC screening rates, four different evidence-based interventions (EBIs) intended to increase screening, clinic characteristics, and clinic contexts. In the analysis (2018), we used weighted ordinary least square multiple regression analyses to associate EBIs and other covariates with clinic-level screening rates. RESULTS: Clinics (N = 581) had an average screening rate of 36.3% (weighted. Client reminders had the highest association (5.6 percentage points) with screening rates followed by reducing structural barriers (4.9 percentage points), provider assessment and feedback (3.2 percentage points), and provider reminders (<1 percentage point). Increases in the number of EBIs was associated with steady increases in the screening rate (5.4 percentage points greater for one EBI). Screening rates were 16.4 percentage points higher in clinics with 4 EBIs vs. no EBI. Clinic characteristics, contexts (e.g. physician density), and context-EBI interactions were also associated with clinic screening rates. CONCLUSIONS: These results may help clinics, especially those serving low income, medically underserved populations, select individual or combinations of EBIs suitable to their contexts while considering costs.

Development and use of an index for measuring implementation of a weight management program in children in primary care clinics in Texas.

BACKGROUND: The Texas Childhood Obesity Research Demonstration study was an integrated, systems-oriented intervention that incorporated primary and secondary obesity prevention approaches targeting multiple sectors, including primary care clinics, to address childhood obesity. The primary care clinic component included the American Academy of Pediatrics' Next Steps weight management counseling materials that support brief healthy lifestyle-focused visits. The current study describes the methodology and assesses the implementation of the Next Steps program in the participating primary care clinics, as well as the association of implementation with enrollment of children with overweight and obesity in the secondary prevention intervention. METHODS: The study used a serial cross-sectional study design to collect data from 11 primary care clinics in Houston (n = 5) and Austin (n = 6), Texas, in 2013-2014. Responses of primary care providers on 42 self-reported survey questions assessing acceptability, adoption, appropriateness, and feasibility of the program were utilized to create a mean standardized clinic implementation index score. Provider scores were aggregated to represent Next Steps implementation scores at the clinic level. A mixed effects logistic regression test was conducted to determine the association between program implementation and the enrollment of children in the secondary prevention. RESULTS: Mean implementation index score was lower at Year 2 of implementation (2014) than Year 1 (2013) although the decrease was not significant [63.2% (12.2%) in 2013 vs. 55.3% (16.5%) in 2014]. There were no significant associations between levels of implementation of Next Steps and enrollment into TX CORD secondary prevention study. CONCLUSIONS: The development of an index using process evaluation measures can be used to assess the implementation and evaluation of provider-based obesity prevention tools in primary care clinics.

[Pharmaceutical Care at the primary care clinic in Garðabær - number and type of drug therapy problems identified among elderly clients].

INTRODUCTION: Elderly people are a rising population in Iceland. With higher age the likelihood of drug consumption increases and thus drug therapy problems. Pharmaceutical care has been established abroad, where the pharmacist works in collaboration with other healthcare professionals to reduce patients' drug therapy problems. The aim of this research was to study the number and types of drug therapy problems of older individuals in primary care in Garðabær, by providing pharmacist-led pharmaceutical care in collaboration with general practitioners. METHODS: Five general practitioners selected patients, 65 years and older, and asked the pharmacist to provide them with pharmaceutical care service. The pharmacist provided pharmaceutical care using a well-defined process. RESULTS: A total of 100 patients participated in the research, 44 men and 56 women. On average the pharmacist identified two drug therapy problems per patient. The most frequent drug therapy problem was related to noncompliance (30.1%), next was adverse drug reaction (26.7%) and the third was unnecessary drug therapy (18.2%). Almost all pharmacist comments were accepted by the general practitioners (90.3%). CONCLUSIONS: Our results reveal that a pharmacist providing pharmaceutical care makes, on average, two comments regarding each drug therapy. In almost all cases the general practitioners accept the comments.

Receiving family physician's advice and the 'stages of change' in smoking cessation among Arab minority men in Israel.

BACKGROUND: Receiving physician advice (PA) can increase patient's willingness to quit smoking and influence the 'stages of change' in quitting. However, less is known about this association among minority groups for whom cessation is more challenging. OBJECTIVE: We examined whether receiving advice on smoking cessation from a family physician is associated with the 'stages of change' in quitting smoking-i.e. pre-contemplation, contemplation, preparation or action-among Arab minority men in Israel with high smoking prevalence. METHODS: In 2011-12, a stratified random sample of 964 Arab men current and past smokers, aged 18-64, were interviewed face-to-face. We used ordered logistic regression models to examine the association between PA and stages of quitting smoking, adjusted for socioeconomic status, health status, sociodemographics, Health Maintenance Organizations (HMO) and smoking-related variables. RESULTS: About 40% of Arab men reported ever receiving PA to quit smoking. Participants with chronic disease(s) and higher nicotine dependence were more likely to receive PA. PA was significantly associated with the stages of change, but not with actual quitting. In multivariable analysis, receiving PA was associated with a greater likelihood of being at the contemplation or preparation stages of cessation, compared to pre-contemplation; odds ratio (OR) and 95% confidence interval (CI) were 1.95 (95% CI = 1.34-2.85) and 1.14 (95% CI = 1.09-2.076), respectively. CONCLUSIONS: Receiving PA among minority men is associated with advanced motivational stages of change in quitting smoking, but not with actual smoking cessation. Culturally, sensitive interventions and involvement of other health care providers may be considered for more comprehensive smoking cessation, in addition to PA.

A qualitative national focus group study of the experience of living with lymphoedema and accessing local multiprofessional lymphoedema clinics.

AIM: The aim of this study was to explore people's experiences of living with lymphoedema and to assess the impact of access to local lymphoedema clinics on their condition and thus their lives. BACKGROUND: A chronic condition caused by reduced lymphatic function, lymphoedema leads to swelling, pain and mobility problems and can adversely affect quality-of-life. It is of international concern as its prevalence is rising. Yet lymphoedema awareness is limited, diagnostic delay common and access to specialist treatment restricted. The concept of local lymphoedema clinics is gaining support and in 2011 the All Wales Lymphoedema Service was founded. However, empirical investigation of local lymphoedema services remains limited. DESIGN: A qualitative exploratory study consisting of focus group interviews in every Welsh lymphoedema clinic (n = 8). METHODS: A convenience sample of adults living with lymphoedema in Wales was recruited. Data were collected in digitally recorded focus groups during July and August 2013. Interviews were fully transcribed and analysed using a qualitative content approach. FINDINGS: Fifty-nine people participated in eight focus groups. Analysis revealed three themes: Living with lymphoedema is a battle; delays in obtaining a correct diagnosis and the positive impact of lymphoedema clinics on participants' lives. Locally accessible clinics made meaningful differences to peoples' lymphoedema, engendered positive outcomes and improved engagement with and adherence to lymphoedema self-management. CONCLUSIONS: Local specialist lymphoedema clinics can make a positive difference. They may be cost-effective and further investigation, including economic evaluation is necessary.

The Implementation of Integrated Behavioral Health Protocols In Primary Care Settings in Project Care.

PURPOSE: The majority of adults with mental health (MH) and substance use (SU) disorders in the United States do not receive treatment. The Affordable Care Act will create incentives for primary care centers to begin providing behavioral health (MH and SU) services, thus promising to address the MH and SU treatment gaps. This paper examines the implementation of integrated care protocols by three primary care organizations. METHODS: The Behavioral Health Integration in Medical Care (BHIMC) tool was used to evaluate the integrated care capacity of primary care organizations that chose to participate in the Kern County (California) Mental Health Department's Project Care annually for 3years. For a subsample of clinics, change over time was measured. Informed by the Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors, inner and outer contextual factors impacting implementation were identified and analyzed using multiple data sources and qualitative analytic methods. RESULTS: The primary care organizations all offered partially integrated (PI) services throughout the study period. At baseline, organizations offered minimally integrated/partially integrated (MI/PI) services in the Program Milieu, Clinical Process - Treatment, and Staffing domains of the BHIMC, and scores on all domains were at the partially integrated (PI) level or higher in the first and second follow-ups. Integrated care services emphasized the identification and management of MH more than SU in 52.2% of evaluated domains, but did not emphasize SU more than MH in any of them. Many of the gaps between MH and SU emphases were associated with limited capacities related to SU medications. Several outer (socio-political context, funding, leadership) and inner (organizational characteristics, individual adopter characteristics, leadership, innovation-values fit) contextual factors impacted the development of integrated care capacity. CONCLUSIONS: This study of a small sample of primary care organizations showed that it is possible to improve their integrated care capacity as measured by the BHIMC, though it may be difficult or unfeasible for them to provide fully integrated behavioral health services. Integrated services emphasized MH more than SU, and enhancing primary care clinic capacities related to SU medications may help close this gap. Both inner and outer contextual factors may impact integrated service capacity development in primary care clinics. Study findings may be used to inform future research on integrated care and inform the implementation of efforts to enhance integrated care capacity in primary care clinics.

Reasons for the low bacteriological coverage of tuberculosis reported in Mpumalanga Province, South Africa.

SETTING: Public sector hospitals and primary health clinics in the Mpumalanga Province of South Africa. OBJECTIVE: To determine whether failure to adhere to tuberculosis (TB) diagnostic guidelines (i.e., submit sputum for smear microscopy) contributed to the low bacteriological coverage reported for TB in 2008 in Mpumalanga Province. METHODS: We reviewed clinical records for new pulmonary TB cases at 30 of 118 randomly selected facilities that met the bacteriological coverage target of 80% and 30/87 facilities that did not. Data for hospital and clinic cases were abstracted into case report forms, captured electronically and compared with data from the electronic TB register (ETR). We assessed age, sex, human immunodeficiency virus (HIV) infection and facility type as potential confounders for recording of smear microscopy results. RESULTS: Age, sex and HIV infection did not influence recording of results. In hospitals, 61.8% of pulmonary TB cases had sputum smear results in their clinical records compared to 93.6% at clinics (P < 0.001). Of the 711 cases (30.3%) that did not have smear results in the ETR, 342 (48.1%) did have smear results in their clinical records. CONCLUSION: Both poor clinical practice (especially in hospitals) and poor record keeping have contributed to the low bacteriological coverage reported. These shortcomings need to be addressed to improve patient care and programme management.

Contexte : Hôpitaux publics et centres de santé primaire de la province de Mpumalanga en Afrique du Sud.Objectif : Déterminer si le défaut de respecter les directives de diagnostic de la tuberculose (TB) (c'est-à-dire soumettre des crachats à la microscopie de frottis) a contribué à la faible couverture bactériologique rapportée en 2008.Méthodes : Nous avons revu les dossiers cliniques des nouveaux cas de TB pulmonaire dans 30 de 118 structures sélectionnées au hasard qui ont atteint la couverture bacteriologique visée de 80% et 30 de 87 structures qui ne l'ont pas atteinte. Les données des cas suivis dans les hôpitaux et les dispensaires ont été résumées sur des formulaires, saisies en informatique et comparées aux données du registre électronique de la TB (ETR). Nous avons évalué l'âge, le sexe, l'infection au virus de l'immunodéficience humaine (VIH) et le type de structure en tant que facteurs de confusion de l'enregistrement des frottis.Résultats : L'âge, le sexe et l'infection VIH n'ont pas influencé l'enregistrement des frottis. Dans les hôpitaux, 61,8% des cas de TB pulmonaire ont eu des résultats de frottis de crachats dans leurs dossiers cliniques comparés à 93,6% dans les dispensaires (P < 0,001). Sur les 711 cas (30,3%) qui n'avaient pas de résultats de frottis dans le ETR, 342 (48,1%) avaient des résultats de frottis dans leurs dossiers cliniques.Conclusion : La faible couverture bactériologique constatée est due à la fois à des pratiques cliniques médiocres (surtout dans les hôpitaux) et à une maintenance insuffisante des dossiers. Ces deux problèmes doivent être résolus afin d'améliorer la prise en charge des patients et la gestion du programme.

Marco de referencia: Los hospitales y los centros de atención primaria del sector público de salud de la provincia de Mpumalanga en Suráfrica.Objetivo: Determinar si la falta de cumplimiento de las normas diagnósticas de la tuberculosis (TB) (por ejemplo, la presentación de muestras de esputo para baciloscopia) contribuye a la baja cobertura bacteriológica notificada en el 2008.Métodos: Se analizaron las historias clínicas de los casos nuevos de TB pulmonar en 30 de los 118 establecimientos escogidos de manera aleatoria que cumplían con la meta de cobertura bacteriológica del 80% de los casos y en 30 de los 87 centros que no cumplían con esta meta. Los datos de los casos de los hospitales y los consultorios se consignaron en formularios de notificación, se captaron en un registro informático y se compararon con los datos del registro electrónico de la TB (ETR). Se evaluaron la edad, el sexo, la infección por el virus de la inmunodeficiencia humana (VIH) y el tipo de establecimiento como posible factores de confusión del registro de la baciloscopia.Resultados: La edad, el sexo y la infección por el VIH no ejercieron ninguna influencia sobre el registro de la baciloscopia. En los hospitales, el 61,8% de los casos de TB pulmonar contaba con resultados de la baciloscopia del esputo en la historia clínica, en comparación con el 93,6% de los casos en los consultorios (P < 0,001). De los 711 casos que carecían de resultados de baciloscopia en el ETR (30,3%), 342 contaban con esta información en los expedientes clínicos (48,1%).Conclusión: Se observaron prácticas clínicas inadecuadas (sobre todo en los hospitales) y deficiencias en los registros, que contribuyeron a la baja cobertura bacteriológica notificada. Es importante remediar estas insuficiencias con el fin de mejorar la atención que se presta a los pacientes y optimizar la gestión del programa contra la TB.

Comparison of the adherence to the american diabetes association guidelines of diabetes care in primary care and subspecialty clinics.

BACKGROUND: Diabetes mellitus is a major public health problem with significant morbidity and mortality. Evidence based guidelines have been proposed to reduce the micro and macrovascular complications, but studies have shown that these goals are not being met. We sought to compare the adherence to the American Diabetes Association guidelines for measurement and control of glycohemoglobin (A1c), blood pressure (BP), lipids (LDL) and microalbuminuria (MA) by subspecialty and primary care clinics in an academic medical center. METHODS: 390 random charts of patients with diabetes from Family Practice (FP), Internal Medicine (IM) and Diabetes (DM) clinics at Michigan State University were reviewed. RESULTS: We reviewed 131, 134 and 125 charts from the FP, IM and DM clinics, respectively. DM clinic had a higher percentage of patients with type 1 diabetes 43/125 (34.4%) compared with 7/131 (5.3%) in FP and 7/134 (5.2%) in IM clinics. A1c was measured in 99%, 97.8% and 100% subjects in FP, IM and DM clinics respectively. B.P. was measured in all subjects in all three clinics. Lipids were checked in 97.7%, 95.5% and 92% patients in FP, IM and DM clinics respectively. MA was measured at least once during the year preceding the office visit in 85.5%, 82.8% and 76.8% patients in FP, IM and DM clinics respectively. A1C was controlled (<7%) in 38.9, 43.3, 28.8% of patients in the FP, IM and DM clinics, respectively (p = 0.034). LDL was controlled (<100 mg/dl or 2.586 mmol/l) in 71.8, 64.9, 64% of patients in the FP, IM and DM clinics, respectively. MA was controlled (<30 mg/gm creatinine) in 60.3%, 51.5% and 60% patients in FP, IM and DM clinics respectively (P = 0.032). BP was controlled (<130/80) in 59.5, 67.2 and 52.8% patients in the FP, IM and DM clinics, respectively. CONCLUSION: Testing rates for A1C, LDL, and MA were high, in both subspecialty and primary care clinics. However, the degree of control was not optimal. Significantly fewer patients in the DM clinic had A1c <7%, the cause of which may be multifactorial.

Effect of a primary care based brief intervention trial among risky drug users on health-related quality of life.

BACKGROUND: Improvement in quality of life (QOL) is a long term goal of drug treatment. Although some brief interventions have been found to reduce illicit drug use, no trial among adult risky (moderate non-dependent) drug users has tested effects on health-related quality of life. METHODS: A single-blind randomized controlled trial of patients enrolled from February 2011 to November 2012 was conducted in waiting rooms of five federally qualified health centers. 413 adult primary care patients were identified as risky drug users using the WHO-ASSIST and 334 (81% response; 171 intervention, 163 control) consented to participate in the trial. Three-month follow-ups were completed by 261 patients (78%). Intervention patients received the QUIT intervention of brief clinician advice and up to two drug-use health telephone sessions. The control group received usual care and information on cancer screening. Outcomes were three-month changes in the Short Form Health Survey (SF-12) mental health component summary score (MCS) and physical health component summary score (PCS). RESULTS: The average treatment effect (ATE) was non-significant for MCS (0.2 points, p-value=0.87) and marginally significant for PCS (1.7 points, p-value=0.08). The average treatment effect on the treated (ATT) was 0.1 (p-value=0.93) for MCS and 1.9 (p-value=0.056) for PCS. The effect on PCS was stronger at higher (above median) baseline number of drug use days: ATE=2.7, p-value=0.04; ATT=3.21, p-value=0.02. CONCLUSIONS: The trial found a marginally significant effect on improvement in PCS, and significant and stronger effect on the SF-12 physical component among patients with greater frequency of initial drug use.