Effect of integration of prescription drug monitoring program data in the electronic health record on queries by primary care providers.

Objective: To evaluate the impact of PDMP integration in the EHR on provider query rates within twelve primary care clinics in one academic medical center. Methods: Using linked data from the EHR and state PDMP program, we evaluated changes in PDMP query rates using a stepped-wedge observational design where integration was implemented in three waves (four clinics per wave) over a five-month period (May, July, September 2019). Multivariable negative binomial general estimating equations (GEE) models assessed changes in PDMP query rates, overall and across several provider and clinic-level subgroups. Results: Among 206 providers in PDMP integrated clinics, the average number of queries per provider per month increased significantly from 1.43 (95% CI 1.07 - 1.91) pre-integration to 3.94 (95% CI 2.96 - 5.24) post-integration, a 2.74-fold increase (95% CI 2.11 to 3.59; p < .0001). Those in the lowest quartile of PDMP use pre-integration increased 36.8-fold (95% CI 16.91 - 79.95) after integration, significantly more than other pre-integration PDMP use quartiles. Conclusions: Integration of the PDMP in the EHR significantly increased the use of the PDMP overall and across all studied subgroups. PDMP use increased to a greater degree among providers with lower PDMP use pre-integration.

Does proactive care in care homes improve survival? A quality improvement project.

BACKGROUND: NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM: To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING: Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD: All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS: By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION: A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

COVID-19 profiles in general practice: a latent class analysis.

BACKGROUND: General practitioners (GPs) were on the front line of the COVID-19 outbreak. Identifying clinical profiles in COVID-19 might improve patient care and enable closer monitoring of at-risk profiles. OBJECTIVES: To identify COVID-19 profiles in a population of adult primary care patients, and to determine whether the profiles were associated with negative outcomes and persistent symptoms. DESIGN, SETTING AND PARTICIPANTS: In a prospective multicentre study, 44 GPs from multiprofessional primary care practices in the Paris area of France recruited 340 consecutive adult patients (median age: 47 years) with a confirmed diagnosis of COVID-19 during the first two waves of the epidemic. METHOD AND OUTCOME: A latent class (LC) analysis with 11 indicators (clinical signs and symptoms) was performed. The resulting profiles were characterised by a 3-month composite outcome (COVID-19-related hospital admission and/or death) and persistent symptoms three and 6 months after inclusion. RESULTS: We identified six profiles: 'paucisymptomatic' (LC1, 9%), 'anosmia and/or ageusia' (LC2, 12.9%), 'influenza-like syndrome with anosmia and ageusia' (LC3, 15.5%), 'influenza-like syndrome without anosmia or ageusia' (LC4, 24.5%), 'influenza-like syndrome with respiratory impairment' (LC5) and a 'complete form' (LC6, 17.7%). At 3 months, 7.4% of the patients were hospitalised (with higher rates in LC5), and 18% had persistent symptoms (with higher rates in LC5 and LC6). At 6 months, 6.4% of the patients had persistent symptoms, with no differences between LCs. CONCLUSION: Our findings might help GPs to identify patients at risk of persistent COVID-19 symptoms and hospital admission and then set up procedures for closer monitoring.

Pandemic-related challenges accessing food and primary healthcare among sex workers during the COVID-19 pandemic: findings from a community-based cohort in Vancouver, Canada.

INTRODUCTION: Globally, the COVID-19 pandemic upended healthcare services and created economic vulnerability for many. Criminalization of sex work meant sex workers were largely ineligible for Canada's government-based financial pandemic relief, the Canadian Emergency Response Benefit. Sex workers' loss of income and inability to access financial support services during the pandemic resulted in many unable to pay rent or mortgage, and in need of assistance with basic needs items including food. Little is known about the unique experiences of sex workers who faced challenges in accessing food during the pandemic and its impact on healthcare access. Thus, we aimed to identify the association between pandemic-related challenges accessing food and primary healthcare among sex workers. METHODS: Prospective data were drawn from a cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers' Health Access, AESHA; 2010-present). Data were collected via questionnaires administered bi-annually from October 2020-August 2021. We used univariate and multivariable logistic regression with generalized estimating equations to assess the association between pandemic-related challenges accessing food and challenges accessing primary healthcare over the study period. RESULTS: Of 170 participants, 41% experienced pandemic-related challenges in accessing food and 26% reported challenges accessing healthcare. Median age was 45 years (IQR:36-53), 56% were of Indigenous ancestry, 86% experienced intimate partner violence in the last six months, and 62% reported non-injection substance use in the last six months. Experiencing pandemic-related challenges accessing food was positively associated with challenges accessing primary healthcare (Adjusted Odds Ratio: 1.99, 95% Confidence Interval: 1.02-3.88) after adjustment for confounders. CONCLUSIONS: Findings provide insight about the potential role community-based healthcare delivery settings (e.g., community clinics) can play in ameliorating access to basic needs such as food among those who are highly marginalized. Future pandemic response efforts should also take the most marginalized populations' needs into consideration by establishing strategies to ensure continuity of essential services providing food and other basic needs. Lastly, policies are needed establishing basic income support and improve access to food resources for marginalized women in times of crisis.

Data analysis plan of the OECD PaRIS survey: leveraging a multi-level approach to analyse data collected from people living with chronic conditions and their primary care practices in 20 countries.

OBJECTIVE: In view of the increasing number of people with (multiple) chronic conditions, the Organisation for Economic Co-operation and Development (OECD) initiated the International Survey of People Living with Chronic Conditions (PaRIS survey), which aims to provide insight in patient-reported outcomes and experiences of chronic care provided by primary care practices to support policy development. The objective of this research note is to describe the structure of the data, collected in the PaRIS survey and how the data will be analysed in a multilevel approach for cross-country comparison. ANALYSIS PLAN: The data structure of the PaRIS survey represents three levels: countries/health systems, primary care practices and patients. Multilevel analysis is used because of its accuracy in estimating country-level outcomes, its flexibility in modelling relationships, and its opportunities in connecting to relevant policy questions. Country-level outcomes will be estimated to facilitate cross-country comparison and (future) within-country comparison over time. Characteristics of patients that potentially explain variation in patient-reported outcomes and experiences can be linked to primary care practice and country/health system characteristics. This makes it possible to address policy-relevant questions relating, e.g., to the impact of chronic care management on patients with a specific chronic condition.

Cannabis Use Reported by Patients Receiving Primary Care in a Large Health System.

Importance: Despite the changing legal status of cannabis and the potential impact on health, few health systems routinely screen for cannabis use, and data on the epidemiology of cannabis use, and especially medical cannabis use among primary care patients, are limited. Objective: To describe the prevalence of, factors associated with, and reasons for past-3 month cannabis use reported by primary care patients. Design, Setting, and Participants: This cross-sectional study used electronic health record data from patients aged 18 years and older who had an annual wellness visit between January 2021 and May 2023 from a primary care clinic within a university-based health system in Los Angeles, California. Exposures: Factors of interest included age, race and ethnicity, sex, employment status, and neighborhood Area Deprivation Index (ADI). Main Outcomes and Measures: Cannabis use was assessed using the Alcohol Substance Involvement Screening Test (ASSIST). Patients were also asked about reasons for use, symptoms for which they used cannabis, and mode of use. Results: Among the 175 734 patients screened, the median (range) age was 47 (18-102) years; 101 657 (58.0%) were female; 25 278 (15.7%) were Asian, 21 971 (13.7%) were Hispanic, and 51 063 (31.7%) were White. Cannabis use was reported by 29 898 (17.0%), with 10 360 (34.7%) having ASSIST scores indicative of moderate to high risk for cannabis use disorder (CUD). Prevalence of cannabis use was higher among male patients than female patients (14 939 [20.0%] vs 14 916 [14.7%]) and younger patients (18-29 years, 7592 [31.0%]; ≥60 years, 4200 [8.5%]), and lower among those who lived in the most disadvantaged neighborhoods (ADI decile 9-10, 189 [13.8%]; ADI decile 1-2, 12 431 [17.4%]). The most common modes of use included edibles (18 201 [61.6%]), smoking (15 256 [51.7%]), and vaporizing (8555 [29.0%]). While 4375 patients who reported using cannabis (15.6%) did so for medical reasons only, 21 986 patients (75.7%) reported using cannabis to manage symptoms including pain (9196 [31.7%]), stress (14 542 [50.2%]), and sleep (16 221 [56.0%]). The median (IQR) number of symptoms managed was 2 (1-4), which was higher among patients who were at moderate to high risk for CUD (4 [2-6] symptoms). Conclusions and Relevance: In this study, cannabis use and risk of CUD were common, and more than three-quarters of patients who reported any cannabis use reported doing so to manage a health-related symptom. These findings suggest that integration of information regarding cannabis use for symptom management could help provide a crucial point-of-care opportunity for clinicians to understand their patients' risk for CUD.

Morbidity profile and pharmaceutical management of adult outpatients between primary and tertiary care levels in Sri Lanka: a dual-centre, comparative study.

BACKGROUND: Outpatient care is central to both primary and tertiary levels in a health system. However, evidence is limited on outpatient differences between these levels, especially in South Asia. This study aimed to describe and compare the morbidity profile (presenting morbidities, comorbidities, multimorbidity) and pharmaceutical management (patterns, indicators) of adult outpatients between a primary and tertiary care outpatient department (OPD) in Sri Lanka. METHODS: A comparative study was conducted by recruiting 737 adult outpatients visiting a primary care and a tertiary care facility in the Kandy district. A self-administered questionnaire and a data sheet were used to collect outpatient and prescription data. Following standard categorisations, Chi-square tests and Mann‒Whitney U tests were employed for comparisons. RESULTS: Outpatient cohorts were predominated by females and middle-aged individuals. The median duration of presenting symptoms was higher in tertiary care OPD (10 days, interquartile range: 57) than in primary care (3 days, interquartile range: 12). The most common systemic complaint in primary care OPD was respiratory symptoms (32.4%), whereas it was dermatological symptoms (30.2%) in tertiary care. The self-reported prevalence of noncommunicable diseases (NCDs) was 37.9% (95% CI: 33.2-42.8) in tertiary care OPD and 33.2% (95% CI: 28.5-38.3) in primary care; individual disease differences were significant only for diabetes (19.7% vs. 12.8%). The multimorbidity in tertiary care OPD was 19.0% (95% CI: 15.3-23.1), while it was 15.9% (95% CI: 12.4-20.0) in primary care. Medicines per encounter at primary care OPD (3.86, 95% CI: 3.73-3.99) was higher than that at tertiary care (3.47, 95% CI: 3.31-3.63). Medicines per encounter were highest for constitutional and respiratory symptoms in both settings. Overall prescribing of corticosteroids (62.7%), vitamin supplements (45.8%), anti-allergic (55.3%) and anti-asthmatic (31.3%) drugs was higher in the primary care OPD, and the two former drugs did not match the morbidity profile. The proportion of antibiotics prescribed did not differ significantly between OPDs. Subgroup analyses of drug categories by morbidity largely followed these overall differences. CONCLUSIONS: The morbidities between primary and tertiary care OPDs differed in duration and type but not in terms of multimorbidity or most comorbidities. Pharmaceutical management also varied in terms of medicines per encounter and prescribed categories. This evidence supports planning in healthcare and provides directions for future research in primary care.

Assessing the impact of annual health screenings in identifying noncommunicable disease risk factors within Qatar's primary health care corporation Qatari registered population.

Background: Noncommunicable diseases (NCDs) are a significant global health burden, including in Qatar, where cardiovascular diseases cause mortality. This study examines the outcomes of the annual health checkup implemented by the Primary Health Care Corporation (PHCC) in Qatar in detecting NCDs risk factors among Qataris aged 18+ years. Methods: A cross-sectional study design was implemented to calculate the prevalence of behavioural and metabolic NCDs risk factors among Qataris who underwent annual health checkups between 2017 and 2019. Data on age, gender, tobacco consumption, height, weight, blood pressure, glycated haemoglobin (HbA1c), and cholesterol levels were extracted from electronic medical records. Results: In 2019, Qatar experienced an 80% rise in Annual Health checkups attendance compared to 2017. Tobacco use fluctuated between 11.79 and 12.91%, peaking at 35.67% among males in 2018. Qataris with elevated blood pressure dropped from 29.44% in 2017 to 18.52% in 2019. Obesity decreased from 48.32 to 42.29%, more prevalent in females. High HbA1c levels reduced from 13.33 to 8.52%, while pre-diabetic levels rose from 21.1 to 25.52%. High cholesterol ranged from 7.31 to 9.47%. In a regression analysis, males had 2.28 times higher odds of elevated blood pressure and 1.54 times higher odds of high HbA1c, with a 0.68 lower odds of obesity compared to females. Ages 36 and above had 2.61 times higher odds of high cholesterol compared to younger age groups. Conclusion: The annual health screening has shown promising results in detecting and addressing NCDs risk factors among Qataris. The attendance rate has increased over the three-year period, and there has been a decrease in the prevalence of elevated blood pressure, obesity, and high HbA1c levels. However, tobacco consumption and pre-diabetic levels remain significant concerns. These findings can guide the implementation of tailored preventative and curative services to improve the health and well-being of the Qatari population.

Voices of care: unveiling patient journeys in primary care for hypertension and diabetes management in Kerala, India.

Background: Diabetes and hypertension are leading public health problems, particularly affecting low- and middle-income countries, with considerable variations in the care continuum between different age, socio-economic, and rural and urban groups. In this qualitative study, examining the factors affecting access to healthcare in Kerala, we aim to explore the healthcare-seeking pathways of people living with diabetes and hypertension. Methods: We conducted 20 semi-structured interviews and one focus group discussion (FGD) on a purposive sample of people living with diabetes and hypertension. Participants were recruited at four primary care facilities in Malappuram district of Kerala. Interviews were transcribed and analyzed deductively and inductively using thematic analysis underpinned by Levesque et al.'s framework. Results: The patient journey in managing diabetes and hypertension is complex, involving multiple entry and exit points within the healthcare system. Patients did not perceive Primary Health Centres (PHCs) as their initial points of access to healthcare, despite recognizing their value for specific services. Numerous social, cultural, economic, and health system determinants underpinned access to healthcare. These included limited patient knowledge of their condition, self-medication practices, lack of trust/support, high out-of-pocket expenditure, unavailability of medicines, physical distance to health facilities, and attitude of healthcare providers. Conclusion: The study underscores the need to improve access to timely diagnosis, treatment, and ongoing care for diabetes and hypertension at the lower level of the healthcare system. Currently, primary healthcare services do not align with the "felt needs" of the community. Practical recommendations to address the social, cultural, economic, and health system determinants include enabling and empowering people with diabetes and hypertension and their families to engage in self-management, improving existing health information systems, ensuring the availability of diagnostics and first-line drug therapy for diabetes and hypertension, and encouraging the use of single-pill combination (SPC) medications to reduce pill burden. Ensuring equitable access to drugs may improve hypertension and diabetes control in most disadvantaged groups. Furthermore, a more comprehensive approach to healthcare policy that recognizes the interconnectedness of non-communicable diseases (NCDs) and their social determinants is essential.

Effets de la pandémie de Covid-19 sur l'accès des personnes âgées aux soins de santé primaires dans la province d'Essaouira, Maroc.

INTRODUCTION: Older adults were among those who suffered most from the COVID-19 pandemic. In Morocco, where 64.4 percent of older adults suffer from a form of chronic illness, the main challenge facing local authorities was how to maintain essential care for this population group in the context of the pandemic. PURPOSE OF THE RESEARCH: The aim of the study was to determine the effects of the COVID-19 pandemic on older adults’ access to primary healthcare in the Essaouira Province (Morocco), with a view to ensuring the ongoing provision of healthcare for older adults during health emergencies. A longitudinal retrospective survey was conducted from October to December 2021 based on a structured questionnaire with a sample of 196 people aged sixty and above. The data obtained were compiled and analyzed using SPSS software (version 20.0). RESULTS: The COVID-19 pandemic has adversely affected older adults’ access to primary healthcare. Older adults’ use of primary healthcare services fell by 51.6 percent during the pandemic compared with the same periods in previous years. In addition, the measures taken to control the pandemic have had a negative impact on the quality of services offered to the survey participants. CONCLUSION: The COVID-19 pandemic resulted in significant changes in the operation of primary healthcare for older populations. The findings of this study provide a basis for anticipatory actions to improve the ongoing provision of healthcare for older adults in the context of health emergencies.

The estimated 10-year risk of first-onset cardiovascular disease in Swedish-born and non-Swedish-born primary healthcare patients.

BACKGROUND: SCORE2 has been introduced as an updated risk assessment tool for calculating the 10-year risk of first-onset cardiovascular disease (CVD). However, it does not account for ethnicity or socioeconomic status, known to affect CVD risk. This study investigated and compared SCORE2 estimates in Swedish-born and non-Swedish-born primary healthcare patients. The second aim was to examine if several risk factors could explain differences in CVD risk between the groups. METHODS: This was an observational, cross-sectional study. Data were obtained from the 4D Diabetes Project study, providing a total of 444 participants aged between 40 and 69 years. All participants had complete risk variable data necessary for the SCORE2 tool and no history of previous CVD. Descriptive analysis was conducted to compare distributions of risk factors between Swedes and immigrants and odds ratios of risk factors amongst these two groups in correlation to elevated CVD risk were calculated using logistic regression. RESULTS: Swedish-born patients showed a significantly higher risk of elevated CVD risk estimates (≥ 2.5% CVD risk increase for individuals < 50 years, respectively, ≥ 5% for individuals aged 51-69) than the non-Swedish-born population, even after adjustment for educational level (OR = 1.61, 95% CI 1.08-2.39). Weekly alcohol consumption implicated a risk of being classified as high risk of CVD risk, regardless of country of birth (OR = 1.93 CI 1.25-3.00). However, Swedes accounted for most of the alcohol consumption (62.6% vs. 19.6%). No other explanatory variable showed significance in association with elevated CVD risk. CONCLUSIONS: Swedish-born patients were found to be at higher risk of an increased 10-year CVD risk. The association of alcohol consumption with elevated CVD risk needs to be further studied in longitudinal studies in representative populations, notably among Sweden's diverse ethnic groups.

SABA prescriptions and asthma management practices in Singapore: results from a cross-sectional, observational SABINA III study.

OBJECTIVES: To evaluate asthma characteristics and treatment patterns, including short-acting ß2-agonist (SABA) prescriptions, in primary and specialist care in the Singapore cohort of the SABA use IN Asthma (SABINA III) study. DESIGN: Cross-sectional, observational study. SETTING: Multicentre study conducted at five sites across Singapore. METHODS: In patients with asthma (aged ≥12 years), data on demographics, disease characteristics and asthma treatment prescriptions were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by 2017 Global Initiative for Asthma recommendations) and practice type (primary/specialist care). RESULTS: Of the 205 patients analysed (mean (SD) age, 53.6 (16.8) years; female, 62%), 55.9% were enrolled by specialists and 44.1% by primary care physicians. Most study patients (80.5%) had moderate-to-severe asthma (86.0% in specialist care and 74.4% in primary care). In the 12 months before study enrolment, 18.0% of patients experienced ≥1 severe exacerbation. Asthma was well or partly controlled in 78.0% of patients. Overall, 17.1% of all patients were overprescribed SABA (≥3 SABA canisters/year) in the preceding 12 months, and overprescription was greater in specialist versus primary care (26.3% vs 5.6%). Only 2.9% of patients were prescribed SABA monotherapy, while 41.0% received SABA in addition to maintenance therapy. Among the latter, 40.5% were overprescribed SABA. Overall, a higher percentage of patients prescribed ≥3 SABA canisters (vs 0-2 SABA canisters) were assessed as having uncontrolled asthma during the study visit (42.9% vs 17.6%). Maintenance therapy in the form of inhaled corticosteroids (ICS) or ICS/long-acting ß2 agonist fixed-dose combinations were prescribed to 14.1% and 84.9% of patients, respectively, in the 12 months before enrolment. CONCLUSIONS: In this Singapore cohort, ~17% of all patients and more than 40% of patients prescribed SABA in addition to maintenance therapy were overprescribed SABA. These findings emphasise the need to align clinical practices with the latest evidence-based treatment recommendations. TRIAL REGISTRATION: NCT03857178.

Trends in C reactive protein testing: a retrospective cohort study in paediatric ambulatory care settings.

OBJECTIVES: This study aims to investigate C reactive protein (CRP) testing practices in paediatric ambulatory care across British primary care and accident and emergency (A&E) departments. DESIGN, SETTING, PARTICIPANTS: This retrospective cohort study included children <18 years old having ≥1 CRP test at primary care or A&E departments in Oxfordshire between 2007 and 2021. OUTCOMES: We estimated the frequency and annual changes in CRP testing in both settings and evaluated referral and admission patterns based on CRP levels: low (<20 mg/L), intermediate or high (≥80 mg/L). RESULTS: Over 15 years, 91 540 CRP tests were requested in 63 226 children, with 33 882 (53.6%) in primary care and 29 344 (46.4%) in A&E. Both settings showed rising trends in test requests, with average annual percentage change of 3.0% (95% CI 1.2% to 4.7%) in primary care and 11.5% (95% CI 8.6% to 14.6%) in A&E. The proportion of intermediate/high-test results remained stable. In primary care, 50 709 (95.8%) of CRP tests were <20 mg/L, with 99.0% of these children managed at home. High and intermediate CRP values increased odds of referral versus low CRP (OR adjusted for age=21.80; 95% CI 16.49 to 28.81 and 4.77; 3.78 to 6.02, respectively). At A&E, 27 610 (71.5%) children had CRP<20 mg/L, of whom 42.5% were admitted while 3776 (9.8%) had CRP≥80 mg/L with 57.9% admission rate. High and intermediate CRP values increased odds of admission versus low CRP (OR adjusted for age=1.90; 95% CI 1.78 to 2.04 and 1.39; 1.32 to 1.46, respectively). CONCLUSION: There are rising trends of CRP test requests in paediatric ambulatory care settings, with no evidence of increases in proportion of intermediate/high-test results in primary care. Low CRP values at primary care were linked to children managed at home, while almost half of children with low CRP values at A&E were admitted to the hospital.

Memory complaint in a middle-income country: a four-year longitudinal study in a cohort with low-education.

BACKGROUND: Memory complaints are frequent in older adults and are associated with higher risk of cognitive decline. OBJECTIVE: To investigate the functional outcome of individuals with memory complaints followed up at primary care centers. METHODS: Data were collected between 2016 e 2020 in primary health care centers in Brazil. Patients underwent the Brief Cognitive Screening Battery, and the Functional Activities Questionnaire. RESULTS: The initial sample (2016) comprised 91 individuals classified into those with subjective cognitive decline (SCD, n = 15), mild cognitive impairment (MCI, n = 45), or dementia (n = 31). During follow-up, 8 individuals (8.8% of the initial sample) died and 26 (28.5% of the initial sample) were not found. Fifty-seven participants underwent clinical reassessment. Of 15 individuals with SCD, 7 were not found (46.7%), 4 (26.7%) progressed to MCI, and 4 (26.7%) remained stable. Of 45 individuals with MCI, 11 were not found (24.4%), 2 (4.4%) died, 6 (13.4%) progressed to dementia, 12 (26.7%) regressed to SCD, and 14 (31.1%) remained stable. Of 31 individuals with dementia, 8 were not found (25.8%), 6 (19.4%) died, 2 (6.5%) regressed to SCD, 7 (22.6%) regressed to MCI, and 8 remained stable (25.8%). Clinical improvement was due to the treatment of reversible causes, such as B12 hypovitaminosis and mood disorders. Older age, lower Mini-Mental State Examination, and higher scores of memory complaint, but not the use of benzodiazepines and of proton pump inhibitors, were predictors of functional status. CONCLUSION: Despite their limits (short sample size, missing data), these results support the idea that adequate screening, follow-up, and treatment of reversible causes of dementia in primary care are essential.

ANTECEDENTES: Queixas de memória são frequentes em idosos e estão associadas ao maior risco de declínio cognitivo. OBJETIVO: Investigar o desfecho funcional de indivíduos com queixas de memória acompanhados em centros atenção primária. MéTODOS: Os dados foram coletados entre 2016 e 2020 em centros de atenção primária à saúde no Brasil. Os pacientes foram submetidos à Bateria Cognitiva Breve e ao Questionário de Atividades Funcionais. RESULTADOS: A amostra inicial (2016) foi composta por 91 indivíduos, classificados como tendo declínio cognitivo subjetivo (DCS, n = 15), comprometimento cognitivo leve (CCL, n = 45), ou demência (n = 31). Durante o seguimento, 8 indivíduos (8,8% da amostra inicial) faleceram e 26 (28,5% da amostra inicial) não foram encontrados. Cinquenta e sete participantes foram submetidos à reavaliação clínica. Dos 15 indivíduos com DCS, 7 não foram encontrados (46,7%), 4 (26,7%) declinaram para CCL e 4 (26,7%) permaneceram estáveis. Dos 45 indivíduos com CCL, 11 não foram encontrados (24,4%), 2 (4,4%) morreram, 6 (13,4%) declinaram para demência, 12 (26,7%) evoluíram para DCS e 14 (31,1%) permaneceram estáveis. Dos 31 indivíduos com demência, 8 não foram encontrados, (25,8%), 6 (19,4%) morreram, 2 (6,5%) evoluíram para DCS e 7 (22,6%) para CCL; e 8 permaneceram estáveis (25,8%). A melhora clínica deveu-se ao tratamento de causas reversíveis, como hipovitaminose B12 e transtornos de humor. A idade avançada, a baixa pontuação no Mini-Exame do Estado Mental e os escores de queixa de memória mais altos, mas não o uso de benzodiazepínicos e inibidores da bomba de prótons, foram preditores de declínio funcional. CONCLUSãO: Apesar de suas limitações (amostra pequena, dados ausentes), esses resultados corroboram que a triagem adequada, o acompanhamento e o tratamento de causas reversíveis de demência na atenção primária são essenciais.

Quality improvement initiative to standardise the anthropometric assessment for children under the age of 5 years at an urban primary health centre in New Delhi.

BACKGROUND: Anthropometric assessment in the paediatric population is particularly important to assess the child's general health status, nutritional adequacy, and growth and developmental pattern. However, there are often shortcomings in the quality of anthropometric assessment done in primary healthcare settings despite the presence of established guidelines. In this study, we plan to use the quality improvement (QI) principles to improve the anthropometric assessment of under-5 children attending an urban primary health centre in Delhi, India. METHODS: The study was conducted from December 2022 to February 2023. A baseline assessment was conducted to identify the gaps in the anthropometric measurement of under-5 children visiting the outpatient department. A QI team consisting of doctors and key health staff of urban health centre as its members was formed. A root cause analysis of the identified problems was done and changes were planned and implemented in a Plan-Do-Study-Act cycle. RESULTS: There was a marked improvement in the quality of anthropometric measurements, particularly in length measurement for children <24 months of age (0% at baseline vs 81.0% at end-line). However, the improvement in weight measurement of children less than 5 years was lesser (16.2% at baseline vs 44.6% at end-line). CONCLUSION: Anthropometric assessment of under-5 children can be standardised through the involvement of all stakeholders and capacity building of the concerned healthcare providers, using the QI approach. Repeated assessments are required to ensure the sustainability of the change.

Model-based disease mapping using primary care registry data.

BACKGROUND: Spatial modeling of disease risk using primary care registry data is promising for public health surveillance. However, it remains unclear to which extent challenges such as spatially disproportionate sampling and practice-specific reporting variation affect statistical inference. METHODS: Using lower respiratory tract infection data from the INTEGO registry, modeled with a logistic model incorporating patient characteristics, a spatially structured random effect at municipality level, and an unstructured random effect at practice level, we conducted a case and simulation study to assess the impact of these challenges on spatial trend estimation. RESULTS: Even with spatial imbalance and practice-specific reporting variation, the model performed well. Performance improved with increasing spatial sample balance and decreasing practice-specific variation. CONCLUSION: Our findings indicate that, with correction for reporting efforts, primary care registries are valuable for spatial trend estimation. The diversity of patient locations within practice populations plays an important role.

Practice Facilitation and Clinical Performance Feedback Using the Electronic Health Record Improved Blood Pressure and Cholesterol Management in Small Primary Care Practices in New York City.

Cardiovascular disease (CVD) disproportionately affects people of color and those with lower household income. Improving blood pressure (BP) and cholesterol management for those with or at risk for CVD can improve health outcomes. The New York City Department of Health implemented clinical performance feedback with practice facilitation (PF) in 134 small primary care practices serving on average over 84% persons of color. Facilitators reviewed BP and cholesterol management data on performance dashboards and guided practices to identify and outreach to patients with suboptimal BP and cholesterol management. Despite disruptions from the COVID-19 pandemic, practices demonstrated significant improvements in BP (68%-75%, P < .001) and cholesterol management (72%-78%, P = .01). Prioritizing high-need neighborhoods for impactful resource investment, such as PF and data sharing, may be a promising approach to reducing CVD and hypertension inequities in areas heavily impacted by structural racism.

Using the Translating Research into Practice framework to develop a diabetes prevention intervention in primary care: a mixed-methods study.

BACKGROUND: Pre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a gap remains in effectively translating and increasing uptake of these interventions into routine care. METHODS: We applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake. RESULTS: In phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components. CONCLUSIONS: The TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.

Measuring burden of disease in both asthma and COPD by merging the ACQ and CCQ: less is more?

Symptoms of asthma and COPD often overlap, and both diseases can co-exist in one patient. The asthma control questionnaire (ACQ) and clinical COPD questionnaire (CCQ) were developed to assess disease burden in respectively asthma or COPD. This study explores the possibility of creating a new questionnaire to assess disease burden in all obstructive lung diseases by integrating and reducing questions of the ACQ and CCQ. Data of patients with asthma, COPD and asthma-COPD overlap (ACO) were collected from a primary and secondary care center. Patients completed ACQ and CCQ on the same day. Linear regression tested correlations. Principal Component Analysis (PCA) was used for item reduction. The secondary cohort with asthma and COPD patients was used for initial question selection (development cohort). These results were reproduced in the primary care cohort and secondary cohort of patients with ACO. The development cohort comprised 252 patients with asthma and 96 with COPD. Correlation between ACQ and CCQ in asthma was R = 0.82, and in COPD R = 0.83. PCA determined a selection of 9 questions. Reproduction in primary care data (asthma n = 1110, COPD n = 1041, ACO = 355) and secondary care data of ACO patients (n = 53) resulted in similar correlations and PCA-derived selection of questions. In conclusion, PCA determined a selection of nine questions of the ACQ and CCQ: working title 'the Obstructive Lung Disease Questionnaire'. These results suggest that this pragmatic set of questions might be sufficient to assess disease burden in obstructive lung disease in both primary as secondary care.

Short- and mid-term morbidity and primary-care burden due to infant respiratory syncytial virus infection: A Spanish 6-year population-based longitudinal study.

BACKGROUND: The morbidity burden of respiratory syncytial virus (RSV) in infants extends beyond hospitalization. Defining the RSV burden before implementing prophylaxis programs is essential for evaluating any potential impact on short- to mid-term morbidity and the utilization of primary healthcare (PHC) and emergency services (ES). We established this reference data using a population-based cohort approach. METHODS: Infants hospitalized for RSV from January 2016 to March 2023 were matched with non-hospitalized ones based on birthdate and sex. We defined the exposure as severe RSV hospitalization. The main study outcomes were as follows: (1) PHC and ES visits for RSV, categorized using the International Classification of Primary Care codes, (2) prescriptions for respiratory airway obstructive disease, and (3) antibacterial prescriptions. Participants were followed up from 30 days before hospitalization for severe RSV until the outcome occurrence or end of the study. Adjusted incidence rate ratios (IRRs) of the outcomes along with their 95% confidence intervals (CI) were estimated using Poisson regression models. Stratified analyses by type of PHC visit (nurse, pediatrician, or pharmacy) and follow-up period were undertaken. We defined mid-term outcomes as those taking place up to 24 months of follow-up period. RESULTS: The study included 6626 children (3313 RSV-hospitalized; 3313 non-hospitalized) with a median follow-up of 53.7 months (IQR = 27.9, 69.4). After a 3-month follow-up, severe RSV was associated with a considerable increase in PHC visits for wheezing/asthma (IRR = 4.31, 95% CI: 3.84-4.84), lower respiratory infections (IRR = 4.91, 95% CI: 4.34-5.58), and bronchiolitis (IRR = 4.68, 95% CI: 2.93-7.65). Severe RSV was also associated with more PHC visits for the pediatrician (IRR = 2.00, 95% CI: 1.96-2.05), nurse (IRR = 1.89, 95% CI: 1.75-1.92), hospital emergency (IRR = 2.39, 95% CI: 2.17-2.63), primary healthcare emergency (IRR: 1.54, 95% CI: 1.31-1.82), as well as with important increase in prescriptions for obstructive airway diseases (IRR = 5.98, 95% CI: 5.43-6.60) and antibacterials (IRR = 4.02, 95% CI: 3.38-4.81). All findings remained substantial until 2 years of post-infection. CONCLUSIONS: Severe RSV infection in infants significantly increases short- to mid-term respiratory morbidity leading to an escalation in healthcare utilization (PHC/ES attendance) and medication prescriptions for up to 2 years afterward. Our approach could be useful in assessing the impact and cost-effectiveness of RSV prevention programs.