The impact of primary care: a focused review

The effect of primary healthcare on mortality: Evidence from Costa Rica

This paper uses the gradual implementation of a primary healthcare (PHC) intervention in Costa Rica to examine the long-term effect of PHC on mortality. Nine years after opening a primary care center, known as a Health Area, there was an associated 13% reduction in age-adjusted mortality rate in the assigned patient population. The effect was highest among adults over 65 years of age and for those with noncommunicable diseases, such as cardiovascular-related causes of death. We also show that as Health Areas opened, more individuals sought care at primary care clinics, while fewer sought care at emergency rooms; these changes may have partially mediated the effect of the intervention on mortality.

Patient perception of attributes of primary care: a study of Aam Aadmi Mohalla Clinics in Delhi, India

BACKGROUND

Aam Aadmi Mohalla Clinics (AAMC) are the community level public primary care facilities recently introduced to strengthen primary care in Delhi, India by bringing affordable healthcare close to home.

OBJECTIVES

This study looks at the primary care attributes of AAMC from a patient perspective, to assess their features, strengths and weaknesses.

METHODS

Using a primary care survey tool, a cross-sectional survey of 360 users was conducted at 18 facilities across 9 districts of Delhi to gather information on six dimensions of primary care delivery. Thematic analysis of responses to quantitative, multiple-choice and Likert scale questions using percentage of respondents in each category; and a strengths, weaknesses, opportunities and suggestions (SWOS) framework, was used to examine the primary care attributes.

RESULTS

AAMCs have done well in improving proximity, availability, physical and financial access to primary care with respondents reporting their residence within 1 kilometre of AAMCs (95%), physician being available (100%), free drugs in stock (99%). Service delivery is however not comprehensive with missing preventive care. Respondents reported missing gatekeeping, weak referral mechanism (6-19%), and low physician's familiarity with their overall health (2%).

CONCLUSION

AAMCs have brought affordable healthcare with free medicines and diagnostics to neighbourhood. There is an opportunity for attaining universal healthcare that is responsive to user needs through provision of comprehensive care. Compulsory enrolment of neighbourhood population with an electronic database of patients has an immense potential to improve longitudinality and coordination of care.

Food and Nutrition Security as Social Determinants of Health: Fostering Collective Impact to Build Equity

An overview of the state of the American diet, how it relates to public health outcomes and the obesity epidemic, and how it arises from the policy and infrastructure that have been developed over the course of the 20th and 21st centuries. The article concludes by laying out concrete solutions for urban revitalization, providing people in underserved communities sovereignty over their food supply, and work with multi-stakeholder cooperatives to overcome the effects of food insecurity and poor diet quality.

Health Equity and Access to Health Care as a Social Determinant of Health: The Role of the Primary Care Provider

Populations of people who suffer poorer health outcomes and increased disease burden, particularly preventable diseases, injury, and violence are experiencing health inequity. Achieving greater health equity by addressing social determinants of health and access to health care is the goal of many primary care physicians, health care advocates, and policy makers. Race, geographic location, age, poverty, disabilities, gender, and mental health are common examples of factors that determine health equity. Access to health care, by itself is a predictor of health outcomes and is influenced by many of the same factors.

The patient's first point of contact (PINPOINT) - protocol of a prospective multicenter study of communication and decision-making during patient assessments by primary care registered nurses

BACKGROUND

A major challenge for primary care is to set priorities and balance demands with available resources. The registered nurses in this study are practice nurses working in primary care offices, playing a large role in initial assessments. The overall objective of this research is to investigate practices of communication and decision-making during nurses' initial assessment of patients' health problems in primary care, examine working mechanisms in good practices and develop feasible solutions.

METHODS

Project PINPOINT aims for a prospective multicenter study using various methods for data collection and analysis. A purposive sample of 150 patient‒nurse consultations, including 30 nurses and 150 patients, will be recruited at primary care centers in three different geographic areas of southwest Sweden. The study will report on outcomes of communication practices in relation to patient-reported expectations and experiences, communication processes and patient involvement, assessment and decision-making, related priorities and value conflicts with data from patient questionnaires, audio-recorded real-time communication, and reflective interviews with nurses.

DISCUSSION

This research will contribute to the knowledge needed for the guidance of first-line decision-making processes to best meet patient and public health needs. This knowledge is necessary for the development of assessments and decisions to be better aligned to patients and to set priorities. Insights from this research can empower patients and service providers and help understand and enhance feasible person-centered communication strategies tailored to patients' level of health literacy. More specifically, this research will contribute to knowledge that can strengthen nurses' communication, assessments, and clinical decision-making in primary care. In the long term, this will contribute to how the competencies of practice nurses and other professionals are organized and carried out to make the best use of the resources within primary care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT06067672.

A Multilevel Analysis of School-Level Human Papillomavirus Vaccination Coverage in Virginia

School nurses improve public health through vaccine promotion and mandate compliance. Despite recommendations and support for comprehensive adolescent HPV vaccination from organizations like the National Association of School Nurses as of 2023 only Virginia, Washington DC, Rhode Island, and Hawaii mandate HPV vaccine in schools. Virginia's mandate allows caregivers to opt out of vaccination. It is important to consider how school-level vaccine compliance is associated with school and community factors. A multilevel analysis explored the association between school and county-level factors and HPV vaccination rates. This study shows schools that report higher rates of economically disadvantaged students had higher HPV vaccine coverage. HPV vaccine rates increased from 2019 to 2021 after the implementation of a gender-inclusive mandate. Virginia HPV rates still lag behind states with no mandate. The results suggest that school nursing practice related to HPV vaccine compliance may be impacted by community factors like economic status.

Homebound Older Adult, Caregiver, and Provider Perspectives on the Benefits of Home-Based Primary Care: A Narrative Review

Home-based primary care (HBPC) is a clinical practice that is being increasingly utilized for the homebound older adult population. As the age demographics in the United States shift over time, these programs will need to be expanded to accommodate the growing aging population. This narrative review aims to compile studies on the benefits of HBPC from the perspective of homebound older adult patients, caregivers, and the health care providers who practice HBPC. Studies were identified through PubMed, Web of Science, and Google Scholar, and a total of 10 papers were included in this review. Identified benefits of HBPC for homebound older adult patients included improved relationships, peace of mind, goal attainment, improved access to care, and avoidance of hospitalization. Benefits for caregivers included providing emotional support, informational support, and easing logistical challenges. Benefits for providers included improved patient care by addressing social determinants of health, improved rapport with patients, and improved provider wellness and attitude. The main limitation of this review is the lack of adequate research on this topic, specifically from the perspective of providers other than resident physicians and nurse practitioners such as nurses and community health workers. As the U.S. population of older adults continues to grow over the coming decades, the need for more home-based medicine should not be seen as a burden but rather as an opportunity to transform and humanize the way medicine is practiced.

Patient Experience With Primary Care Physician Assistants in Ontario, Canada: Impact of Trust, Knowledge, and Access to Care

Physician assistants (PAs) have been integrated into primary care settings to reduce wait times and to optimize continuity of care. Though previous studies suggest that PA utilization leads to improved healthcare access, few studies have investigated patient experience with primary care PAs in Canada. The objective of this study is to explore patient perspectives on primary care PAs in Ontario. A patient survey was developed and distributed to patients seen by PAs in 4 family medicine practices across Ontario, Canada. Results demonstrate that many patients are highly satisfied with their experience including the PA's ability to address their medical needs, establish rapport, and provide fast access to care (including same-day and after-hours appointments). Despite preferring to see a physician for more complex concerns, participants felt that PAs demonstrate similar medical knowledge, competencies, and scope of practice as family physicians. Patients demonstrated a solid understanding of the PA role and recognized the collaborative PA-physician relationship. These findings describe successful patient awareness and acceptance of the PA profession, largely due to positive PA-patient interactions in family medicine settings.

An 8-Year Review of Match Outcomes From a Primary Care Pipeline Program

BACKGROUND AND OBJECTIVES

Primary care supports the global health care system. With an increased need for primary care physicians, medical schools must provide resources, role models, and opportunities to increase the number of medical students matching into primary care residencies. Some medical schools have developed primary care pipeline programs for students. The outcomes of one such program-the Primary Care Program (PCP)-at the Keck School of Medicine (KSOM) of the University of Southern California (USC), an urban and private academic medical training center, are evaluated here.

METHODS

We reviewed PCP student outcome data for students who graduated between 2015 and 2022. Data were gathered through surveys, residency match lists, and graduation records.

RESULTS

Among PCP matriculates (n=134), 70% were female and 39% were underrepresented in medicine. Thirteen percent (n=16) of PCP graduates (n=122) completed a master of public health (MPH) degree. Among PCP graduates, 70% matched into primary care residencies compared to 36% of non-PCP graduates (P<.001). The most common residencies that PCP graduates matched into were family medicine (n=45, 37%), internal medicine (n=20, 16%), pediatrics (n=12, 10%), surgery (n=10, 8%), and psychiatry (n=9, 7%). A higher percentage of KSOM students matched into primary care residencies in the 8 graduation years after PCP was instituted (39%) than in the 8 graduation years before PCP was instituted (33%, P=.003).

CONCLUSIONS

The PCP data demonstrate the program's success at increasing the number of KSOM graduates matching into primary care residencies. The program provides a replicable training model.

Low rates of prescribing alcohol relapse prevention medicines in Australian Aboriginal Community Controlled Health Services

INTRODUCTION

Alcohol dependence is a chronic condition impacting millions of individuals worldwide. Safe and effective medicines to reduce relapse can be prescribed by general practitioners but are underutilised in the general Australian population. Prescription rates of these medicines to Aboriginal and Torres Strait Islander (First Nations) Australians in primary care are unknown. We assess these medicines in Aboriginal Community Controlled Health Services and identify factors associated with prescription.

METHODS

Baseline data (spanning 12 months) were used from a cluster randomised trial involving 22 Aboriginal Community Controlled Health Services. We describe the proportion of First Nations patients aged 15+ who were prescribed a relapse prevention medicine: naltrexone, acamprosate or disulfiram. We explore associations between receiving a prescription, a patient AUDIT-C score and demographics (gender, age, service remoteness) using logistic regression.

RESULTS

During the 12-month period, 52,678 patients attended the 22 services. Prescriptions were issued for 118 (0.2%) patients (acamprosate n = 62; naltrexone n = 58; disulfiram n = 2; combinations n = 4). Of the total patients, 1.6% were 'likely dependent' (AUDIT-C ≥ 9), of whom only 3.4% received prescriptions for these medicines. In contrast, 60.2% of those who received a prescription had no AUDIT-C score. In multivariate analysis, receiving a script (OR = 3.29, 95% CI 2.25-4.77) was predicted by AUDIT-C screening, male gender (OR = 2.24, 95% CI 1.55-3.29), middle age (35-54 years; OR = 14.41, 95% CI 5.99-47.31) and urban service (OR = 2.87, 95% CI 1.61-5.60).

DISCUSSION AND CONCLUSIONS

Work is needed to increase the prescription of relapse prevention medicines when dependence is detected. Potential barriers to prescription and appropriate ways to overcome these need to be identified.

Identifying Factors that Support the Delivery of Exceptional Care in General Practice and Development of the IDEAL Framework: A Qualitative Study

The positive deviance approach seeks to identify and learn from those that perform exceptionally well. Positive deviance as an approach to quality improvement is gaining traction in general practice. This study aimed to explore and compare stakeholders' perceptions of the factors that support the delivery of exceptional care in general practice and to refine a previously developed theoretical framework of factors associated with positively deviant care in general practice: the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Semi-structured interviews were conducted with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers in Irish general practice. Subsequently, a directed content analysis approach was employed to deductively analyse interview data using the IDEAL framework, and newly emerging factors were inductively analysed and abstracted into the framework. Several distinct strategies (e.g. patient activation and team collaboration), structures (e.g. facilities and staffing), and contextual factors (e.g. communication and rapport, and culture) were found to support the delivery of exceptional care, and differences in perceptions, values, and expectations emerged between patients and practice staff. Interview data largely supported the pre-determined factors posited by the IDEAL framework, and new factors were abstracted into the framework (e.g. facilities and infrastructure). Stakeholder engagement regarding the factors supporting exceptional care in general practice supported and extended the IDEAL framework, contributing to a more comprehensive understanding of how exceptional care is delivered in general practice. The refined framework will support researchers, policymakers, and teams looking to support, measure, and achieve exceptionally good patient care in general practice.

A qualitative investigation of uninsured patient and primary care provider perspectives on specialty care eConsults

BACKGROUND

Uninsured and underinsured patients face specialty care access disparities that prevent them from obtaining the care they need and negatively impact their health and well-being. We aimed to understand how making specialty care electronic consultations (eConsults) available at a multi-site Federally Qualified Health Center (FQHC) in central Texas affected uninsured patients' care-seeking experiences and impacted their ability to receive the needed care.

METHODS

We used concepts from Ecological Systems Theory to examine individual, interpersonal, organization-level, social, and health policy environment factors that impacted patients' access to specialty care and the use of eConsults. We conducted thematic analysis of semi-structured, qualitative interviews with patients about seeking specialty care while uninsured and with uninsured patients and FQHC PCPs about their experience using eConsults to obtain specialists' recommendations.

RESULTS

Patients and PCPs identified out-of-pocket cost, stigma, a paucity of local specialists willing to see uninsured patients, time and difficulty associated with travel and transportation to specialty visits, and health policy limitations as barriers to obtaining specialty care. Benefits of using eConsults for uninsured patients included minimizing/avoiding financial stress, expanding access to care, expanding scope of primary care, and expediting access to specialists. Concerns about the model included patients' limited understanding of eConsults, concern about cost, and worry whether eConsults could appropriately meet their specialty needs.

CONCLUSIONS

Findings suggest that eConsults delivered in a primary care FQHC addressed uninsured patients' specialty care access concerns. They helped to address financial and geographic barriers, provided time and cost savings to patients, expanded FQHC PCPs' knowledge and care provision options, and allowed patients to receive more care in primary care.

Association of Established Primary Care Use With Postoperative Mortality Following Emergency General Surgery Procedures

Importance

Sixty-five million individuals in the US live in primary care shortage areas with nearly one-third of Medicare patients in need of a primary care health care professional. Periodic health examinations and preventive care visits have demonstrated a benefit for surgical patients; however, the impact of primary care health care professional shortages on adverse outcomes from surgery is largely unknown.

Objective

To determine if preoperative primary care utilization is associated with postoperative mortality following an emergency general surgery (EGS) operation among Black and White older adults.

Design, Setting, and Participants

This was a retrospective cohort study that took place at US hospitals with an emergency department. Participants were Medicare patients aged 66 years or older who were admitted from the emergency department for an EGS condition between July 1, 2015, and June 30, 2018, and underwent an operation on hospital day 0, 1, or 2. The analysis was performed during December 2022. Patients were classified into 1 of 5 EGS condition categories based on principal diagnosis codes; colorectal, general abdominal, hepatopancreatobiliary, intestinal obstruction, or upper gastrointestinal. Mixed-effects multivariable logistic regression was used in the risk-adjusted models. An interaction term model was used to measure effect modification by race.

Exposure

Primary care utilization in the year prior to presentation for an EGS operation.

Main Outcome and Measures

In-hospital, 30-day, 60-day, 90-day, and 180-day mortality.

Results

A total of 102 384 patients (mean age, 73.8 [SD, 11.5] years) were included in the study. Of those, 8559 were Black (8.4%) and 93 825 were White (91.6%). A total of 88 340 patients (86.3%) had seen a primary care physician in the year prior to their index hospitalization. After risk adjustment, patients with primary care exposure had 19% lower odds of in-hospital mortality than patients without primary care exposure (odds ratio [OR], 0.81; 95% CI, 0.72-0.92). At 30 days patients with primary care exposure had 27% lower odds of mortality (OR, 0.73; 95% CI, 0.67-0.80). This remained relatively stable at 60 days (OR, 0.75; 95% CI, 0.69-0.81), 90 days (OR, 0.74; 95% CI, 0.69-0.81), and 180 days (OR, 0.75; 95% CI, 0.70-0.81). None of the interactions between race and primary care physician exposure for mortality at any time interval were significantly different.

Conclusions and Relevance

In this observational study of Black and White Medicare patients, primary care utilization had no impact on in-hospital mortality for Black patients, but was associated with decreased mortality for White patients. Primary care utilization was associated with decreased mortality for both Black and White patients at 30, 60, 90 and 180 days.

GPs in UK: From Health Gatekeepers in Primary Care to Health Agents in Primary Health Care

After 75 years of reformed practice, general practitioners (GPs) in the UK have transformed from health gatekeepers who simply provide medical decision-making such as diagnostic and treatment services and referral services, to health agents who proactively provide more relevant health services such as immunizations, health monitoring and health management, etc. In order to discuss this transformation of the role of the general practitioner and the conditions for the evolution of the role, this study chose the documentary analysis method to provide a comprehensive overview of the legal and normative documents related to the general practitioner. Furthermore, this study uses a comparative analysis method to conclude the definition and role characteristics of GPs as health agents. This study summarises the general pattern of evolution of GPs into health agents. The transformation into a health agent relies on the interpersonal trust and rigorous institutional of society on the general practitioner system. The expansion of GPs' clientele and range of services, together with the motivation to proactively provide services, have combined to push for a "qualitative change" in the GP's role as health agent. The transformation of the role of the general practitioner to a health agent is a historical necessity. It responds to the evolution of society's understanding of health and the need for higher levels of health. Therefore, recognizing the role of GPs as health agents is important for optimizing the use of health care resources and improving the health of society by taking advantage of this role.

Impact of Voluntary, Community and Social Enterprise (VCSE) Organisations Working with Underserved Communities with Type 2 Diabetes Mellitus in England

The Voluntary, Community and Social Enterprise (VCSE) sector offers services and leadership within the health and care system in England and has a specialist role in working with underserved, deprived communities. This evaluation aims to identify best practices in self-management support for those living with type 2 diabetes mellitus (T2DM) and to develop a theory of change (TofC) through understanding the impact of VCSE organisations on diabetes management. An appreciative inquiry (AI) was carried out and co-delivered using qualitative interviews and an embedded analysis with VCSE partners. A voluntary service coordinated seven VCSE organisations who assisted with recruiting their service users and undertook interviews to identify the impact of existing activities and programmes. People living with T2DM were interviewed about services. Themes were as follows: (a) individual and group activities; (b) trusted services and relationships across the community; (c) long-term engagement; (d) sociocultural context of diet and nutritional choices; (e) experience of adaptation; and (f) culturally appropriate advice and independent VCSE organisations. The structured educational approach (DESMOND) for T2DM was accessed variably, despite these services being recommended by NICE guidelines as a standard intervention. The VCSE offered continuity and culturally appropriate services to more marginalised groups. This evaluation highlights the importance of targeted engagement with underserved communities, particularly where primary care services are more limited. The TofC is a unique insight into the impact of VCSE services, offering bespoke support to manage T2DM, suggesting areas for improvements in capacity and offering the capability to sustain the VCSE sector as an essential element of the T2DM care pathway in England.

Emergency department use and geospatial variation in social determinants of health: a pilot study from South Carolina

BACKGROUND

Health systems are increasingly addressing patients' social determinants of health (SDoH)-related needs and investigating their effects on health resource use. SDoH needs vary geographically; however, little is known about how this geographic variation in SDoH needs impacts the relationship between SDoH needs and health resource use.

METHODS

This study uses data from a SDoH survey administered to a pilot patient population in a single health system and the electronic medical records of the surveyed patients to determine if the impact of SDoH needs on emergency department use varies geospatially at the US Census block group level. A Bayesian zero-inflated negative binomial model was used to determine if emergency department visits after SDoH screening varied across block groups. Additionally, the relationships between the number of emergency department visits and the response to each SDoH screening question was assessed using Bayesian negative binomial hurdle models with spatially varying coefficients following a conditional autoregressive (CAR) model at the census block group level.

RESULTS

Statistically important differences in emergency department visits after screening were found between block groups. Statistically important spatial variation was found in the association between patient responses to the questions concerning unhealthy home environments (e.g. mold, bugs/rodents, not enough air conditioning/heat) or domestic violence/abuse and the mean number of emergency department visits after the screen.

CONCLUSIONS

Notable spatial variation was found in the relationships between screening positive for unhealthy home environments or domestic violence/abuse and emergency department use. Despite the limitation of a relatively small sample size, sensitivity analyses suggest spatially varying relationships between other SDoH-related needs and emergency department use.

Primary care engagement in health system change: a scoping review of common barriers and effective strategies

BACKGROUND

The complexity of health systems necessitates coordination between a multitude of stakeholders to enact meaningful change. Primary care physicians are a crucial partner to engage, as their investment and participation are critical to the success of any system-level initiative. The aim of this scoping review is to identify common barriers and effective strategies when engaging primary care physicians in designing and implementing health system change.

METHODS

A scoping review was performed. A literature search was performed in March 2020 using five databases. 668 unique articles were identified and underwent a title and abstract review. 23 articles met criteria for full text review and 10 met final inclusion criteria. A backward citation analysis identified two articles. 12 articles underwent data extraction and thematic analysis.

RESULTS

Several barriers to engagement were identified including a lack of trust between primary care physicians and decision-makers, strong professional physician identity, clinically irrelevant and complex proposals, and a lack of capacity and supports. Described strategies to overcome these barriers included building trust and relationships, contextual engagement strategies, working with physician leadership, enabling open and intentional communication channels, designing clinically relevant and straightforward initiatives, and considering financial incentives.

CONCLUSIONS

Barriers to primary care engagement should be addressed with contextually designed strategies and a focus on relationship building, collaborative efforts, and implementing relevant and feasible initiatives. Further research should explore how to best develop relationships with primary care, working with collective voices of primary care physicians, and to better understanding the impact of financial incentives on engagement.

The Relationship between Body Weight and Primary Healthcare Visits

In the United States (U.S.), currently more than 40% of adults have obesity. This high prevalence presents great concern to demographers because of the potential consequences obesity holds for population health trajectories in morbidity and mortality and individuals' well-being. Primary care providers are critical for managing chronic health conditions, including obesity. This makes it vital to understand whether and how weight shapes primary care use in the U.S. We make this contribution by investigating how obesity is related to annual visits with two of the most common primary healthcare providers used by U.S. men and women- general physicians and gynecologists. Analysis of data from National Health Interview Survey (2010-2018) participants suggests that obesity and overweight are positively associated with annual physician visits among both men and women, with men with class II and III obese having significantly higher odds of annual physician visits than women. In addition, although women with obesity have greater odds of general physician visits than women with normal weight, the former group has lower odds of gynecological visits. This study offers important insights into how obesity positively shapes annual physician visits but negatively shapes gynecological care of women-especially those with class III obesity.

Previous Health Care Experiences' Influence on Health Care Perceptions Among Residents of Six Homeless Shelters in Seattle, Washington, July-October 2021

Purpose

The study purpose was to learn and describe 1) where homeless shelter residents receive health care, 2) what contributes to positive or negative health care experiences among shelter residents, and 3) shelter resident perceptions toward health care.

Methods

Semi-structured interviews (SSIs) utilizing purposive sampling and focus group discussions (FGDs) utilizing convenience sampling were conducted at 6 homeless shelters in Seattle-King County, Washington, during July-October 2021. All residents (age ≥18) were eligible to participate. SSIs were conducted with 25 residents, and 8 FGDs were held. Thematic analysis was conducted using Dedoose.

Results

Participants received health care in settings ranging from no regular care to primary care providers. Four elements emerged as contributing positively and negatively to health care experiences: 1) ability to access health care financially, physically, and technologically; 2) clarity of communication from providers and staff about appointment logistics, diagnoses, and treatment options; 3) ease of securing timely follow-up services; and 4) respect versus stigma and discrimination from providers and staff. Participants who felt positively toward health care found low- or no-cost care to be widely available and encouraged others to seek care. However, some participants described health care in the United States as greedy, classist, discriminatory, and untrustworthy. Participants reported delaying care and self-medicating in anticipation of discrimination.

Conclusions

Findings demonstrate that while people experiencing homelessness can have positive experiences with health care, many have faced negative interactions with health systems. Improving the patient experience for those experiencing homelessness can increase engagement and improve health outcomes.

Nevada's Healthcare Crisis: A Severe Shortage of Physicians and Residency Positions

The state of Nevada is home to millions of people and a prominent entertainment industry. However, the state ranks among the lowest in terms of available primary care doctors and general surgeons per capita, resulting in limited access to essential healthcare services and an increased reliance on emergency departments and hospitals. Nevada also faces the challenges posed by an aging physician workforce and a significant proportion of inactive providers. The scarcity of residency positions in Nevada's medical schools drives many graduates to seek residency training opportunities elsewhere, leading to a reduced likelihood of their return to practice within the state. We propose potential solutions, including increased funding for residency positions, prioritizing the retention of medical school graduates through local residency training, and the establishment of interdisciplinary comprehensive academic health centers. These measures are essential to meet the escalating healthcare demands of Nevada's rapidly growing population and to ultimately enhance patient outcomes.

'Space to talk': a Portuguese focus group study of parents' experiences, needs and preferences in parenting support during prenatal and well-child care

OBJECTIVE

To explore the experiences, needs and preferences of a group of parents regarding the parenting support received during prenatal and well-child care in the Portuguese National Health Service.

DESIGN AND SETTING

We undertook descriptive-interpretive qualitative research running multiple focus groups in Porto, Northern Portugal.

PARTICIPANTS, DATA COLLECTION AND ANALYSIS

Purposive sampling was used between April and November 2018. Focus groups were conducted with 11 parents of a 0-3 years old with well-child visits done in primary care units. Thematic analysis was performed in a broadly inductive coding strategy and findings are reported in accordance with Consolidated Criteria for Reporting Qualitative Research guidelines.

RESULTS

Three main themes were identified to describe parents' experience when participating in their children's healthcare: (1) logistics/delivery matter, including accessibility, organisation and provision of healthcare activities, unit setting and available equipment; (2) prenatal and well-child care: a relational place to communicate, with parents valuing a tripartite space for the baby, the family and the parent himself, where an available and caring health provider plays a major role and (3) parenting is challenging and looks for support, based on key points for providers to watch for and ask about, carefully explained and consensual among health providers.

CONCLUSION

This study provides insight into parents' needs and healthcare practices that affect the parenting experience. To meet parents' preferences, sensitive health providers should guarantee a relational place to communicate and person-centredness, accounting for the whole family system to support healthy parenting collaboratively. Future studies are warranted to further strengthen the knowledge in the field of a population-based approach for parenting support.

The quality of migrant patients' primary healthcare experiences and patient-centered medical home achievement by community health centers: results from the China greater bay area study

BACKGROUND

In China, Community Health Centers (CHCs) provide primary healthcare (PHC); however, few studies have examined the quality of PHC services experienced by migrant patients. We examined the potential association between the quality of migrant patients' PHC experiences and the achievement of Patient-Centered Medical Home by CHCs in China.

METHODS

Between August 2019 and September 2021, 482 migrant patients were recruited from ten CHCs in China's Greater Bay Area. We evaluated CHC service quality using the National Committee for Quality Assurance Patient-Centered Medical Home (NCQA-PCMH) questionnaire. We additionally assessed the quality of migrant patients' PHC experiences using the Primary Care Assessment Tools (PCAT). General linear models (GLM) were used to examine the association between the quality of migrant patients' PHC experiences and the achievement of PCMH by CHCs, adjusting for covariates.

RESULTS

The recruited CHCs performed poorly on PCMH1, Patient-Centered Access (7.2 ± 2.0), and PCMH2, Team-Based Care (7.4 ± 2.5). Similarly, migrant patients assigned low scores to PCAT dimension C-First-contact care-which assesses access (2.98 ± 0.03), and D-Ongoing care (2.89 ± 0.03). On the other hand, higher-quality CHCs were significantly associated with higher total and dimensional PCAT scores, except for dimensions B and J. For example, the total PCAT score increased by 0.11 (95% CI: 0.07-0.16) with each increase of CHC PCMH level. We additionally identified associations between older migrant patients (> 60 years) and total PCAT and dimension scores, except for dimension E. For instance, the average PCAT score for dimension C among older migrant patients increased by 0.42 (95% CI: 0.27-0.57) with each increase of CHC PCMH level. Among younger migrant patients, this dimension only increased by 0.09 (95% CI: 0.03-0.16).

CONCLUSION

Migrant patients treated at higher-quality CHCs reported better PHC experiences. All observed associations were stronger for older migrants. Our results may inform future healthcare quality improvement studies that focus on the PHC service needs of migrant patients.

Associations between primary healthcare and infant health outcomes: a cohort analysis of low-income mothers in Rio de Janeiro, Brazil

Background

Expanding primary healthcare to urban poor populations is a priority in many low-and middle-income countries and is essential to achieve universal health coverage (UHC). Between 2008 and 2016 the city of Rio de Janeiro undertook an ambitious programme to rapidly expand primary care to low-income areas through the family health strategy (FHS). Infant health impacts of this roll out are unknown. This study examines associations between maternal FHS utilisation and birth outcomes, neonatal and infant mortality.

Methods

A cohort of 75,339 live births (January 2009-December 2014) to low-income mothers in Rio de Janeiro was linked to primary care, birth, hospital and death records. The relationship between maternal FHS use and infant health outcomes was assessed through logistic regression with inverse probability treatment weighting and regression adjustment. Socioeconomic inequalities in the associations between FHS use and outcomes were explored through interactions. Primary outcomes were neonatal and infant death. Thirteen secondary outcomes were also examined to explore other important health outcomes and potential mechanisms.

Results

A total of 9002 (12.0%) infants were born to mothers in the cohort who used FHS services either before pregnancy or in the first two trimesters. There was a total of 527 neonatal and 893 infant deaths. Maternal FHS usage during the first two trimesters was associated with substantial reductions in neonatal [adjusted odds ratio (aOR): 0.527, 95% confidence interval (95% CI): 0.345; 0.806] and infant mortality (aOR: 0.672, 95% CI: 0.48; 0.924). Infants born to lower-income mothers and those without formal employment had larger reductions in neonatal and infant mortality associated with FHS use. Maternal FHS in the first two trimesters use was also associated with more antenatal care consultations and a lower risk of low birth weight and preterm birth.

Interpretation

Expanding primary care to low-income populations in Rio de Janeiro was associated with improved infant health and health equity benefits.

Funding

DFID/MRC/Wellcome Trust/ESRC.

Improving skin health of community-dwelling older people: a scoping review protocol

INTRODUCTION

Ageing is accompanied by an age-related decrease in mobility or cognitive and sensory functions; in addition, physiological changes in the skin occur with age. Therefore, the skin requires appropriate care and observation in order to prevent or manage a variety of dermatological diseases and conditions, and to prevent or minimise effects on the quality of life.Globally, most older people live at home, and the need to establish sustainable structures and processes to support and to care for people at home for as long as possible has been emphasised. The body of evidence supporting screening, diagnosis and management of skin conditions in older people living at home has not been collated and summarised to date. The aim of this scoping review is to describe and summarise the extent and nature of the available body of evidence in this regard.

METHODS AND ANALYSIS

This scoping review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Eligibility criteria were developed using the Population, Concept and Context framework, and the search will focus on systematic and scoping reviews as well as clinical practice guidelines. Two reviewers will conduct systematic searches, screen and select identified evidence as well as extract and chart data, independently. Finally, data will be systematically analysed and summarised descriptively to map existing evidence and identify gaps.

ETHICS AND DISSEMINATION

Due to the nature of research, not involving humans or unpublished secondary data, approval of an ethics committee is not required. The dissemination of findings is planned via professional networks and publication in scientific open access journals.

Behavioral deviations: healthcare-seeking behavior of chronic disease patients with intention to visit primary health care institutions

BACKGROUND

Although primary health care (PHC) has been proven to be effective in preventing and treating chronic diseases, the visits rate of PHC institutions is still not ideal. Some patients initially express a willingness to visit PHC institutions but end up seeking health services at non-PHC institutions, and the reasons for this behavior remain unclear. Therefore, the objective of this study is to analyze the factors that contribute to behavioral deviations among chronic disease patients who originally intended to visit PHC institutions.

METHODS

Data were collected from a cross-sectional survey among chronic disease patients with original intention to visit PHC institutions in Fuqing City, China. The analysis framework was guided by Andersen's behavioral model. Logistic regression models were employed to analyze the factors affecting the behavioral deviations among chronic disease patients with a willingness to visit PHC institutions.

RESULTS

A total of 1,048 individuals were finally included and about 40% of the participants with the original willingness to seek care from PHC institutions finally chose non-PHC institutions in their subsequent visits. The results of logistic regression analyses indicated that at the predisposition factor level, older participants (aOR_60-69 = 0.602, P < 0.01; aOR_70-75 = 0.475, P < 0.01) were less likely to have behavioral deviations. At the enabling factor level, compared to those covered by Urban Employee Basic Medical Insurance (UEBMI) and not reimbursed, those covered by Urban-Rural Resident Basic Medical Insurance (URRBMI) (aOR = 0.297, P < 0.01), and those answering that reimbursement from medical institutions was convenient (aOR = 0.501, P < 0.01) or very convenient (aOR = 0.358, P < 0.001) were less likely to have behavioral deviations. At the need factor level, participants who visited PHC institutions due to illness last year (aOR = 0.348, P < 0.001) and with polypharmacy (aOR = 0.546, P < 0.01) were less likely to have behavioral deviations compared to those without the visit of PHC institutions and not taking polypharmacy, respectively.

CONCLUSIONS

The deviations between the original willingness of PHC institution visits and subsequent behavior among chronic disease patients were associated with a number of predisposing, enabling, and need factors. Developing the health insurance system, strengthening the technical capacity of PHC institutions, and steadily developing a new concept of orderly healthcare-seeking behavior among chronic disease patients, will help promote their access to PHC institutions as well as improve the effectiveness of the tiered medical system for chronic disease care.

Commercializing Personal Health Information: A Critical Qualitative Content Analysis of Documents Describing Proprietary Primary Care Databases in Canada

BACKGROUND

Commercial data brokers have amassed large collections of primary care patient data in proprietary databases. Our study objective was to critically analyze how entities involved in the collection and use of these records construct the value of these proprietary databases. We also discuss the implications of the collection and use of these databases.

METHODS

We conducted a critical qualitative content analysis using publicly available documents describing the creation and use of proprietary databases containing Canadian primary care patient data. We identified relevant commercial data brokers, as well as entities involved in collecting data or in using data from these databases. We sampled documents associated with these entities that described any aspect of the collection, processing, and use of the proprietary databases. We extracted data from each document using a structured data tool. We conducted an interpretive thematic content analysis by inductively coding documents and the extracted data.

RESULTS

We analyzed 25 documents produced between 2013 and 2021. These documents were largely directed at the pharmaceutical industry, as well as shareholders, academics, and governments. The documents constructed the value of the proprietary databases by describing extensive, intimate, detailed patient-level data holdings. They provided examples of how the databases could be used by pharmaceutical companies for regulatory approval, marketing and understanding physician behaviour. The documents constructed the value of these data more broadly by claiming to improve health for patients, while also addressing risks to privacy. Some documents referred to the trade-offs between patient privacy and data utility, which suggests these considerations may be in tension.

CONCLUSION

Documents in our analysis positioned the proprietary databases as socially legitimate and valuable, particularly to pharmaceutical companies. The databases, however, may pose risks to patient privacy and contribute to problematic drug promotion. Solutions include expanding public data repositories with appropriate governance and external regulatory oversight.

Enhancing Primary Care Payments Without Adding Financial Risk

The delivery of primary healthcare in the USA is threatened on multiple fronts. To preserve and strengthen this critical part of the healthcare delivery system, a rapid and broadly accepted change in the basic payment strategy is needed. This paper describes the changes in the delivery of primary health services that demand additional population-based funding and the need to provide sufficient funding to sustain direct provider-patient interaction. We additionally describe the merits of a hybrid payment model that continues to include some level of fee-for-service payment and point to the pitfalls of imposing substantial financial risk on primary care practices, particularly small- and medium-sized primary care practices lacking the financial reserves to sustain monetary losses.

The Role of Primary Care in Improving Population Health

Policy Points Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure. Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges. Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

Taiwan's National Health Insurance at the Emergency Department following the COVID-19 outbreak

Taiwan's National Health Insurance (NHI) is a widely acclaimed universal healthcare system. In the past few years, particularly following the COVID-19 outbreak, challenges related to maintaining the NHI system have surfaced. Since 2020, NHI has faced a series of challenges, including excessive patient visits to the hospital emergency department, a lack of an effective primary care and referral system, and a high turnover rate of healthcare workers. We review major problems related to Taiwan's NHI, emphasizing input from frontline healthcare workers. We provide recommendations for potential policies addressing the concerns around NHI, for example, strengthening the role of primary care services under the NHI administration, reducing the high turnover rate of healthcare workers, and increase the premium and copayments. We hope that this policy analysis may allow policymakers and scholars to understand both the merits and critical problems related to NHI from the clinical perspective.

Evaluation of the implementation of single points of access for unattached patients in primary care and their effects: a study protocol

INTRODUCTION

Attachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients' barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec's 18 administrative regions to implement single points of access for unattached patients (Guichets d'accès première ligne (GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients' experiences of navigation, access and service utilisation.

METHODS AND ANALYSIS

A longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients' experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases.

ETHICS AND DISSEMINATION

This study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l'innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

A Predictive Decision Analytics Approach for Primary Care Operations Management: A Case Study of Double-Booking Strategy Design and Evaluation

Primary care plays a vital role for individuals and families in accessing care, keeping well, and improving quality of life. However, the complexities and uncertainties in the primary care delivery system (e.g., patient no-shows/walk-ins, staffing shortage, COVID-19 pandemic) have brought significant challenges in its operations management, which can potentially lead to poor patient outcomes and negative primary care operations (e.g., loss of productivity, inefficiency). This paper presents a decision analytics approach developed based on predictive analytics and hybrid simulation to better facilitate management of the underlying complexities and uncertainties in primary care operations. A case study was conducted in a local family medicine clinic to demonstrate the use of this approach for patient no-show management. In this case study, a patient no-show prediction model was used in conjunction with an integrated agent-based and discrete-event simulation model to design and evaluate double-booking strategies. Using the predicted patient no-show information, a prediction-based double-booking strategy was created and compared against two other strategies, namely random and designated time. Scenario-based experiments were then conducted to examine the impacts of different double-booking strategies on clinic's operational outcomes, focusing on the trade-offs between the clinic productivity (measured by daily patient throughput) and efficiency (measured by visit cycle and patient wait time for doctor). The results showed that the best productivity-efficiency balance was derived under the prediction-based double-booking strategy. The proposed hybrid decision analytics approach has the potential to better support decision-making in primary care operations management and improve the system's performance. Further, it can be generalized in the context of various healthcare settings for broader applications.

Patient and provider-level drivers of healthcare utilization related to a diagnosis of a precancerous condition: monoclonal gammopathy of undetermined significance (MGUS)

PURPOSE

Monoclonal gammopathy of undetermined significance (MGUS) is the precursor of multiple myeloma. This qualitative study described patient (n = 14) experiences and healthcare providers' (n = 8) opinions and practices concerning care for patients with MGUS in the US.

METHODS

Semi-structured, in-depth interviews were analyzed using thematic analysis.

RESULTS

We identified six overarching themes related to the care pathway for patients with MGUS: (1) Process of MGUS diagnosis, (2) Providers' explanations, (3) Patients' understanding, (4) Impact of the diagnosis, (5) Follow-up/management, and (6) Factors influencing healthcare utilization. Patients demonstrated a basic understanding of MGUS. However, some patients felt anxiety around the diagnosis, which may affect other aspects of their lives. Non-hematologist providers report having less MGUS-specific knowledge. Older age, high-risk MGUS, and insurance coverage/healthcare costs influenced healthcare utilization.

CONCLUSION

Patients with MGUS may have difficulty processing this premalignant diagnosis. Non-hematologist providers may have gaps in knowledge around specific care for patients with MGUS.

Primary Health Care: Our Experience From an Urban Primary Health Care Center in Greece

This observational study reported patient data derived from the emergency files of a primary health care (PHC) center in Greece, with the aim of providing potential solutions for a well-organized, well-structured, and effective social healthcare system. This series was conducted at a single urban PHC center in Greece between August 2017 and March 2020. A total of 83,592 patient visits were registered. The mean patient age was 42.5 years (range: three months to 93 years). Demographics, presenting complaints, and the need for patients who visited the healthcare center to be referred to tertiary hospitals were examined. Further perspectives and future strategies to strengthen the national PHC system were addressed. The most common reasons for visits were pathological (33.6%), followed by general surgery (21.2%) and orthopedics (18.1%). Pediatric conditions accounted for 12% of visits, cardiological conditions accounted for 8.6%, and dental problems accounted for 6.8%. The majority of the patients (n = 81,317, 97.3%) were managed within the health center, and only 2.7% of cases (n = 2275) needed to be referred to a secondary or tertiary healthcare structure. Reasons for patient referral included the severity or complexity of the patient's situation, lack of a specific medical specialty, and the unavailability of overnight laboratory tests. The PHC center remains the cornerstone of a high-quality healthcare system. A well-structured PHC unit can improve health outcomes and decongest secondary and tertiary health care.

Observational Analysis of a Generalized, Health Plan-led Community Health Worker Intervention in Medicaid

INTRODUCTION/OBJECTIVES

In 2018, a Medicaid managed care plan launched a new community health worker (CHW) initiative in several counties within a state, designed to improve the health and quality of life of members who could benefit from additional services. The CHW program involved telephonic and face-to-face visits from CHWs who provided support, empowerment, and education to members, while identifying and addressing health and social issues. The primary objective of this study was to evaluate the impact of a generalized (not disease-specific), health plan-led CHW program on overall healthcare use and spending.

METHODS

This retrospective cohort study used data from adult members who received the CHW intervention (N = 538 participants) compared to those who were identified for participation but were unable to be reached (N = 435 nonparticipants). Outcomes measures included healthcare utilization, including scheduled and emergency inpatient admissions, emergency department (ED) visits, and outpatient visits; and healthcare spending. The follow-up period for all outcome measures was 6 months. Using generalized linear models, 6-month change scores were regressed on baseline characteristics to adjust for between-group differences (eg, age, sex, comorbidities) and an indicator for group.

RESULTS

Program participants experienced a greater increase in outpatient evaluation and management visits (0.09 per member per month [PMPM]) than the comparison group during the first 6 months of the program. This greater increase was observed across in-person (0.07 PMPM), telehealth (0.03 PMPM), and primary care (0.06 PMPM) visits. There was no observed difference in inpatient admissions, ED utilization or allowed medical spending and pharmacy spending.

CONCLUSIONS

A health plan-led CHW program successfully increased multiple forms of outpatient utilization in a historically disadvantaged population of patients. Health plans may be particularly well positioned to finance, sustain, and scale programs that address social drivers of health.

Barriers to COVID-19 vaccine uptake among resource-limited adults diagnosed with chronic illness

Background

Despite the use of interventions (e.g., monetary incentives, educational campaigns, on-site workplace vaccination) to increase COVID-19 vaccination, differences in uptake persist by poverty level, insurance status, geography, race, and ethnicity, suggesting that these interventions may not be adequately addressing the barriers faced by these populations. Among a sample of resource-limited individuals with chronic illnesses, we (1) described the prevalence of different types of barriers to the COVID-19 vaccination and (2) identified associations between patients' sociodemographic characteristics and barriers to vaccination.

Methods

We surveyed a national sample of patients with chronic illness and demonstrated healthcare affordability and/or access challenges about barriers to COVID-19 vaccination in July 2021. We categorized participant responses into cost, transportation, informational, and attitudinal barrier domains and assessed the prevalence of each domain, both overall and by self-reported vaccination status. Using logistic regression models, we examined unadjusted and adjusted associations between respondent characteristics (sociodemographic, geographic, and healthcare access) and self-reported barriers to vaccination.

Results

Of 1,342 respondents in the analytic sample, 20% (264/1,342) reported informational barriers and 9% (126/1,342) reported attitudinal barriers to COVID-19 vaccination. Transportation and cost barriers were reported much less commonly, by only 1.1% (15/1,342) and 0.7% (10/1,342) of the sample, respectively. Controlling for all other characteristics, respondents with either a specialist as their usual source of care or no usual source of care had an 8.4 (95% CI: 1.7-15.1) and 18.1 (95% CI: 4.3-32.0) percentage point higher predicted probability, respectively, of reporting informational barriers to care. Compared to females, males had an 8.4% point (95% CI: 5.5-11.4) lower predicted probability of reporting attitudinal barriers. Only attitudinal barriers were associated with COVID-19 vaccine uptake.

Conclusion

Among a sample of adults with chronic illnesses who had received financial assistance and case management services from a national non-profit, informational and attitudinal barriers were more commonly reported than logistical or structural access barriers (i.e., transportation and cost barriers). Interventions should target attitudinal barriers among patients with chronic illness, who may have particular concerns about the interaction of the vaccine with ongoing medical care. Additionally, interventions targeting informational barriers are particularly needed among individuals without a usual source of care.

Factors related to Japanese internal medicine doctors' retention or migration to rural areas: a nationwide retrospective cohort study

BACKGROUND

Internal medicine (IM) doctors in Japan play the role of primary care physicians; however, the shortage of rural physicians continues. This study aims to elucidate the association of age, sex, board certification, type of work, and main clinical work with the retention or migration of IM doctors to rural areas.

METHODS

This retrospective cohort study included 82,363 IM doctors in 2010, extracted from the national census data of medical doctors. The explanatory variables were age, sex, type of work, primary clinical work, and changes in board certification status. The outcome was retention or migration to rural areas. The first tertile of population density (PD) of municipalities defined as rural area. After stratifying the baseline ruralities as rural or non-rural areas, the odds ratios (ORs) of the explanatory variables were calculated using generalized estimation equations. The analyses were also performed after age stratification (<39, 40-59, ≥60 years old).

RESULTS

Among the rural areas, women had a significantly higher OR for retention, but obtaining board certification of IM subspecialties had a significantly lower OR. Among the non-rural areas, physicians who answered that their main work was IM without specific subspecialty and general had a significantly higher OR, but obtaining and maintaining board certification for IM subspecialties had a significantly lower OR for migration to rural areas. After age stratification, the higher OR of women for rural retention was significant only among those aged 40-59 years. Those aged under 40 and 40-59 years in the non-rural areas, who answered that their main work was IM without specific subspecialty had a significantly higher OR for migration to rural areas, and those aged 40-59 years in the rural areas who answered the same had a higher OR for rural retention.

CONCLUSIONS

Obtaining and maintaining board certification of IM subspecialties are possible inhibiting factors for rural work, and IM doctors whose main work involves subspecialties tend to work in non-rural areas. Once rural work begins, more middle-aged female IM doctors continued rural work compared to male doctors.

Evaluation of a pilot emergency department linkage to care program for patients previously diagnosed with Hepatitis C

There is a significant number of Emergency Department (ED) patients with known chronic hepatitis C virus (HCV) infection who have not been treated with directly acting antivirals. We implemented a pilot ED-based linkage-to-care program to address this need and evaluated the impact of the program using the HCV Care Continuum metrics. Between March 2015 and May 2016, dedicated patient care navigators identified HCV RNA-positive patients in an urban ED and offered expedited appointments with the on-site viral hepatitis clinic. Patient demographics and care continuum outcomes were abstracted from the EMR and analysed to determine significant factors influencing linkage-to-care (LTC) and treatment initiation rates. The ED linkage-to-care program achieved a 43% linkage-to-care rate (165/384), 22% treatment rate (84/384) and 16% sustained virologic response rate (63/384). Significant associations were found between linkage-to-care and increasing age (OR = 1.03), Medicare insurance (OR = 2.21) and having a primary care physician (PCP) (OR = 4.03). For patients who were linked, the odds of initiating treatment were also positively significantly associated with increasing age (OR = 1.04) and having a PCP (OR = 2.77). For patients who initiated treatment, the odds of sustained virologic response were marginally associated with having a PCP (OR = 4.92).Our ED linkage-to-care program utilized care coordination to successfully link nearly half of approached HCV RNA-positive patients to care. This design can be feasibly replicated by other EDs given limited non-clinical training required for linkage-to-care staff. Adoption of similar programs in other EDs may improve the rates of LTC and treatment initiation for previously diagnosed HCV patients.

The Contributions of Population Distribution, Healthcare Resourcing, and Transportation Infrastructure to Spatial Accessibility of Health Care

Population demand, healthcare resourcing, and transportation linkage are considered as major determinants of spatial access to health care. Temporal changes of the 3 determinants would result in gain or loss of spatial access to health care. As a remarkable milestone achieved by Targeted Poverty Reduction Project launched in China, the significant improvements in spatial access to health care served as an ideal context for investigating the relative contributions of these 3 determinants to the changes in spatial access to health care in a rural county. A national level poverty-stricken county, Chishui county from Guizhou province, China, was chosen as our study area. The enhanced two-step floating catchment area model and the chain substitution method were employed for analysis. The relative contributions of the 3 determinants demonstrated variations with villages. The relative contributions of healthcare resourcing were positive in all villages as indicated by sharp increases in healthcare resources. Population changes and transportation infrastructure expansion had both negative and positive effects on spatial access to health care for different villages. Decisionmakers should take into account the duration of travel time spent between where people live, where transport hubs are located, and where healthcare services are delivered in the process of formulating policies toward rural healthcare planning. For villages with poorly-established infrastructure, the optimization of population distribution and healthcare resourcing should be considered as the priority. A stronger marginal effect would be induced by transportation infrastructure expansion with increased spatial accessibility. This study provides empirical evidences to inform healthcare planning in low- and middle-income countries.

Role of Primary Care in Bridging Gaps in the Health Care System for Vulnerable Children in the United States of America: A Sickle Cell Disease Case Study

Sickle cell disease (SCD) is a life-threatening condition. Given the nature of the disease and associated complications with high mortality and morbidity rates, it is imperative that patients are diagnosed in early infancy, are established with specialists and general pediatric care immediately, and receive continuity in care. A percentage of patients diagnosed with SCD fall within a vulnerable, at-risk population. This population may face greater social barriers that lead to missed or late diagnosis and therefore delayed management, significantly increasing the risk of morbidity and mortality. Screening tools such as state newborn screens help to identify the diagnosis early. However, patients in vulnerable, at-risk populations who are not established in the health care system may not receive timely communication about their illness and necessary next steps for care. We present a case of a 12-month-old female who is an example of one of the many patients who despite having undergone newborn screening, fell through the cracks due to social barriers including housing instability, food insecurity, and lack of access to transportation. This paper emphasizes the need for and provides a real example of the benefit of access to longitudinal primary care for vulnerable patients. We also demonstrate the role of primary care in clearing the care gaps and coordinating services quickly to ultimately prevent life-threatening complications specifically for children with previously undiagnosed chronic illnesses.

Experiences of discrimination or violence and health outcomes among Black, Indigenous and People of Colour trans and/or nonbinary youth

AIMS

Identify the relationship between experiences of discrimination or violence and health outcomes for transgender and nonbinary Black, Indigenous and People of Colour (BIPOC) compared to their white trans and nonbinary peers.

DESIGN

A national online survey, the 2019 Canadian Trans and Nonbinary Youth Health Survey, was conducted among youth ages 14-25, in English and French.

METHODS

Participants were recruited from November 2018 to May 2019 (N = 1519). BIPOC youth comprised 25.7% of the sample (n = 390). Questions about six types of discrimination (e.g. racism and sexism) and violence (physically threatened or injured), plus foregone health care, self-harm and suicidality were drawn from existing validated measures. Analyses involved cross-tabulations with chi-square tests and logistic regressions.

RESULTS

Trans and non-binary BIPOC reported significantly higher prevalence of suicide attempts (24.9% vs. 19.5%) and violence victimization compared to white youth. They had significantly higher odds of self-harm and foregone health care when experiencing discrimination by ethnicity or culture. All types of violence were significantly associated with higher odds of foregone physical health care, self-harm, suicide ideation and suicide attempt.

CONCLUSION

In Canada, trans and nonbinary youth who are BIPOC face disparities in health outcomes and experiences of violence and discrimination compared to white trans and nonbinary youth.

IMPACT

Nurses should assess for violence exposure and discrimination among trans and/or nonbinary youth of colour, and promote health equity by advocating for policies to reduce violence and discrimination, including racism, for trans and nonbinary young people.

A qualitative study of challenges and enablers faced by private general practitioners providing primary care to patients with complex needs in Singapore

Background

Singapore faces an ageing population with increasingly complex healthcare needs, a problem which could be addressed by high quality primary care. Many patients with complex needs are not managed by private general practitioners (GPs) who form the majority of the primary care workforce. Currently, there is paucity of literature describing the needs of these private GPs in providing such care.

Aim

Understand the challenges, enablers and possible solutions from the perspective of private GPs in providing primary care of patients with complex needs.

Method

We conducted a qualitative study using an inductive approach. Private GPs were interviewed using a semi-structured question guide with convenience sampling until thematic saturation was reached. These 12 interviewees were part of a network of clinics that provide primary care for complex patients who were recently discharged from a community hospital providing post-acute care. Data was transcribed prior to a process of familiarisation, coded and analysed using thematic analysis by three independent investigators.

Results

Three themes emerged in the analysis. From a micro-organizational standpoint, private GPs and patients with complex needs must be willing to accept each other to have a therapeutic encounter (e.g., patients’ multidimensional needs, GP clinic set-up is simple yet busy). Next, from a meso-organizational view, trust and good communication channels between the referring doctors and private GPs must exist for effective collaboration in managing complex care. Lastly, macro-organizationally, external stakeholders (e.g., policy-makers) should fund care models, which are financially viable to both patients, and private GPs (e.g., via adequate subsidies and renumeration respectively) as such complex care require many resources.

Conclusion

Multiple factors exist which influence the ability of private GPs in Singapore to care for patients with complex needs. Addressing these factors may reduce the over dependence on high-cost hospitals for care delivery in similar healthcare systems.

Can higher spending on primary healthcare mitigate the impact of ageing and non-communicable diseases on health expenditure?

INTRODUCTION

Financing healthcare for ageing populations has become an increasingly urgent policy concern. Primary healthcare (PHC) has been viewed as the cornerstone of health systems. While most research has examined the effects of PHC on population health, there is still a relative paucity of analysis on the effects of PHC on health expenditures, particularly, in low-income and middle-income countries. Knowledge on PHC's potential role in mitigating the impact of ageing and non-communicable diseases (NCDs) on health expenditure remains limited.

METHODS

Using publicly accessible secondary data at country level, this paper examines the impact of ageing and the NCD burden on health expenditures. Regression with the interaction terms is used to explore whether greater expenditures on PHC can mitigate the growing fiscal pressure from ageing and the NCD burden.

RESULTS

The empirical evidence shows that a higher share of PHC spending is correlated with lower per capita non-PHC spending, after controlling for population aged 60 and over and NCD burden, and gross domestic product per capita. However, the mitigating effects of PHC spending to reduce non-PHC expenditure caused by ageing and NCDs are not significant.

CONCLUSIONS

The findings suggest that more PHC spending can potentially lower total health expenditure. However, higher primary health spending cannot fulfil that potential without scrupulous attention to the way it is delivered. More spending on PHC, together with changes in PHC service delivery, highlighting its coordination and referring roles, will put nations on a pathway to achieving universal health coverage more sustainably.

Factors associated with selection of practice in primary care and rural health among medical and nursing students in China

BACKGROUND

China has a shortage of physicians and nurses in primary care and rural health. This study explores factors that influence the choices of medical and nursing students in China to select a career in primary care, or in rural health.

METHODS

A total of 3826 medical students and 1771 nursing students were surveyed in China. Data were analysed using descriptive statistics, Chi-squared tests, and logistic regression models.

RESULTS

The majority of medical and nursing students were willing to practice primary care (55% and 59%, respectively). Yet, only 16% and 5% of medical and nursing students, respectively, desired to work in a village or small city. The most common reasons cited to not practice primary care is the lack of opportunities for clinical skills improvement, academic and personal development, and networking. Medical students who were living in a rural residence between ages 1 and 15years were more likely to report a willingness to work in a rural location (OR: 2.18, 95% CI: 1.33-3.58) or in primary care (OR: 1.72, 95% CI: 1.31-2.25).

CONCLUSION

More efforts are needed to understand how preferences among medical and nursing students influence their career choices and change in choices over time. Understanding the concerns of students can help to tailor interventions in healthcare education and training to increase student satisfaction with their career choice and enrolment counts in medical and nursing fields.

Primary care physicians' awareness and perceptions on adherence to primary cardiovascular disease prevention guidelines in Lebanon: A cross-sectional study

OBJECTIVES

To assess the awareness and have an insight on practice patterns of primary care physicians (PCPs) with respect to several professional primary cardiovascular diseases (CVDs) preventive guidelines.

METHODS

This is a cross-sectional study, questionnaire-based using a non-probability convenience sampling. Data collection occurred at the annual conferences of the Lebanese Societies of General Practice, Family Medicine, and Internal Medicine in Lebanon. 104 PCPs were recruited.

MAIN OUTCOME MEASURES

Awareness and practices of CVDs preventive guidelines.

RESULTS

The response rate was 37%. Awareness of the various CVD preventive guidelines was high among PCPs (&gt;81%). Around 69% of PCPs reported that they always calculate the total cardiovascular risk assessment score. Gaps in managing patients according to guidelines' recommendations were higher in statin initiation compared to antihypertensive initiation. There is over prescription of statin in low risk patients and underutilization in high risk patients. Around 20% of PCPs would initiate aspirin for a low risk patient. Around 17% of physicians do not perform abdominal aortic aneurysm screening.

DISCUSSION

Although PCPs demonstrated high level of awareness regarding CVD preventive guidelines, gaps remain present in managing patients according to guidelines' recommendations. Less adherence to guidelines will increase mortality and affect patient care.

Web-Based Health Information-Seeking Methods and Time Since Provider Engagement: Cross-sectional Study

BACKGROUND

The use of web-based methods to seek health information is increasing in popularity. As web-based health information (WHI)-seeking affects health-related decision support and chronic symptom self-management, WHI-seeking from online sources may impact health care decisions and outcomes, including care-seeking decisions. Patients who are routinely connected to physicians are more likely to receive better and more consistent care. Little is known about whether WHI-seeking impacts the frequency at which patients engage with health care providers.

OBJECTIVE

Our primary objective was to describe the associations between the use of web-based methods to seek information about one's own health and the time since last engaging with a health care provider about one's own health. Additionally, we aimed to assess participants' trust in health care organizations to contextualize our findings.

METHODS

We analyzed data from US adults participating in the nationally representative Tufts Equity in Health, Wealth, and Civic Engagement Survey (N=1034). Bivariate associations between demographic characteristics and health information-seeking methods were assessed with Pearson chi-squared tests. Bivariate associations of Medical Mistrust Index (MMI) scores with each health information-seeking method and time since provider engagement were assessed with F tests and adjusted Wald tests. We fit a multivariable logistic regression model to assess the association between WHI-seeking within the 12 months prior to survey (alone or in combination with provider-based methods versus provider only) and engagement with a provider more than 1 year prior to the time of survey, adjusting for age, race and ethnicity, sex, education, insurance coverage, and MMI.

RESULTS

Age, race and ethnicity, educational attainment, health insurance source, MMI, and time since provider engagement were each significantly associated with the health information-seeking method in bivariate analyses. Compared to using only provider-based health information seeking methods, WHI-based methods alone or in combination with provider-based methods were associated with a 51% lower likelihood (odds ratio 0.49, 95% CI 0.27-0.87) of engaging with a provider within the previous year. Participants who used WHI-seeking methods alone and those who had not engaged with a health care provider within the previous year demonstrated a higher mean MMI score; however, MMI was not a significant predictor of time since engagement with a provider in the multivariable analysis.

CONCLUSIONS

Our findings from a nationally representative survey suggest that for those who use WHI-seeking methods (alone or in combination with provider-based information-seeking methods), there is a statistically significant lower likelihood of engaging with a provider in a year compared to those who only use provider-based methods. Future research should consider the intent of a person's visit with a provider, trust in health care systems, methods of provider engagement, and specific web-based platforms for health information.

Equality and social determinants of spatial accessibility, availability, and affordability to primary health care in Hong Kong, a descriptive study from the perspective of spatial analysis

Objective

Primary health care (PHC) is widely perceived to be the backbone of health care systems. Since the outbreak of COVID-19, PHC has not only provided primary medical services, but also served as a grassroots network for public health. Our research explored the accessibility, availability, and affordability of primary health care from a spatial perspective, to understand the social determinants affecting access to it in Hong Kong.

Method

This constitutes a descriptive study from the perspective of spatial analysis. The nearest neighbor method was used to measure the geographic accessibility of PHC based on the road network. The 2SFCA method was used to measure spatial availability and affordability to primary health care, while the SARAR model, Spatial Error model, and Spatial Lag model were then constructed to explain potential factors influencing accessibility and availability of PHC.

Results

In terms of accessibility, 95% of residents in Hong Kong can reach a PHC institution within 15 minutes; in terms of availability, 83% of residents can receive PHC service within a month; while in terms of affordability, only 32% of residents can afford PHC services with the support of medical insurance and medical voucher. In Hong Kong, education status and household income show a significant impact on accessibility and availability of PHC. Regions with higher concentrations of residents with post-secondary education receive more PHC resources, while regions with higher concentrations of high-income households show poorer accessibility and poorer availability to PHC.

Conclusion

The good accessibility and availability of primary health care reflects that the network layout of existing PHC systems in Hong Kong is reasonable and can meet the needs of most residents. No serious gap between social groups further shows equality in resource allocation of PHC in Hong Kong. However, affordability of PHC is not ideal. Indeed, narrowing the gap between availability and affordability is key to fully utilizing the capacity of the PHC system in Hong Kong. The private sector plays an important role in this, but the low coverage of medical insurance in outpatient services exacerbates the crowding of public PHC and underutilization of private PHC. We suggest diverting patients from public to private institutions through medical insurance, medical vouchers, or other ways, to relieve the pressure on the public health system and make full use of existing primary health care in Hong Kong.

Caregiver perspectives on barriers and facilitators to primary care for autistic adults: A qualitative study

Background

Primary care is associated with greater access to healthcare services and improved health outcomes. However, autistic adults report challenges accessing and utilizing primary care, in addition to unmet healthcare needs. The need to minimize existing barriers and identify strategies to facilitate successful healthcare encounters is increasingly important as autistic adults represent a growing segment of society. Minimal research has examined primary healthcare encounters for this population.

Methods

As part of a larger convergent parallel design mixed-methods study that recruited autistic adults, caregivers of autistic adults, and primary care providers treating autistic adults, interviews were conducted with 31 caregivers of autistic adults. Caregivers were predominantly female (94%), and the autistic adult they cared for were primarily male (87%), with a mean age of 24 years. Thematic analysis was employed to elucidate the barriers to care, suggestions to mitigate challenges, and/or successful strategies implemented during care encounters for autistic adults, as reported by their caregivers.

Results

Reported here are the results only from the caregiver interviews, in which seven themes emerged: (1) finding a primary care provider; (2) patient-provider communication; (3) anxiety due to unpredictability, an overstimulating sensory environment, and waiting time; (4) participation of consumers in the healthcare process; (5) stigma and assumptions about autism; (6) caregiver experiences; and (7) the impact of culture and ethnicity on care.

Conclusion

Findings from this study have the potential to inform the development of, or improve existing, client-centered interventions to improve primary healthcare services for autistic adults.