The impact of primary care: a focused review

Efficient and Effective Diabetes Care in the Era of Digitalization and Hypercompetitive Research Culture: A Focused Review in the Western Pacific Region with Malaysia as a Case Study

There are approximately 220 million (about 12% regional prevalence) adults living with diabetes mellitus (DM) with its related complications, and morbidity knowingly or unconsciously in the Western Pacific Region (WP). The estimated healthcare cost in the WP and Malaysia was 240 billion USD and 1.0 billion USD in 2021 and 2017, respectively, with unmeasurable suffering and loss of health quality and economic productivity. This urgently calls for nothing less than concerted and preventive efforts from all stakeholders to invest in transforming healthcare professionals and reforming the healthcare system that prioritizes primary medical care setting, empowering allied health professionals, improvising health organization for the healthcare providers, improving health facilities and non-medical support for the people with DM. This article alludes to challenges in optimal diabetes care and proposes evidence-based initiatives over a 5-year period in a detailed roadmap to bring about dynamic and efficient healthcare services that are effective in managing people with DM using Malaysia as a case study for reference of other countries with similar backgrounds and issues. This includes a scanning on the landscape of clinical research in DM, dimensions and spectrum of research misconducts, possible common biases along the whole research process, key preventive strategies, implementation and limitations toward high-quality research. Lastly, digital medicine and how artificial intelligence could contribute to diabetes care and open science practices in research are also discussed.

The Primary Care Medical Record Industry in Canada and Its Data Collection and Commercialization Practices

Importance

Massive volumes of health data flow to commercial data brokers worldwide, yet little empirical research has examined how this industry functions and the implications for patients.

Objective

To describe and analyze the primary care medical record industry in Canada and its data collection and commercialization practices.

Design, Setting, and Participants

This qualitative study of the Canadian primary care health data industry used situational analysis, a grounded theory methodology. Data sources included semistructured interviews of individuals affiliated with the commercial health data industry from May 2022 to May 2023 and publicly available documents. Data were analyzed from May 2022 to May 2024.

Main Outcomes and Measures

Individual semistructured interviews and relevant publicly available documents were analyzed to gain an understanding of data collection and commercialization practices in the primary care record industry. The analysis involved a continuous and iterative process of data collection and analysis, theoretical sampling, data-driven coding, and creation of theoretical concepts.

Results

A total of 19 interviews were conducted and 22 documents were sampled. Study participants described the primary care medical record industry in Canada as consisting of complex reciprocal relationships between commercial health data brokers, physicians, for-profit chains of primary care clinics, and pharmaceutical companies. In an emerging vertically integrated business model, the data broker brought the primary care clinics and physicians in house as a clinical subsidiary, thus obtaining more control over clinical practices. Participants understood the primary care medical record industry as having potential to transform patient care, but-because of financial considerations-also tied to pharmaceutical industry interests. According to participants, patients were not involved in decisions related to how their records were collected and used.

Conclusions and Relevance

This qualitative study found that each entity within the Canadian primary care medical record industry contributes to, and benefits from, the conversion of patient medical records into commercial assets. The industry's activities reflect the pharmaceutical companies' interests. Patients are notably absent from decision-making; thus, the industry's activities may not reflect their values or interests.

Colorado integrated behavioral health plus (CIBH+): aligning behavioral health within a generalist approach to primary care

As healthcare costs and physician burnout in the U.S. escalate, and the acuity and prevalence of behavioral health issues hit historical highs, it is critically important that we continue to evolve care approaches that can deliver good health and well-being at the population level. Colorado Integrated Behavioral Health Plus (CIBH+) uses a whole-person health perspective, aligning psychologists, primary care physicians, and other specialists, within a generalist approach to primary care. Here, we document our local experience in services delivery, including the rationale for the CIBH+ approach, key implementation elements, and the ability to mitigate population, patient, and provider challenge by building upon existing clinically-and cost-effective models of integrated care. With this description, we hope to spark optimism, enthusiasm, and ongoing innovation in other multidisciplinary care teams seeking ways to improve patient and provider experience.

Validity and Reliability Study of the Turkish Adaptation of the "Medical Office Survey on Patient Safety Culture"

INTRODUCTION

The safety culture within health care organizations is essential for ensuring patient well-being and optimizing health care delivery. This study addresses the pressing need to establish a culture of patient safety within primary health care settings. The aim is to conduct a comprehensive validity and reliability study for the Turkish adaptation of the "Medical Office Survey on Patient Safety Culture" (MOSPSC) scale, designed to assess patient safety culture in primary care medical offices.

METHODS

The research model follows rigorous methodology, including a systematic translation and adaptation process aligned with World Health Organization guidelines. A diverse sample of 402 family physicians from primary health care centers across Turkey participated in the study. Descriptive results highlight participants' characteristics, work environments, and experiences in primary care. The scale's construct validity is evaluated using the Kaiser-Meyer-Olkin (KMO) and Bartlett tests, while its reliability is assessed through internal consistency analyses, including Cronbach α, split-half reliability, and item-total correlation.

RESULTS

Results indicate strong internal consistency, with Cronbach α values ranging from 0.42 to 0.91 for scale dimensions and an overall value of 0.89. Construct validity assessment attests to the scale's appropriateness for assessing patient safety culture. Challenges in conducting factor analysis due to participant responses are discussed.

CONCLUSIONS

The study contributes to the field by providing a validated and reliable tool specifically tailored for assessing patient safety culture in primary care medical offices. The Turkish adaptation of the MOSPSC scale offers health care professionals and organizations a valuable instrument for enhancing patient safety culture, identifying areas for improvement, and ultimately optimizing patient care within primary health care settings.

Feasibility and Acceptability of the "About Me" Care Card as a Tool for Engaging Older Adults in Conversations About Cognitive Impairment

PURPOSE

We aimed to address fears and lived experiences of cognitive decline among adults via whole-person conversations that elicit problems and goals that matter most to patients. Currently, 6.7 million Americans have Alzheimer disease or related dementias, with an additional 28 million people reporting subjective cognitive decline-a possible indicator of Alzheimer disease and related dementias. A review of tools for older adults with cognitive impairment showed strong clinical specificity, with insufficient whole-person support for patients. We developed and tested the feasibility and acceptability of a tool to enhance conversations for adults with cognitive impairment at the point of care.

METHODS

We conducted a feasibility study to build a conversation tool, guided by principles of shared decision making, called the "About Me" Care Card. Informed by an environmental scan, we created and pilot-tested prototypes at implementation sites. All phases were overseen by a multidisciplinary steering committee.

RESULTS

Fourteen diverse clinicians consisting of 7 clinician types across 7 institutions piloted the card during in-person visits or by telephone. Observations showed that the card (1) allowed time to elicit what matters most to patients, (2) created space for personalized care conversations, (3) opened an examination of social care needs, and (4) moderated emotional relationships between families and individuals.

CONCLUSION

A community-based codesign process led to a feasible tool for primary care teams to facilitate whole-person conversations with aging adults. The About Me Care Card appeared to broaden conversations compared with routine care. More work is needed to determine scalability and effects on outcomes.

Changing primary care capacity in Canada: protocol for a cross-provincial mixed methods study

INTRODUCTION

Despite having more family physicians (FPs) and nurse practitioners (NPs) per capita than ever before in Canada, there is a clear gap between population primary care needs and system capacity. Primary care needs may be shaped by population ageing, increasing clinical and social complexity and growing service intensity. System capacity may be shaped by falling practice volumes, increasing administrative workload, changing clinician demographics and new health system roles (eg, hospitalist and focused practices). These changing factors could contribute to reduced patient access to primary care, worsened health inequities and stress and overwork among primary care clinicians. Workforce planning tools used in most countries do not adequately consider these factors. Our study will identify and explore factors shaping population service use and system capacity over time and develop planning tools to estimate future primary care needs and capacity.

METHODS AND ANALYSIS

We will interview FPs and NPs about factors shaping workload, including patient characteristics, practice expectations and system context. This will inform analysis of administrative data to describe factors shaping primary care need (patient demographics, clinical and social complexity, service intensity) and capacity (provider supply, demographics, service volume, roles) over a 20-year period from 2004/2005 to 2023/2024. Qualitative and quantitative findings will inform analytical models that project and compare need and capacity under stakeholder-informed scenarios. The study includes the Canadian provinces of British Columbia, Manitoba, New Brunswick and Nova Scotia, provinces with varied policy and population contexts and complementary administrative health data.

ETHICS AND DISSEMINATION

Research ethics board (REB) approval for the qualitative study has been provided by Research Ethics BC, with subsequent approvals from Horizon Health Network, Nova Scotia Health, University of Manitoba and University of Ottawa. REB approval for analysis of linked administrative data was obtained from the Nova Scotia Health REB, Research Ethics BC, University of Manitoba and University of New Brunswick. Our findings will support primary care capacity planning to equitably meet the needs of a growing and ageing population.

Use of patient-reported outcome measures (PROMs) in primary care-based mental health programming: an environmental scan of Alberta, Canada

Background

Many Primary Care Networks (PCNs) in Alberta collect Patient Reported Outcome Measures (PROMs) to support patient-centered care. However, there is limited knowledge on what tools are currently being administered across PCNs and how the data is used. For this study, we focused on PROMs for mental health programming (MHP). Our objectives are to identify what PROMs are currently being administered in PCNs and what domains they measure for MHP; understand PCNs’ capacity to implement and use PROMs data effectively for their PCN MHP; describe how PROMs are currently being reported in PCNs for MHP; and understand the feasibility of having standardized and consistent measurement of PROMs in general across PCNs.

Methods

This environmental scan employs a survey for PCN evaluators (those responsible for managing PROMs data for their PCN), tailored to examine PROMs in PCN MHP across all populations. Evaluators from all 39 Alberta PCNs were invited to complete the survey on behalf of their PCN. It included closed and open-ended questions. Survey results were aggregated and reported by objective.

Results

Evaluators from 20 PCNs (51%) completed the survey, with a mix of rural/urban and across all five health zones. Nine out of 20 reported 11 tools currently being collected and seven out of nine reported using more than one tool for MHP. The most used tools were the EQ-5D-5 L (7/9) and PHQ-9 (6/9). Seven respondents indicated the EQ-5D-5Lwas useful or sometimes useful; five reported the PHQ-9 was useful or sometimes useful. While the use of each PROM varied, most PROMs are used for clinical care decisions and internal reporting. Most respondents indicated standardizing PROMs across PCNs would be challenging, however having alignment of PROMs and sharing best practices for PCNs would be beneficial.

Conclusions

These results provide a better understanding of the current use of PROMs in PCNs, specific to MHP, which will be further examined through future narrative conversations. Overall, this study informs primary care leadership on the current use of PROMs and supports the advancement of PROMs use in Alberta.

Examining health determinants and outcomes of older adults across Ghana's North-South divide

Healthcare services and outcomes are often not evenly distributed across geographic regions. This study used the harmonized data from the Research on Early Life and Trends and Effects (RELATE) to compare the health outcomes of older adults across the North-South divide of Ghana and identify the factors underlying these differences. Although the literature indicates that the South has more health resources and better health indicators, the current study revealed that, for older adults, health outcome in the North was comparatively better than that in the South. The optimal health index scores show that older adults in the North are living at 86% of their optimal health compared with 82% in the South. Work-related physical activity and age substantially influenced optimal health in both regions. Additionally, healthcare use and gender were influential, particularly in the South. The results of the current study suggest that healthcare service availability can impact health outcomes, but so can behavioral and sociodemographic factors.

Comprehensiveness in Primary Care: A Scoping Review

Policy Points Efforts to address a perceived decline of comprehensiveness in primary care are hampered by the absence of a clear and common understanding of what comprehensiveness means. This scoping review mapped two domains of comprehensiveness (breadth of care and approach to care) as well as a set of factors that enable comprehensive practice. The resulting conceptual map supports greater clarity for future use of the term comprehensiveness, facilitating more precisely targeted research, practice, and policy efforts to improve primary care systems.

CONTEXT

Associated with system efficiency and patient-perceived quality, comprehensiveness is widely recognized as foundational to high-quality primary care. However, there is concern that comprehensiveness is declining and that primary care physicians are providing a narrower range of services. Efforts to address this perceived decline are hampered by the many different and sometimes vague definitions of comprehensiveness in current use. This scoping review explored how comprehensiveness in primary care is conceptualized and defined in order to map its attributes in support of being able to more clearly and precisely define this key concept in research, practice, and policy.

METHODS

We conducted a scoping review, following the methods of Arksey and O'Malley and Levac and colleagues. The search included terms for two key concepts: primary care and comprehensiveness. Developed in Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), the search was adapted for Cumulated Index in Nursing and Allied Health Literature (CINAHL) and Embase, as well as for gray literature. After a multistep review, included sources underwent detailed data extraction.

FINDINGS

A total of 360 sources were extracted; 57% were empirical studies and 65% were published between 2010 and 2022. Across these sources, we identified nine attributes of comprehensiveness in primary care. We mapped these attributes into two conceptual domains: breadth of care (services, settings, health needs and conditions, patients served, and availability) and approach to care (one-stop shop, whole-person care, referrals and coordination, and longitudinal care). Additionally, we identified three enablers of comprehensiveness, namely structures and resources, teams, and competency.

CONCLUSIONS

The conceptual map of comprehensiveness in primary care offers a valuable tool that supports clarity for future use of the term comprehensiveness. The domains and attributes we identified can be used to develop definitions and measures that are appropriate to research, practice, and policy contexts, enabling more precise efforts to improve primary care systems.

Patient Satisfaction with Primary Health Care Services in Riyadh, Saudi Arabia

Background

Patient satisfaction emerges as an indicator for enhancing the quality of health organizations, facilitating the evaluation and identification of the most significant characteristics of patient experience and their corresponding satisfaction levels. This can guide decisions to improve healthcare services and develop policies for better care. This study seeks to assess the level of patient satisfaction with primary healthcare (PHC) services in a large military hospital in Riyadh, Saudi Arabia, and to determine the extent of association between the level of satisfaction and patients' social and demographic factors.

Methods

A cross-sectional study was carried out on a convenient sample who received primary health care at the Security Forces Hospital in Riyadh, Saudi Arabia, between January and June 2023. Comparisons between qualitative variables were made using the chi-square to test significance and the One-Way ANOVA test was used to compare the means of total patient satisfaction scores, p < 0.05 was considered significant.

Results

Among the 379 participants, 268 (70.7%) were males, 271 (71.2%) were married, 222 (58.6%) were military personnel, and 207 (54.6%) were between the ages of 31 and 49. The average satisfaction with PHC clinics was 52.1 (SD=4.9, highest score=60) while the average satisfaction with general evaluation was 27.6 (SD=3.4, highest score=35). Male participants exhibited greater satisfaction levels (M= 117.8, SD=12.8) than their female counterparts (M= 115.7, SD=15.3, p-value = 0.01). Patients aged 18-30 had greater satisfaction levels (M= 117.5, SD=16.8, p-value = 0.02). Individuals who were single reported higher levels of satisfaction (M= 118.3, SD=16.2, p-value = 0.001). Participants with lower earnings (less than 5000 SR) had greater satisfaction levels compared to individuals having a greater income (p-value = 0.002).

Conclusion

Patients attending a PHC center in a large military hospital in Riyadh generally reported high levels of satisfaction, particularly among male, single, younger, and low-income individuals. Despite these favorable results, several aspects of healthcare need enhancement to fulfill patient expectations and guarantee optimal healthcare provision. Therefore, healthcare practitioners must persist in determining and addressing these areas to guarantee that patients obtain optimal care and experience in primary healthcare clinics.

Addressing Diabetes Distress in Primary Care: Where Are We Now, and Where Do We Need to Go?

PURPOSE OF REVIEW

Addressing diabetes distress (DD), the emotional demands of living with diabetes, is a crucial component of diabetes care. Most individuals with type 2 diabetes and approximately half of adults with type 1 diabetes receive their care in the primary care setting. This review will provide guidance on addressing DD and implementing targeted techniques that can be tailored to primary care patients.

RECENT FINDINGS

Structured educational, behavioral, and emotion-focused techniques have promise for treating DD. These interventions are unlikely to require advanced training and can be feasibly integrated into primary care settings without creating additional burdens on time or resources. Interventional studies examining treatment for DD are limited, leaving a gap for clear direction and consensus on how to target and treat DD in primary care patients. This review consolidates recommendations and approaches from recent findings on how to treat DD within the context of primary care.

Primary care functional features and their health impact on patients enrolled in the Shanghai family doctor service: a mixed-methods study

Background

While research in multiple countries confirms that primary care functional features significantly improve patient health, China's primary care system differs markedly due to unique structural and contextual factors. This study aims to measure and explore the functional features experienced by patients received family doctor contract service in the past year, evaluating the impacts and pathways of these primary care features on health outcomes.

Methods

We employed a mixed-methods explanatory sequential design. In the quantitative phase, we randomly selected 2118 residents from 12 primary care institutions. The intensity of functional features was assessed using the Person-Centered Primary Care Measure (PCPCM), and their association with levels of EuroQol Visual Analogue Scale (EQ VAS) was evaluated through multilevel modelling. In the qualitative phase, a qualitative description approach was used, conducting 24 focus groups with a total of 85 patients to gather in-depth information about their experiences with functional features and perceived health impacts. Finally, the quantitative and qualitative data were integrated using meta-synthesis and joint display methods to validate, interpret, and expand the results.

Results

The average PCPCM score was 3.65, with subdomain scores ranging from 3.39 to 3.83. Qualitative findings confirmed the quantitative results regarding the intensity and manifestation of features like accessibility, coordination, and relationship-building. However, discrepancies were noted in features such as comprehensiveness, integration, and family and community context. Additionally, two new functional features, 'being appreciated' and 'being cared for,' were identified. The quantitative results also showed that higher PCPCM scores were positively associated with EQ VAS levels (odds ratio (OR) = 1.18; 95% confidence interval (CI) = 1.03-1.35, P < 0.001). Furthermore, qualitative results revealed six key pathways supporting the beneficial effects of local primary care functional features on health maintenance and improvement.

Conclusions

This study demonstrates high functional scores for Shanghai's family doctor services and highlights a positive association between primary care functionality and population health. These features and their health benefits are deeply shaped by the local social and health care context. This confirms the progress of Shanghai's primary care development and underscores the need for further exploration of primary care functional features across China, along with the development of tools tailored to local conditions to better measure and improve primary care quality and health outcomes.

Keywords

primary healthcare; primary care; quality measurement; population health; mixed method research; China.

Business Venturing in Regulated Markets-Taxonomy and Archetypes of Digital Health Business Models in the European Union: Mixed Methods Descriptive and Exploratory Study

BACKGROUND

Digital health technology (DHT) has the potential to revolutionize the health care industry by reducing costs and improving the quality of care in a sector that faces significant challenges. However, the health care industry is complex, involving numerous stakeholders, and subject to extensive regulation. Within the European Union, medical device regulations impose stringent requirements on various ventures. Concurrently, new reimbursement pathways are also being developed for DHTs. In this dynamic context, establishing a sustainable and innovative business model around DHTs is fundamental for their successful commercialization. However, there is a notable lack of structured understanding regarding the overarching business models within the digital health sector.

OBJECTIVE

This study aims to address this gap and identify key elements and configurations of business models for DHTs in the European Union, thereby establishing a structured understanding of the archetypal business models in use.

METHODS

The study was conducted in 2 phases. First, a business model taxonomy for DHTs was developed based on a systematic literature review, the analysis of 169 European real-world business models, and qualitative evaluation through 13 expert interviews. Subsequently, a 2-step clustering analysis was conducted on the 169 DHT business models to identify distinct business model archetypes.

RESULTS

The developed taxonomy of DHT business models revealed 11 central dimensions organized into 4 meta-dimensions. Each dimension comprises 2 to 9 characteristics capturing relevant aspects of DHT business models. In addition, 6 archetypes of DHT business models were identified: administration and communication supporter (A1), insurer-to-consumer digital therapeutics and care (A2), diagnostic and treatment enabler (A3), professional monitoring platforms (A4), clinical research and solution accelerators (A5), and direct-to-consumer wellness and lifestyle (A6).

CONCLUSIONS

The findings highlight the critical elements constituting business models in the DHT domain, emphasizing the substantial impact of medical device regulations and revenue models, which often involve reimbursement from stakeholders such as health insurers. Three drivers contributing to DHT business model innovation were identified: direct targeting of patients and private individuals, use of artificial intelligence as an enabler, and development of DHT-specific reimbursement pathways. The study also uncovered surprising business model patterns, including shifts between regulated medical devices and unregulated research applications, as well as wellness and lifestyle solutions. This research enriches the understanding of business models in digital health, offering valuable insights for researchers and digital health entrepreneurs.

Over-the-Counter Hearing Aids: A Nationwide Survey Study to Understand Perspectives in Primary Care

OBJECTIVES

The expansion of over-the-counter (OTC) hearing aids has raised inquiries regarding primary care physicians' (PCP) knowledge, perspective, and perceived roles. We aimed to understand PCP perspectives on OTC hearing aids via nationwide online surveys.

METHODS

RedCap survey was distributed to PCPs via online forums and public mailing lists. Outcomes included PCPs' attitudes toward, perceived role surrounding, confidence managing, and knowledge of OTC hearing aids. Regression analyses were performed to identify associated factors including demographics and practice characteristics.

RESULTS

Cohort included 111 PCPs primarily working in non-rural (83.8%) outpatient academic medical centers (47.5%), with a mean (SD) of 16.9 (11.6) years practicing. Most reported unfamiliarity (61.3%) with OTC hearing aids but viewed them positively (91.9%). They often perceived themselves as poor sources of OTC hearing aid information (63.1%) but desired involvement (90.1%) and believed associated knowledge is important (98.2%). Rural practice environment was associated with less familiarity toward OTC hearing aids (β = -0.72, [95% CI -1.40 to -0.04]). Respondents answered 5.0 (2.4) of 10 OTC hearing aid knowledge questions correctly. Using 5-point Likert scale, participants reported most confidence recognizing signs/symptoms of hearing loss 3.71 (0.84), but less confidence educating 1.68 (0.96) about and determining candidacy 1.72 (1.05) for OTC hearing aids. Participants reported continuing medical education courses and published guidelines would effectively improve their OTC hearing aid knowledge.

CONCLUSION

PCPs displayed positive attitudes toward OTC hearing aids and valued involvement. Addressing unfamiliarity/knowledge gaps surrounding OTC hearing aids through courses and published guidelines may help clarify misconceptions and promote hearing health care.

LEVEL OF EVIDENCE

NA Laryngoscope, 135:299-307, 2025.

Opportunities and Challenges for Large Language Models in Primary Health Care

Primary Health Care (PHC) is the cornerstone of the global health care system and the primary objective for achieving universal health coverage. China's PHC system faces several challenges, including uneven distribution of medical resources, a lack of qualified primary healthcare personnel, an ineffective implementation of the hierarchical medical treatment, and a serious situation regarding the prevention and control of chronic diseases. The rapid advancement of artificial intelligence (AI) technology, large language models (LLMs) demonstrate significant potential in the medical field with their powerful natural language processing and reasoning capabilities, especially in PHC. This review focuses on the various potential applications of LLMs in China's PHC, including health promotion and disease prevention, medical consultation and health management, diagnosis and triage, chronic disease management, and mental health support. Additionally, pragmatic obstacles were analyzed, such as transparency, outcomes misrepresentation, privacy concerns, and social biases. Future development should emphasize interdisciplinary collaboration and resource sharing, ongoing improvements in health equity, and innovative advancements in medical large models. There is a demand to establish a safe, effective, equitable, and flexible ethical and legal framework, along with a robust accountability mechanism, to support the achievement of universal health coverage.

The Transformative Care Continuum: implementing an accelerated pathway that addresses the new roles of the family medicine physician

BACKGROUND

The Transformative Care Continuum (TCC) emerged in 2018 at Ohio University's Heritage College of Osteopathic Medicine, combining a three-year medical education track with a three-year family medicine residency. TCC aligns evolving family physician roles through the Kern model, AMA's Master Adaptive Learner model, Health Systems Science Training, and Kirkpatrick's evaluation model.

METHODS

The TCC curriculum emphasizes intensive coaching, clinical encounter video evaluation, reflection, and case-log review. It fosters longitudinal clinical integration, community engagement, and a dynamic learning atmosphere. Students receive rigorous patient-centered communication training and engage in residency-based quality improvement projects, targeting care gap closure and community health in an accelerated 3-year program.

OUTCOMES

Assessment of TCC graduates demonstrates advanced team communication, leadership, and project management skills, with entrustable professional activities (EPA) scores meeting or surpassing those of traditional program graduates. Projects led by students have yielded notable clinical enhancements, national recognition, and significant philanthropic funding for non-medical determinants of health. Finally, there is an overall increase in scholarly activity and leadership roles within the residency programs that have engaged these students.

DISCUSSION

Lessons reveal intrinsic challenges and heightened academic demands for students and residency programs. Additional educational support for students may be necessary, though costly. Limitations in residency slots and faculty availability as student educators potentially hinder scalability. Ongoing faculty training, cultural support, and early integration of digital systems for curriculum management and evaluation are vital for success. Obtaining patient satisfaction, health outcomes, and program measures remains challenging due to privacy concerns and approval processes between institutions.

CONCLUSION

Programs like TCC effectively prepare students for family physician leadership and change management roles through tailored learning, longitudinal experiences, health systems training, and addressing critiques of traditional medical education. Continuous feedback and robust communication strategies are essential for program improvement, fostering well-prepared family physicians committed to health system enhancement.

Improving GPs' Emotional Intelligence and Resilience to Better Manage Chronic Respiratory Diseases Through an Experiential Online Training Intervention: A Mixed Methods Study

BACKGROUND/OBJECTIVES

High levels of emotional intelligence (EI) and resilience in primary care physicians (PCPs) can help them communicate better with patients, build stronger relationships with colleagues, and foster a positive and collaborative workplace. However, studies have indicated that primary care physicians (PCPs) often do not focus enough on developing these skills. Consequently, the purpose of this mixed methods study was to evaluate the effectiveness of an experiential online training (EOT) intervention in enhancing the EI and resilience of PCPs who treat patients with chronic respiratory diseases (CRDs).

METHODS

A total of 46 PCPs from Greece participated in a 25-hour EOT program, which focused on counseling skills for lifestyle change and breathing techniques for self-regulation. Quantitative data were collected using the Trait Emotional Intelligence Questionnaire-Short Form (TEIQue-SF) and the Connor-Davidson Resilience Scale (CD-RISC-25) before, immediately after, and three months post-intervention. Additionally, qualitative data were obtained through written reflections from participants regarding their clinical practice.

RESULTS

The results revealed significant improvements in EI and resilience scores immediately after the intervention (ΕΙ: 5.13, SD: 0.65 vs. 5.3, SD: 0.57, p = 0.007; resilience: 76.6, SD: 11.75 vs. 79.83, SD: 10.24, p = 0.029), as well as at the three-month follow-up (ΕΙ: 5.3, SD: 0.57 vs. 5.36, SD: 0.48, p = 0.007; resilience: 79.83, SD: 10.24 vs. 81.03, SD: 7.86, p = 0.029). The thematic analysis of qualitative data identified improvements in five key themes: communication skills, stress management, emotional awareness, resilience, and patient care. Participants reported feeling more confident, empathetic, and effective when interacting with patients, particularly those from diverse backgrounds. The convergence of the quantitative and qualitative findings showed the efficacy of the EOT intervention in enhancing PCPs' EI, resilience, well-being, and, ultimately, their practice.

Awareness, Availment, and Satisfaction on various Health Services among Residents of a Rural Community in Samar, Philippines: A Mixed Methods Study

Objectives

This study sought to investigate citizens' awareness, availment, satisfaction, and perceived need for action with health services offered by a rural municipality in Samar, Philippines.

Methods

This study utilized an explanatory-sequential research design, involving 150 participants selected through the Kish Grid Method via a multi-stage sampling approach within the community. The Citizen Satisfaction Index System was employed to assess the levels of awareness, utilization, and satisfaction with health services in the municipality.

Results

Among the assessed health services, the cohort had low awareness and low availment on services for communicable diseases, basic dental/oral hygiene, and reproductive health. While high awareness was observed for childbirth services, there was low availment on these. The participants showed high awareness and availment for only two services namely, free general consultation and the free medicine program. While high satisfaction was seen among all services that were assessed, the participants also expressed a high perceived need for action to improve their delivery.

Conclusion

This study presents a comprehensive view of rural healthcare in Samar, Philippines. Despite high satisfaction rates, gaps persist in the citizen's awareness and availment due to accessibility, costs, fear, misinformation, and cultural differences. The findings of this study can guide policymakers in identifying gaps in healthcare in rural areas.

Consensus on COVID-19 vaccine recommendations: Challenges and strategies for high-risk populations in Taiwan

The COVID-19 pandemic has had a profound impact globally, particularly in high-risk populations such as those with underlying health conditions. In response to the evolving pandemic landscape and the recent surge in confirmed cases in Taiwan, the Taiwan Association of Family Medicine (TAFM) established a consensus on COVID-19 vaccine recommendations for vulnerable groups through a comprehensive literature review, expert panel discussions, and a practice-oriented formulation procedure to develop evidence-based guidance. Its key findings highlight the increased risk of severe COVID-19 outcomes among individuals with disorders such as diabetes, obesity, chronic kidney disease, cardiovascular disease, and respiratory illness. It emphasizes the safety and effectiveness of COVID-19 vaccines, particularly mRNA vaccines, in these high-risk populations. It particularly underscores the critical role of family medicine physicians in the COVID-19 response, including routine screening, health education, vaccination delivery, and continuous research to optimize strategies. Ongoing monitoring, adaptation, and collaborative efforts will be essential to ensure the continued effectiveness of these recommendations in the evolving COVID-19 landscape. In conclusion, the TAFM consensus recommendations provide a robust framework to guide healthcare providers and policymakers in tailoring vaccination efforts to address the unique needs of vulnerable groups in Taiwan and are an applicable template for neighboring countries.

Food insecurity is associated with greater difficulty accessing care among people living with HIV with or without comorbid non-communicable diseases in western Kenya

INTRODUCTION

The relationship between food insecurity and access to healthcare in low-resource settings remains unclear. Some studies find that food insecurity is a barrier to accessing care, while others report that food insecurity is associated with a greater need for care, leading to more care utilisation. We use data from the Harambee study in western Kenya to assess the association between food insecurity and difficulty accessing care among people living with HIV (PLWH) with or without comorbid non-communicable diseases (NCDs).

METHODS

The Harambee study is a cluster randomised trial that tested the effectiveness of delivering integrated HIV and NCD care for PLWH. In this cross-sectional analysis, we examined baseline data from Harambee participants to investigate the relationship between household food insecurity and difficulty accessing care, using multivariable logistic regression models, controlling for sociodemographic factors and care satisfaction. We tested for effect measure modification by gender and household wealth and stratified analyses by NCD status.

RESULTS

Among 1039 participants, 11.1% reported difficulty accessing care, and 18.9% and 51.9% of participants had moderate and severe food insecurity, respectively. Among those with difficulty accessing care, 73.9% cited transportation issues as the major barrier. Difficulty accessing care was greater with higher levels of food insecurity: among participants with low, moderate and severe food insecurity, 5.9%, 9.7% and 14.4% reported difficulty accessing care, respectively. After adjusting for confounders, severe food insecurity was independently associated with difficulty accessing care (adjusted OR=2.5, 95% CI 1.4 to 4.4). There was no statistical evidence for effect measure modification by gender or wealth.

CONCLUSIONS

We found that greater food insecurity was associated with greater difficulty accessing care among PLWH with or without NCDs in rural western Kenya. These findings suggest that addressing social determinants of health may be necessary when implementing integrated HIV and NCD care programmes.

The Role of Primary Care in Achieving Life's Essential 8: A Scientific Statement From the American Heart Association

To reduce morbidity and mortality rates of cardiovascular disease, an urgent need exists to improve cardiovascular health among US adults. In 2022, the American Heart Association issued Life's Essential 8, which identifies and defines 8 health behaviors and factors that, when optimized through a combination of primary prevention, risk factor management, and effective treatments, can promote ideal cardiovascular health. Because of its central role in patient care across the life span, primary care is in a strategic position to promote Life's Essential 8 and improve cardiovascular health in the United States. High-quality primary care is person-centered, team-based, community-aligned, and designed to provide affordable optimized health care. The purpose of this scientific statement from the American Heart Association is to provide evidence-based guidance on how primary care, as a field and practice, can support patients in implementing Life's Essential 8. The scientific statement aims to describe the role and functions of primary care, provide evidence for how primary care can be leveraged to promote Life's Essential 8, examine the role of primary care in providing access to care and mitigating disparities in cardiovascular health, review challenges in primary care, and propose solutions to address challenges in achieving Life's Essential 8.

Changes in location and number of nurse consultations as the supply of general practitioners decreases in primary health care: six-year register-based follow-up cohort study in the city of Vantaa, Finland

OBJECTIVE

To investigate whether the location and the number of nurse consultations have changed in response to the continuously decreasing number of GP consultations in the fourth-largest city in Finland. It has been suggested that nurse consultations are replacing GP consultations.

DESIGN

A retrospective register-based follow-up cohort study.

SETTING

Public primary health care in the City of Vantaa, Finland.

SUBJECTS

All documented face-to-face office-hour consultations with practical and registered nurses, and consultations with practical and registered nurse in the emergency department of Vantaa primary health care between 1 January 2009 and 31 December, 2014.

MAIN OUTCOME MEASURES

Change in the number of consultations with practical and registered nurses between 2009 and 2014 in primary health care both during office-hours and in the emergency department.

RESULTS

Over the follow-up period, the monthly median number of practical nurse consultations in the emergency department per 1000 inhabitants increased from 1.6 (interquartile range [IQR] 1.3-1.7) to 10.5 (10.3-12.2) (p < 0.001) and registered nurse consultations from a median of 3.6 (3.0-4.0) to 14.5 (13.0-16.6) (p < 0.001). However, there was no significant change in the median monthly number of office-hour consultations with practical or registered nurses.

CONCLUSIONS

It appears that in primary health care, medical consultations have shifted from GPs to nurses with lower education levels, and from care during office-hours to emergency care.

Whole Health Revolution: Value-Based Care + Lifestyle Medicine

An outdated and burdensome fee-for-service (FFS) reimbursement system has significantly compromised primary care delivery in the US for decades, leading to a dire shortage of primary care workers. Support for primary care must increase from all public and private payers with well-designed value-based primary care payment. Patient care enabled by value-based payment is typically described or "labeled" as value-based care and commonly viewed as distinctly different from other models of care delivery. Unfortunately, labels tend to put individuals in camps that can make the differences seem greater than they are in practice. Achieving the aims of value-based care, aligned with the quintuple aims of health care, is common across many delivery models. The shrinking primary care workforce is too fragile to be fragmented across competing camps. Seeing the alignment across otherwise separate disciplines, such as lifestyle medicine and value-based care, is essential. In this article, we point to the opportunities that arise when we widen the lens to look beyond these labels and make the case that a variety of models and perspectives can meld together in practice to produce the kind of high-quality primary care physicians, care teams, and patients are seeking.

Factors associated with patients' experience of access to their multidisciplinary primary health care clinic: A multilevel analysis

BACKGROUND

Understanding patients' experiences accessing primary health care (PHC) is necessary to improve service organisation. This study aims to examine individual, organisational, and contextual factors associated with patients' experience of accessing the multidisciplinary PHC clinic to which they are attached.

METHODS

This cross-sectional study builds on survey data collected in multidisciplinary PHC clinics located in 14 regions in the province of Quebec (Canada). Between September 2022 and June 2023, an online questionnaire was sent to patients with an email contact and attached to a family physician. Two patient-reported experience measures were assessed: (1) difficulty obtaining an appointment with their regular family physician or nurse practitioner and (2) perceived unmet healthcare needs. A self-reported online questionnaire based on the advanced access model was also sent to PHC professionals and administrative staff to assess the use of advanced access strategies in their practice. Multilevel logistic regression models were fit. Stratified analyses were conducted according to the number of consultations received.

FINDINGS

In total, 122,397 patients and 847 family physicians, 97 nurse practitioners and 347 administrative staff nested into 104 clinics answered the survey. In the overall sample, having a chronic disorder was the only individual factor associated with the patient experience of access. Organizational factors including estimation of demand and supply, use of a referral algorithm, and strategies to optimise consultations were associated with a better access experience. Patients from medium size clinics compared to small clinics had better experiences of care for both outcomes. Stratified analysis indicated similar results for patients who consulted at the clinic 1-5 times in the last 12 months as observed in the overall sample.

CONCLUSIONS

This study indicates that enhancing organizational processes can improve patients' access experiences.

Organizational innovations related to Primary Care Access Points (GAP) for unattached patients in Quebec: a multi-case qualitative study

BACKGROUND

Being attached to a primary care (PC) provider is at the core of a strong primary health care system. Centralized waiting lists (CWL) for unattached patients have been implemented in eight provinces of Canada to support the attachment process. In Quebec, the Ministry of Health mandated the implementation of Primary Care Access Points (GAP) across the province to help unattached patients navigate the health system while awaiting attachment through the CWL. Several local health territories developed complementary innovations to the GAP to respond to local population needs. This paper aims to describe five organizational innovations implemented locally.

METHODS

This multi-case qualitative study was conducted in four local health territories in the province of Quebec. Fifty-two semi-structured interviews with healthcare managers, nurses, physicians, other health professionals and administrative staff were conducted between April 2023 and April 2024. An interview guide was developed based on existing frameworks on the implementation of innovations and the evaluation of the GAP. Thematic analysis was conducted using NVivo software. Inductive and deductive approaches were used to develop relevant codes and themes. Logic models were built to describe the organizational innovations.

RESULTS

Five organizational innovations are described. First, a multidisciplinary clinic aimed at responding to patients with mental health issues was implemented. Second, a nurse clinic was implemented to provide temporary care for patients with unstable chronic illnesses. The third innovation is a mobile proximity clinic where unattached GAP patients are first evaluated by a paramedic before receiving care from a nurse. Fourth, a pharmacist trajectory was implemented to increase engagement of community pharmacists to respond to GAP patients. The last innovation is a decentralized GAP offering in-person nursing care to unattached GAP patients.

CONCLUSIONS

Descriptions of these five innovations are key to inform other territories and provinces on ways to improve access for unattached patients while they are waiting to be attached. The introduction of the GAP and the organizational innovations, suggests a transition where access to PC services does not rely solely on attachment status.

The contribution of Specialist Family Physicians to South Africa's private sector: A position statement

No abstract available.

Artificial Intelligence Algorithms in Predictive Factors for Hematologic Toxicities During Concurrent Chemoradiation for Cervical Cancer

The most recent research conducted for the International Federation of Gynecology and Obstetrics indicates that, depending on the stage of cervical cancer (CC), several therapies can provide similar overall survival and progression-free survival rates. To determine the hematologic toxicities during concurrent chemotherapy for cervical cancer, we evaluated these two therapies (cisplatin or carboplatin). Hematologic markers have been studied using statistical models and descriptive statistics. Artificial intelligence models were built using the treatment data and all the information gathered from each patient after one or more administrations to forecast the CC stage. The information was gathered from stage III cervical cancer patients and provided by Oncohelp Hospital from the West Region of Romania. Many traditional machine learning techniques, such as naïve Bayes (NB), random forest (RF), decision trees (DTs), and a trained transformer called TabPFN, were used in the current study to obtain the tabular data. The algorithms NB, RF, and DTs yielded the greatest classification score of 100% when it came to cervical cancer prediction. On the other hand, TabPFN demonstrated an accuracy of 88%. The effectiveness of the models was evaluated by computing the computational complexity of traditional machine learning methods. Early detection increases the likelihood of a good prognosis during the precancerous and malignant stages. Being aware of any indications and symptoms of cervical cancer can also help to prevent delays in diagnosis. These hematologic toxicities, which have been demonstrated to grow linearly with lowering hematologic markers below their normal expectations, would significantly impair patients' quality of life.

[Systematic review of the primary care quality assessment instruments used in the last 10 years]

OBJECTIVE

There are numerous instruments in the scientific literature for the evaluation of the quality of Primary Care (PC) and to know which of them are the most used and in which countries provides more information to make a well-founded decision. The aim is to determine which, between 2013 and 2023, have been the instruments used to assess the international quality of PC, its evolution and geographical distribution.

DESIGN

Systematic review.

DATA SOURCES

PubMed and Embase. From March to December 2023.

INCLUSION CRITERIA

1) Validation studies of specific assessment instruments to measure the quality of PC and/or the satisfaction of patients, providers or managers. 2) carried out in the field of PC and 3) published between 1/01/2013 and 01/02/2023. 83 full-text articles were included.

DATA EXTRACTION

From each publication, an instrument used to evaluate the quality of the PC, attributes of the PC it evaluates, recipient of the evaluation, user, provider or manager, year, and country.

RESULTS

Fifteen PC assessment instruments were found. The most widely used is the Primary Care Assessing Tool (PCAT), with wide geographical distribution, versions in several languages, is more limited in Europe, except in Spain, and is mostly used in the Primary Care Assessing Tool (PCAT).

CONCLUSIONS

The PCAT, due to its cultural adaptability, availability in several languages, its ability to evaluate the fundamental principles of PC enunciated by the World Health Organization and to contemplate the perspectives of all health agents, is a complete, versatile, and consistent questionnaire for the evaluation of the quality of PC.

Barriers and Facilitators to the Implementation of Digital Health Services for People With Musculoskeletal Conditions in the Primary Health Care Setting: Systematic Review

BACKGROUND

In recent years, the effectiveness and cost-effectiveness of digital health services for people with musculoskeletal conditions have increasingly been studied and show potential. Despite the potential of digital health services, their use in primary care is lagging. A thorough implementation is needed, including the development of implementation strategies that potentially improve the use of digital health services in primary care. The first step in designing implementation strategies that fit the local context is to gain insight into determinants that influence implementation for patients and health care professionals. Until now, no systematic overview has existed of barriers and facilitators influencing the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting.

OBJECTIVE

This systematic literature review aims to identify barriers and facilitators to the implementation of digital health services for people with musculoskeletal conditions in the primary health care setting.

METHODS

PubMed, Embase, and CINAHL were searched for eligible qualitative and mixed methods studies up to March 2024. Methodological quality of the qualitative component of the included studies was assessed with the Mixed Methods Appraisal Tool. A framework synthesis of barriers and facilitators to implementation was conducted using the Consolidated Framework for Implementation Research (CFIR). All identified CFIR constructs were given a reliability rating (high, medium, or low) to assess the consistency of reporting across each construct.

RESULTS

Overall, 35 studies were included in the qualitative synthesis. Methodological quality was high in 34 studies and medium in 1 study. Barriers (-) of and facilitators (+) to implementation were identified in all 5 CFIR domains: "digital health characteristics" (ie, commercial neutral [+], privacy and safety [-], specificity [+], and good usability [+]), "outer setting" (ie, acceptance by stakeholders [+], lack of health care guidelines [-], and external financial incentives [-]), "inner setting" (ie, change of treatment routines [+ and -], information incongruence (-), and support from colleagues [+]), "characteristics of the healthcare professionals" (ie, health care professionals' acceptance [+ and -] and job satisfaction [+ and -]), and the "implementation process" (involvement [+] and justification and delegation [-]). All identified constructs and subconstructs of the CFIR had a high reliability rating. Some identified determinants that influence implementation may be facilitators in certain cases, whereas in others, they may be barriers.

CONCLUSIONS

Barriers and facilitators were identified across all 5 CFIR domains, suggesting that the implementation process can be complex and requires implementation strategies across all CFIR domains. Stakeholders, including digital health intervention developers, health care professionals, health care organizations, health policy makers, health care funders, and researchers, can consider the identified barriers and facilitators to design tailored implementation strategies after prioritization has been carried out in their local context.

Post-ICU Care: Why, What, When and How? ISCCM Position Statement

How to cite this article: Ramakrishnan N, Abraham BK, Barokar R, Chanchalani G, Jagathkar G, Shetty RM, et al. Post-ICU Care: Why, What, When and How? ISCCM Position Statement. Indian J Crit Care Med 2024;28(S2):S279-S287.

Limited Awareness of Long COVID Despite Common Experience of Symptoms Among African American/Black, Hispanic/Latino, and Indigenous Adults in Arizona

OBJECTIVES

Communities of color might disproportionately experience long-term consequences of COVID-19, known as Long COVID. We sought to understand the awareness of and experiences with Long COVID among African American/Black (AA/B), Hispanic/Latino (H/L), and Indigenous (Native) adults (18 + years of age) in Arizona who previously tested positive for COVID-19.

METHODS

Between December 2022 and April 2023, the Arizona Community Engagement Alliance (AZCEAL) conducted 12 focus groups and surveys with 65 AA/B, H/L and Native community members. Data from focus groups were analyzed using thematic analysis to identify emerging issues. Survey data provided demographic information about participants and quantitative assessments of Long COVID experiences were used to augment focus group data.

RESULTS

Study participants across all three racial/ethnic groups had limited to no awareness of the term Long COVID, yet many described experiencing or witnessing friends and family endure physical symptoms consistent with Long COVID (e.g., brain fog, loss of memory, fatigue) as well as associated mental health issues (e.g., anxiety, worry, post-traumatic stress disorder). Participants identified a need for Long COVID mental health and other health resources, as well as increased access to Long COVID information.

CONCLUSION

To prevent Long COVID health inequities among AA/B, H/L, and Native adults living in AZ, health-related organizations and providers should increase access to culturally relevant, community-based Long COVID-specific information, mental health services, and other health resources aimed at serving these populations.

Primary Care: Its Pokemon Moment

Primary care in the United States is undergoing bursts of evolution in response to health system stresses, changing demographics, and expansion of risk and value-based reimbursement structures. The impact of primary care remains substantive and associated with improved population health. However, the spectrum of services, the nature of the physicians involved and new ways of including the patient in her, or his own care suggests that a new definition of primary care be considered, and patient expectations be heeded and understood. Evolutionary bursts yield new traits and in primary care, they are spawning new care models with significant implications for general internal medicine, internal medicine/pediatrics trained individuals and medicine subspecialties given the focus of these models on Medicare Advantage. Ultimately, changes in reimbursement and creative incentives will be two factors among many that will solidify the next stage of primary care in the United States.

Healthcare stereotype threat, healthcare access, and health outcomes in a probability sample of U.S. transgender and gender diverse adults

Background

Health inequities among transgender and gender diverse (TGD) populations are well-documented and may be partially explained by the complex social power dynamics that lead to stigmatization. Healthcare Stereotype Threat (HCST) refers to the fear and threat of being perceived negatively based on identity-related stereotypes and may influence health and healthcare experiences. Few studies have investigated associations of HCST with healthcare access and health outcomes for TGD individuals.

Methods

We analyzed the U.S. Transgender Population Health Survey, a cross-sectional national probability sample of 274 TGD adults recruited April 2016-December 2018. Participants self-reported HCST through a 4-item scale. We estimated prevalence ratios (PR) for the association between HCST and binary healthcare access indicators and health outcomes using Poisson models with robust variance. Prevalence ratios (PR) were estimated using negative binomial models for the association between HCST and number of past-month poor physical and mental health days. Models adjusted for sociodemographics and medical gender affirmation.

Results

The mean age was 34.2 years; 30.9 % identified as transgender men, 37.8 % transgender women, and 31.3 % genderqueer/nonbinary. HCST threat was associated with increased prevalence of not having a personal doctor/healthcare provider (PR = 1.25; 95 %CI = 1.00-1.56) and reporting fair/poor general health vs good/very good/excellent health (PR = 1.92; 95 %CI = 1.37-2.70). Higher HCST was also associated with more frequent past-month poor physical (PR = 1.34; 95 %CI = 1.12-1.59) and mental (PR = 1.49; 95 %CI = 1.33-1.66) health days.

Conclusion

HCST may contribute to adverse healthcare access and health outcomes in TGD populations, though prospective studies are needed. Multilevel interventions are recommended to create safe, gender-affirming healthcare environments that mitigate HCST.

Analysis of Popular Gastroesophageal Reflux Disease Content on TikTok

Researchers used the TikTok platform to investigate the quality of select TikTok educational content regarding gastroesophageal reflux disease (GERD). One hundred TikTok videos that fit the inclusion criteria were analyzed using DISCERN, a tool that evaluates the quality of consumer health information on the internet. There was no substantial difference in DISCERN scores between physicians and non-physician content creators. Nevertheless, both groups consistently scored low (<3) in areas such as providing sources of information, indicating the publication date of their sources, discussing treatment risks, and outlining potential consequences if no treatment is pursued.

Factors Associated with College Students' Attitudes Toward Telehealth for Primary Care

Introduction: Establishing routine primary care visits helps to prevent serious health issues. College students are less likely than the general population to have a regular primary care provider and engage in routine health visits. Recent research provides evidence that telehealth is a convenient alternative to in-person primary care and that college students are comfortable using this technology, suggesting that telehealth has the potential to mitigate this disparity. As attitudes toward telehealth are one critical precursor to behavioral intention and actual utilization of telehealth, the goal of this study was to investigate which factors predict positive or negative attitudes toward telehealth. Methods: Data for this study were collected from a sample of 621 college students at a large southeastern university between September 19, 2022 and December 19, 2022. Results: The study found that college students who reported more trust in physicians, less medical mistrust, and less discrimination in health care settings reported more positive attitudes toward telehealth. Conclusions: These findings suggest that health care providers' skills in delivering patient-centered culturally informed care and building trust and rapport with patients might promote more positive attitudes toward telehealth and, potentially, greater overall utilization of health care services (including both telehealth and in-person services) among college students. This study lays the foundation for future research to examine psychological mechanisms underlying individuals' utilization of telehealth.

Exploring the role of physician associates in Aotearoa New Zealand primary health care

Introduction New Zealand's health care system faces significant shortages in health care workers. To address workforce challenges and meet the population's health needs, health care systems around the world have introduced new clinical roles, such as physician associates/assistants (PAs) into existing health care teams. Aim This article aims to examine the benefits, challenges, and broader implications of regulating PAs in the context of New Zealand's primary care sector, with a specific emphasis on how it may impact general practice. Methods A range of literature surrounding the role, impact, and perception of PAs were selected and included in this article. Results The PA profession can significantly strengthen New Zealand's primary care workforce, improving patient access and continuity of care. However, the global deployment of PAs has faced scrutiny due to concerns about its potential risks to patient safety and the overall viability of such a role. Discussion If regulated, the PA profession can reshape New Zealand's primary care, offering a partial solution to current medical staff shortages. Trained under a generalised medical model similar to doctors, PAs possess the necessary skills to perform both routine and non-routine medical tasks. This dual capability can significantly improve primary care service provision, reduce existing workloads, and allow for a more efficient deployment of doctor expertise. However, medico-legal issues and the supervisory burden can impede widespread integration into general practice. Despite challenges, the success of the PA role relies on mutual trust, respect, and support from other clinical team members within primary health care.

Public experiences and perspectives of primary care in Canada: results from a cross-sectional survey

BACKGROUND

Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care.

METHODS

We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models.

RESULTS

We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use.

INTERPRETATION

More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting.

Assessing multidisciplinary follow-up pattern efficiency and cost in follow-up care for patients in cervical spondylosis surgery: a non-randomized controlled study

Background

The use of multidisciplinary treatment programs in out-of-hospital healthcare is a new area of research. Little is known about the benefits of this method in the management of discharged patients undergoing cervical spondylosis surgery.

Objective

This study aimed to explore the effect of a contracted-based, multidisciplinary follow-up plan in patients after cervical spondylosis surgery.

Methods

This non-blinded non-randomized controlled study was conducted with 88 patients (44 in the intervention group, 44 in the control group). The clinical outcomes, including Neck Disability Index (NDI), pain score (VAS), Self-Efficacy for Managing Chronic Disease 6-item Scale (SECD-6), and 12-Item Short-Form Health Survey (SF-12) score were assessed at the time of discharge, 24-72 h, 1 month, and 3 months post-discharge. The complications, patient satisfaction, and economic indicators were assessed at the final follow-up (3 months).

Results

Patients who received contracted follow-up showed greater improvement in neck dysfunction at 24-72 h, 1 month, and 3 months after discharge compared to those who received routine follow-up (p < 0.001). At 1 month after discharge, the intervention group exhibited better self-efficacy (p = 0.001) and quality of life (p < 0.001) than the control group, and these improvements lasted for 3 months. The intervention group reported lower pain scores at 24-72 h and 1 month (p = 0.008; p = 0.026) compared to the control group. The incidence of complications was significantly lower in the intervention group (11.4%) compared to the control group (40.9%). The total satisfaction score was significant difference between the two groups (p < 0.001). Additionally, the intervention group had lower direct medical costs (p < 0.001), direct non-medical costs (p = 0.035), and total costs (p = 0.04) compared to the control group. However, there was no statistically significant difference in indirect costs between the two groups (p = 0.59).

Conclusion

A multidisciplinary contract follow-up plan has significant advantages regarding neck disability, self-efficacy, quality of life, postoperative complications, patient satisfaction, and direct costs compared with routine follow-up.

Race-ethnicity and sex differences in 1-year survival following percutaneous coronary intervention among Medicare fee-for-service beneficiaries

RATIONALE

Existing literature describing differences in survival following percutaneous coronary intervention (PCI) by patient sex, race-ethnicity and the role of socioeconomic characteristics (SEC) is limited.

AIMS AND OBJECTIVES

Evaluate differences in 1-year survival after PCI by sex and race-ethnicity, and explore the contribution of SEC to observed differences.

METHODS

Using a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee-for-service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race-ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1-year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI), county SEC, medical resource availability and inpatient versus outpatient procedural status.

RESULTS

We identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non-Hispanic White patients to die within 1 year after PCI. After controlling for Black-White differences in comorbidities, the differences in 1-year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence.

CONCLUSION

Women were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1-year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.

A Community Survey of Referral Sources to Identify Primary Care and Gender-Affirming Care Providers

Introduction

Barriers exist in access to primary care as well as specialty healthcare such as gender-affirming care. Understanding the referral sources used to identify new providers for these types of care can help healthcare systems facilitate access.

Methods

Using data from a community-based survey, demographics and information relevant to finding new healthcare providers were assessed.

Results

Data from 165 participants suggest that seeking a new primary care provider was perceived as challenging. The most common referral sources for primary care providers were family/friends, a doctor, or a medical center website. The most common referral sources for gender-affirming care providers were a doctor, family/friends, or social media. There were significant differences in the types of referral sources most likely to be utilized for primary versus gender-affirming care.

Conclusions

Personal connections, including trusted doctors, can be important sources of provider referrals. Additional resources may be needed to facilitate their ability to make quality connections. Community resources and social media can be important sources when existing social networks may not have knowledge about the needs of particular communities, especially those who may be at risk of discrimination. More inclusive and secure referral sources may be needed to ensure gender-affirming care referrals are made.

Perceptions of access to care after a rural hospital closure in an economically distressed county of Appalachian Tennessee

PURPOSE

The rise in rural hospital closures has sparked concern about the potential loss of essential health care services for rural communities. It is crucial to incorporate the perspectives of community residents, which have been largely missing from the literature, when devising strategies to improve health care for this population. The purpose of this study was to describe community residents' perceptions of access to care following a rural hospital closure in an economically distressed Appalachian county of Tennessee.

METHODS

This study used a qualitative descriptive approach to illustrate how community residents perceive accessing care post hospital closure. We conducted semi-structured interviews with 24 community residents via telephone in May through August of 2020. Interviews were analyzed using conventional content analysis.

FINDINGS

Five themes were identified based on Penchansky and Thomas' framework of health care: accessibility, availability, affordability, accommodation, and acceptability. Accessibility was identified as the most common concern among participants. Specifically, participants perceived longer travel times to receive care, reduced availability of emergency and specialty care, increased costs associated with ambulance services, and extended wait times to see providers.

CONCLUSIONS

Our findings provide a critical perspective to inform local leaders and policymakers on the impacts of a hospital closure in a rural community. As rural hospitals continue to close, it is crucial to develop multi-level, community-driven solutions to ensure access to care for rural communities.

Patient-reported primary health care experiences in Canada: The challenges faced by Nepalese immigrant men

Background

Despite the Canadian universal healthcare system, new immigrants face a number of challenges in accessing primary healthcare (PHC) services. As immigration to Canada consistently increases, understanding various types of barriers to PHC and how they differ across different sub-groups is critical. We conducted a qualitative study among Nepalese immigrant men to learn from their experience with PHC access to inform healthcare providers, stakeholders, and policymakers to devise feasible approaches to enhancing access to care.

Methods

We undertook a qualitative research approach employing focus groups among a sample of first-generation Nepalese immigrant men who had prior experience with accessing PHC in Canada.

Data collection and analysis

We conducted six focus groups in total with 34 participants (each group comprising 5-7 participants) in their preferred language, Nepalese, or English. Demographic information was collected prior to each focus group. Transcriptions of the discussions were prepared, and thematic analysis was employed in the qualitative data set.

Results

Participants reported experiencing barriers at two stages: before accessing PHC services and after accessing PHC services. The barriers before accessing PHC were long wait time for an appointment with physicians, limited knowledge of own health- and services-related issues, limited service availability hours, cultural differences in health practices, and transportation and work-related challenges. The barriers after accessing PHC were long wait time in the clinic to meet with the physicians at the time of appointment, communication challenges and misunderstandings, high healthcare costs associated with dental and vision care and prescribed medicines, and inappropriate behaviours and practices of doctors and service providers. To our knowledge, this is the first study in Canada which explored barriers faced by Nepalese immigrant men in accessing PHC.

Conclusions

This study identifies barriers to accessing PHC in Canada from a group of immigrant men's perspective. It is important to account for these while making any reforms and adding new care services to the existing healthcare system so that they are equitable for these groups of individuals as well.

Conceptualizing the Biopsychosocial-Spiritual Health Influences of Adverse Childhood Experiences and the Application of Primary Care Behavioral Health for Their Treatment

Adverse Childhood Experiences (ACEs) are common and affect the overall functioning of adults, but there is a need to understand how to better address the health impact of ACEs on adults in primary healthcare settings. A narrative review was utilized to extract data from seminal articles to (1) operationalize the influence of ACEs on health outcomes, (2) assess the primary care behavioral health (PCBH) model as a mechanism to address the influence of ACEs, and (3) identify mechanisms to expand the PCBH model to explicitly address spiritual determinants of health. The extracted data revealed that ACEs influence the biological, psychological, social, and spiritual health of patients providing a rationale for integrating psychosocial and spiritual treatment within primary healthcare settings. Simultaneously, the PCBH model integrates psychosocial interventions into existing primary care services but does not explicitly address spiritual determinants. Recommendations for expansion include (1) training for clinicians on evidence-based interventions to address spirituality, (2) spiritual screening tools in PCBH settings, and (3) consultation with chaplains as needed.

Navigating the doctor-patient-AI relationship - a mixed-methods study of physician attitudes toward artificial intelligence in primary care

BACKGROUND

Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.

METHODS

From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents.

RESULTS

Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship).

CONCLUSION

Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.

Rehabilitation in primary care for an ageing population: a secondary analysis from a scoping review of rehabilitation delivery models

BACKGROUND

The world population is ageing rapidly. Rehabilitation is one of the most effective health strategies for improving the health and functioning of older persons. An understanding of the current provision of rehabilitation services in primary care (PC) is needed to optimise access to rehabilitation for an ageing population. The objectives of this scoping review are a) to describe how rehabilitation services are currently offered in PC to older persons, and b) to explore age-related differences in the type of rehabilitation services provided.

METHODS

We conducted a secondary analysis of a scoping review examining rehabilitation models for older persons, with a focus on PC. Medline and Embase (2015-2022) were searched to identify studies published in English on rehabilitation services for people aged 50 + . Two authors independently screened records and extracted data using the World Health Organization (WHO)'s operational framework, the Primary Health Care Systems (PRIMASYS) approach and the WHO paper on rehabilitation in PC. Data synthesis included quantitative and qualitative analysis.

RESULTS

We synthesised data from 96 studies, 88.6% conducted in high-income countries (HICs), with 31,956 participants and identified five models for delivering rehabilitation to older persons in PC: community, home, telerehabilitation, outpatient and eldercare. Nurses, physiotherapists, and occupational therapists were the most common providers, with task-shifting reported in 15.6% of studies. The most common interventions were assessment of functioning, rehabilitation coordination, therapeutic exercise, psychological interventions, and self-management education. Environmental adaptations and assistive technology were rarely reported.

CONCLUSIONS

We described how rehabilitation services are currently provided in PC and explored age-related differences in the type of rehabilitation services received. PC can play a key role in assessing functioning and coordinating the rehabilitation process and is also well-placed to deliver rehabilitation interventions. By understanding models of rehabilitation service delivery in PC, stakeholders can work towards developing more comprehensive and accessible services that meet the diverse needs of an ageing population. Our findings, which highlight the role of rehabilitation in healthy ageing, are a valuable resource for informing policy, practice and future research in the context of the United Nations Decade of Healthy Ageing, the Rehab2030 initiative and the recently adopted WHA resolution on strengthening rehabilitation in health systems, but the conclusions can only be applied to HICs and more studies are needed that reflect the reality in low- and middle-income countries.

Barriers and enablers to implementing interprofessional primary care teams: a narrative review of the literature using the consolidated framework for implementation research

BACKGROUND

Interprofessional primary care teams have been introduced across Canada to improve access (e.g., a regular primary care provider, timely access to care when needed) to and quality of primary care. However, the quality and speed of team implementation has not kept pace with increasing access issues. The aim of this research was to use an implementation framework to categorize and describe barriers and enablers to team implementation in primary care.

METHODS

A narrative review that prioritized systematic reviews and evidence syntheses was conducted. A search using pre-defined terms was conducted using Ovid MEDLINE, and potentially relevant grey literature was identified through ad hoc Google searches and hand searching of health organization websites. The Consolidated Framework for Implementation Research (CFIR) was used to categorize barriers and enablers into five domains: (1) Features of Team Implementation; (2) Government, Health Authorities and Health Organizations; (3) Characteristics of the Team; (4) Characteristics of Team Members; and (5) Process of Implementation.

RESULTS

Data were extracted from 19 of 435 articles that met inclusion/exclusion criteria. Most barriers and enablers were categorized into two domains of the CFIR: Characteristics of the Team and Government, Health Authorities, and Health Organizations. Key themes identified within the Characteristics of the Team domain were team-leadership, including designating a manager responsible for day-to-day activities and facilitating collaboration; clear governance structures, and technology supports and tools that facilitate information sharing and communication. Key themes within the Government, Health Authorities, and Health Organizations domain were professional remuneration plans, regulatory policy, and interprofessional education. Other key themes identified in the Features of Team Implementation included the importance of good data and research on the status of teams, as well as sufficient and stable funding models. Positive perspectives, flexibility, and feeling supported were identified in the Characteristics of Team Members domain. Within the Process of Implementation domain, shared leadership and human resources planning were discussed.

CONCLUSIONS

Barriers and enablers to implementing interprofessional primary care teams using the CFIR were identified, which enables stakeholders and teams to tailor implementation of teams at the local level to impact the accessibility and quality of primary care.

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

Importance

Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models.

Objective

To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care.

Design, Setting, and Participants

Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices.

Interventions

Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support.

Main Outcomes and Measures

The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions).

Results

Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures.

Conclusions and Relevance

Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.