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This study aimed to describe the characteristics, healthcare resources utilized and costs incurred by adults receiving publicly funded obesity care in Ontario, Canada. People living with obesity who first visited Wharton Medical Clinic, a weight and diabetes management clinic in Ontario, between 2015 and 2018 were identified. Pseudoanonymized data were linked to administrative databases to understand healthcare utilization and costs borne by the public payer over 3 years. 6208 participants had linked data, 63.9% and 27.3% of whom remained followed one and two years after their first clinic visit, respectively. The cohort was 71.84% female with a mean (SD) age of 50.86 (13.28) years and BMI of 40.21 (7.06) kg/m 2 . Approximately 25% of participants were prescribed pharmacotherapy (liraglutide, orlistat, naltrexone/bupropion), 4% received psychological therapy and 2% had weight-loss surgery. Common obesity-related complications were hypertension (42.62%), musculoskeletal pain (35.20%) and dyslipidaemia (33.65%). Participants had 22.16 physician visits per person-year in year one, mostly to general practitioners and endocrinologists, which decreased to 17.38 visits per person-year by year three. Mean total costs (excluding privately covered prescriptions) per person-year decreased from $5227.25 (Canadian dollars) (SE: $0.97) to $4982.88 (SE: $2.16) over the same period. Participants were mostly female and presented with obesity-related complications. Although healthcare utilization and costs incurred by the cohort were high, both showed a decreasing trend over the follow-up period., (© 2024 World Obesity Federation.)

Objective: Tapering of chronic opioids has increased, with subsequent reports of exacerbated pain among patients who tapered. We aimed to evaluate the association between opioid dose tapering and subsequent pain-related healthcare utilization (ED visits, hospitalizations and primary care visits)., Design, Setting and Subjects: We conducted a retrospective cohort study from 2015-2019 using data from the Optum Labs Data Warehouse that contains de-identified retrospective administrative claims data for commercial and Medicare Advantage enrollees in the US. Adults aged ≥18 years who were prescribed stable doses of opioids, ≥50 morphine milligram equivalents (MME)/day, during a 12-month baseline period., Methods: Tapering was defined as ≥ 15% relative reduction in mean daily opioid dose during one of 6 overlapping 60-day periods. Tapered patient-periods were subclassified as tapered-and-continued (MME > 0) vs. tapered-and-discontinued (MME = 0). We modeled monthly counts of visits for pain diagnoses up to 12 months after cohort entry using negative binomial regression as a function of tapering, baseline utilization, and patient level-covariates., Results: Among 47,033 patients, 13,793 patients tapered. Compared to no taper, any taper was associated with more ED visits for pain (adjusted incidence rate ratio [aIRR] 1.21, 95% CI: 1.11-1.30), tapered then continued status was associated with more ED visits (aIRR 1.23, CI: 1.14-1.32) and hospitalizations (aIRR 1.14, CI: 1.03-1.27) for pain, and tapered-and-discontinued was associated with fewer primary care visits for pain (aIRR 0.68, CI: 0.61-0.76)., Conclusions: These associations suggest that opioid tapering may lead to increased emergency and hospital utilization for acute pain and possibly a decreased perceived need for primary care for those whose opioids were discontinued., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

We evaluated the feasibility and acceptability of frailty screening using handgrip strength with gait speed measures within four primary care-based memory clinics in Ontario. This mixed methods quality improvement initiative examined the reach, effectiveness, adoption, implementation, and maintenance of frailty screening from the perspective of patients ( N = 216), care partners ( N = 142), and healthcare providers ( N = 9). Frailty screening was well-received by patients and care partners and perceived as quick and easy to administer and integrate into assessment processes by healthcare providers at all four memory clinics. The ease of integrating frailty screening into clinic processes was a key factor facilitating implementation; few challenges or suggestions for improvement were identified. All four clinics plan to continue frailty screening, three using the methods adopted in this study. Integrating frailty screening into memory assessments is feasible and acceptable and, given the interactional relationship between frailty and dementia, provides a significant opportunity to improve health outcomes for older adults.

Objectives: The primary focus of pay-for-performance (P4P) schemes in the UK has traditionally been related to the public health and inclusion elements related to the activities of doctors with comparatively less attention given to nursing care as a component of the scheme. However, nursing is an integral part of healthcare delivery in the National Health Service and nurses constitute the major group of healthcare professionals in most countries. Our aim was to explore advanced nurse practitioner (ANPs) experiences of the Quality and Outcomes Framework (QOF), using the Implicit Leadership Theory (ILT) frame., Methods: We used a case study approach. Six articles on the QOF work were synthesised, focused on ANPs and their leadership potential in healthcare. Evidence showed that despite having importance in delivering the activities of QOF, nursing activities overlooked. We undertook a thematic synthesis of these papers, with a specific focus ANPs' leadership development in Long Term Conditions (LTC) care within general practice and capacity to influence the healthcare system., Findings: Six themes were identified: (1) sensitivity, patient-centred care, context and continuity of care; (2) intelligence-leaders capable of making strategic decisions in healthcare settings, (3) dedication, trust, equity and equality, (4) dynamism of nursing, (5) tyranny, guise of teamwork, collaboration and (6) nursing and healthcare leadership., Conclusions: Nurses in leadership roles created good working relationships, coped with conflicts and contributed to shared objectives and were sympathetic collaborators. Using the six ILT characteristics, we found that nurses were collaborators. Future P4P schemes should benefit from a collective lens of healthcare personnel when focusing on quality initiatives and improving the delivery of healthcare activities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To quantify the costs of hypertension diagnosis and treatment in Australia, particularly in primary care, including general practices and pharmacies., Study Design: Economic analysis; analysis of Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) data., Setting: Australia, 2012-22., Main Outcome Measure: Estimated expenditure on hypertension care (adjusted to 2022 Australian dollars), overall and by expenditure type (general practice consultations, medications), cost bearer (PBS, MBS, patient out-of-pocket costs), and broad expenditure category (medication costs, pharmacy costs, general practice consultations, ambulatory blood pressure monitoring)., Results: During 2012-22, estimated total expenditure for the diagnosis and treatment of hypertension in Australia was $12.2 billion: $7.3 billion (60%) was borne by the MBS and PBS, $4.9 billion (40%) by patients as out-of-pocket costs. During 2021-22, an estimated $1.2 billion was spent on the management of hypertension; the three main cost components were pharmacy-related costs (administration and handling fees, dispensing fees, electronic prescription fees: $611.1 million, 50.8%), general practice consultations ($342.7 million, 28.5%), and blood pressure-lowering medications (manufacturer and wholesale costs: $244.3 million, 20.3%)., Conclusions: During 2012-22, about 40% of the cost of managing hypertension in Australia was borne directly by patients (about $494 million per year). Important changes to pharmacy supply and payment policies were introduced in 2023, but further efforts may be needed to reduce treatment costs for patients. These changes are particularly important if the hypertension control rate is to be substantially improved in Australia, given the large numbers of undertreated and untreated people with hypertension., (© 2024 AMPCo Pty Ltd.)

Introduction: Overuse of medical services is a challenge worldwide, posing a threat to the quality of care, patient safety and the sustainability of healthcare systems. Some data suggest that females receive more low-value practices (LVPs)-defined as medical interventions that provide little or no benefit to patients and can even cause harm-than males. This study aims to evaluate and compare the occurrence of LVPs in primary care among both males and females., Design: A retrospective study was conducted., Setting: Primary care in the Alicante province (Spain) during 2022., Participants: Data were extracted from the digital medical records of 978 936 patients attended by 1125 family physicians across 262 primary healthcare centres in the Alicante province., Outcome Measures: Data on age, sex, diagnosis and treatment were extracted. The primary outcome measure was the frequency of 12 selected LVPs prescribed to male and female patients. These LVPs were expected to be relatively frequent occurrences with the potential to cause harm., Results: A total of 45 955 LVPs were identified, of which 28 148 (5.27% of 534 603, CI95% 5.20-5.32) were prescribed to female patients and 17 807 (4.00% of 444 333, CI95% 3.95-4.06) to male patients (x², p value <0.0001). The most common LVPs were prescribing treatment for overactive bladder without excluding other pathologies that may cause similar symptoms (30.87%), using hypnotics without having a previous aetiological diagnosis in patients with difficulty maintaining sleep (14%) and recommending analgesics (NSAIDs, paracetamol and others) for more than 15 days per month in primary headaches that do not respond to treatment (13.33%)., Conclusions: Future clinical training, management and research must consider biological differences or those based on gender factors when analysing the frequency and causes of LVP., Trial Registration Number: NCT05233852., Competing Interests: Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Guidelines recommend the identification of potential mental and/or cognitive disorders (MCD) in patients with coronary heart disease (CHD). However, compliance with these guidelines appears to be lacking in primary care. A minimal invasive intervention was tailored with experts for the primary care setting to increase the identification of this patient group and ensure proper treatment. The intervention includes: A trigger question, screening tests and question prompt sheet for patients. Following the implementation of this intervention in primary care physician (PCP) offices, the aim of this study is to evaluate the implementation outcomes., Methods: Semi-structured interviews were conducted with ten PCPs who tested the intervention for six months. The study was guided by Proctor's Framework on Implementation Outcomes to understand the appropriateness, feasibility, acceptability, fidelity and sustainability of the intervention as proxies for implementation success., Results: Relevance of the topic and the need for the intervention is recognised by all of the PCPs. All PCPs were willing to try the intervention and considered it generally appropriate and feasible. Additionally, supporting implementation resources were considered helpful in familiarising with the intervention. Screening of patients with a first diagnosis of CHD, those who have had experienced a recent coronary event and those who have been hospitalised for CHD is considered practical and appropriate. Known barriers such as lack of knowledge, perceived relevance and awareness were successfully addressed. It was not possible to overcome barriers such as time pressure, forgetfulness, and patient reaction. Additionally, the paper format of the information materials was perceived as impractical, and integration into the physician information system was identified as a possible way to increase acceptance. Nevertheless, PCPs stated they will continue to be aware of the link between CHD and MCD and want to maintain their individualised approach., Conclusions: The study provides important insights into the use of a minimal invasive intervention in primary care. Despite tailoring the intervention to the primary care setting, implementation success was suboptimal due to individual barriers in PCP offices. This highlights the need for tailored approaches at the level of individual PCP offices to better address context-specific barriers., Competing Interests: Declarations. Ethics approval and consent to participate: The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Medical Faculty of the University of Cologne (#21-1530). Written informed consent was obtained from all participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Aims: The aim of this study was to evaluate the association between living alone and mortality among older patients with and without diabetes., Methods: Electronic patient records were used to identify patients at least 65 years of age with a diagnosis of diabetes and two age- and sex-matched controls without diabetes for each patient with diabetes in 2015. The study population in this analysis consisted of 429 patients with diabetes and 650 controls who returned a questionnaire that contained questions about their diseases, symptoms, and functions. The mortality (2015-2019) data were based on the national registry of Statistics Finland. Cumulative mortality was estimated with Kaplan-Meier's method and compared with the log-rank test. Cox proportional hazards regression was used to estimate the adjusted hazard ratios (HR) and their 95% confidence intervals (CI)., Results: The median follow-up time was 4.3 years. 208 of the controls (32%) and 156 (36%) of the patients with diabetes lived alone. Of the controls, 8.1% (95% CI 5.9-11.1) of those not living alone and 20.2% (95% CI 15.3-26.3) living alone died. The corresponding numbers for patients with diabetes were 15.1% (95% CI 11.3-19.8) and 28.8% (95% CI 22.4-36.7). Among all patients, living alone was associated with increased mortality (HR = 1.84; 95% Cl 1.30-2.61), whereas the diagnosis of diabetes was not (HR = 1.31; 95% Cl 0.94-1.81)., Conclusions: The results of this study show that living alone had a significant impact on the mortality of older patients, regardless of whether they had diabetes or not. Diabetes was not clearly associated with the increased mortality among these older home-dwelling patients., Competing Interests: Declarations. Ethics approval and consent to participate: The survey was conducted in accordance with the ethical principles set by the National Advisory Board on Research Ethics of Finland (15). The study protocol was reviewed and approved by the Research Ethics Committee of the Northern Savo Hospital District, Kuopio, Finland (256/2015) and approved by the Inner Savo Health Care Federation of Municipalities (61 A/2015). By filling out and returning the survey, all participants gave their informed consent. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Depression is a very common disorder and comorbidity. Primary care providers are the first medical contacts to diagnose and treat depression. Video calls are emerging communication tools to deliver psychological interventions., Aims: To examine the effectiveness of videocall delivered psychological interventions to treat depressive symptoms in adult patients in primary care, as well as a systematic assessment of implementation factors., Methods: We conducted a systematic literature search in PubMed Central, Embase, PsycInfo, Cochrane Library and the WHO COVID-19 database and included randomized controlled trials only. Two authors screened the studies and assessed the risk of bias independently (Cochrane RoB tool). We followed the PRISMA guidelines. The study protocol was published in PROSPERO (CRD42022295238). The results were synthesized narratively., Results: Of 6.971 identified studies, we included six publications. Studies powered to detect clinically significant changes in primary outcomes, identified video calls to be effective for delivering complex psychological interventions in an integrated primary care setting., Conclusion: Further research is needed to consolidate the findings on a larger scale and evaluate the effectiveness in comparison with alternatives such as telephone-delivered care. Results are promising and indicate the need for replication in larger studies as well as different health care settings.

Objective: The prognosis of isolated headache intracranial vertebral artery dissection (iVAD) without subarachnoid hemorrhage (SAH) or stroke is unknown. The authors of this study aimed to evaluate isolated headache iVAD prognosis., Methods: This is a single-center retrospective study of consecutive patients who presented with headache as their main complaint and underwent MRI between November 2016 and August 2022; those with acute isolated headache iVAD who were followed up for vascular morphological stability were eligible for study inclusion. The patients were divided into three groups based on the vascular morphology at initial diagnosis: aneurysm dilatation without stenosis (group 1), aneurysm dilatation with stenosis (group 2), and no aneurysm dilatation (group 3). Prognosis, time to radiological stability, and final vascular morphology were compared among the groups., Results: One hundred five patients with isolated headache iVAD were included in the study. During a median follow-up of 478 (IQR 143-1094) days, none of the patients developed SAH or stroke, but 3/41 (7%) patients in group 1 underwent endovascular intervention for aneurysm enlargement. Patients in group 1 required significantly more long-term follow-up for morphological stability (p = 0.013), primarily due to aneurysm enlargement (p < 0.001), and were more likely to require surgical intervention (p = 0.043) than those in the other two groups. Residual aneurysm risk was significantly associated with initial vascular morphology in group 1 (OR 7.28, 95% CI 2.30-23.1, p < 0.001)., Conclusions: Most patients with isolated headache iVAD had a favorable prognosis. However, patients with aneurysm dilatation without stenosis required the most careful follow-up, as this group had the highest aneurysm enlargement risk from early disease onset through the chronic phase. In such cases, patients may require surgical intervention to prevent critical conditions.

Background: Weight bias is characterised by negative attitudes towards people with a higher weight and is widespread in healthcare. Primary care professionals sometimes avoid discussing weight with patients due to concerns about upsetting them, insufficient training, resources, or referral pathways. There is, however, a responsibility for primary care professionals to address the health needs of patients, which may require discussing weight., Objective: The current study aimed to understand primary care professionals and trainee perceptions of the appropriateness of weight-centric, weight-inclusive/holistic, and avoidant approaches for discussing weight with higher weight individuals when patients were and were not seeking weight management advice., Design: Mixed methods design., Participants: Primary care professionals and trainees (N = 112) within Australia., Approach: Participants first completed an online survey and provided demographic data and completed measures of implicit and explicit weight bias. Secondly, participants viewed simulated patient consultations, reflecting each of the three approaches (weight-centric, weight-inclusive/holistic, and avoidant) in a weight-related and non-weight related context. Participants then evaluated the appropriateness of the language and strategies used., Key Results: The participants showed, on average, low to moderate levels of explicit weight bias but high levels of implicit weight bias. For the consultations, language and strategies of the holistic approach were considered the most appropriate in both contexts. In the weight-related consultation, language used in the weight-centric and avoidant approaches were deemed equally inappropriate. However, weight-centric strategies were considered more appropriate than avoidant strategies. In the non-weight related consultation, the language and strategies of the avoidant approach were considered more appropriate than those of the weight-centric approach., Conclusions: Primary care professionals and trainees favoured the holistic approach to discussing weight when patients presented with weight-related or non-weight related concerns. These findings have potential practical implications for health professional education., Competing Interests: Declarations:. Conflict of Interest:: G.S. receives grant funding from the National Health and Medical Research Council of Australia. All other authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: The management of type 2 diabetes mellitus (T2DM) includes mastery of complex care activities, self-management skills, and routine health care encounters to optimize glucose control and achieve good health. Given the lifelong course of T2DM, patients are faced with navigating complex medical and disease-specific information. This health-seeking behavior is a driver of health disparities and is associated with hospitalization and readmission. Given that health-seeking behavior is a potentially intervenable social determinant of health, a better understanding of how people navigate these complex systems is warranted., Objective: To address this need, we aimed to develop new patient-reported outcome (PRO) measures that evaluate health-seeking behavior in persons with T2DM. These new PROs were designed to be included in the Re-Engineered Discharge for Diabetes-Computer Adaptive Test (REDD-CAT) measurement system, which includes several other PROs that capture the importance of social determinants of health., Methods: Overall, 225 participants with T2DM completed 56 self-report items that examined health-seeking behaviors. Classical Test Theory and Item Response Theory were used for measurement development. Exploratory factor analysis (EFA; criterion ratio of eigenvalue 1 to eigenvalue 2 being >4; variance for eigenvalue 1 ≥40%) and confirmatory factor analysis (CFA; criterion 1-factor CFA loading <.50; 1-factor CFA residual correlation >.20; comparative fit index ≥0.90; Tucker-Lewis index ≥0.90; root mean square error of approximation <0.15) were used to determine unidimensional sets of items. Items with sparse responses, low-adjusted total score correlations, nonmonotonicity, low factor loading, and high residual correlations of high error modification indices were candidates for exclusion. A constrained graded response model was used to examine item misfit, and differential item functioning was examined to identify item bias. Cronbach α was used to examine internal consistency reliability for the new PROs (criterion ≥0.70), and floor and ceiling effects were examined (criterion ≤20%)., Results: Four unidimensional sets of items were supported by EFA (all EFA eigenvalue ratios >4; variance for eigenvalue 1=41.4%-67.3%) and CFA (fit statistics all exceeded criterion values). This included (1) "Health-Seeking Behavior: PCP-Specific" (6 items); (2) "Health-Seeking Behavior: General Beliefs" (13 items); (3) "Health-Seeking Behavior: Family or Friends-Specific" (5 items); and (4) "Health-Seeking Behavior: Internet-Specific" (4 items). All items were devoid of differential item functioning for age, sex, education, or socioeconomic status factors. "Health-Seeking Behavior: General Beliefs" was developed to include both a computer adaptive test and a 6-item short form version; all other PROs were developed as static short forms. The psychometric reliability of these new PROs was supported; internal consistency ranged from acceptable to excellent (Cronbach α=.78-.91), and measures were free of significant floor or ceiling effects (floor effects range: 0%-8.9%; ceiling effects range: 0%-8.4%)., Conclusions: The new REDD-CAT Health-Seeking Behavior PROs provide reliable assessments of health-seeking behaviors among those with T2DM., (©Suzanne E Mitchell, Michael A Kallen, Jonathan P Troost, Barbara A De La Cruz, Alexa Bragg, Jessica Martin-Howard, Ioana Moldovan, Jennifer A Miner, Brian W Jack, Noelle E Carlozzi. Originally published in JMIR Diabetes (https://diabetes.jmir.org), 22.11.2024.)

Infectious intestinal disease (IID) is a syndrome consisting of diarrhoea and vomiting symptoms linked to a causative pathogen. The Third Study of IID (IID3) will report its incidence in the community within the UK and assess how it has changed since the second IID study (IID2) in 2012. We implemented an automated, online patient recruitment process within a national sentinel surveillance network and compared its performance versus IID2 in terms of: Patient recruitment rates and demographic characteristics of recruited participants. We utilised a text messaging system (TMS) running off a computerised medical record systems (CMR) application programme interface (API). Demographic analysis showed that the majority of those recruited to IID3/IID2 studies were >65 years and female. However, the recruitment of participants of non-white ethnicity was statistically significantly different between IID3/IID2. Further work is required to improve recruitment in the younger patient demographic and in ethnic minority populations.

Objective: Analyze the notifications made by Primary Care (PC) professionals of Galicia, in the Notification and Learning system for Patient Safety (SiNASP), of the Ministry of Health of Spain, its variables and the factors that contribute to its appearance for thus characterize security incidents in this healthcare field., Materials and Methods: This is a retrospective descriptive study of notifications made in PC, between October 2010 and December 2019, in the SiNASP, in the Autonomous Community of Galicia. The data are presented using absolute and relative frequencies. Incidents are determined on the total number of personnel of different professional categories. To contrast the relationship between different variables, the Chi-square test was used., Results: 1863 notifications corresponded to PC (10% of the total). There were no differences in terms of sex, but it was observed that the incidence increases with age. The largest number of notifications was made by doctors, although, in percentage terms, pharmacists are the professionals who report the most incidents. The largest number of safety events occurred in consultations, with the most frequent being those due to a problem related to medication. Approximately 1 in every 200 incidents that reached the patient were classified as catastrophic., Conclusions: Even though there are fewer notifications and possibly having a lower incidence than in hospitals, security incidents in PC are frequent and, sometimes, serious. Therefore, measures that influence the promotion of safety culture and raise awareness, in this sense, among managers and professionals in this healthcare field are essential., Competing Interests: Conflicto de intereses Los autores no declaran conflictos de intereses., (Copyright © 2024 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: When research and management of Dupuytren's disease (DD) shift from symptom relief to preventing contractures, general practitioner (GP) care may become more central to treatment. However, the presentation and course of DD in GP care are underexplored and this has been recognized as a knowledge gap that hinders effective treatment decisions. This study is the first to map the trajectory of DD patients in GP care., Methods: Using electronic health records from Dutch general practices in a regional research network, we conducted a registration-based cohort study in a dynamic population. Descriptive statistics detailed patient demographics, number of contacts, and symptoms per contact. The time and number of contacts before diagnosis were also analysed. Sankey diagrams illustrated the relationship between management options and symptoms., Results: Over a 16-year period, 84% of patients with a DD diagnosis had visited their GP for this reason, with 73% only having one GP contact. The diagnosis was made at first contact for 93% of patients. Initial contacts often reported a lump (57.3%), but this symptom was less frequent in subsequent visits. 'Daily life impairment' increased after the first contact. The most common management options were referral to secondary care (37.7%) and watchful waiting (35.1%)., Conclusion: The diagnosis and management of DD in GP care are in line with the current guidelines. Less than half of the DD patients were referred to secondary care during follow-up. This may give room for preventive treatment that limits progression. Future studies should focus on the accuracy of diagnosis and the feasibility of effective treatments in GP care., (© The Author(s) 2024. Published by Oxford University Press.)

Background: The University of New Mexico School of Medicine established the combined baccalaureate/medical degree (BA/MD) program in response to critical physician shortages in New Mexico (NM). This 8-year program aims to improve health care in NM by expanding access to medical education for local students, particularly from rural and underserved communities and/or racial/ethnically underrepresented in medicine (URiM) in NM., Objectives: To describe the BA/MD program's initial design, the impact of improvements on retention, and the outcomes in terms of physicians in practice, particularly in primary care specialties., Methods: The study reviews the BA/MD program's progress from 2006 to 2023, focusing on curriculum and support enhancements. Retention rates and choice of primary care specialties were analyzed by geographic origin and racial/ethnic background., Results: From 2006 to 2023, the program graduated 81 physicians, with 53 practicing in 10 of NM's 33 counties. Approximately two-thirds specialize in primary care, and a similar proportion are URiM. Students from 31 of NM's 33 counties were admitted, with two-thirds coming from outside the state's metropolitan area. Overall retention and retention across demographic groups improved significantly in the baccalaureate phase of the program due to changes in curriculum and support services., Conclusions: The program has effectively addressed physician shortages in NM, particularly in rural and underserved areas. Its success in training and retaining physicians from diverse backgrounds, with a focus on primary care, is crucial for improving health care access in the state. Ongoing improvements in the program are essential to sustaining and enhancing these outcomes., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The knowledge and proficiency of primary care practitioners (PCPs) in diagnosing and managing irritable bowel syndrome (IBS) remain generally low and variable internationally. This variability is partly due to a lack of familiarity with the Rome Foundation diagnostic criteria and treatment guidelines for this condition., Methods: We conducted an electronic survey of PCPs in the United States and nine European countries to assess their understanding of IBS pathophysiology; the use of Rome IV criteria in diagnosis, knowledge of and frequency in prescribing various recommended treatments; and the likelihood of referring patients with suspected IBS to subspecialists., Results: Most PCPs in the United States and Europe perceive IBS as a diagnosis of exclusion rather than a definitive diagnosis. They also believe IBS is underdiagnosed in primary care and challenging to diagnose confidently. The majority of PCPs consider diet as a crucial component of IBS management. Notably, US PCPs reported greater confidence than their European counterparts in recommending dietary interventions such as increased dietary fiber, a low FODMAP diet, and gluten restriction. Conversely, both groups exhibited moderate to high confidence in recommending over-the-counter treatments. European PCPs showed greater confidence in treating IBS with antispasmodics and secretagogues, while US PCPs expressed greater confidence in prescribing neuromodulators. Additionally, US PCPs were more likely to refer patients with suspected IBS to a gastroenterologist, whereas both US and European PCPs showed similar referral patterns to dietitians and referred very few patients to mental health providers. Both US and European PCPs reported that IBS is moderately to extremely difficult to treat effectively and emphasized the importance of a strong and longitudinal doctor-patient relationship in managing the condition., Conclusion: Despite the Rome Foundation recommendations and criteria to support a positive diagnosis of IBS, most PCPs still rely on exclusionary investigations such as endoscopy and a serologic workup, while a significant percentage suggest referring patients to gastroenterologists., (© 2024 The Author(s). Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Background: Electronic Risk Assessment Tools (eRATs) are intended to improve early primary care cancer diagnosis. eRATs which interrupt a consultation to suggest a possibility of a cancer diagnosis, could impact clinical appraisal and the experience of the consultation. This study explores this issue using data collected within the context of the ERICA trial., Aim: To explore experiences of General Practitioners (GPs) who used the ERICA eRATs, and how the tool impacted their perception of risk and diagnostic thinking, and communication of this to patients., Design & Setting: Qualitative interviews with GPs from English General Practices undertaking the ERICA trial., Method: Participants were purposefully sampled from practices participating in the intervention arm of the ERICA trial. 18 GPs undertook semi-structured interviews via MS Teams. Thematic Analysis was used to explore their perspectives the impact of eRATs on consultations, diagnostic thinking related to cancer and other conditions, and how this information is communicated to patients., Results: Three themes were developed: 1) eRATs were perceived as "Additional Armour", offering a layer of protection against missing a cancer diagnosis, the defence coming at a cost of anxiety and complexity of consultation; 2) eRATs were seen as another actor in the consultation, separate from clinician and patient, and challenging GP autonomy; and 3) GPs were conflicted about whether the numerical eRAT outputs were helpful when communicating with patients., Conclusion: eRATs are appreciated as a defence against missing a cancer diagnosis. This defence comes at a cost and challenges GP's freedom in communication and decision making., (Copyright © 2024, The Authors.)

Background: Socioeconomically disadvantaged populations have a high prevalence of chronic pain, exacerbated by social isolation, intersectional stigma, and disparities in pain assessment and treatment. Effective interventions using a multilevel, biopsychosocial approach are needed to decrease the unequal burden of pain. Group-based integrative pain management in primary care safety net clinics is a promising model to improve pain care for racially and ethnically diverse low-income people., Objective: To describe a study protocol to test the impacts of 2 group-based models - group acupuncture and integrative group medical visits - on multilevel pain-related outcomes., Methods: The study uses a 2x2 factorial randomized clinical trial to test two 12 week group-based models: group acupuncture and integrative group medical visits (IGMV, with psychoeducation, mind-body approaches, and social support). English or Spanish-speaking adults with chronic pain for ≥3 months receiving care in San Francisco Department of Public Health primary care clinics are eligible for the trial. All participants will receive usual care and be randomized to group acupuncture, IGMV, both, or waitlist control. The primary outcomes are changes from baseline to 3 month follow-up in pain impact and in social support for chronic pain. Secondary outcomes include pain interference, pain intensity, depression, anxiety, quality of life, and social isolation. Data will include patient-reported outcomes, electronic health record data, and qualitative interviews, focus groups and observations to assess multilevel individual, interpersonal and organizational outcomes., Discussion: Multilevel approaches are needed to advance health equity in pain management. Our study contributes to knowledge of group-based integrative pain management in primary care safety net clinics to address multilevel barriers and disparities in pain care., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

The 2024 European Society of Hypertension clinical practice guidelines for the management of arterial hypertension (ESH Guidelines 2024) have recently been published, a brief document but with a very elaborate infographic that summarizes as much as possible the previous guidelines for the management of arterial hypertension (HTN), aimed at serving as a quick reference tool to make decisions in daily clinical practice. The main objective of this work is to analyze the recommendations and innovations of these guidelines from the perspective of their applicability and taking into account all the scientific societies in the specialty of Family and Community Medicine, Internal Medicine and the Spanish Society of Hypertension (SEHLELHA) in order to achieve more homogeneous and evidence-based care for HTN in Spain. The most important results include the maintenance of the thresholds to define HTN and the therapeutic objectives, as well as the recommendation to initiate pharmacological treatment based on both the blood pressure values and the cardiovascular risk estimated by SCORE2 and the presence of organic damage. New are the introduction of practical tables to estimate the fragility of hypertensive subjects based on their age and autonomy, as well as precise recommendations for monitoring HTN. In summary, the ESH 2024 Guidelines represent a useful, reasoned and concise instrument that can serve as a tool to improve the control of HTN in our environment., (Copyright © 2024. Publicado por Elsevier España, S.L.U.)

Introduction: Temporomandibular disorders (TMDs) are common musculoskeletal pain conditions that can significantly impact daily activities such as eating, talking, breathing, intimacy, and expressing emotion. TMDs are often complex and multifactorial, and many patients experience overlapping pain conditions, sleep difficulties, and mental health challenges. The National Academies of Sciences, Engineering and Medicine (NASEM) has called for improved TMD education and training for health professionals, as current training opportunities are limited., Methods: To prepare health professionals to care for patients who have a TMD, we designed a 5-hour, interactive, module-based curriculum aligned with the 2020 NASEM recommendations. The four-part module set addresses TMD physiology and pathophysiology, assessment, diagnosis, and management. Instructional methods are founded on the Cognitive Theory of Multimedia Learning and include engaging videos, clinical evaluation and education tools, and interactive digital simulation scenarios., Results: Thirty learners from diverse health professional backgrounds (medicine, dentistry, physician assistant, nursing, physical therapy) participated. Multiple-choice question assessments and pre/post retrospective survey scores demonstrated enhanced knowledge ( M = 2.9 vs. M = 4.2, p < .001) and perceived competence ( M = 1.9 vs. M = 3.4, p < .001), respectively. Encouragingly, all participants indicated applicability to their clinical practice., Discussion: Our modules offer educators and clinicians a valuable resource to improve TMD knowledge and facilitate best practices. Supplementary resources included in the curriculum are conducive to clinical implementation, fostering improved clinician assessment and patient education., (US Government work in the public domain.)

Background: Technology-enabled services (TES; clinical services that include both technology-driven [e.g., personal sensing technologies] and person-powered support elements) may address gaps in depression and anxiety treatments in healthcare settings. The current study: (1) developed a TES tailored for Primary Care patients with depression and/or anxiety, and (2) conducted a pilot randomized controlled trial to assess the efficacy of the TES compared to a digital psychoeducation control app., Methods: Participants were randomized to either: (1) TES: the "Vira" smartphone app (Ksana Health Inc.), informed by behavioral activation and using passive sensing technology to provide behavioral "insights" and target behaviors associated with mental health symptoms, alongside lay-provider coaching, or (2) Control: the Mood Education mobile app (ME), containing static psychoeducational resources designed to target mental health symptoms. Both apps collected usage data. Participants completed assessments on depression (PHQ-9), anxiety (GAD-7), health-related quality of life (PedsQL), and engagement (TWEETs) at baseline, mid-treatment (week 4), end-of-treatment (week 8), and post-treatment (week 12)., Results: Participants (N = 130) were randomized to receive either the TES (Vira; M age = 30) or ME (M age = 33). Linear mixed-effects models determined significant improvements in PHQ-9 and GAD-7 scores for participants across both conditions (ps < 0.001). There was no interactive effect of intervention and time for the PHQ-9 (p = .90) nor the GAD-7 (p = .49). Adjusting for baseline differences and randomization strata, TES participants reported a greater change in a quality of life rating of Physical Functioning (PedsQL) across time (p = .018). TES participants also reported higher levels of engagement and demonstrated higher app usage. However, adjusting for baseline symptom severity, neither app usage nor coach interaction frequency moderated outcomes (ps ≥ 0.2)., Conclusions: While the TES demonstrated superior engagement, improvements in depressive and anxious symptoms for both conditions speak to the potential benefit of both TES and low-intensity psychoeducation treatments in care settings. Future research is needed to better understand which patients might differentially benefit from TESs and broader personal sensing technologies over low-intensity treatments., Trial Registration: ClinicalTrials.gov NCT05406791., Competing Interests: Declarations Ethics approval and consent to participate This research was conducted in accordance with the Declaration of Helsinki. All procedures were approved by the Northwestern University Institutional Review Board (IRB; STU# 00211887) and via a relying protocol approved by the IRB at Rush University Medical Center (“RUSH”; ORA# 18050901). Participants completed electronic informed consent, and teen participants completed electronic assent and parent/guardian permission. The trial was preregistered on ClinicalTrials.gov (NCT05406791). Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Human papillomavirus (HPV) testing became the primary cervical screening modality in Aotearoa New Zealand in September 2023. To inform the national roll-out of HPV primary screening, a multiregion implementation study ('Let's Test for HPV') was undertaken in primary care in 2022-2023., Aims: To explore participant perspectives and information needs following receipt of an HPV detected result., Materials and Methods: An online survey completed in 2023 by 921 Let's Test for HPV participants included 95 people with an HPV detected result (10.3%). Data collection included: adequacy of information provision, receipt of results, emotional response, views on HPV primary screening and needing cervical cytology and/or colposcopy, and intent to screen again., Results: Receipt of an HPV detected result was worrying for most people and many had unanswered questions about HPV, how HPV testing fits with cytology, implications for follow-up and outcomes. Knowledge gaps and uncertainty appeared to be linked with feeling anxious about possible outcomes and fear of a cancer diagnosis. All survey participants received recommended follow-up (cytology and/or colposcopy). Having a choice of screening test and the ability to self-test were welcomed and the majority (88%) expressed intent to screen again., Conclusions: These survey findings highlight the importance of giving clear information about potential outcomes at the time of screening and again when sharing results. Sensitive delivery of results, providing reassurance and answering questions are also important to mitigate fear and worry. Population-level education would help improve understanding of key messages about HPV testing and the changes to cervical screening., (© 2024 Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Non-fatal overdoses frequently precede fatal overdoses, thus identifying risk factors for non-fatal overdoses could help develop strategies to prevent substance related deaths., Aim: This study aimed to identify patterns, circumstances and risk factors leading to non-fatal substance overdose in people experiencing homelessness., Method: All recorded cases of non-fatal substance overdose from a population of people experiencing homelessness registered at a specialist homelessness primary care centre in England were identified using electronic medical records. Overdose details and patient characteristics were extracted. The heterogeneity between variables in people with and without a recorded non-fatal overdose were tested and multivariable logistic regressions were used to identify the risk factors of non-fatal overdoses., Results: From the 1221 registered patients, 194(16%) were identified as having had a non-fatal overdose with 428 overdoses between them. Half were polypharmacy events with the main substances of overdose being: heroin, paracetamol, benzodiazepines, cocaine, antipsychotics, SSRIs and synthetic cannabinoids. Risk of non-fatal overdose was greater in females, white ethnicity, ages 36-45, and in those with a recorded use of tobacco, alcohol or illicit substance use. Chronic physical and mental health conditions increased the risk of non-fatal overdose including respiratory conditions, blood borne viruses, migraines, anxiety and depression., Conclusion: With a high number of non-fatal overdoses within this population, identifying individuals at risk based on the factors identified in this research could enable primary care providers to apply prevention actions such as overdose awareness and naloxone provision to avoid drug harm and deaths. Future work should explore the role of chronic physical conditions and their treatment on non-fatal overdose risks., Competing Interests: Conflicts of interest Vibhu Paudyal is an Associate editor of the International Journal of Clinical Pharmacy. He had no role in handling the manuscript, specifically the processes of editorial review, peer review and decision making., (© 2024. The Author(s).)

Background: A new model of care enables French physiotherapists (PT) working in collaboration with family physicians (FP) to expand their usual scope of practice for patients with acute low back pain (LBP). The aim of our study is to evaluate the impact of this new first-contact physiotherapy (FCP) advanced practice model compared to usual FP care., Methods: A multicentre pragmatic non-inferiority cluster randomised controlled trial (RCT) has been conducted in six multidisciplinary primary healthcare centres in France. Patients from 20 to 55 years old with acute LBP consulted either the PT or the FP. PT independently assessed and managed patients including medication prescription. The primary outcome measure was disability at six weeks (Roland Morris Disability Questionnaire, range 0-24). Secondary outcomes include pain, risk disability prognosis, satisfaction with care, healthcare resources use and wait times. Data were collected at baseline, six and twelve weeks. Outcomes across arms were compared using mixed models regression analysis. Except for non-inferiority analysis of the primary outcome measure, other analyses were performed with a two-sided significance level of 0.05., Results: Sixty patients were recruited (PT: 32, FP: 28). The adjusted mean difference between groups for disability at 6 weeks was 0.39 in favour of the FP group (95%CI: -2.03; 2.81, p = 0.753). Considering a 5 points minimal clinically important difference, the FCP-led model of care was not inferior to usual FP care for the primary outcome. There was no statistically significant difference between groups in disability at 3 months and pain at 6 weeks and 3 months. PTs prescribed significantly less medications than FPs (p < 0.001). No statistically significant difference was found for other healthcare resource use outcomes, patients' satisfaction and wait times., Conclusion: This is the first RCT to evaluate the impact of a FCP advanced practice model of care including medical delegated acts in a primary care setting. Our results suggest that the FCP-led model of care is not inferior to usual FP care regarding disability at 6 weeks. The FCP model could result in possible benefits in terms of healthcare resources use. Further adequate powered studies with larger sample size are needed to draw stronger conclusions., Trial Registration: The study has been registered in ClinicalTrials.gov (NCT05200533) on the 20th of January 2022., Competing Interests: Declarations Ethics approval and consent to participate The study have been conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the French ethics committee: Comité de Protection des Personnes Ouest IV Nantes (Committee for the protection of subjects West Nantes IV, number 21.01537.000012). All participants offered written informed consent prior to the enrolment in the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: The aim of this quality improvement (QI) project was to increase Colorectal Cancer (CRC) screening in patients ages 50-75 years from a baseline of 27-40% within 12 months in a primary care clinic in limited resource communities., Methods: The multidisciplinary QI-team applied the Plan-Do-Study-Act method and developed stakeholder analysis, an Ishikawa fish bone diagram, a process flow map, and a driver diagram. Major barriers to suboptimal CRC screening included limited health literacy, language preferences, absence of stool test options, and knowledge gaps among patients and providers. The outcome measure was CRC screening rates, while stool test and colonoscopy completion rates served as process measures. Major interventions included the use of a patient-navigator, leveraging digital health technology to create a novel CRC screening data dashboard, educating patients and providers, patient centered-shared decision making, and creating messages and educational videos in patient's preferred languages. We used monthly run charts and statistical process control charts (SPC) for data analysis., Results: We observed a sustainable, steady increase in CRC screening rates from baseline rates of 27.0-40.0% (n = 1304/3271) during the study period and 45.6% (n = 1493/3,271) six months post-study, with median rates of 34.0% in the run chart and mean rates of 43.0% in the SPC chart. Furthermore, we observed an increase in colonoscopy completion rates during the study and six months post-study to 65.0% (n = 411/631) and 72.9% (n = 461/631) respectively, from a baseline rate of 25.0%, with a median of 63.0% in the monthly run chart., Conclusion: The increase in CRC screening rates highlights the effectiveness of addressing barriers such as health literacy, language preferences, and knowledge gaps. This underscores the value of a multifaceted approach and the role of a patient navigator in enhancing preventive, patient-centered care. This project focused on population health and addressing social determinants of health to overcome disparities and improve CRC screening in a primary care setting. Continued emphasis on these strategies is likely to further advance colorectal cancer screening efforts., Competing Interests: Declarations Ethics approval and consent to participate This study was reviewed by the University at Buffalo human subject institutional review board and was classified as exempt from human subjects. The University at Buffalo human subject institutional review board determined that the proposed activity is not research involving human subjects (Exempt). It was written and planned as a Quality Improvement project. STUDY00005976. Informed consent was waived by University at Buffalo human subject institutional review board. Survey was developed for this study. Consent for publication The University at Buffalo human subject institutional review board determined that the proposed activity is not research involving human subjects. Informed consent was waived by the University at Buffalo human subject institutional review board. No consent for publication necessary. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Annual influenza vaccination reduces disease burden but vaccination rates are suboptimal, with persistent disparities among subpopulations. The purpose of this trial is to evaluate multicomponent behavioural economic nudge interventions to clinicians and patients to increase influenza vaccination. This trial also includes an intensification nudge to reduce disparities in vaccination among older adult, primary care patients., Methods: This is a two-part, multisite cluster randomised, pragmatic clinical trial. In the first part, a multicomponent nudge intervention will be tested over approximately 6 months (September 2023-February 2024). The second part consists of a replication trial conducted at an additional site during the following influenza season (September 2024-February 2025). Primary care clinics will be randomised to the nudge intervention or usual care. Eligible clinicians and patients at intervention clinics will receive the intervention, and patients deemed high risk for not receiving a vaccine will be further randomised to receive an intensification nudge. The primary outcome is vaccine completion during the eligible visit and the secondary outcome is vaccine completion within 3 months of the eligible visit., Analysis: The effect of the clinic-level nudge intervention on the primary and secondary outcomes will be evaluated using generalised estimating equations (GEEs) with a clinic-level exchangeable working correlation to account for clustering of observations within the clinic. GEE models with an independent working correlation will be used to evaluate the impact of the additional intensification nudge on the primary and secondary outcomes., Ethics and Dissemination: The University of Pennsylvania Institutional Review Board (IRB) approved this trial and serves as the single IRB of record (IRB #851838). Results will be disseminated via peer-reviewed publication and conference presentations., Trial Registration Number: NCT06057727., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Mental disorders and physical-health conditions frequently co-occur, impacting treatment outcomes. While most prior research has focused on single pairs of mental disorders and physical-health conditions, this study explores broader associations between multiple mental disorders and physical-health conditions., Methods: Using the Norwegian primary-care register, this population-based cohort study encompassed all 2 203 553 patients born in Norway from January 1945 through December 1984, who were full-time residents from January 2006 until December 2019 (14 years; 363 million person-months). Associations between seven mental disorders (sleep disturbance, anxiety, depression, acute stress reaction, substance-use disorders, phobia/compulsive disorder, psychosis) and 16 physical-health conditions were examined, diagnosed according to the International Classification of Primary Care., Results: Of 112 mental-disorder/physical-health condition pairs, 96% of associations yielded positive and significant ORs, averaging 1.41 and ranging from 1.05 (99.99% CI 1.00-1.09) to 2.38 (99.99% CI 2.30-2.46). Across 14 years, every mental disorder was associated with multiple different physical-health conditions. Across 363 million person-months, having any mental disorder was associated with increased subsequent risk of all physical-health conditions (HRs:1.40 [99.99% CI 1.35-1.45] to 2.85 [99.99% CI 2.81-2.89]) and vice versa (HRs:1.56 [99.99% CI 1.54-1.59] to 3.56 [99.99% CI 3.54-3.58]). Associations were observed in both sexes, across age groups, and among patients with and without university education., Conclusions: The breadth of associations between virtually every mental disorder and physical-health condition among patients treated in primary care underscores a need for integrated mental and physical healthcare policy and practice. This remarkable breadth also calls for research into etiological factors and underlying mechanisms that can explain it.

Existing evidence regarding the impact of continuity of care (COC) in asthma patients is limited, and its quality is low to moderate. This study aimed to investigate associations between relational COC within primary care and asthma-related hospitalizations in children using a robust methodology. This study is a population-based cohort study that utilized a national claims database in South Korea. The study comprised 136,296 individuals under 20 years old who were newly diagnosed with asthma between 2015 and 2016. These were classified into high, medium, and low continuity groups based on the continuity of care index (COCI). The primary outcome measure was the incidence of asthma-related hospitalizations. During a two-year follow-up period, 10,922 patients (8.01%) were hospitalized: 2520 (5.59%) in the high-continuity group, 3188 (6.98%) in the medium-continuity group, and 3867 (8.48%) in the low-continuity group. After adjusting for confounding covariates, patients in the low- and medium-continuity groups exhibited significantly higher risks of hospital admission (adjusted hazard ratio (aHR) = 1.30 [95% confidence interval = 1.24-1.37] and aHR = 1.14 [1.08-1.20], than those in the high-continuity group. Sensitivity and subgroup analyses findings were consistent. In a young population with asthma increased continuity of primary care was associated with less hospitalization., Competing Interests: Declarations Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Low back pain significantly impacts global health, particularly in low-income areas where primary care challenges are prevalent. Assessing both biophysical and psychological factors associated with low back pain-related disability is crucial for developing effective screening and management strategies., Objectives: This study aimed to examine the association between fear of movement, trunk mobility, pain intensity, physical activity, and low back pain-related disability, and to identify key factors contributing to higher disability levels in patients with chronic low back pain., Methods: This cross-sectional study analyzed data from 381 chronic low back pain patients aged over 18, collected at a primary care ambulatory between 2015 and 2019. Variables measured included pain intensity, fear of movement, physical activity, trunk mobility, and disability. A Classification and Regression Tree approach was used to model disability predictors., Results: Fear of movement was the main driver of high disability (OR = 17.3, 95%CI 8.9-33.7). Two profiles were particularly prone to higher disability: patients with high fear of movement (>47.5) and pain intensity > 1.5; and those with lower fear of movement but poor trunk mobility (>36.5 cm). Patients with better trunk mobility and low pain intensity (≤3.5) showed significantly less disability (OR = 0.06, 95%CI 0.02-0.17)., Conclusions: The findings highlight the need for integrating better psychological and biophysical assessments in managing chronic low back pain. Understanding how fear of movement, trunk mobility, and pain interaction can improve screening accuracy and optimize care in resource-limited settings, using valid and feasible tools for these scenarios.

Background: We conducted a mixed methods evaluation to assess whether implementing a primary care quality improvement (QI) programme utilising a digital call-and-recall tool improved timely receipt and equity of first measles, mumps and rubella (MMR) and diphtheria tetanus, pertussis and polio-containing (DTaP /IPV) vaccinations., Methods: 138,133 and 136,952 children were eligible to receive first MMR and DTaP/IPV respectively between 1st January 2019 and 31st January 2024 in North East London. We compared proportions with timely first MMR or DTaP/IPV receipt (by ages 18 and six months respectively) pre- and post-implementation using an interrupted time series analysis. We calculated change in the Slope Index of Inequality (SII) by an area-level deprivation measure. We conducted 'Think Aloud' exercises and semi-structured interviews with users., Findings: The proportion of children with timely first MMR receipt increased by 5·3 % (Rate Ratio [RR]:1·053, 95 % confidence interval [CI]:1·033-1·073), equating to an absolute increase in timely MMR receipt of 4·1 % - from 77·7 % to 81·8 % - and for first DTaP/IPV by 0·9 % (RR:1·009, 95 % CI:1·003-1·015). There was no significant change in SII for either vaccine. Users reported improved recall with tool use, but identified practice-level and systemic barriers, including staff dynamics and unachievable national targets, limiting its consistent use., Interpretation: In a real-world setting, a call-and-recall tool within a primary care QI programme improved timely first MMR receipt. Sustained improvement requires additional support including by incentivising achievable targets and improving staff capacity and training., Funding: National Institute of Health and Care Research; Barts Charity., Competing Interests: Declaration of competing interest The authors would like to declare that they have received support from the appended list of institutions:, (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: This study aims to describe the main type 2 diabetes mellitus (T2DM) quality improvement (QI) challenges identified by primary care teams in the province of Quebec who participated in the COMPAS + QI collaborative., Methods: A qualitative descriptive design was used to analyse the results of 8 COMPAS + workshops conducted in 4 regions of the province between 2016 and 2020. Deductive content analysis was performed to classify the reported QI priorities under the Consolidated Framework for Implementation Research domains; and proposed change strategies under the Behavior Change Wheel (BCW) intervention functions., Results: A total of 177 participants attended the T2DM COMPAS + workshops. Three QI priorities were identified: (1) lack of coordination and integration of T2DM care and services; (2) lack of preventive services for pre-diabetes and T2DM; and (3) lack of integration of the patients-as-partners approach to support T2DM self-management. The proposed QI strategies to address those priorities were classified under the education, training, persuasion, habilitation and restructuring BCW intervention functions., Conclusion: This study provides insights on how QI collaboratives can support the identification of QI priorities and strategies to improve T2DM management in primary care., Competing Interests: Declarations Ethics approval and consent to participate The study was approved by the Research Ethics Board of the CIUSSS de l’Est de l’Île de Montréal (MP-12-2019-1760). All participating organizations gave informed consent to use the material related to the COMPAS + program’s implementation and follow-up. The REB did not require explicit signed consent from individual workshop participants because these were QI activities and analysis were performed retrospectively on workshop reports. As described by Hall et al. (2020) [66], informed consent for QI initiatives should be obtained by all participants only if their participation poses more than a minimal risk. For this study, no personal information about participants was sent to the research team, and the study was deemed by the REB to pose minimal risks to workshop participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Telehealth, including video consultation (VC), has become prevalent during the COVID-19 pandemic. However, the experience and concern of women using VC for postpartum care has yet to be adequately studied but is crucial for their adoption. The study aimed to assess the experience and attitude of postpartum mothers (PPM) towards using VC as a novel model of care delivery and the factors that could potentially affect their adoption., Method: Data were gathered from PPM participating in VC using Zoom platform for postpartum care using mixed method. In-depth interviews (IDI) of twenty-five PPM were audio-recorded, transcribed verbatim and audited for accuracy. Thematic analysis was conducted to identify themes relating to perceived threat, usefulness, ease of use, and attitudes toward using VC in postpartum care. The themes are reported based on the "Health Information Technology Acceptance Model" framework. Preliminary quantitative data on the acceptability of VC were collected using structured surveys., Results: PPMs valued convenience, accessibility, and personalised care VC offered to address their immediate postpartum concerns. They perceived VC as suitable for seeking medical opinions, improving confidence in parent crafting, and providing better care access. They recognised the lack of physical examination as a major limitation in VC and proposed a hybrid postpartum care model, combining VC and in-person consultation to cater to individual needs and preferences. PPMs alluded to trust in the care providers, flexibility in VC appointment timings and enhanced interface of remote platforms as enablers for VC adoption. Preliminary quantitative data shows that PPMs found VC saved time (100%), energy (98%), and money (90%) and was appropriate (94%), easy to use (96%), acceptable (96%) for postpartum care., Conclusion: PPMs favoured combining VC and in-person consultation to mitigate their concerns and personalise their care needs., Competing Interests: Declarations Ethics approval and consent to participants The study was approved by the SingHealth Centralised Institutional Review Board (CIRB 2021/2732). The research was conducted according to International Conference on Harmonisation Guidelines for Good Clinical Practice. All participants signed written informed consent before study activities. Consent for publication Not applicable. Author information The research team included four female PCP, one male PCP, two female nurses and one female student. The nurses are qualified lactational counselors. ASM and PZ are trained in qualitative and quantitative research. NCT is a trainer and experienced researcher in both qualitative and quantitative research. The PCPs and nurses manage and counsel patients in polyclinics, including mothers, during antenatal and postnatal periods. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Our objective in this article was to develop a predictive model for obesity in the third trimester of pregnancy using the plasma and clinical biomarkers that are managed within the Chromosomopathies Programme in the Andalusian Public Healthcare System. Methods: The epidemiological design was observational, of the unmatched case-control type. The geographical environment was the Seville Primary Healthcare District (DSAP Sevilla). The information was collected between 2011 and 2021. The reference cohort consisted of women who had carried a pregnancy to term. The variables and biomarkers studied correspond to those managed within the primary-care Pregnancy Integrated Care Pathway (ICP). Unconditional binary logistic regression (BLR) models were created, with the outcome variable being whether or not the women were obese in their third trimester of pregnancy. Results : A total of 423 controls and 104 cases of obesity were obtained for women in their third trimester who had not been obese in their first trimester. The average age for the sample group (P50) was 34 years old. The final, most parsimonious model included the variables PAPP-A ( p = 0.074), beta-hCG ( p = 0.1631), and systolic blood pressure (SBP) ( p = 0.085). ROC curve = 0.75 (C.I. at 95%: 0.63-0.86). Discussion : The results of this research can only be extrapolated to primary care and to pregnancies with no complications. PAPP-A has been shown in our research to be a significant predictor of obesity risk in the third trimester of pregnancies with no complications (OR = 0.53; C.I. at 95%: 0.39-0.66; p = 0.04 in the single-variant study; OR = 0.58; C.I. at 95%: 0.29-0.93; p = 0.074 in the multi-variant analysis). This predictive capacity is further enhanced from an operational perspective by beta-hCG and 12-week SBP.

Aim: Heart failure (HF) is a highly prevalent condition managed in both primary care (PC) and hospital care (HC)-based settings. HF patients managed in these two settings may differ in their demography, comorbidities and outcomes, so we aimed to compare the patient management in PC and HC in the Västra Götaland Region (VGR) in Sweden., Methods: The VEGA database is an administrative database that includes all patients living in VGR. Patients with a first principal or contributory diagnosis of HF (I50) ≥18 years old between 2008 and 2017 were included. One-year mortality was used as the outcome., Results: In total, 35 375 new-onset HF cases were included with 18 722 identified only in PC and 16 651 in HC. HF patients in PC were older (80.7 ± 10.9 vs. 76.1 ± 13.6), more women (57.1% vs. 44.9%), with more hypertension, musculoskeletal and mental disorders, but less myocardial infarction. Patients in HC had almost 4 times higher all-cause 1 year mortality [3.92 (3.77-4.08), P < 0.0001] compared with PC after adjustment for age and sex. Over a 10 year period, despite decreasing mortality in both settings, hazard ratios for HC versus PC were significantly increased for all patients (P for interaction 0.0004), which was more marked in female and for 70-80 years old patients., Conclusion: Over a 10 year period, we demonstrated the differences in demography, comorbidities and outcomes between heart failure patients managed in hospital care versus primary care., (© 2024 The Author(s). ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Objectives : To investigate the willingness of the general Hong Kong population to use teleconsultation in primary care and the factors affecting their decisions and to ascertain the medical problems for which people will consider using teleconsultation in primary care. The study was a cross-sectional territory-wide random population survey on adults recruited through a computer-assisted telephone interview system. Outcome Measures : Outcomes were the proportion of the general Hong Kong population indicating their willingness to use teleconsultation in primary care; the drivers and barriers affecting their willingness; and the medical problems in primary care for which people would consider using teleconsultation. Results : After applying population weighting, 51.6% of the study respondents were found to be willing to use teleconsultation in primary care. The main drivers were possessing the perception that teleconsultation would serve the majority of their health problems (odds ratio [OR] = 3.693, p < 0.001), provision of government subsidy (OR = 3.567, p < 0.001), and ownership of a computer/tablet (OR = 2.116, p < 0.001). A major barrier for people's reluctance to use teleconsultation in primary care was having an education level of primary or below (OR = 0.388, p = 0.002). The majority of people had reasonable expectations on which medical conditions teleconsultation could be helpful but misunderstandings did exist. Conclusion : Our survey estimated that more than half of the general Hong Kong population was willing to use teleconsultation in primary care. Health care service providers and the government should address the drivers and barriers and clarify any misconceptions if teleconsultation is to be further developed in the Hong Kong primary care system.

Background: During the COVID-19 pandemic, digital health solutions ensured the continuity of care especially in primary healthcare practices. COVID-19 accelerated the adoption of digital health solutions. The aim of this study is to describe the digital health-related attitudes and experiences of Hungarian Primary Care Physicians (PCPs) and also analyse the socio-demographic effects on digital health attitudes among PCPs., Methods: This study used a quantitative and qualitative mixed methodological approach to examine the digital health-related attitudes and experience of Hungarian PCPs. As part of the "E-physicians and E-patients in Hungary" survey, we conducted an online survey among medical doctors working in Hungary between July 2021 to May 2022. A total of 1,774 questionnaires were received, consisting of 1,576 medical doctors and 198 dentists. Among the medical doctors there were 415 primary care physicians (PCPs). In addition to the online questionnaire survey, qualitative research in the form of semi-structured interviews with doctors was also conducted. These interviews took place between October 2021 and June 2022. A total of 62 interviews were conducted,19 with PCPs., Results: Primary care physicians are more open to technologies that facilitate communication and collaboration with patients, while showing less interest in technologies that support clinical work. Of the demographic variables (age, gender, type of settlement), age was found to have the most significant effect on digital health knowledge, use and intended use. Both the interviews and the multivariate analysis indicate that individuals with greater knowledge, expertise, and experience are more likely to perceive the advantages of digital solutions. This highlights the importance of training, especially given the significant aging population among Hungarian primary care physicians, who may not be accustomed to using these tools naturally. The way PCPs perceive patient expectations regarding the use of digital health tools has a significant impact on the PCPs' use and intended use of digital tools. When looking at perceived patient needs among PCPs the effect of age and municipality type of PCPs is significant. As age increases, the perception of patient needs decreases (from 5.02 to 4.47), and by municipality type, the average number of perceived needs decreases as one moves from larger cities to smaller municipalities (from 4.85 to 4.14)., Conclusions: Digital health solutions have the potential to enhance the work of PCPs, but successful implementation requires addressing specific needs, demographic differences, and challenges faced by PCPs. Development of infrastructure, education, and institutional support is necessary to ensure more efficient and higher-quality healthcare delivery through the use of digital technologies., Competing Interests: Declarations Ethics approval and consent to participate The authors confirm that all methods were carried out in accordance with relevant guidelines and regulations.The research has ethical approval by TUKEB (Hungarian Scientific Research and Research Ethics Committee) with the reference number IV-10927–1 TUKEB. This is a national body, so the ethical approval is not from the authors affiliation.The authors confirm that all experimental protocols were approved the TUKEB (Hungarian Scientific Research and Research Ethics Committee).The authors confirm that informed consent was obtained from all subjects and/or their legal guardian(s). Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Cardiovascular diseases (CVD) are among the most prevalent and preventable chronic diseases in the 21st century The global burden of disease: 2004 update. The Report in Sections. A person's risk of developing CVD can be reduced by adopting healthy lifestyles, spiritual and religious practices The American Heart Association Life's Simple 7 in African Americans of the Jackson Heart Study. Fasting as a spiritual practice is not exempted from these benefits. Most world's religions recommend a period of fasting. The obligatory Ramadan fasting in Islam may provide an interesting opportunity to reduce food intake and increase physical activity. The main objective of this study is to investigate the effect of Ramadan fasting on cardiovascular risk factors on healthy adult Muslims., Method: The study was pre/post-test single arm intervention conducted at the staff clinic of Family Medicine department, AKTH, and Northwest, Nigeria. Kano. The study recruited healthy adults 18yrs and above not on any medications that can affect metabolic profiles consecutively from two weeks before Ramadan fasting of 2018 and the last week of Ramadan of the same year. The questionnaire included information on sociodemographic, clinical parameters and Lifestyle pattern., Result: Thirty healthy volunteers were included in this study, 25 males (83.3%) and 5 females (16.7%). The mean age was 38.23 ± 6.35(SD). Twenty-five participants were married (83.3%) with 4 singles (13.3%) and 1 divorcee (3.3%). During Ramadan fasting, weight reduced (67.90 ± 11.61 versus 66.53 ± 12.13 4th week of Ramadan p-value < 0.002) Body Mass Index (22.89 ± 3.63 versus 4th week of Ramadan 22.38 ± 3.64 p-value < 0.002) and systolic blood pressure (120.33 ± 19.91versus 4th week of Ramadan 115.33 ± 14.32 p-value 0.003) reduced significantly compared to baseline. The waist circumference, pulse rate, fasting blood sugar and cholesterol were reduced but were not statistically significant., Conclusion: The result from this study suggested that Ramadan fasting may be a useful means of reducing burden of cardiovascular diseases, as the improved cardiovascular risk factors associated with fasting may translate into a significant health benefit., Competing Interests: Declarations Ethical approval Ethical approval was obtained from AKTH Research and Ethics Committee. Reference (NHREC/21/08/2008/AKTH/EC/2224). All participants signed informed consent for the study. Consent for publication Not applicable. Clinical trial number Not applicable since no drugs were introduced. The intervention was religious practice fasting during Ramadan. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Resilience is crucial for a health system to better prevent and respond to public health threats and provide high-quality services. Despite the growing interest in the concept of resilience in health care, however, there is little empirical evidence of the impact of organizational resilience, especially in primary care settings. As the largest professional group in primary care, primary care nurses are taking more and more responsibilities during their daily practice, which influences both their work conditions and well-being. This study aims to examine the association between organizational resilience and primary care nurses' working conditions and well-being. Using a convenience sampling approach, we recruited 175 primary care nurses from 38 community health centres (CHCs) in four cities in China. Organizational resilience was operationalized as comprising two domains: adaptive capacity and planning capacity, and measured using a 16-item scale. The primary care nurses' working condition indicators comprised variables of psychological safety, organizational commitment, professional commitment, and self-directed learning; well-being indicators included depression and burn-out. Hierarchical linear regression models were built for analysis. We found that the sampled CHCs have a relatively high level of organizational resilience. The organizational resilience was positively associated with the four indicators of working conditions: psychological safety (β = 0.04, P < 0.01), organizational commitment (β = 0.38, P < 0.01), professional commitment (β = 0.39, P < 0.01), and self-directed learning (β = 0.28, P < 0.01). However, organizational resilience was not significantly associated with the two well-being indicators. Furthermore, we found that the adaptive capacity has stronger association compared with planning capacity. Therefore, primary care manager should build resilient organizations, especially the adaptive capacity, in order to enhance primary care nurses' psychological safety, commitment and learning behaviours. Further studies should also be conducted to understand the link between organizational resilience and primary care nurses' well-being., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

In recent decades, Nigeria has implemented a number of health financing reforms, yet progress towards Universal Health Coverage (UHC) has remained slow. In particular, the introduction of the Basic Health Care Provision Fund (BHCPF) through the National Health Act of 2014 sought to increase coverage of basic health services in Nigeria. However, recent studies have shown that health financing schemes like the BHCPF in Nigeria are suboptimal and have frequently attributed this to weak accountability and governance of the schemes. However, little is known about the accountability and governance of health financing in Nigeria, particularly from the perspective of key actors within the system. This study explores perceptions around governance and accountability through qualitative in-depth interviews with key BHCPF actors, including high-level government officers, academics and Civil Society Organizations. Thematic analysis of the findings reveals broad views among respondents that financial processes are appropriately ring-fenced, and that financial mismanagement is not the most pressing accountability gap. Importantly, respondents report that accountability processes are unclear and weak in subnational service delivery, and cite low utilization, implicit priority setting and poor quality as issues. To accelerate UHC progress, the accountability framework must be redesigned to include greater strategic participation and leadership from subnational governments., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Background: The prevalence of neovascular age-related macular degeneration (nAMD) continues to increase. Hospital Eye Services are operating above capacity, innovative solutions to minimise the high proportion of false negative referrals, improve the care pathway and increase capacity for those patients who need ongoing care are essential are essential., Methods: A two-phase retrospective longitudinal analysis of all patients referred and assessed for nAMD between; April 2019 to March 2020 (Phase 1) n=394, and April 2020 to March 2021 (Phase 2) n= 414, within Swansea Bay University Health Board (SBUHB). All patients with suspect nAMD were referred to the hospital based nAMD clinic in phase 1, and a community optometry nAMD decision making pathway in phase 2. All clinical records were reviewed, and data collated for subsequent analysis. Age, sex, date of referral, diagnosis, and treatment date were all recorded and analysed., Results: During phase 1, 104 new nAMD cases needing treatment were diagnosed with 85% (n=88) receiving treatment within 2 weeks of initial referral. During phase 2, 230 new nAMD cases requiring treatment were diagnosed with 94% (n=216) receiving treatment within 2 weeks of initial referral. Both the proportion of nAMD cases diagnosed (χ² = 70.8; p<0.001) and proportion of those treated within 2 weeks of initial diagnosis (χ² = 7.57; p<0.05) were significantly higher during phase 2., Conclusion: There are advantages to a community optometry nAMD decision-making pathway with regard to 1) decreasing the number of patients requiring HES attendance, 2) increasing the number of patients able to access treatment for nAMD within 2 weeks of initial referral 3) an increased rate of diagnosis confirmation of nAMD and 4) a decrease in the rate of false-positive referrals., Competing Interests: The authors declare that they have no conflicts of interest., (© 2024 Sanders et al.)

Background: In 2019, 1.8 million new cancer cases occurred, and 500,000 cancer deaths were expected in the United States, costing $21 billion. Regular primary care screenings have correlated with early cancer detection, treatment, health promotion, and reduced costs. Objectives: The aim was to increase effective primary care screenings in adults in St. Thomas U.S. Virgin Islands Department of Health Community Clinic to 75% within 8 weeks. Methods: This quality improvement initiative used four Plan-Do-Study-Act cycles over 8 weeks. Two core interventions, each with four tests of change, were implemented. Interventions: Core interventions included screening utilizing a checklist for body mass index, depression, and colorectal, lung, breast, cervical, uterine, and prostate cancer and engagement utilizing a checklist for correlated screening-related education, interventions, shared decision-making, and referral. Results: Primary care screenings increased from 55% to 96%, and patient engagement increased from 6% to 82%. Effective primary care screenings increased to 89%, exceeding the aim. Conclusions: This project improved primary care screening and engagement and effectively applied patient-centered care. Achievements were made through standardized screening and engagement. Implications for Nursing: This quality improvement project may be spread to other clinics to improve patient health outcomes., (© 2024 Springer Publishing Company, LLC.)

Background: Black-White coronary heart disease (CHD) treatment disparities are well documented, especially regarding the use of high-quality hospitals. Physician referral networks may play a role., Objective: To understand how primary care physicians (PCPs) make specialty referrals for CHD treatment and how referrals may contribute to treatment disparities., Design: Qualitative study using semi-structured interviews and focus group discussions., Participants: We purposively recruited 45 PCPs (50 invited, 90% response rate) in three metro areas with high Black-White segregation of cardiac care networks (New York City; Chicago; Atlanta)., Approach: We developed the focus group discussion guide from interviews and current literature. We conducted two focus groups per metro area via Zoom. Two expert team members independently coded the transcripts using inductive techniques and analyzed focus group content and themes using Dedoose., Key Results: Most participants were male (62.2%), White (57.8%), and practiced for at least 23 years. We identified several recurrent themes for factors influencing cardiology referrals. The most frequently mentioned themes were heavy reliance on professional networks, specialist availability, timeliness, communication style, patient geographic and economic constraints, and patient preferences. PCPs used anecdotal and not data-driven evidence to assess hospital quality and viewed Black-White differences in high-quality hospital use as due to patient economic status and preferences or differences in hospital access and provider referral bias., Conclusion: PCPs' referral decisions for CHD treatment are primarily driven by access to specific professional networks and the socioeconomic circumstances of their patients. Nevertheless, PCPs strive to make the best available decisions, leaning into their networks and honoring patient preferences. While PCPs acknowledged existing disparities, they attributed them to patient and system factors rather than provider referral bias. Mitigating disparities will require interventions to improve minority-serving providers' formal and informal connections with high-quality specialists and hospitals, address patient socioeconomic constraints, and train providers to recognize their potential biases and misconceptions., Competing Interests: Declarations: Conflict of Interest: No author reports any conflicts of interest., (© 2024. The Author(s).)

Background: The German College of General Practitioners and Family Physicians (DEGAM) issued a COVID-19 guideline with eleven recommendations to support primary care services during the pandemic. Their use in general practices beyond the pandemic can contribute to pandemic preparedness. This study analysed general practitioners' (GPs) interest in applying recommended organisational changes in non-pandemic times., Methods: Data from the German egePan GP survey (n = 516 GPs) - a multi-level clustered randomised web-based survey - were analysed. GPs' interest in the future application of the eleven guideline recommendations was calculated. In addition, each recommendation was evaluated by the GPs using a Net-Promoter-Score (NPS range - 100 to 100). A linear regression model identified GP and practice characteristics associated with a higher interest in applying recommendations in non-pandemic times., Results: 98.5% of the GPs indicated the intention to implement at least one guideline recommendation prospectively: disinfectant dispensers at the entrance (86%), optimised consultation scheduling to reduce waiting times (83%), and glass screens in the reception area (72%), which also received the highest NPS scores. In contrast, lower interest was observed for items such as insurance card readers handled by patients (48%), only selected staff treating infectious patients (44%), and video consultations for patients with infections (26%). A higher interest to implement recommendations in non-pandemic times was associated with a higher crisis leadership score (p < 0.001), using the Corona-Warn-App (p = 0.007), and being a female GP (p = 0.045). In addition, GPs from Western, Northern, and Southern, and those with a higher patient volume per three months, were more interested in future implementation., Conclusions: Overall, GPs demonstrated the readiness to follow the DEGAM COVID-19 guideline outside pandemic periods, establishing them as key contributors to pandemic preparedness in Germany., Competing Interests: Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the Medical Faculty of the University of Bonn (reference number: 419/20, date of approval: 5 February 2021) and has been performed in accordance with the Declaration of Helsinki. Informed consent was obtained from all participants and/or their legal guardian(s). Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: Future Health Today (FHT) is a technology program that integrates with general practice clinical software to provide point of care (PoC) clinical decision support and a quality improvement dashboard. This qualitative study looks at the use of FHT in the context of cardiovascular disease risk in chronic kidney disease (CKD)., Objective: This study aims to explore factors influencing clinical implementation of the FHT module focusing on cardiovascular risk in CKD, from the perspectives of participating general practitioner staff., Methods: Practices in Victoria were recruited to participate in a pragmatic cluster randomized controlled trial using FHT, of which 19 practices were randomly assigned to use FHT's cardiovascular risk in CKD program. A total of 13 semistructured interviews were undertaken with a nominated general practitioner (n=7) or practice nurse (n=6) from 10 participating practices. Interview questions focused on the clinical usefulness of the tool and its place in clinical workflows. Qualitative data were coded by 2 researchers and analyzed using framework analysis and Clinical Performance Feedback Intervention Theory., Results: All 13 interviewees had used the FHT PoC tool, and feedback was largely positive. Overall, clinicians described engaging with the tool as a "prompt" or "reminder" system. Themes reflected that the tool's goals and clinical content were aligned with clinician's existing priorities and knowledge, and the tool's design facilitated easy integration into existing workflows. The main barrier to implementation identified by 2 clinicians was notification fatigue. A total of 7 interviewees had used the FHT dashboard tool. The main barriers to use were its limited integration into clinical workflows, such that some participants did not know of its existence; clinicians' competing clinical priorities; and limited time to learn and use the tool., Conclusions: This study identified many facilitators for the successful use of the FHT PoC program, in the context of cardiovascular risk in CKD, and barriers to the use of the dashboard program. This work will be used to inform the wider implementation of FHT, as well as the development of future modules of FHT for other risk or disease states., (© Caroline McBride, Barbara Hunter, Natalie Lumsden, Kaleswari Somasundaram, Rita McMorrow, Douglas Boyle, Jon Emery, Craig Nelson, Jo-Anne Manski-Nankervis. Originally published in JMIR Human Factors (https://humanfactors.jmir.org).)

Background: Implementation of screening brief intervention and referral to treatment (SBIRT) and medication-assisted treatment for alcohol use disorder (MAUD) remains low in primary care. ANTECEDENT (Partnerships to Enhance Alcohol Screening, Treatment, and Intervention) was a practice-facilitator led implementation study to increase SBIRT and MAUD use in diverse primary care clinics., Methods: From November 2019 - April 2023, we conducted a convergent parallel mixed methods evaluation. Participants were small and medium-sized primary care clinics in the Northwestern U.S. Clinics received foundational support (i.e., baseline/exit assessment, access to SBIRT Oregon website) and the option for supplemental implementation support (e.g., practice facilitation, expert consultation) over the 15-month intervention to improve SBIRT and MAUD. Qualitative and quantitative data regarding clinic characteristics, implementation strategies, and SBIRT/MAUD outcomes were collected through practice facilitator interviews, periodic reflections and clinic contact logs, interviews, pre-post surveys, and electronic health record (EHR) queries. Quantitative analyses included descriptive statistics, logistic regression, and the Wilcoxon sign-ranked test. Qualitative analysis took an immersion crystallization approach. Data were reviewed in a matrix to evaluate intervention adoption, implementation, and effectiveness., Results: We recruited 75 unique clinics; 66 participated and 48 (73%) completed the study. Eight participating clinics chose to receive foundational support only (12%) while 58 chose to engage in supplemental support (88%) activities. Clinics that received supplemental support and completed the intervention (n = 42) engaged in practice facilitation (Mean: 293 min, range: 75-550 min); data review (38%), HIT support (31%), expert consultation (19%), and peer-to-peer learning (5%). Pre- and post-intervention assessments showed significant improvement in self-reported SBIRT process outcomes. Performance data improved among the subset of completing clinics able to produce data (n = 17). Clinics described positive experiences with ANTECEDENT support and highlighted remaining barriers to SBIRT and MAUD implementation., Conclusions: Participating clinics engaged in a diverse range of supportive activities. A flexible approach using practice facilitation and implementation support could be helpful for low-resourced primary care clinics in improving SBIRT and MAUD for unhealthy alcohol use., Competing Interests: Declarations Ethics approval and consent to participate Study activities were approved by the Oregon Health & Sciences University Institutional Review Board (IRB) through an expedited review (STUDY00020592). The study obtained a waiver of HIPAA authorization for use of the EHR data on patient outcomes. All participants gave their informed consent to participate in the study after receiving a study information sheet. The IRB-approved information sheet included information describing the study including voluntariness, risks, benefits, and ability not to participate without penalty. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)