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Objective: This study aimed to assess the changes in the frequency of physical activity (PA) counseling and in the predictors of primary care PA promotion in Québec primary care physicians (PCPs) between 2010 and 2020. Methods: In 2010, we conducted a survey among Québec PCPs. Questions included: frequency of promoting PA to patients, perceived barriers, needs to improve PA promotion practice, frequency of PCPs' PA practice, and sociodemographic information. In 2020, we took over the 2010 questionnaire to document the evolution of the PA promotion practice. Results: The proportion of PCPs discussing PA with their patients significantly increased (P <.05) in 2020 for the following health conditions: depression, low back pain, chronic obstructive pulmonary disease, and cancer; it declined (P <.05) for overweight patients, those with metabolic syndrome, and in primary prevention. Collaboration with PA professionals was the major need identified, and it increased in 2020. PCPs' own practice of PA was a predictor of PA promotion in 2010 (odds ratio = 6.679; P <.001) and in 2020 (odds ratio = 6.679; P <.001). In both 2010 and in 2020, older or more experienced PCPs were more likely to discuss PA with their patients without diagnosed diseases than younger ones or those with less experience. Conclusions: Over the last 10 years, there has been a significant increase in PCPs promoting PA in Québec; however, it has been mainly oriented toward secondary prevention. It is concerning that PA counseling in primary prevention has declined, notably among younger PCPs. The stronger claim for closer collaboration with kinesiologists suggests that PCPs are in favor of an interprofessional strategy, namely collaboration with PA specialists. [ABSTRACT FROM AUTHOR]

BackgroundSocial care integration refers to the incorporation of activities into health systems that assist patients with health-related social needs (HRSNs) that negatively impact the health outcomes of their patients, such as food insecurity or homelessness. Social care integration initiatives are becoming more common. The COVID-19 pandemic strained health systems while simultaneously increasing levels of unmet social needs.ObjectiveTo describe the effects of the COVID-19 pandemic on established social care delivery in a primary care setting.DesignWe used qualitative semi-structured interviews of stakeholders to assess barriers and facilitators to social care delivery in the primary care setting during the COVID-19 health emergency. Data was analyzed using a hybrid inductive/deductive thematic analysis approach with both the Consolidated Framework for Implementation Research (CFIR) and the Screen-Navigate-Connect-Address-Evaluate model of social care integration.SettingTwo safety-net, hospital-based primary care clinics with established screening for food insecurity, homelessness, and legal needs.ParticipantsSix physicians, six nurses, six members of the social work team (clinical social workers and medical case workers), six community health workers, and six patients (total N = 30) completed interviews.ResultsFour major themes were identified. (1) A strained workforce experienced challenges confronting increased levels of HRSNs. (2) Vulnerable populations experienced a disproportionate negative impact in coping with effects of the COVID-19 pandemic on HRSNs. (3) COVID-19 protections compounded social isolation but did not extinguish the sense of community. (4) Fluctuations in the social service landscape led to variable experiences.ConclusionsThe COVID-19 pandemic disrupted established social care delivery in a primary care setting. Many of the lessons learned about challenges to social care delivery when health systems are strained are important considerations that can inform efforts to expand social care delivery.

BACKGROUND: This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion. METHODS: Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation. RESULTS: We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care. CONCLUSION: Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined. TRIAL REGISTRATION: Registry: Clinicaltrials.gov. TRIAL REGISTRATION NUMBER: NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

BACKGROUND: Urinary tract infections (UTI) affect almost two-thirds of all women during their lives and many experience recurrent infections. There are evidence-based guidelines from multiple international societies for evaluation and treatment; however, recent claims-based analyses have demonstrated that adherence to these guidelines is poor. This study seeks to understand the barriers experienced by U.S. primary care providers (PCPs) to providing guideline-based care for UTI and recurrent UTI (rUTI). METHODS: Semi-structured interviews of 18 PCPs, recruited from the greater Los Angeles area, examined real-world clinical management of UTI/rUTI episodes, decisions to refer to subspecialty care, and resources guiding counseling and management. Grounded theory methodology served to analyze interview transcripts and identify preliminary and major themes. RESULTS: Participants expressed the desire to obtain urine cultures for each cystitis episode, but felt pressured to make compromises by patient demands or barriers to care. PCPs had lower thresholds to empirical treatment if patients had a history of rUTIs, were elderly, or declined evaluation. Laboratory data was minimally utilized in clinical decision-making: urinalyses were infrequently considered when interpreting culture data. PCPs treated a broad set of urologic and non-urologic symptoms as UTI, even with negative cultures. PCPs did not feel comfortable initiating UTI prophylaxis, instead seeking specialist evaluation for anatomic causes. They were unaware of management guidelines, typically utilizing UpToDate® as their primary resource. Few evidence-based UTI prevention interventions were recommended by providers. CONCLUSIONS: Low availability of succinct and clear professional guidelines are substantial barriers to appropriate UTI/rUTI care. Poor useability of clinical guidance documents results in substantial confusion about the role of preventative measures and additional diagnostic testing. Difficulties in patient access to care providers lead to expectations for presumptive treatment. Future studies are needed to determine if improved educational materials for providers and/or management algorithms can improve guideline concordance of UTI management.

ProblemOur nation faces an urgent need for more primary care (PC) physicians, yet interest in PC careers is dwindling. Students from underrepresented in medicine (UIM) backgrounds are more likely to choose PC and practice in underserved areas yet their representation has declined. Accelerated PC programs have the potential to address workforce needs, lower educational debt, and diversify the physician workforce to advance health equity.ApproachWith support from Kaiser Permanente Northern California (KPNC) and the American Medical Association's Accelerating Change in Medical Education initiative, University of California School of Medicine (UC Davis) implemented the Accelerated Competency-based Education in Primary Care (ACE-PC) program - a six-year pathway from medical school to residency for students committed to health equity and careers in family medicine or PC-internal medicine. ACE-PC accepts 6-10 students per year using the same holistic admissions process as the 4-year MD program with an additional panel interview that includes affiliated residency program faculty from UC Davis and KPNC. The undergraduate curriculum features: PC continuity clinic with a single preceptor throughout medical school; a 9-month longitudinal integrated clerkship; supportive PC faculty and culture; markedly reduced student debt with full-tuition scholarships; weekly PC didactics; and clinical rotations in affiliated residency programs with the opportunity to match into specific ACE-PC residency tracks.OutcomesSince 2014, 70 students have matriculated to ACE-PC, 71% from UIM groups, 64% are first-generation college students. Of the graduates, 48% have entered residency in family medicine and 52% in PC-internal medicine. In 2020, the first graduates entered the PC workforce; all are practicing in California, including 66% at federally qualified health centers, key providers of underserved care.

BACKGROUND: The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 authorized a major expansion of purchased care in the community for Veterans experiencing access barriers in the Veterans Affairs (VA) health care system. OBJECTIVE: To estimate changes in primary care, mental health, and emergency/urgent care visits in the VA and community fiscal years (FY) 2018-2021 and differences between rural and urban clinics. DESIGN: A national, longitudinal study of VA clinics and outpatient utilization. Clinic-level analysis was conducted to estimate changes in number and proportion of clinic visits provided in the community associated with the MISSION Act adjusting for clinic characteristics and underlying time trends. PARTICIPANTS: In total, 1050 VA clinics and 6.6 million Veterans assigned to primary care. MAIN MEASURES: Number of primary care, mental health, and emergency/urgent care visits provided in the VA and community and the proportion provided in the community. KEY RESULTS: Nationally, community primary care visits increased by 107% (50,611 to 104,923), community mental health visits increased by 167% (100,701 to 268,976), and community emergency/urgent care visits increased by 129% (142,262 to 325,407) from the first quarter of 2018 to last quarter of 2021. In adjusted analysis, after MISSION Act implementation, there was an increase in community visits as a proportion of total clinic visits for emergency/urgent care and mental health but not primary care. Rural clinics had larger increases in the proportion of community visits for primary care and emergency/urgent care than urban clinics. CONCLUSIONS: After the MISSION Act, more outpatient care shifted to the community for emergency/urgent care and mental health care but not primary care. Community care utilization increased more in rural compared to urban clinics for primary care and emergency/urgent care. These findings highlight the challenges and importance of maintaining provider networks in rural areas to ensure access to care.

Primary care is at the forefront of healthcare delivery. It is the site of disease prevention and health management and serves as the bridge between communities and the health care system As ethnographers of primary care, in this article we discuss what is gained by situating anthropological inquiry within primary care. We articulate how anthropologists can contribute to a better understanding of the issues that emerge in primary care. We provide a review of anthropological work in primary care and offer empirical data from two ethnographic case studies based in the United States, one focused on social risk screening in primary care and the other examining the diagnosis and care of people with dementia in primary care. Through these cases, we demonstrate how research of and within primary care can open important avenues for the study of the multidimensionality of primary care. This multidimensionality is apparent in the ways the medical field addresses the social and structural experiences of patients, scope of practice and disciplinary boundaries, and the intersection of ordinary and extraordinary medicine that emerge in the care of patients in primary care.

BackgroundAchilles tendinopathy can be a devastating condition in ballet dancers. Initial medical evaluation is frequently conducted by generalist physicians, who may lack the perspective of dance and sports medicine focused training and often prescribe complete rest for chronic overuse injuries. In order to provide targeted information about Achilles tendinopathy and the unique needs of elite athletes, such as ballet dancers, we designed an educational intervention that covers relevant anatomy, physiology, biomechanics, clinical presentation and evaluation, and recommendations for initial treatment and sub-specialty referral. The objectives of this study were to determine baseline understanding of Achilles tendinopathy by generalist physicians and to evaluate the efficacy of an educational intervention on their knowledge.MethodsThis was a prospective pre- post-test study, to measure improvement in knowledge about Achilles tendinopathy. Emergency Medicine and Primary Care physicians participated in an educational intervention with didactic and hands-on components. Data were analyzed using a two-tailed t-test.ResultsTwenty generalist physicians participated. There was significant improvement in their knowledge of Achilles tendinopathy for all our educational objectives (Pre-test: 59% correct answers; post-test: 79% correct answers; P

BACKGROUND: Effective primary care necessitates follow-up actions by the patient beyond the visit. Prior research suggests room for improvement in patient adherence. OBJECTIVE: This study sought to understand patients views on their primary care visits, the plans generated therein, and their self-reported adherence after 3 months. METHODS: As part of a large multisite cluster randomized pragmatic trial in 3 health care organizations, patients completed 2 surveys-the first within 7 days after the index primary care visit and another 3 months later. For this analysis of secondary outcomes, we combined the results across all study participants to understand patient adherence to care plans. We recorded patient characteristics and survey responses. Cross-tabulation and chi-square statistics were used to examine bivariate associations, adjusting for multiple comparisons when appropriate. We used multivariable logistic regression to assess how patients intention to follow, agreement, and understanding of their plans impacted their plan adherence, allowing for differences in individual characteristics. Qualitative content analysis was conducted to characterize the patients self-reported plans and reasons for adhering (or not) to the plan 3 months later. RESULTS: Of 2555 patients, most selected the top box option (9=definitely agree) that they felt they had a clear plan (n=2011, 78%), agreed with the plan (n=2049, 80%), and intended to follow the plan (n=2108, 83%) discussed with their provider at the primary care visit. The most common elements of the plans reported included reference to exercise (n=359, 14.1%), testing (laboratory, imaging, etc; n=328, 12.8%), diet (n=296, 11.6%), and initiation or adjustment of medications; (n=284, 11.1%). Patients who strongly agreed that they had a clear plan, agreed with the plan, and intended to follow the plan were all more likely to report plan completion 3 months later (P

BACKGROUND: Navigating the logistics and emotional processing of a patients death is an inevitable part of many physicians roles. While research has primarily examined how inpatient clinicians cope with patient loss, little work has explored how primary care clinicians (PCCs) handle patient death in the outpatient setting, and what support resources could help PCCs process loss. OBJECTIVE: To explore PCCs experiences with the logistics and emotional processing of patient deaths and suggestions for supportive resources. DESIGN: Qualitative study using semi-structured interviews conducted between March and May 2023. PARTICIPANTS: Recruitment emails were sent to 136 PCCs (physicians and nurse practitioners) at three San Francisco academic primary care clinics. Twelve clinicians participated in the study. APPROACH: This study used a template analysis approach. Interview transcripts were analyzed in an iterative fashion to identify themes for how PCCs navigate patient death. RESULTS: Participants (n=12) described outpatient death notification as inconsistent, delayed, and rife with uncertainty regarding subsequent actions. They felt various emotions, notably sadness and guilt, especially with deaths of young, vulnerable patients or those from preventable illnesses. Participants identified strategies for emotional processing and recommended improvements including clear procedural guidance, peer debriefings, and formal acknowledgements of deceased patients. CONCLUSIONS: Interviewing PCCs about their experiences following a patient death revealed key themes in logistical and emotional processing, and clinic resource recommendations to better support PCCs. Given the distinct characteristics of primary care-such as enduring patient relationships, greater isolation in ambulatory settings compared to inpatient environments, and rising burnout rates-enhancing guidance and support for PCCs is crucial to mitigate administrative burdens and grief after patient loss.

BACKGROUND: Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. Mis-implementation refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange. AIMS AND OBJECTIVES: We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs). METHODS: We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors. FINDINGS: Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic. DISCUSSION AND CONCLUSION: Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

BACKGROUND: Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms. METHODS: From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents. RESULTS: Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship). CONCLUSION: Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.

BACKGROUND: In the United States, Latinos face a wide array of cultural and structural barriers to accessing and utilizing mental health care. Latino men specifically are at high risk of receiving inadequate mental health care, possibly due to additional obstacles they experience that are related to masculinity. Among men more generally, greater adherence to emotional control and self-reliance is associated with higher depression severity and less depression help-seeking. Men experience more stigma toward depression and help-seeking and are less likely to be diagnosed with depression than women. However, Latino mens barriers and facilitators to depression care remain largely unexplored. The objective of this study was to examine barriers and facilitators to depression care that are related to masculinity among English- and Spanish-speaking Latino men in a primary care setting. METHODS: We used convenience and purposive sampling to recruit primary care patients who self-identified as Latino men, spoke English or Spanish, and screened positive for depressive symptoms on the Patient Health Questionnaire-2 or had a history of depression. Semi-structured interviews were conducted between December 2020 and August 2021. The interview guide examined views and experiences of depression, masculinity, and barriers and facilitators to engaging in depression care. Utilizing consensual qualitative research and thematic analysis informed by modified grounded theory, barriers and facilitators to depression care were identified. RESULTS: We interviewed thirteen participants who varied in English proficiency, education, income, and country of origin. Barriers and facilitators were placed into three domains-Self-Recognition of Depression, Seeking Help for Depression, and Depression Diagnosis and Treatment. Participants described aspects of masculinity as barriers (emotional control and pressure to provide), facilitators (honesty, courage, collaboration, practicality, and responsibility), or both (self-reliance and autonomy). CONCLUSIONS: Masculinity influences barriers and facilitators for depression care among Latino men at the levels of self-recognition, seeking help, and diagnosis and treatment. Clinicians may promote Latino mens engagement in depression care by understanding patients values and framing depression care as affirming masculinity. Providing education to primary care physicians and other healthcare professionals on gender and depression and addressing structural barriers are essential to providing access to all who need depression care.

BackgroundA longer duration of untreated psychosis (DUP) is associated with poorer treatment outcomes. Screening for psychosis spectrum disorders in the primary care setting could help support the earlier detection and treatment of individuals in need. However, the acceptability of screening for psychosis in this setting as part of routine care is currently unknown.MethodsWe conducted a qualitative interview study with providers and service users who participated in an early psychosis screening program conducted in an integrated behavioral health primary care (IBH-PC) setting. Interviews were recruited from one of eight WellSpace Federally Qualified Health Center IBH-PC clinics in the Sacramento, CA area. Transcripts of the recorded interviews were analyzed using thematic analysis.ResultsIn total, 12 providers and eight service users participated in the interviews. Most service user and provider participants were supportive of psychosis screening in an IBH-PC setting, but not as part of the general practitioner consultation due to the brief, non-behavioral health nature of many of the appointments, and the expected low prevalence of psychosis in this population. The support of leadership, adequate training and support, staff turnover, and organizational changes were all seen to impact the successful implementation of the program. Different barriers and facilitators were considered important at each stage of the process from introducing the screening procedures to service users; to determining when, where, and how to screen; and how to effectively manage the referral and post-referral stages.ConclusionsDespite the additional challenges of screening in an IBH-PC setting relative to secondary mental health services, the process was considered acceptable and feasible to providers and service users. Services that plan to conduct psychosis screening in their clinics need to consider the challenges and their potential solutions to implementation at each stage of the screening process.

BackgroundImplementation science frameworks situate intervention implementation and sustainment within the context of the implementing organization and system. Aspects of organizational context such as leadership have been defined and measured largely within US health care settings characterized by decentralization and individual autonomy. The relevance of these constructs in other settings may be limited by differences like collectivist orientation, resource constraints, and hierarchical power structures. We aimed to adapt measures of organizational context in South African primary care clinics.MethodsWe convened a panel of South African experts in social science and HIV care delivery and presented implementation domains informed by existing frameworks and prior work in South Africa. Based on panel input, we selected contextual domains and adapted candidate items. We conducted cognitive interviews with 25 providers in KwaZulu-Natal Province to refine measures. We then conducted a cross-sectional survey of 16 clinics with 5-20 providers per clinic (N = 186). We assessed reliability using Cronbach's alpha and calculated interrater agreement (awg) and intraclass correlation coefficient (ICC) at the clinic level. Within clinics with moderate agreement, we calculated correlation of clinic-level measures with each other and with hypothesized predictors - staff continuity and infrastructure - and a clinical outcome, patient retention on antiretroviral therapy.ResultsPanelists emphasized contextual factors; we therefore focused on elements of clinic leadership, stress, cohesion, and collective problem solving (critical consciousness). Cognitive interviews confirmed salience of the domains and improved item clarity. After excluding items related to leaders' coordination abilities due to missingness and low agreement, all other scales demonstrated individual-level reliability and at least moderate interrater agreement in most facilities. ICC was low for most leadership measures and moderate for others. Measures tended to correlate within facility, and higher stress was significantly correlated with lower staff continuity. Organizational context was generally more positively rated in facilities that showed consistent agreement.ConclusionsAs theorized, organizational context is important in understanding program implementation within the South African health system. Most adapted measures show good reliability at individual and clinic levels. Additional revision of existing frameworks to suit this context and further testing in high and low performing clinics is warranted.

BACKGROUND AND OBJECTIVES: Half of older persons experience serious hearing loss, yet it remains under-assessed in primary care clinics. Providers note time constraints as barriers and patients often minimize or deny their hearing loss. We tested the effectiveness of a simple hearing screen in primary care settings and whether including a brochure describing hearing loss, its consequences, and treatment would increase referrals for formal audiometric assessments. RESEARCH DESIGN AND METHODS: We designed a longitudinal effectiveness study assessing three interventions: Screening alone; Screening plus a brochure handed to the person testing positive; and Screening plus the brochure with a brief review. The screening was accomplished by intake personnel. The results of a positive screen were given to the primary care practitioner. The approach was designed to enable its use across a range of primary care settings. Follow-ups occurred at 4 and 8 months. RESULTS: A total of 111 older adults attending 7 primary care clinics screened positive for having possible hearing loss by intake personnel. A total of 46 received the educational brochure. Physicians discussed test results with two-thirds yet recommended further testing for only half of the participants. Physician recommendations were strongly motivating (OR = 9.12, 95% CI: 3.54-23.52) and those receiving the brochure were still more likely to seek further testing (OR = 2.61, 95% CI: 1.07-6.36) even when physician recommendations were controlled. Additionally, when combined, the 2 options were strongly motivating: all participants receiving both a referral and a brochure sought further testing. DISCUSSION AND IMPLICATIONS: A simple screen and educational brochure on hearing loss improved follow-up for a formal hearing evaluation which may improve hearing health care and minimize negative outcomes. The study also identified barriers to implementation, including how to motivate practitioners and assist intake personnel in integrating hearing screening into their routine intake procedures, supporting further research. Clinical Trials Registration Number: NCT0203713 9.

OBJECTIVES: Patients with pre-transplant metabolic dysfunction-associated steatohepatitis (MASH) are at high risk of metabolic syndrome (MetS) after liver transplant. While many patients are co-managed by a transplant team, most preventative screening and MetS management may occur in the primary care setting. We aimed to evaluate primary care utilization by MASH liver transplant recipients as well as MetS screening and control. METHODS: We conducted a retrospective chart review that included adults who underwent liver transplant for MASH or cryptogenic cirrhosis at a single institution from January 2010 to December 2016, had available primary care data, and at least 36-months of follow-up post-transplant. Measures included primary care utilization, adherence to screening guidelines, and control of MetS. We used Fischers exact test to explore the association of primary care utilization with screening and control. RESULTS: A total of 37 patients met inclusion criteria with 366 visits reviewed. The median time to first visit was 68 days post-transplant and patients had a median of 9 total visits. Few patients met screening guidelines for diabetes (8.1%) or hyperlipidemia (10.8%). The percentage of patients with control of obesity, hypertension, diabetes, and hyperlipidemia decreased over the 36-month follow-up period. Primary care utilization was not associated with adherence to screening recommendations for diabetes (P = .141) or hyperlipidemia (P = .103). Higher primary care utilization was not associated with control of hypertension (P = .107), diabetes (P = .871), or hyperlipidemia (P = .999). CONCLUSION: More research is needed to investigate barriers to screening and management of MetS conditions in this high-risk patient population in the primary care setting as well as to optimize post-transplant care coordination.

BackgroundHIV or sexually transmitted infections remain a significant public health concern in the United States, with adolescents affected disproportionately. Adolescents engage in HIV/STI risk behaviors, including drug use and condomless sex, which increase the risk for HIV/STIs. At-risk adolescents, many of whom are racial minorities, experience HIV/STI disparities. Although at-risk adolescents are disproportionately affected by HIV/STI risk behaviors and infections and although the Centers for Disease Control and Prevention recommends routine HIV/STI testing for adolescents, relatively few adolescents report having ever been tested for HIV/STI. With expected increases in health clinic visits as a result of the Affordable Care Act combined with technological advances, health clinics and mobile health (mHealth), including apps, provide innovative contexts and tools to engage at-risk adolescents in HIV/STI prevention programs. Yet, there is a dearth of efficacious mHealth interventions in health clinics to prevent and reduce both condomless sex and drug use and increase HIV/STI testing for at-risk adolescents.ObjectiveTo address this gap in knowledge, we developed a theory-driven, culturally congruent mHealth intervention (hereon referred to as S4E [Storytelling 4 Empowerment]) that has demonstrated feasibility and acceptability in a clinical setting. The next step is to examine the preliminary efficacy of S4E on adolescent HIV/STI testing and risk behaviors. This goal will be accomplished by 2 aims: the first aim is to develop a cross-platform and universal version of S4E. The cross-platform and universal version of S4E will be compatible with both iOS and Android operating systems and multiple mobile devices, aimed at providing adolescents with ongoing access to the intervention once they leave the clinic, and the second aim is to evaluate the preliminary efficacy of S4E, relative to usual care control condition, in preventing or reducing drug use and condomless sex and increasing HIV/STI testing in a clinical sample of at-risk adolescents aged 14-21 years living in Southeast Michigan.MethodsIn this study, 100 adolescents recruited from a youth-centered community health clinic will be randomized via blocked randomization with random sequences of block sizes to one of the 2 conditions: S4E mHealth intervention or usual care. Theory-driven and culturally congruent, S4E is an mHealth adaptation of face-to-face storytelling for empowerment, which is registered with the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices.ResultsThis paper describes the protocol of our study. The recruitment began on May 1, 2018. This study was registered on December 11, 2017, in ClinicalTrials.gov. All participants have been recruited. Data analysis will be complete by the end of March 2024, with study findings available by December 2024.ConclusionsThis study has the potential to improve public health by preventing HIV/STI and substance use disorders.Trial registrationClinicalTrials.gov NCT03368456; https://clinicaltrials.gov/study/NCT03368456.International registered report identifier (irrid)DERR1-10.2196/47216.

Background: Mobile device-based cognitive screening has the potential to overcome the limitations in diagnostic precision and efficiency that characterize conventional pen and paper cognitive screening. Several mobile device-based cognitive testing platforms have demonstrated usability, but the usability of take-home mobile device-based cognitive screening in typical adult primary care patients requires further investigation. Methods: This study set out to test the usability of a prototype mobile device-based cognitive screening test in older adult primary care patients across a range of cognitive performance. Participants completed the St. Louis University Mental Status Examination (SLUMS) and then used a study-supplied mobile device application at home for 5 days. The application presented 7 modules lasting approximately 15 min. Participants completed the System Usability Scale (SUS) after using the application. Results: A total of 51 individuals participated, with a median (IQR) age of 81 (74–85) years. Cognitive impairment (SLUMS score < 27) was present in 30 (59%) of participants. The mean (95% Confidence Interval [CI]) SUS score was 76 (71–81), which indicates good usability. Usability scores were similar across ranges of cognitive impairment. A Lower SLUMS score predicted early withdrawal from the study with an area under the receiver operating characteristic curve (95% CI) of 0.78 (0.58–0.97). Conclusion: Take-home mobile device-based cognitive testing is a usable strategy for many older adult primary care patients. Depending on patient preferences and abilities, it could be part of a flexible cognitive testing and follow-up strategy that includes mobile device-based testing in healthcare settings and pen-and-paper cognitive testing. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion The COVID‐19 pandemic challenged primary care to rapidly innovate. In response, the Western Victorian Primary Health Network (WVPHN) developed a COVID‐19 online Community of Practice comprising general practitioners (GPs), practice nurses, pharmacists, aged care and disability workers, health administrators, public health experts, medical specialists, and consumers. This Experience Report describes our progress toward a durable organizational learning health system (LHS) model through the COVID‐19 pandemic crisis and beyond.In March 2020, we commenced weekly Community of Practice sessions, adopting the Project ECHO (Extension of Community Health Outcomes) model for a virtual information‐sharing network that aims to bring clinicians together to develop collective knowledge. Our work was underpinned by the LHS framework proposed by Menear et al. and aligned with Kotter's eight‐step change model.There were four key phases in the development of our LHS: build a Community of Practice; facilitate iterative change; develop supportive organizational infrastructure; and establish a sustainable, ongoing LHS. In total, the Community of Practice supported 83 unique COVID‐19 ECHO sessions involving 3192 h of clinician participation and over 10 000 h of organizational commitment. Six larger sessions were run between March 2020 and September 2022 with 3192 attendances. New models of care and care pathways were codeveloped in sessions and network leaders contributed to the development of guidelines and policy advice. These innovations enabled WVPHN to lead the Australian state of Victoria on rates of COVID vaccine uptake and GP antiviral prescribing.The COVID‐19 pandemic created a sense of urgency that helped stimulate a regional primary care‐based Community of Practice and LHS. A robust theoretical framework and established change management theory supported the purposeful implementation of our LHS. Reflection on challenges and successes may provide insights to support the implementation of LHS models in other primary care settings. [ABSTRACT FROM AUTHOR]

Caregiver trust in medical providers and the healthcare system is essential to pediatric primary care. Relatively little research has been conducted on contributors to caregivers’ trust, or lack thereof, in aspects of pediatric primary care, especially for those who have experienced adversity. To examine the relationship between caregiver trust and adverse childhood experiences (ACEs) in pediatric primary care, we measured four aspects of trust in 76 caregivers (74 mothers, 2 aunts) of children at an urban primary care clinic. We ran correlation and regression analyses to examine the relationship between the Philadelphia ACEs and caregiver trust. Results indicated that specific ACEs (e.g. experiencing abuse) were associated with caregiver mistrust in the healthcare system and lower trust in the child’s pediatrician. Some ACEs (e.g. community discrimination) were associated with only general trust. Thus, the relationship between trust and trauma varied based on the levels of trust and types of ACEs. [ABSTRACT FROM AUTHOR]

Background: Nutrition interventions targeting early childhood can be cost-effective and may provide lifelong, intergenerational benefits. From October 2022 to April 2023 the Nutrition Now (NN) e-learning resource was implemented within Early Childhood Education and Care centres and the Maternal and Child Healthcare Centre (MCHC) in a southern Norwegian municipality. As part of the NN project, the present study aims to explore the MCHC staff's experiences with implementing the NN resource, to gain insights into measures important to scale up digital early-life nutrition interventions. Methods: Three group interviews were conducted among public health nurses and midwives alongside one individual interview with the department leader of a MCHC in May 2023. An inductive thematic analysis, as described by Braun and Clarke, was conducted to generate the key themes and subthemes regarding the implementation process of NN within the MCHC. Results: Three main themes were generated: [1] Important resource but not always utilized; [2] Parents are interested but had issues with access; and [3] Staff and stakeholder buy-in and commitment needed from the start. Overall, the staff viewed the NN resource as a potential tool for promoting diet-related topics and believed it could support the guidance they were already providing parents. However, few staff members fully familiarized themselves with the resource. While staff perceived parents as positive when informed about NN, they believed issues such as access challenges, competing platforms, and time constraints reduced parental engagement. Lastly, staff suggested improvements for NN's implementation, including enhanced training, better planning, assigning champions, and lowering the threshold for access. Conclusion: The findings of this study suggest that the real-world implementation of digital evidence-based health behaviour interventions is feasible but would be enhanced by employing strategies focusing on engagement and utilization. Trial registration: The main study is registered in the ISRCTN registry with ID ISRCTN10694967, https://doi.org/10.1186/ISRCTN10694967. (Registration date: 19-06-2022). [ABSTRACT FROM AUTHOR]

Background: Addressing mental health disparities following COVID-19 requires adaptive, multi-sectoral, equity-focused, and community-based approaches. Mental health task-sharing in gateway settings has been found to address mental health care gaps in low- and middle-income countries, but is not a common practice in the U.S., especially in non-medical settings, such as low-income housing developments (LIH). This research study will evaluate the effectiveness of a multisectoral community-engaged collaborative for task-sharing mental health care on consumer, provider, and implementation outcomes, as well as identify barriers and facilitators for implementation. Methods: In this stepped-wedge randomized controlled trial with technology supplementation, LIH and primary care sites will be randomly assigned to one of five sequences of three implementation strategies: (1) Education and Resources (E&R), which involves online training and resources on basic mental health task-sharing skills, (2) Multisectoral Community Collaborative Care (MCC), which consists of all E&R resources plus additional community responsive implementation supports and participation in a multisectoral coalition and (3) MCC + Technology, which combines the MCC condition resources with a community crowdsourced technology solution to support implementation. The primary outcome is the effectiveness in meeting consumers' needs through direct service (e.g., adequately addressing depression and anxiety symptoms), and through implementation to increase access to mental health care (reach). The secondary outcome examines additional consumer outcomes including health functioning and social risks, as well as implementation outcomes including provider skills, program adoption, and factors related to barriers and facilitators of quality implementation. A total of 700 consumers receiving mental health care at 20 sites will be surveyed at baseline, 6-, and 12-month follow-ups. Additionally, 100 providers will be evaluated at baseline, 6-, 12-, and 24-month follow-ups before training and after randomization. Discussion: We hypothesize that MCC and MCC + Technology conditions will demonstrate significantly higher efficacy in changing primary outcomes compared to E&R, and the MCC + Technology supplement will show significantly higher levels of reach of mental health tasks compared to the MCC condition alone. These findings will demonstrate the feasibility of mental health integration into accessible, non-medical community settings such as LIH. Moreover, it will help establish a multilevel system solution based on community engagement and planning with a multisectoral collaboration that can be sustained community-wide. Trial registration: NCT05833555 on Clinicaltrials.gov. Registered April 26, 2023 [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Design Methods Results Conclusion Implications for the Profession and Patient Care Impact Reporting Method Patient or Public Contribution What does this Paper Contribute to the Wider Global Clinical Community? To describe vaccination roles of primary care nurses during the COVID‐19 pandemic in Canada.This analysis was part of a larger mixed‐methods case study.We conducted semi‐structured qualitative interviews from May 2022 to January 2023 with primary care nurses across four provinces: British Columbia, Ontario, Newfoundland and Labrador, and Nova Scotia. We asked participants to describe their roles during various stages of the pandemic, facilitators and challenges encountered and possible roles that nurses could have played. We used thematic analysis and analysed codes relevant to vaccination.We interviewed a total of 76 nurses and identified four key functions of primary care nurses' roles in COVID‐19 vaccination: (1) education, (2) vaccine administration, (3) outreach and (4) advocacy. Themes outlined nurses' roles with respect to patient education, addressing vaccine hesitancy, partaking in vaccination roles outside of regular primary care practice and supporting accessibility in COVID‐19 vaccination. Specific tasks varied by nursing professions.Primary care nurses fostered trust through existing patient–provider relationships to enhance roles and activities related to education, outreach and advocacy in COVID‐19 vaccination. Some COVID‐19 vaccine‐related roles were more easily integrated into primary care, whereas others competed with routine primary care roles.Findings highlight the vital contributions of primary care nurses towards COVID‐19 vaccination efforts in Canada. Leveraging nursing expertise can enhance future pandemic response efforts and improve patient care by addressing barriers to vaccination and promoting equitable access to vaccination services.This study addresses a knowledge gap by describing the vaccination‐related roles of primary care nurses during the pandemic. Findings illustrate that nurses demonstrated adaptability through their engagement in vaccine education, administration, outreach and advocacy. This research informs resource allocation, policy development and workforce planning for future vaccination efforts during a pandemic response.The authors have adhered to the Standards for Reporting Qualitative Research (SRQR) guidelines included in the Empirical Research Qualitative reporting method.No patient or public contribution. Provides insight into the pivotal roles of primary care nurses during the COVID‐19 vaccination efforts in Canada, highlighting their diverse contributions towards education, vaccine administration, outreach and advocacy. Offers implications for future pandemic planning by informing resource allocation, policy development and workforce planning for vaccination efforts. [ABSTRACT FROM AUTHOR]

Background: Depression and panic disorders have high prevalence rates in primary care. Given the crucial role of general practitioners in diagnosing and treating mental disorders, the two-arm cluster-randomized, controlled PREMA trial was designed. PREMA was aimed at investigating a new intervention combining cognitive behavioral therapy, case management and eHealth components for patients with depression and/or panic disorder with or without agoraphobia in primary care practices in Germany. This qualitative study, embedded in the PREMA trial, explores primary healthcare professionals' lived experiences in using the new treatment program. Using a qualitative design, we conducted eleven interviews with general practitioners and medical assistants from Hesse, Germany, between July 2021 and March 2022. For both groups we relied on a semi-structured interview guide covering the following subjects: study procedures, implementation, practicality, and individual components of the treatment program. Interviews were audio-recorded, transcribed verbatim and analyzed by two researchers using content analysis. A deductive-inductive approach was used for the analysis according to Kuckartz. Results: We narratively summarized the facilitators and barriers from two different stakeholders across five key themes regarding experiences of feasibility and practicability of the new treatment program: study instruction materials, individual components of the treatment program, practicality, target population, and benefits of the treatment program. Facilitators to become familiar with the study include study instruction materials that are easy to understand and not too complex, considering the limited time resources available; barriers included text-heavy instruction materials, lack of collegial exchange, and issues especially with digital materials also involved access and log-in difficulties on the online platform. Facilitators for using the treatment program include the combination of face-to-face consultations and the use of an online platform, enabling a structured approach and regularity; barriers included patients feeling unsupported in performing anxiety exercises independently at home. For practicality, the professional skills of medical assistants and their central role as points of contact for patients facilitated the implementation; barriers included time-intensive organization and planning of monitoring phone calls and consultations. Regarding the target population, general practitioners and medical assistants state that the treatment program would be most appropriate for patients with mild to moderate depression and for those waiting for psychotherapeutic treatment; it would be less suitable for older patients, and those with negative attitudes towards technological tools. For benefits of the program, facilitating factors included free and low-threshold access to the online platform and strengthening the relationship between medical assistants and patients; barriers included a preference for in-person conversations and the inability of some people to use online applications. Conclusions: The complexity of the new treatment program and the associated high workload underline the need for further adjustments to the treatment approach. Team-based care and the expanded responsibilities of medical assistants demonstrated promising results. Trial registration: The study was registered in the German Clinical Trials Register (DRKS00016622) on February 22, 2019. [ABSTRACT FROM AUTHOR]

The National Health Mission (NHM) was launched in India in 2005 to improve population health by restructuring the health system and enhancing primary care. After nearly 20 years, it is essential to review its impact on the health system. This scoping review is the first of its kind which aimed to review and synthesize research on the effects of the NHM on human resources for health and governance, and its overall impact on the health system. We identified 46 research articles, 19 (41%) on human resources for health, 17 (37%) on governance, and 14 (30%) studying the overall impact. Most of the research on human resources was focused on the ASHA program and RKS and VHSNC dominated governance research. Maternal and child health studies dominated the health system impact literature. Outcomes show a partial achievement of the NHM's goals. Health workforce supplementation has improved access to healthcare in rural areas but remains inadequate to rising demand. Similarly, decentralization mechanisms have improved accountability, however, more community empowerment is needed. Healthcare demand has staggered to primary care facilities and improvements in some population health indicators have been observed, but social inequities and poor care quality remain. Further research and policy initiatives are needed to address several issues such as rational resource deployment, career progression for contractually hired care providers and ASHA, building health awareness at the grassroots for better community representation, and increased attention to non‐communicable diseases, mental health, and the impacts of aging and climate change. [ABSTRACT FROM AUTHOR]

Key content: Learning objectives: Ethical issues: Urethral caruncle is a common post‐menopausal finding. This common benign lesion can be mistaken as a malignancy. Management should be based on the patient's symptoms. Vaginal estrogen should be considered as first‐line management before surgical excision. To evaluate the symptomatic presentation of urethral caruncle. To establish the differential diagnosis of a mass in the urethra. To review the management options of urethral caruncle including medical and surgical excision. To highlight primary care management of urethral caruncle. Owing to poor recognition of urethral caruncle, many patients are put through the emotional distress of referral to cancer pathways. Surgery should be considered first line for large urethral caruncle or in symptomatic patients. [ABSTRACT FROM AUTHOR]

Objective Methods Results Significance The incidence of late‐onset epilepsy (LOE) is rising, and these patients may use an excess of health care resources. This study aimed to measure pre‐/post‐diagnostic health care use (HCU) for patients with LOE compared to controls.This was an observational open cohort study covering years 1998–2019 using UK population‐based linked primary care (Clinical Practice Research Datalink [CPRD]) and hospital (HES) electronic health records. The participants included patients with incident LOE enrolled in CPRD and 1:10 age‐, sex‐, and general practice–matched controls. The exposure was incident LOE (diagnosed at age ≥65) using a 5‐year washout. The main outcome was all HCU (primary care [PC], accident and emergency [A&E], admitted patient and outpatient care) using inverse proportional weighting to PC use and HCU by setting. An interrupted time‐series analysis was used to examine pre‐/post‐diagnostic HCU between patients with LOE and controls over 4 years either side of diagnosis/matching date. An adjusted mixed‐effects negative binomial regression was used for post‐diagnosis HCU interactions.Of 2 569 874 people ≥65 years of age, 1048 (4%) developed incident LOE. Mean weighted total HCU increased by 32 visits per patient‐year (95% confidence interval [95% CI]: 13–50, p = .003) until LOE diagnosis, and then dropped by a mean of 60 visits per patient‐year (95% CI: −81 to −40). There was an acute rise and fall over the 1–2 years immediately pre‐/post‐diagnosis. Incident HCU remained higher for LOE compared to controls post‐diagnosis (adjusted incidence rate ratio: 1.72; 95% CI: 1.65–1.70; p < .001), including A&E, outpatient, and admitted care.Health care use demonstrates an acute on chronic rise over the 4 years before diagnosis of LOE. To what extent the partial reversal of the acute pre‐diagnosis rise, and the mediators of the accelerated increase compared to controls are attributed to epilepsy, comorbid and bidirectional disease states, or a combination of both warrants further exploration. [ABSTRACT FROM AUTHOR]

Summary Primary care is central to ongoing health care following bariatric surgery and patients indicate a preference for receiving follow‐up support by their primary care practitioner (PCP). This meta‐synthesis investigates the perspectives of both PCPs and patients in post‐bariatric surgery care provided by PCPs. The aim was to synthesize themes from qualitative research to recommend improvements in post‐bariatric surgery clinical care in primary care settings. Systematic searches of Scopus, Medline, EMBASE, PsycINFO, the Cochrane Library, and Google Scholar resulted in the inclusion of eight papers in the meta‐synthesis. Papers were critiqued using the Critical Appraisal Skills Program (CASP) and thematically coded in Quirkos Cloud. Seven themes were reached by author consensus including stigma and judgment; clinician barriers and facilitators; patient‐related support needs; communication considerations; patient context or determinants; health care setting; and adapting to life after surgery. PCPs reported barriers including poor communication and guidance from bariatric surgery centers, limited knowledge and training in bariatric patient care, and patients who may have unrealistic outcomes and poor health literacy. Patients seek comprehensive care from their PCP, however, barriers hindering the provision of this care include adverse surgical outcomes, a poor relationship with their PCP, and limited and short‐term follow‐up care from the PCP. Insights from this meta‐synthesis offer actionable recommendations for PCPs and bariatric surgery centers to enhance patient care immediately. [ABSTRACT FROM AUTHOR]

Aims Methods Results Conclusion Registration We aimed to determine the impact of codeine rescheduling on prescribing of codeine and other opioids, with a focus on demographic and diagnoses associated with codeine prescribing before and after rescheduling of codeine to prescription‐only in February 2018.We used interrupted time series analysis (February 2016‐February 2020) and probit regression to examine prescribing of codeine and other opioids according to primary care data from 464 general practice clinics in Victoria, Australia.The rate of codeine prescribing increased in the month following rescheduling (additional 76 people/10000, 95% confidence interval [CI] 49‐103), then declined to baseline rates (slope −2.02, 95% CI 3.79, −0.25). Prescribing of other opioids did not change. Post rescheduling, females were more likely to receive codeine prescriptions compared to males (β = 0.094, 95% CI 0.08‐0.108) and those aged 70‐79 years were more likely to receive codeine compared to those aged <30 years. Those residing in the least disadvantaged areas had a greater probability of being prescribed codeine than those in more disadvantaged areas after rescheduling (β = 0.154, 95% CI 0.129‐0.179). A documented mental health diagnosis (β = 0.067, 95% CI 0.052‐0.082) or migraine diagnosis (β = 0.057, 95% CI 0.037‐0.078) was associated with increased likelihood of receiving a codeine prescription after rescheduling compared to before in contrast to those without such a diagnosis.Codeine rescheduling did not result in a sustained increase in codeine prescribing nor a change in the prescribing of other opioids. Patient factors associated with increased codeine prescribing after compared to before rescheduling included female sex, older age, migraine diagnosis and comorbid mental health conditions.EU PAS Register (EUPAS43218). [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions As the US population ages, there is an increasing demand for home‐based primary care (HBPC) by those with Alzheimer's/dementia, multiple chronic conditions, severe physical limitations, or those facing end‐of life. Nurse practitioners (NPs) are increasingly providing HBPC, yet little is known about their quality of care in this unique setting.This observational study uses Medicare claims data from 2018 to assess the quality of care for high‐intensity HBPC users (5 or more visits/year) based on provider type (NP‐only, physician (MD)‐only, or both NP and MDs). We employ 12 quality measures from 3 care domains: access and prevention, acute care utilization, and end‐of‐life. Analysis includes bivariate comparisons and logistic regression models that adjust for demographic, clinical, and geographic characteristics.Among the 574,567 beneficiaries with 5 or more HBPC visits, 37% saw an NP, 37% saw a MD, and 27% saw both NPs and MDs. In multivariate models, those receiving HBPC from an NP or both NP‐MD are significantly more likely to receive a flu shot than the MD‐only group, but less likely to access preventive care. NP‐only care is associated with more acute care hospitalizations, avoidable ED visits, and fall‐related injuries, but significantly fewer avoidable admissions. For end‐of‐life care, those with NP‐only or both NP‐MD care are significantly more likely to have an advanced directive, be in hospice in the last 3 days of life, and more likely to die in hospice. The NP group is also more likely to die in the next year.HBPC patients are complex, with both palliative and curative needs. NPs provide almost half of HBPC in the Medicare program, to patients who are possibly sicker than those treated by physicians, with similar quality to MDs. [ABSTRACT FROM AUTHOR]

The study examines the behavioral intention to use an AI doctor at the individual level at primary, secondary, and tertiary care levels. The research model has been designed according to the unified theory of acceptance and use of technology to understand the acceptance and use of an AI doctor at the individual level. The causal comparison screening approach, which is used to identify the causes and effects of people's attitudes, behaviors, ideas, and beliefs, has been employed. This study utilized a hybrid analysis methodology combining two-phase analysis using partial least squares structural equation modeling and evolving artificial intelligence named deep learning (Artificial Neural Network) on 432 usable responses. The first step was using structural equation modeling to examine the hypotheses; then the nonlinear interactions between the variables have been examined using an artificial neural network. According to the analysis results, perceived task-technology fit, perceived privacy, performance expectancy, and social influence constructs affecting the intention to use an AI doctor in primary, secondary, and tertiary levels of care are the main constructs. A strong behavioral intention exists at all levels of healthcare, primary, secondary, and tertiary, to use an AI doctor for individual-level healthcare. [ABSTRACT FROM AUTHOR]

Background: Cataract surgery is one of the most common surgical procedures performed in older adults in the United States and is generally considered to be extremely low-risk. As of 2019, routine preoperative evaluation within 30 days of surgery is no longer mandated by the United States of America (USA) Centers for Medicare & Medicaid Services (CMS) for ambulatory surgery centers, but it is unclear how primary care providers perceive this change. Methods: We performed a qualitative analysis of semi-structured interviews with six primary care providers to explore primary care providers' perspectives on routine preoperative assessment for cataract surgery. Results: Primary care providers commented on the large number of referrals they receive for preoperative assessment before cataract procedures. The analysis revealed an overarching sentiment of resentment over the time, effort, and resources expended on these assessments. Themes included the lack of awareness of the updated regulations that no longer require a history and physical to be completed within 30 days and the perception of a universal lack of medical necessity to perform preoperative assessment for cataract surgery. Providers also commented on the strain on limited resources and the burden on patients. The relationship between specialties and professional roles emerged as another important theme. Conclusions: Referrals for preoperative clearance for cataract surgery continue to burden providers, patients, and the health system, and represent an opportunity to streamline care in this patient population. [ABSTRACT FROM AUTHOR]

Background: The mental health service delivery gap remains high globally. Appropriate telehealth use may increase capacity through flexible remote care provision. Despite the historical lack of telehealth integration into publicly funded mental health services, during COVID‐19 lockdowns, services rapidly switched to telephone and audiovisual care provision. In Aotearoa New Zealand (NZ), this was abandoned when no longer required by COVID‐19 restrictions. This study explores environmental factors associated with telehealth implementation and ongoing use or discontinuation across a multiregional outpatient mental health service. This work contributes to understanding system‐level factors influencing telehealth use and thus informs policy and practice in postpandemic environments. Methods: This mixed methods study applied an interpretive description methodology. Semistructured interviews with 33 mental health clinicians were thematically analysed. Qualitative findings were reframed and evaluated using time series analyses of population‐level quantitative data (prior to and throughout the pandemic). Findings were synthesised with qualitative themes to develop an understanding of environmental factors contributing to telehealth use. Results: Findings highlighted an increase in clients assessed by mental health services and declining clinician numbers, contributing to pressure placed on clinicians. There was a lack of culture supporting telehealth, including limited awareness, leadership, and champions to facilitate implementation. Some teams provided services suited to telehealth; other subspeciality teams had limited applications for telehealth. There was a general lack of policy and guidelines to support telehealth use and limited technical support for clinicians unfamiliar with audiovisual software. Conclusion: Disorganised telehealth adoption in the study regions provides insight into wider environmental drivers affecting telehealth uptake. For telehealth to become a workable service delivery mode following COVID‐19, stewardship and culture shifts are required, including policy development, technical support, and resources to support clinical teams. Telehealth may address growing service demand by improving interfaces with primary care and providing timely access to specialist input. [ABSTRACT FROM AUTHOR]

A significant proportion of primary care consultations now happen remotely. Although the vast majority occur safely, a recent study highlighted areas of risk which may be compounded by the limited training many GPs have received in remote consulting. To provide safe remote services, consideration needs to be given to adapting practice workflow to optimise remote care. Patients less suitable for remote consulting, either due to disease, extremes of age, disability or for social reasons should be identified and prioritised for face-to-face encounters. Training supports both the development of individual communication skills for remote care, and effective team working. Practice-based group learning events can be used to share experiences, identify resources, and consider the risks in remote care and how they can be mitigated. The paper presents some fictionalised cases, illustrating where patients came to harm, as a result of a remote consultation, and where harm was averted due to actions taken by practice teams. These can be used to support critical thinking and discussion within practice development meetings and tutorials with trainee GPs and other practice staff. Using the paper as a basis for reflection, teaching and action can facilitate the delivery of safer remote care. [ABSTRACT FROM AUTHOR]

Anxiety is highly prevalent, but undertreated, in primary care. Brief, non-pharmacological interventions are needed. Modular Anxiety Skills Training (MAST), a cognitive-behavioral anxiety intervention, was developed for primary care and tailored for a Veteran sample (MAST-V). The purpose of this mixed methods pilot study was to evaluate MAST-V's feasibility, acceptability, and implementation potential, and preliminarily examine its effectiveness compared to Primary Care Behavioral Health (PCBH) usual care. This hybrid I randomized controlled trial (conducted 2019–2021) assigned 35 primary care patients (M age = 47, 17 % female, 27 % racial/ethnic minority) with clinically significant anxiety symptoms to receive MAST-V or PCBH usual care. Participants completed validated measures of anxiety symptoms and functional impairment at 0, 4, 8, 12, and 16 weeks. Participants attended more sessions in MAST-V than usual care. After necessary adjustments to reduce session duration, MAST-V will likely fit within PCBH practice parameters. Participants in both conditions valued treatment, but treatment satisfaction, credibility, and therapeutic alliance were higher for MAST-V. Study therapists achieved high treatment fidelity and rated MAST-V as highly feasible, acceptable, and appropriate for PCBH. They identified ways to address potential barriers to implementation. MAST-V was more effective than usual care in reducing anxiety symptoms and impairment. This was a small pilot study at a single site using study therapists. Results should be considered preliminary until replicated in a full-scale clinical trial. This brief modular anxiety intervention, which was designed with implementation in mind, may help to address the anxiety treatment gap in primary care. • Brief nonpharmacological anxiety interventions feasible in primary care are needed. • We conducted a pilot RCT of a modular cognitive-behavioral anxiety intervention. • The intervention was feasible and highly acceptable for patients and therapists. • Clinical outcomes improved more than with usual care (primarily supportive therapy). • The intervention's potential for implementation in routine primary care is high. [ABSTRACT FROM AUTHOR]

Introduction and Objective: Suicide is a major public health concern. Recently, suicide rates have increased among traditionally low-risk groups (e.g., white, middle-aged males). Suicide risk assessments and prevention strategies should be tailored to specific at-risk populations. This systematic review examines suicide risk detection and management in primary care, focusing on treatments to reduce suicide rates and improve prevention efforts. Methodology: A systematic review was conducted following PRISMA guidelines. Literature was collected and analyzed using Boolean operators with relevant keywords in databases (e.g., PubMed, Google Scholar, PsycINFO) to identify randomized and non-randomized studies focusing on suicide risk factors and management strategies in primary care, published in the past 10 years. The risk of bias 2.0 and Newcastle Ottawa scale was used to assess risk of bias, and data from moderate-quality studies were synthesized. Results: Thirteen moderate-quality studies were reviewed. Key findings include the need for assessingmodifiable risk factors like substance use and mental health. General practitioner (GP) engagement post-suicide attempt (SA) improves outcomes and reduces repeat SAs. Effective strategies include comprehensive risk assessments, collaborative treatment, and enhanced GP support. Barriers to effective suicide prevention include insufficient information, judgmental communication, lack of positive therapeutic relationships, and inadequate holistic assessments. These findings highlight the need for tailored suicide prevention strategies in primary care. However, the evidence sample size is small with reduced statistical power that limits generalizability. The included studies were also regional examinations, which restrict their broader relevance. Discussion: Significant risk factors, barriers, and effective strategies for suicide prevention were identified. For children aged 12 or younger, preexisting psychiatric, developmental, or behavioral disorders, impulsive behaviors, aggressiveness, and significant stressful life events within the family were critical. For adults, loneliness, gaps in depression treatment, and social factors are significant. Barriers to suicide prevention included insufficient information, judgmental communication, lack of positive therapeutic relationships, inadequate holistic risk assessments, lack of individualized care, insufficient tangible support and resources, inconsistent follow-up procedures, variability in risk assessment, poor communication, stigma, and negative attitudes. Effective methods include the Postvention Assisting Bereaved by Suicide training program, continued education, comprehensive clinical assessments, individualized care, and community-based interventions like the SUPRANET program. [ABSTRACT FROM AUTHOR]

Background: Effective transitions of patients from Secondary Care Services (SCSs) to primary care are necessary for optimization of resources and care. Factors that enable or restrict smooth transitions of individuals with Serious Mental Illness (SMI) to primary care from SCSs have not been comprehensively synthesized. Methods: A scoping review was conducted to answer the questions (1) "What are the barriers and facilitators to discharge from SCSs to primary care for adults with SMI?" and (2) "What programs have been developed to support these transitions?". Results: Barriers and facilitators of discharge included patient-, primary care capacity-, and transition Process/Support-related factors. Patient-related barriers and facilitators were most frequently reported. 11 discharge programs were reported across the evidence sources. The most frequently reported program components were the provision of additional mental health supports for the transition and development of care plans with relapse signatures and intervention plans. Conclusions: Established discharge programs should be comprehensively evaluated to determine their relative benefits. Furthermore, research should be expanded to evaluate barriers and facilitators to discharge and discharge programs in different national contexts and models of care. Trial Registration: The protocol for this scoping review is registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/NBTMZ). [ABSTRACT FROM AUTHOR]

Background: Community health workers (CHWs) remain an underutilized resource in social risk diagnostics in the primary care setting. This process evaluation study seeks to assess the role of CHWs in social risk screening, referral, and follow-up through process mapping to identify barriers to the process for future quality improvement efforts. Methods: Researchers at the Arizona Prevention Research Center (AzPRC) engaged with two Federally Qualified Health Centers (FQHCs) in two of Arizona's major urban areas to evaluate their internal processes for social risk screening and intervention. The Consolidated Framework for Implementation Research (CFIR) was used to direct a process mapping exercise to visually describe the workflow, gaps, and barriers to identifying and addressing social risk. Results: The process unveiled key areas for health system improvements in the community setting, the organizational setting, and in the implementation of social risk screening, referral, and follow-up. Further, process maps highlight the potential resources needed for effective CHW integration to address social risk in the primary care setting. Conclusions: Our findings demonstrate the importance of organizational tools, such as process mapping, to assist primary care settings in evaluating internal processes for quality improvement in addressing social risk and in effectively integrating the CHW workforce. Subsequent research will evaluate rates of social risk screening, referral, and follow-up within all of Arizona's FQHCs and propose models for CHW integration to address social risk in primary care and strengthen social risk screening reach and effectiveness. [ABSTRACT FROM AUTHOR]

Background: Swine flu might serve as a model for challenges that primary care faces during pandemics. This study examined changes in the numbers and diagnoses of general practitioner (GP) visits during and after the Swine flu pandemic in Vantaa, a Finnish city, and how GP activities recovered after the pandemic. Putative sex and age group differences were also evaluated. Methods: The study was an observational retrospective study. The monthly number of patient visits to primary care GPs by women and men in age groups 0–19, 20–64 and 65 + years was recorded before, during and two years after the Swine flu pandemic. The recorded diagnoses were also examined. The investigation period was from 2008 to 2012. Results: The numbers of monthly visits to primary care decreased from 12 324 (mean) to 10 817 in women and from 8563 to 7612 in men during the first six months of the Swine flu, returning to the original level afterwards. This decrease was thus slightly more prominent in women. However, as the size of the population increased during the follow-up period, the actual number of GP visits adjusted for the size of population remained at a decreased level for two years after the Swine flu. This decrease was observed especially in office-hours visits of men (from 3692 to 3260) and women (from 6301 to 5428) of 20–64 years. Swine flu did not alter the number of visits to the primary care Emergency Department. The proportion of visits with diagnostic recordings of common infectious diseases mostly decreased during the Swine flu. Only a minor impact on the distribution of recordings of chronic diagnoses was found. Conclusion: A pandemic, such as Swine flu, may decrease office-hours visits to primary care GPs. This in turn may lead to activities of primary care being adjusted downward for a long time following the pandemic. Especially the age group 20–64 years may be affected. This risk should be considered when recovery from the COVID-19 pandemic begins. Swine flu did not affect the proportion of consultations of chronic diseases, but the number of diagnoses of common infectious diseases had diminished. [ABSTRACT FROM AUTHOR]

Background: Identifying women aged 30–39 years at increased risk of developing breast cancer would allow them to receive screening and prevention offers. For this to be feasible, the practicalities of organising risk assessment and primary prevention must be acceptable to the healthcare professionals who would be responsible for delivery. It has been proposed that primary care providers are best placed to deliver a breast cancer risk assessment and primary prevention pathway. The present study aimed to investigate a range of primary care provider's views on the development and implementation of a breast cancer risk assessment and primary prevention pathway within primary care for women aged 30–39 years. Methods: Twenty-five primary care providers working at general practices in either Greater Manchester or Cambridgeshire and Peterborough participated in five focus groups (n = 18) and seven individual interviews. Data were analysed thematically and organised using a framework approach. Results: Three themes were developed. Challenges with delivering a breast cancer risk assessment and primary prevention pathway within primary care highlights that primary care are willing to facilitate but not lead delivery of such a pathway given the challenges with existing workload pressures and concerns about ensuring effective clinical governance. Primary care's preferred level of involvement describes the aspects of the pathway participants thought primary care could be involved in, namely co-ordinating data collection for risk assessment and calculating and communicating risk. Requirements for primary care involvement captures the need to provide a training and education package to address deficits in knowledge prior to involvement. Additionally, the reservations primary care have about being involved in the management of women identified as being at increased risk are discussed and suggestions are provided for facilitating primary care to take on this role. Conclusions: Despite optimism that primary care might lead a breast cancer risk assessment and primary prevention pathway, participants had a range of concerns that should be considered when developing such a pathway. [ABSTRACT FROM AUTHOR]