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A atenção primária em saúde (APS) é o primeiro nível de atenção em saúde, sendo um elo entre a população e o setor de saúde. Tem-se buscado a humanização dos atendimentos, e essa mudança, refletida pelas mudanças da sociedade, trouxe a implementação da Política Nacional de Práticas Integrativas e Complementares (PNPIC) no SUS. O objetivo deste trabalho foi realizar uma análise da tendência da quantidade das práticas integrativas e complementares realizadas nas regionais de saúde de Sergipe de 2017 a 2023, associando com a cobertura da atenção primária. Foi realizada análise de dados secundários através do Departamento de Informática do Sistema Único de Saúde (DATASUS), como forma de organização no período de junho/2015 a junho/2023 por regional de saúde de Sergipe. As análises dos dados foram descritivas e de correlação e por meio de análise de série temporal. A regional de saúde de Lagarto foi a que mais executou as práticas integrativas e complementares no período analisado e algumas regionais não tiveram continuidade na realização destas práticas. A regional de saúde com maior cobertura de APS foi Itabaiana. Não foi possível observar associação entre o número de práticas e a cobertura de atenção primária. Com o intuito de que o atendimento aos indivíduos seja cada vez mais humanizado, e em virtude da realização das práticas integrativas ter baixo índice ou descontinuidade em algumas regiões de Saúde de Sergipe, é relevante que os profissionais de saúde busquem conhecimentos sobre essas práticas, como também, os gestores em saúde incentivem esta ação.

Primary health care (PHC) is the first level of health care, being a link between the population and the health sector. The aim has been to humanize care, and this change, reflected by changes in society, has led to the implementation of the National Policy on Integrative and Complementary Practices (PNPIC) in the SUS. The objective of this work was to carry out an analysis of the trend in the number of integrative and complementary practices carried out in the health regions of Sergipe from 2017 to 2023, associating it with primary care coverage. Secondary data analysis was carried out through the Department of Informatics of the Unified Health System (DATASUS), as a form of organization from June/2015 to June/2023 by health region in Sergipe. Data analyzes were descriptive and correlational and through time series analysis. The Lagarto health region was the one that carried out the most integrative and complementary practices in the period analyzed and some regions did not continue to carry out these practices. The health region with the highest PHC coverage was Itabaiana. Observing an association between the number of practices and primary care coverage was impossible. With the aim that care for individuals is increasingly humanized, and because the implementation of integrative practices has a low rate or discontinuity in some Health regions of Sergipe, health professionals must seek knowledge about these practices as well as health managers encourage this action.

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Introdução: No processo de edificação da Política Nacional de Saúde Integral LGBT+, a Atenção Básica ganha importante destaque, pois deveria funcionar como o contato preferencial dos usuários transgênero (trans). Objetivo: Investigar quais as percepções dos profissionais da Atenção Básica quanto às situações de vulnerabilidade enfrentadas pelas pessoas trans, bem como pesquisar os impedimentos que eles consideram existir na busca dessa população por acesso a esses serviços. Métodos: Utilizou-se uma abordagem qualitativa por meio de entrevistas semiestruturadas com 38 profissionais de saúde atuantes das Estratégias Saúde da Família de dois municípios do interior do estado de São Paulo. O material obtido foi submetido à análise de conteúdo de Bardin. Resultados: Os resultados apontaram para o desconhecimento quanto aos reais empecilhos que dificultam o acesso e seguimento de pessoas trans nos serviços de saúde. Observou-se ainda a manutenção de preconceitos e ideias que reforçam estereótipos ligados ao tema e que se estendem ao exercício da profissão. Isso se relaciona diretamente com a falta da abordagem de assuntos relacionados à sexualidade humana na graduação desses profissionais, além da falta de atualização quanto ao tema, o que impacta a qualidade do serviço que é ofertado à população em estudo. Conclusões: As normativas e portarias já existentes precisam ser efetivamente postas em prática, fazendo-se imperativas a ampliação e difusão do conhecimento a respeito da temática trans no contexto dos serviços públicos de saúde, o que pode servir como base para subsidiar a formação dos profissionais que atuam nesse setor, bem como políticas públicas efetivas.

Introduction: In the process of creating the National LGBT+ Comprehensive Health Policy, primary care has important prominence as it must work as the preferential contact of transgender (trans) users. Objective: To investigate the perceptions of primary care professionals about the vulnerability situations faced by trans persons and also hindrances they consider existing in this population's search for access to these services. Methods: A qualitative approach was used through semi-structured interviews with 38 health care professionals working in the Family Health Strategy of two cities in the countryside of the state of São Paulo. The material obtained was submitted to analysis of Bardin content. Results: The results pointed to a lack of knowledge about real hindrances that obstruct the access to and follow-up by health services for trans persons. It was also observed the maintenance of prejudices and ideas that reinforce stereotypes connected to the matter and extend to the practice of professionals. It is directly related to the lack of approach of issues related to human sexuality in the education of those professionals, in addition to lack of update about it, which impacts the quality of service offered to the population under study. Conclusions: The standards and ordinances already existing need to be effectively practiced, being crucial the extension and spread of knowledge about trans matters in the context of public health services. It can be the basis for subsidizing the education of professionals who work in this field, as well as effective public policies.

Introducción: En el proceso de edificación de la Política Nacional de Salud Integral LGBT+, la Atención Básica tiene importante destaque, pues debería funcionar como contacto preferente de los usuarios transgénero (trans). Objetivo: Investigar las percepciones de los profesionales de Atención Básica sobre las situaciones de vulnerabilidad que enfrentan las personas trans, así como investigar los impedimentos que consideran que existe en la búsqueda de esta población por el acceso a estos servicios. Métodos: Se utilizó un abordaje cualitativo por medio de entrevistas semiestructuradas con 38 profesionales de salud actuantes de las Estrategias de Salud de la Familia de dos municipios del interior del estado de São Paulo. El material obtenido fue sometido a análisis de contenido de Bardin. Resultados: Los resultados apuntaron al desconocimiento sobre los reales obstáculos que dificultan el acceso de personas trans a los servicios, además del segmento de los cuidados en las unidades. Se observó además que se mantienen los prejuicios e ideas que refuerzan estereotipos vinculados al tema y que se extienden al ejercicio de la profesión. Esto se relaciona directamente a la falta da abordaje de asuntos relacionados a la sexualidad humana en la graduación de estos profesionales, además de la falta de actualización sobre el tema, lo que impacta en la calidad del servicio que se ofrece a la población en estudio. Conclusiones: Las normas y ordenanzas ya existentes deben ser efectivamente puestas en práctica, por lo que es imperativo ampliar y difundir el conocimiento sobre la temática trans en el contexto de los servicios públicos de salud, que pueda servir de base para apoyar la formación de profesionales que actúan en este sector, así como políticas públicas efectivas.

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OBJECTIVE: To examine primary care (PC) team members' characteristics associated with video use at the Veterans Health Administration (VA). METHODS: VA electronic data were used to identify PC team characteristics associated with any video-based PC visit, during the three-year study period (3/15/2019-3/15/2022). Multilevel mixed-effects logistic regression models on repeated yearly observations were used, adjusting for patient- and healthcare system-level characteristics, and study year. We included five PC team categories: 1.PC providers (PCP), which includes physicians, nurse practitioners, physician assistants, 2.Nurses (RN/LVN/LPN/other nurses), 3.Mental health (MH) specialists, 4.Social workers (SW), and 5.Clinical pharmacists (PharmD). POPULATION: 54,494 PC care team members nationwide (61,728,154 PC visits; 4,916,960 patients), including 14,422 PCPs, 30,273 nurses, 2,721 MH specialists, 4,065 SWs, and 3,013 PharmDs. RESULTS: The mean age was 46.1(SD = 11.3) years; 77.1% were women. Percent of video use among PC team members varied from 24 to 84%. In fully adjusted models, older clinicians were more likely to use video compared to the youngest age group (18-29 years old) (example: 50-59 age group: OR = 1.12,95%CI:1.07-1.18). Women were more likely to use video (OR = 1.18, 95%CI:1.14-1.22) compared to men. MH specialists (OR = 7.87,95%CI:7.32-8.46), PharmDs (OR = 1.16,95%CI:1.09-1.25), and SWs (OR = 1.51,95%CI:1.41-1.61) were more likely, whereas nurses (OR = 0.65,95%CI:0.62-0.67) were less likely to use video compared to PCPs. CONCLUSIONS: This study highlights more video use among MH specialists, SWs, and PharmDs, and less video use among nurses compared to PCPs. Older and women clinicians, regardless of their role, used more video. This study helps to inform the care coordination of video-based delivery among interdisciplinary PC team members.

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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.

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In decision making for cancer treatment, information is crucial for patients and health care professionals. Although conversations about treatment decisions take place in hospitals, many patients also appreciate the insights of their general practitioner (GP). GPs indicated that, in order to have meaningful conversations about treatment decisions with their patients, they need additional information about treatment options and considerations, such as expected benefits and side effects. In this practice innovation, we developed and implemented a new written communication format from medical specialists to GPs, aimed at providing accurate treatment information to facilitate GPs in supporting patients with cancer in decision-making. The new format added 3 specific headings to standard letters in the electronic patient files (EPFs): (1) treatment options, (2) treatment considerations, and (3) treatment intent. This innovation was implemented in a large university hospital in the Netherlands between 2020 and 2021. We performed a process evaluation of the implementation using the RE-AIM model, based on assessment of written communication obtained from patients' EPFs, and telephonic interviews with specialists and GPs. In the Netherlands, all inhabitants are registered with a GP, who acts as a gatekeeper to specialist care, and has a comprehensive overview of a patient's history, based on digital communication with hospitals after referral for specialist care. EPFs are used to generate digital letters to communicate between medical specialists in a hospital and GPs outside the hospital. Incorporating new headings in the communication format in the EPF successfully encouraged medical specialists to share such information when used appropriately. Treatment options, considerations, and treatment intent were stated more often in the new format compared with the old format. GPs appreciated the new format, highlighting the value of including treatment considerations, which enhanced their comprehension of the medical specialist's thought processes. Recognition of the problem and motivation for improvement facilitated the implementation. Specialists stated the format to be time-efficient compared with the old format; however, technical improvements could make it easier to use. Automaticity to use of the old format, inadequate information, and technical issues were a barrier for implementation. In summary, a straightforward innovation can improve communication between medical specialists and GPs and promote the role of the GPs in decision making for cancer treatment.

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Background: Although clinical guidelines endorse screening for metabolic dysfunction-associated steatotic liver disease (MASLD) with advanced fibrosis in people with type 2 diabetes (T2D), the feasibility of and barriers and considerations relevant to implementing this approach in the community remain unclear. Methods: Sequential adults with T2D attending selected community clinics during 2021-2023 were invited to receive a "liver health check" (n=543). A further 95 participants were referred directly from their general practitioner (GP) or self-referred to the study. A total of 302 participants underwent a point of care assessment of hepatic steatosis and stiffness (FibroScan) and were advised to see their GP to discuss the results. "Template" letters containing key results, their interpretation and advice about management of cardiometabolic risk, patient follow-up and referral criteria, were sent to participants' GPs. Results: Referral to a tertiary liver clinic was advised in GP letters for 45 (15%) participants with an increased risk of clinically significant fibrosis (liver stiffness measurement ≥8), 15 participants with 'red flags' (eg splenomegaly, thrombocytopenia) and 2 with unsuccessful FibroScan examinations. A referral from GPs to the liver clinic was received for 27 (44%) of these 62 participants. Approximately 90% of GPs rated the "template" letters favourably on a Likert rating scale. Conclusion: The low rate of participation in the "liver health check" and liver clinic referral reflects a real-world scenario and may stem from societal under-recognition and engagement with MASLD, competing health priorities or under-appreciation of the link between liver fibrosis severity and mortality risk. Further studies need to address strategies to enhance participation in liver health assessments and determine their impact on liver-related morbidity/mortality and overall survival.

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Depression is a prevalent mental health disorder that significantly impacts primary care settings. This editorial explores the potential of artificial intelligence (AI)-powered chatbots in managing depression within primary care environments. AI chatbots offer innovative solutions to challenges faced by healthcare providers, including limited appointment times, delayed access to specialists, and stigma associated with mental health issues. These digital tools provide continuous support, personalized interactions, and early symptom detection, potentially improving accessibility and outcomes in depression management. The integration of AI chatbots in primary care presents opportunities for round-the-clock patient support, personalized interventions, and the reduction of mental health stigma. However, challenges persist, including concerns about assessment accuracy, data privacy, and integration with existing healthcare systems. Successful implementation requires systematic approaches, stakeholder engagement, and comprehensive training for healthcare providers. Ethical considerations, such as ensuring informed consent, managing algorithmic biases, and maintaining the human element in care, are crucial for responsible deployment. As AI technology evolves, future directions may include enhanced natural language processing, multimodal integration, and AI-augmented clinical decision support. This editorial emphasizes the need for a balanced approach that leverages the potential of AI while acknowledging its limitations and the irreplaceable value of human clinical judgment in depression management within primary care settings.

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The Southern United States (US) bears the highest burden of HIV prevalence in the country, disproportionately affecting African American communities. Despite the proven efficacy of pre-exposure prophylaxis (PrEP) in reducing HIV transmission, its uptake remains suboptimal in this region. This study aimed to identify factors influencing PrEP-prescribing behaviors among primary care providers (PCPs) in the Southern US through the application of the transtheoretical model of behavior change. A cross-sectional survey was conducted among PCPs in 10 Southern states to assess their PrEP-prescribing practices, barriers, and facilitators. The results indicate that non-White PCPs and those practicing in urban and suburban settings are more likely to prescribe PrEP. Key barriers include lack of training, perceived stigma, and systemic issues such as health insurance coverage and time constraints. Significant facilitators are access to prescribing resources, streamlined insurance procedures, and patient motivation. Targeted educational programs and policy changes to address these barriers can enhance PrEP uptake, thereby reducing HIV transmission in high-risk populations. The findings underscore the need for tailored interventions to support PCPs in integrating PrEP into routine care, ultimately contributing to better public health outcomes in the Southern US.

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Objectives: To assess the delay in the diagnosis of axial SpA (axSpA) in a real-world cohort over a 16-year period and to evaluate factors associated with this delay. We implemented a service improvement project and evaluated its effectiveness in improving time to diagnosis of axSpA. Methods: A cohort of axSpA patients newly diagnosed between January 2008 and December 2023 were studied. Surveys were carried out in 2013, 2017, 2019 and 2023 to assess time to diagnosis, which was divided into four periods from onset of inflammatory back pain to year of axSpA diagnosis. The time to diagnosis over the study period was analysed using a statistical process control chart. Results: Over the study period, 988 referrals were received and 366 (37%) had axSpA. There was a progressive increase in the number of females with axSpA. The mean time to diagnosis significantly decreased from 9.8 years (s.d. 1.2) in 2008 to 1.0 years (s.d. 1.0) in 2023. The greatest delay was from the onset of back pain to first seeing their general practitioners (GPs; mean 3.2 years). There was a significant improvement in the mean time to diagnosis across the time periods through the service improvement interventions. Conclusion: Structural and organizational change in triage, referral and clinic pathways has led to earlier recognition of axSpA. This is further enhanced through an integrated education program and awareness campaign for the public, GPs and healthcare professionals, including physiotherapists. With continuous quality improvement cycles, we achieved our aim of reducing the mean time to diagnosis to 1 year.

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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 assessing modifiable 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. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024550904.

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Introduction: There is limited research examining factors impacting MOUD retention in rural settings, especially within the context of the COVID-19 pandemic. Using electronic health records data collected as part of a NIDA Clinical Trials Network study (CTN-0102), this study explored how the onset of the COVID-19 pandemic may have impacted MOUD retention in a sample of 563 rural primary care patients. Methods: Cox regression model was applied to examine if COVID-19 was related to treatment retention, controlling for demographics, clinic, insurance type, and other diagnoses. The independent variable was the number of days between the patient's first MOUD prescription date during the pre-COVID observation period (10/1/2019-3/13/2020) and the start of the COVID-19 pandemic. The dependent variable was retention on MOUD, defined as the time from the first MOUD prescription documented during the pre-COVID observation period to the first break in consecutive MOUD prescriptions (right censored at 180 days). Results: The findings demonstrated that there was a reduced risk of a prescription break for every 10-day increase in the time from the first documented MOUD prescription to the onset of the COVID-19 pandemic (HR = 0.96, 95 % CI = 0.92-0.99; p = 0.011). Conclusions: While the data did not include complete treatment histories to determine who was new to MOUD treatment, the findings suggest that patients whose first documented MOUD prescription in the dataset was closer to the onset of the pandemic had a greater likelihood of experiencing retention challenges. This underscores the importance for clinics to establish comprehensive contingency plans for future emergencies to ensure uninterrupted MOUD treatment and support, particularly for individuals in the early stabilization phase of their recovery.

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BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

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AIM: Faecal immunochemical testing (FIT) is used to triage people with signs or symptoms of a colorectal cancer (CRC). Recent guidelines have recommended further research to improve access, uptake and return of FIT. This systematic scoping review aims to understand the barriers and facilitators to FIT testing in symptomatic patients. METHOD: Qualitative, quantitative and mixed-methods studies published after September 2013 were included. MEDLINE, EMBASE and PsycINFO databases were searched to identify publications examining barriers and facilitators to FIT. Initially, the data underwent thematic analysis, and subsequently, factors were aligned to components of the Capability, Opportunity, Motivation, Behaviour model. All outcomes are presented in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: One thousand two hundred thirty-two papers were identified; 11 met the inclusion criteria. Barriers and facilitators were identified at the patient (e.g., knowledge), provider (e.g., general practitioner awareness) and service level (e.g., method of providing FIT kits). Factors were categorised into the subcomponents of the model: psychological capability (e.g., lack of FIT knowledge), reflective motivation (e.g., beliefs regarding FIT sampling and faeces being unhygienic) and automatic motivation (e.g., embarrassment, scary, anxiety provoking). Gaps in knowledge emerged in three domains: (1) patient experience, (2) FIT pathway and (3) healthcare professionals experience of FIT. CONCLUSION: This systematic scoping review provides a summary of the literature on FIT uptake, and identified factors across multiple levels and components. To increase adherence to FIT completion within primary care, a multifaceted theory and evidence-based approach is needed to underpin future behavioural science interventions.

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BACKGROUND: The National Health Service (NHS) Long Term Plan, published in 2019, committed to ensuring that every patient in England has the right to digital-first primary care by 2023-2024. The COVID-19 pandemic and infection prevention and control measures accelerated work by the NHS to enable and stimulate the use of online consultation (OC) systems across all practices for improved access to primary care. OBJECTIVE: We aimed to explore general practice coding activity associated with the use of OC systems in terms of trends, COVID-19 effect, variation, and quality. METHODS: With the approval of NHS England, the OpenSAFELY platform was used to query and analyze the in situ electronic health records of suppliers The Phoenix Partnership (TPP) and Egton Medical Information Systems, covering >53 million patients in >6400 practices, mainly in 2019-2020. Systematized Medical Nomenclature for Medicine-Clinical Terminology (SNOMED-CT) codes relevant to OC systems and written OCs were identified including eConsultation. Events were described by volumes and population rates, practice coverage, and trends before and after the COVID-19 pandemic. Variation was characterized among practices, by sociodemographics, and by clinical history of long-term conditions. RESULTS: Overall, 3,550,762 relevant coding events were found in practices using TPP, with the code eConsultation detected in 84.56% (2157/2551) of practices. Activity related to digital forms of interaction increased rapidly from March 2020, the onset of the pandemic; namely, in the second half of 2020, >9 monthly eConsultation coding events per 1000 registered population were registered compared to <1 a year prior. However, we found large variations among regions and practices: December 2020 saw the median practice have 0.9 coded instances per 1000 population compared to at least 36 for the highest decile of practices. On sociodemographics, the TPP cohort with OC instances, when compared (univariate analysis) to the cohort with general practitioner consultations, was more predominantly female (661,235/1,087,919, 60.78% vs 9,172,833/17,166,765, 53.43%), aged 18 to 40 years (349,162/1,080,589, 32.31% vs 4,295,711/17,000,942, 25.27%), White (730,389/1,087,919, 67.14% vs 10,887,858/17,166,765, 63.42%), and less deprived (167,889/1,068,887, 15.71% vs 3,376,403/16,867,074, 20.02%). Looking at the eConsultation code through multivariate analysis, it was more commonly recorded among patients with a history of asthma (adjusted odds ratio [aOR] 1.131, 95% CI 1.124-1.137), depression (aOR 1.144, 95% CI 1.138-1.151), or atrial fibrillation (aOR 1.119, 95% CI 1.099-1.139) when compared to other patients with general practitioner consultations, adjusted for long-term conditions, age, and gender. CONCLUSIONS: We successfully queried general practice coding activity relevant to the use of OC systems, showing increased adoption and key areas of variation during the pandemic at both sociodemographic and clinical levels. The work can be expanded to support monitoring of coding quality and underlying activity. This study suggests that large-scale impact evaluation studies can be implemented within the OpenSAFELY platform, namely looking at patient outcomes.

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CONTEXT: Aging and increasing comorbidities in the population are leading to more complex care for patients and primary healthcare providers. Community organizations (COs) may play a role in the services offered to support patients with chronic diseases (PCDs) but there are currently no clear guidelines to support primary healthcare providers in linking patients to COs. OBJECTIVES: The aim of this study was to describe the role of primary healthcare providers regarding linking PCDs to COs by: (1) describing linking activities; and (2) identifying the main facilitators and barriers associated with these activities. METHODS: This scoping review was based on the Arksey and O'Malley method, completed by Levac, Colquhoun, and O'Brien. Related keywords were used in 7 databases to search relevant studies. After the initial screening, 135 full texts were assessed for eligibility by 2 reviewers using inclusion/exclusion criteria. Empirical studies describing activities performed by primary healthcare providers in linking PCDs to COs or describing facilitators or barriers to linking activities were included. Studies describing activities linking to other services than COs or located in emergency departments were excluded. RESULTS: In total, 28 studies were included. Information reported in the studies was classified into 8 main linking activities: capacity development, patient identification, assessment, information, planning, referral, follow-up, and collaboration. Facilitators and barriers to these activities were related to intrapersonal characteristics of providers and patients, professional practice, work environment, relationships, and external influences. Healthcare providers' involvement was often adapted according to their field of practice. CONCLUSION: This scoping review details the role of primary healthcare providers when linking PCDs to COs in a collaborative and interdisciplinary context, which can be adapted to clinical practice by providers, experts, or stakeholders to support improvement in chronic care management.

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BACKGROUND: Health care systems are increasingly partnering with community-based organizations to address social determinants of health (SDH). We established a program that educates and connects patients with SDH needs at a primary care clinic to community services and facilitated referrals. OBJECTIVE: To evaluate the effect of addressing SDH soon after discharge on hospital readmission in a clinic population. DESIGN: Pre/post, quasi-experimental design with longitudinal data analysis for quality improvement. PARTICIPANTS: Clinic patients (n = 754) having at least one hospital discharge between June 1, 2020, and October 31, 2021, were included. Of these, 145 patients received the intervention and 609 served as comparison. INTERVENTIONS: A primary care liaison was employed to assess and educate recently discharged clinic patients for SDH needs and refer them for needed community services from June 1, 2020, to October 31, 2021. MAIN MEASURES: Hospital readmissions within 30, 60, and 90 days of discharge were tracked at 6-month intervals. Covariates included patient age, sex, race/ethnicity, insurance status, income, Hierarchical Condition Category risk scores, and Clinical Classification Software diagnosis groups. Data for all hospital discharges during the intervention period were used for the main analysis and data for the year before the intervention were extracted for comparison. KEY RESULTS: Overall, patients in the intervention group were older, sicker, and more likely to have public insurance. The reductions in 30-, 60-, and 90-day readmissions during the intervention period were 14.39%, 13.28%, and 12.04% respectively in the intervention group, while no significant change was observed in the comparison group. The group difference in reduction over time was statistically significant for 30-day (Diff = 12.54%; p = 0.032), 60-day (Diff = 14.40%; p = 0.012), and 90-day readmissions (Diff = 14.71%; p = 0.036). CONCLUSION: Our findings suggest that screening clinic patients for SDH, and educating and connecting them to community services during post-hospital care may be associated with reductions in hospital readmissions.

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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.

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BACKGROUND: Delivering prescription digital therapeutics (ie, evidence-based interventions designed to treat, manage, or prevent disorders via websites or smartphone apps) in primary care could increase patient access to substance use disorder (SUD) treatments. However, the optimal approach to implementing prescription digital therapeutics in primary care remains unknown. OBJECTIVE: This pilot study is a precursor to a larger trial designed to test whether implementation strategies (practice facilitation [PF] and health coaching [HC]) improve the delivery of prescription digital therapeutics for SUDs in primary care. This mixed methods study describes outcomes among patients in the 2 pilot clinics and presents qualitative findings on implementation. METHODS: From February 10 to August 6, 2021, a total of 3 mental health specialists embedded in 2 primary care practices of the same integrated health system were tasked with offering app-based prescription digital therapeutics to patients with SUD. In the first half of the pilot, implementation activities included training and supportive tools. PF (at 1 clinic) and HC (at 2 clinics) were added in the second half. All study analyses relied on secondary data, including electronic health records and digital therapeutic vendor data. Primary outcomes were the proportion of patients reached by the prescription digital therapeutics and fidelity related to ideal use. We used qualitative methods to assess the adherence to planned activities and the barriers and facilitators to implementing prescription digital therapeutics. RESULTS: Of all 18 patients prescribed the apps, 10 (56%) downloaded the app and activated their prescription, and 8 (44%) completed at least 1 module of content. Patients who activated the app completed 1 module per week on average. Ideal use (fidelity) was defined as completing 4 modules per week and having a monthly SUD-related visit; 1 (6%) patient met these criteria for 10 weeks (of the 12-week prescription period). A total of 5 (28%) patients had prescriptions while HC was available, 2 (11%) were successfully contacted, and both declined coaching. Clinicians reported competing clinical priorities, technical challenges, and logistically complex workflows in part because the apps required a prescription. Some pilot activities were impacted by staff turnover that coincided with the COVID-19 pandemic. The facilitators to implementation were high engagement and the perception that the apps could meet patient needs. CONCLUSIONS: The pilot study encountered the barriers to implementing prescription digital therapeutics in a real-world primary care setting, especially staffing shortages, turnover, and competing priorities for clinic teams. The larger randomized trial will clarify the extent to which PF and HC improve the implementation of digital therapeutics. TRIAL REGISTRATION: ClinicalTrials.gov NCT04907045; https://clinicaltrials.gov/study/NCT04907045.

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BACKGROUND: Preparing healthcare systems for emergencies is crucial to maintaining healthcare quality. Nursing homes (NHs) require tailored emergency plans. This article aims to develop a typology of French private NHs and study their early COVID-19 responses and mortality outcomes. METHODS: We conducted a cross-sectional survey among NHs of a French network consisting of 290 facilities during the first wave of the COVID-19 pandemic. A Hierarchical Clustering on Principal Components (HCPC) was conducted to develop the typology of the NHs. Association tests were used to analyze the relationships between the typology, prevention and control measures, COVID-19 mortality, and the satisfaction of hospitalization requests. RESULTS: The 290 NHs vary in size, services, and location characteristics. The HCPC identified three clusters: large urban NHs with low levels of primary care (Cluster 1), small rural NHs (Cluster 2), and medium urban NHs with high levels of primary care (Cluster 3). The COVID-19 outcomes and response measures differed by cluster, with Clusters 1 and 2 experiencing higher mortality rates. Nearly all the NHs implemented preventive measures, but the timing and extent varied. CONCLUSIONS: This typology could help in better preparing NHs for future health emergencies, allowing for targeted resource allocation and tailored adaptations. It underscores the importance of primary care territorial structuring in managing health crises.

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BACKGROUND: As primary care is an important infrastructure for the entire health system, the employment structure choices of family physicians-whether to work in a managed care organization or be self-employed, can impact all effectiveness parameters of healthcare: quality, access, health equity, patients' experiences, and cost-effectiveness. The aim of this study is to assess the push and pull factors influencing family physicians' employment choices. METHODS: This study employed a qualitative approach to explore the experiences of family physicians (FPs) who choose to work a self-employment practice. We conducted semi-structured interviews with twenty-seven self-employed FPs in Israel, selected through purposive and snowball sampling. The interviews were conducted via Zoom, recorded, and transcribed verbatim. Data analysis followed thematic analysis framework. The analysis yielded 10 themes, which were organized into two categories: pull and push factors. RESULTS: Pull factors, i.e., factors that attract family physicians to become self-employed, included professional self-fulfillment, higher income, professional and business autonomy, working with secretaries according to one's personal choice, designing the space of the clinic, and flexibility in working hours. Push factors, i.e., factors that demotivated family physicians to work under managed care and pushed them to choose self-employment included low control over the work environment, workload, decreased professional and organizational autonomy, managerial pressures on quality measures, engagement in marketing activities, and tensions with non-medical staff in the Health Maintenance Organization. CONCLUSIONS: There are obvious implications of this work for Health Maintenance Organizations' policy makers. Balancing managerial pressure and tensions between family physicians and non-medical administration and ensuring suitable working conditions increased physicians' control over the work environment, and professional autonomy may decrease push factors and retain family physicians as Health Maintenance Organization-employed. Understanding pull factors may help to develop a strategy for maximizing cooperation with self-employed family physicians and reinforce physicians' linkage to the healthcare system's treatment objectives.