We conducted a cross-sectional cohort study to assess how continuity of primary care within community-based health centers (CHCs) might have changed during the years surrounding the COVID-19 pandemic and how continuity varied by patient and visit characteristics. In a national sample of CHCs providing primary care, we assessed the usual provider of care (UPC) index-the fraction of patient visits to the patient's most frequently seen clinician within the CHC-for patients with at least 2 primary care encounters within a calendar year during 2019-2023. We used age-stratified multilevel logit analyses to assess patient, clinic, and visit characteristics associated with the perfect UPC index of 1 in 2023. Among an annual average of 353,608 patients seen in an average of 186 CHCs, the median UPC index was 1 in each year, with the mean index varying from a low of 0.822 in 2020 to a high of 0.831 in 2021. In the 2023 sample, logit analyses adjusted for clustering of patients within clinics found that among adults, the likelihood of achieving a UPC index of 1 was higher for patients who were middle-aged or older and had an income greater than 138% of the federal poverty level or an unknown income, whereas it was lower for patients who were of Hispanic ethnicity, were of Black/African American race, had multimorbidity, had a telehealth visit, and received care at large clinics. Among children, the likelihood of achieving a UPC of 1 was lower for those who were of Hispanic ethnicity, had a telehealth visit, and received care at large clinics. In a large national sample of patients seen at CHCs, continuity of primary care within CHCs remained high before, during, and after the COVID-19 pandemic, and was associated with practice and patient characteristics that provide targets for systemic intervention. Although health care systems explore different approaches to balance continuity with easy access, CHCs continue to value and deliver high-continuity care.
Understanding and addressing increased administrative workload among family physicians is receiving attention, but data describing administrative tasks are limited. We used electronic health record (EHR) data to describe trends in orders made by family physicians, capturing changes in total workload per physician and the volume of per-patient contact over time. We used national Canadian Primary Care Sentinel Surveillance Network EHR data to measure annual counts of patient contacts, laboratory tests, referrals made, and prescriptions per physician from 2011 to 2021. We evaluated trends in the annual rates of these orders per patient contact by fitting multivariable Poisson regression within a generalized estimating equation framework. Family physicians reporting EHR data saw more unique patients, had more total contacts, and had more days with patient contact in 2021 than 2011. In 2021, the average numbers of laboratory tests, referrals, and prescriptions per physician were greater than in 2011 (68.5%, 80.2%, and 43.1% increases, respectively). Rates of referrals and laboratory tests increased by 57% (incident rate ratio [IRR]2021; 95% CI = 1.57; 1.36-1.80) and 29% (IRR2021; 95% CI = 1.29; 1.18-1.41), respectively. The number of prescriptions per patient contact remained constant (IRR2021; 95% CI = 0.96; 0.90-1.03). Our results suggest a significant increase in family physician administrative workload per patient contact over a period of 11 years. Whereas further research is needed to better understand drivers of increased referrals and laboratory tests, strategies to streamline administrative tasks in primary care could help inform the development of effective policy.
We aimed to evaluate the multicomponent School of Caring program supporting caregivers of patients with dementia with respect to caregiver burden, quality of life, emotional well-being, self-efficacy, and social support. We conducted a quasi-experimental pre-/postintervention study with a 6-month follow-up conducted in primary care in Spain. Participants were caregivers of dependent people with dementia. Sociodemographic characteristics and information regarding care tasks were collected using an ad hoc questionnaire. We evaluated the program's effectiveness using the Zarit Burden Interview, EuroQol 5 dimensions 3 levels scale, General Self-Efficacy Scale, Warwik-Edinburgh Mental Wellbeing Scale, and Oslo Social Support Scale, validated questionnaires to assess caregiver burden, quality of life, self-efficacy, emotional well-being, and social support. The analysis compared the results of the outcomes at 3 time points (baseline, postintervention, and follow-up). We used multivariate regression to identify characteristics related to improvements produced by the program. The School of Caring program was delivered to 8 groups, comprising 14-19 participants/group, from 2019 to 2023. A total of 132 caregivers completed the program and were evaluated pre-/postintervention, 33 (25%) of whom were lost to follow-up. The program produced significant improvements in all outcomes, which was maintained up to 6 months postintervention. At this stage, inexperienced caregivers showed the greatest improvement compared with former caregivers relative to burden levels. Overall, the amount of time dedicated to caregiving each day and experiencing a health issue were the elements that most significantly affected caregiver burden and quality of life. The School of Caring program produced notable improvements in the burden and well-being of informal caregivers of dependent people with dementia. The findings provide evidence of the effectiveness of group-based, community primary care programs that support caregivers of people with high care demands such as dependent people with dementia.
It is unclear whether patients with cancer continue to benefit from antithrombotic therapy (ATT) during the last phase of life. We estimated the incidences of ATT discontinuation, bleeding, and venous thromboembolic (VTE) and arterial thromboembolic (ATE) events among patients with cancer during the last phase of life. We included patients aged ≥18 years with cancer during the period 2018 to 2022 at the time a reimbursement claim for general practitioner (GP) palliative care was made. We manually identified ATT discontinuation, along with reasons, and the incidences of bleeding events, VTE events, and ATE events in free-text reports of routine primary care consultations until death. Among the 2,860 included patients, 32.5% used ATT at the index date. The median follow-up was 43 (interquartile range [IQR] 14-190) days for ATT users and 42 (IQR 13-149) days for nonusers. During follow-up, 22.1% of ATT users discontinued ATT, with a median of 8 (IQR 3-26) days before death. The most common reason for discontinuation was recognition of the terminal phase (22.9%). Bleeding occurred for 28.5% (95% CI, 25.7%-31.5%) of ATT users and 22.0% (95% CI, 20.2%-23.9%) of nonusers. Venous thromboembolic events occurred for 3.1% (95% CI, 2.2%-4.4%) of ATT users and 3.0% (95% CI, 2.3%-3.9%) of nonusers, and ATE events occurred for 2.5% (95% CI, 1.7%-3.7%) of ATT users and 1.9% (95% CI, 1.4%-2.6%) nonusers. One-third of patients with cancer used ATT at the initiation of GP palliative care, with most continuing treatment until death or discontinuing shortly before death. Bleeding events largely outnumbered ATE and VTE events among both ATT users and non-users. These findings provide new insights into ATT management by GPs and inform future research on optimizing ATT use for patients with cancer during the last phase of life.
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A better understanding of the association of isolation with preventive care uptake and material deprivation-2 potential drivers of worse health outcomes among isolated individuals-could inform health policy to mitigate the health harms of isolation. We analyzed data from the 2022 Behavioral Risk Factor Surveillance System. Our exposures were self-reported social isolation and physical isolation (assessed from transportation barriers). We examined the association of each form of isolation with indicators of material deprivation and with the uptake of 6 recommended preventive care services (COVID, influenza, and pneumococcal vaccinations, and cervical, colorectal, and breast cancer screenings). Our population included 281,592 adult respondents; 82,816 (31.9%) reported social isolation and 18,181 (8.2%) reported physical isolation. In unadjusted analyses, each form of isolation was associated with reduced uptake of preventive care services. After multivariate adjustment, social isolation remained associated with reduced uptake of 2 services-breast cancer screening (adjusted odds ratio [AOR] = 0.70; 95% CI, 0.65-0.76) and colorectal cancer screening (AOR = 0.91; 95% CI, 0.85-0.97)-and physical isolation remained associated with reduced uptake of 3 services-influenza vaccination (AOR = 0.89; 95% CI, 0.82-0.97), breast cancer screening (AOR = 0.57; 95% CI, 0.49-0.66), and colorectal cancer screening (AOR = 0.81; 95% CI, 0.71-0.93). Social isolation and physical isolation are associated with reduced preventive care use, but adjustment for material deprivation substantially attenuates these associations. Policies to foster social connectedness and alleviate transportation barriers may improve health outcomes, but intervention on socioeconomic factors will likely also be necessary.
Genomic tests can illuminate and mislead. I cared for a school-aged boy with short stature whose copy-number variant at 1q21.1-typically associated with variable neurodevelopmental and cardiac features rather than isolated short stature-seduced me into a syndromic label. I told his family that a "pathogenic" deletion likely explained his growth. Months later, family segregation testing contradicted the story: some short relatives lacked the deletion; a taller cousin carried it. His excellent response to growth hormone pointed to treatable growth hormone deficiency, not a genetic syndrome. I returned to the family to revise-both the diagnosis and my words. This reflection traces how the promise of precision medicine can eclipse bedside sense, and how apology, delabeling, and a new clinic script helped me re-center care on phenotype, family context, and uncertainty handled with humility.
Timely access to primary care remains a major challenge. Advanced access, an organizational model for appointment management, aims to improve accessibility by allowing patients to consult their health care professional in a timely manner. This systematic review evaluated its association with several key dimensions of primary care performance. We conducted a comprehensive search in MEDLINE, Embase, Web of Science, CINAHL, and the Cochrane Library from inception to May 10, 2025. Randomized intervention studies, nonrandomized intervention studies, and observational studies comparing advanced access with traditional scheduling systems among patients in primary care were eligible. Outcomes were the wait time to an appointment, continuity of care, emergency department (ED) use, and patient satisfaction. Two independent reviewers selected studies, extracted data, and assessed risk of bias. We performed a narrative synthesis, separately analyzing universal and non-universal health care systems. Among 7,595 unique records identified, 29 studies were included. Of these, 23 evaluated appointment wait time, 13 examined continuity of care, 3 assessed ED use, and 13 evaluated patient satisfaction. Appointment wait time decreased in all 23 studies assessing this outcome, with 13 reporting statistically significant reductions. Continuity of care improved in 11 of 13 studies, of which 7 reported statistically significant improvements. All 3 studies evaluating ED use reported reductions in ED visits, although none demonstrated statistical significance. Patient satisfaction improved in 8 studies, with 3 reporting statistically significant improvements. Overall, findings were consistent across universal and non-universal health care systems. Advanced access appears to improve appointment timeliness, continuity of care, and patient satisfaction, and may help reduce avoidable ED use across diverse health care systems.
We sought to describe the current state of data governance principles in Canadian practice-based research and learning networks (PBRLNs) and to examine opportunities and challenges in applying Indigenous data sovereignty frameworks. We conducted a cross-sectional survey of Canadian PBRLN leaders. Survey results were described using summary statistics and directed content analysis of open-text responses. Indigenous data sovereignty frameworks were identified through a scan of recent publications. We identified and synthesized the main principles presented in each framework and assessed their relevance to PBRLNs. Eleven of 15 Canadian PBRLN leaders participated in the survey. The respondents noted several activities to be important for Indigenous data sovereignty: building knowledge of Indigenous data sovereignty within PBRLNs, having resources specifically dedicated to advance Indigenous data sovereignty, and understanding ways in which PBRLNs can advance this sovereignty. We identified 9 frameworks addressing Indigenous data sovereignty. Common principles among the frameworks were fostering relationships; ensuring collective benefits and action; respecting Indigenous ways of knowing and space for co-learning; prioritizing relevance to communities and places; ensuring data governance; building capacity; and striving for ethical sustainability. Our survey suggests that improving knowledge of Indigenous data sovereignty within PBRLNs is a necessary step in Canada. We identified a set of principles in Indigenous data sovereignty frameworks that should be applied in PBRLNs. Networks and learning health systems need to adopt "wise practices" that focus on place-based and relational learning to advance Indigenous reconciliation.
Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a multisystem neurologic disease characterized by profound fatigue and decreased functional capacity, postexertional malaise, and unrefreshing sleep, along with cognitive impairment and/or orthostatic intolerance. Its prevalence has risen exponentially with the COVID-19 pandemic. Pharmacologic therapies have been used successfully by ME/CFS specialists but may be underused by the general medical field. To assess this potential practice gap, we retrospectively analyzed the records of 571 patients with an ME/CFS diagnosis referred to our ME/CFS specialty clinic in Minnesota during 2018-2022. We ascertained medications that had already been tried at the time of consultation and also ascertained supplement use. With the exception of medications primarily used for pain and anxiety, use of pharmacotherapy for ME/CFS symptom management as proposed by specialists was limited. Overall, 68.3% of patients had had at least 1 medication potentially prescribed for ME/CFS; the most common were serotonin-norepinephrine reuptake inhibitors, gabapentin, and tricyclic antidepressants. A slightly larger share of patients, 72.2%, reported having taken at least 1 dietary supplement; the most common were vitamin D, vitamin B12 and B complex, and fish oil. Our findings suggest that potentially helpful medications for ME/CFS are being underprescribed in the general medical field and that patients may resort to supplements to manage symptoms. Better education of clinicians about available treatment options and treatment guides may improve management of this debilitating disease.
We aimed to evaluate continuity of care (CoC) for patients receiving home-based care and assess its effect on urgent care use and hospital admissions. This cohort study used data from a population-based electronic health record system across 3 primary health care (PHC) centers in Barcelona, Spain, involving patients receiving permanent home care. We measured CoC with the usual provider of care for general practitioners (GPs) and nurses over a 1-year period. Associations were analyzed using adjusted logistic-mixed regression models. We used time-dependent receiver operating characteristic curves to identify the optimal CoC threshold and adjusted Cox survival models to examine cumulative incidence. We studied 1,207 patients (71.5% women) with a mean age of 88.5 years. General practitioners showed a mean CoC of 73.3% and PHC nurses 83.1%. Greater CoC for GPs and PHC nurses was associated with decreased urgent care use and hospital admissions (all odds ratios ≤ 0.45; P ≤ .004). An optimal CoC threshold of ≥75% for GPs was identified (sensitivity = 0.78; 95% CI, 0.74-0.83), with a modest area under the curve of 0.59 (95% CI, 0.55-0.62). Multivariate models showed that this threshold was significantly associated with decreased urgent care use and hospital admissions for both providers (hazard ratios = 0.61-0.69; P < .05). Greater CoC for GPs and nurses was associated with decreased urgent care and hospital admissions. A threshold of ≥75% of visits with assigned GPs or nurses might optimize health outcomes for these vulnerable patients. Maintaining a high level of relational CoC, particularly for older adults requiring home care services, can lead to more efficient and targeted health care utilization.
Medicare Annual Wellness Visits (AWVs) offer many potential benefits to older adults, but patients in racial and ethnic minority groups have lower rates of AWV completion. Our objective was to understand older minority patients' attitudes and preferences related to preventive care and AWVs. From June 2024 through October 2024, we conducted 4 focus groups at 2 urban primary care settings (ie, an academic health system and a Federally Qualified Health Center) among Medicare enrollees aged 66 years or more with 1 or more primary care encounter at a participating organization during the prior year. We recruited patients with Black race or Hispanic ethnicity documented in the electronic health record. Domains of interest were communication preferences, attitudes about preventive care and AWVs, and barriers to care. Focus groups were audio recorded, and transcripts were coded into key themes using a template analysis approach. There were 45 participants, who had a mean age of 71 years (SD = 4); most were female and identified as Black. Participants reported various forms of preferred communication, including patient portal, phone calls, and mailed letters. Five themes emerged: (1) the value participants placed on their health and preventive care; (2) the value placed on relationships with trusted primary care physicians; (3) barriers to scheduling and attending medical visits; (4) confusion or uncertainty about terminology describing preventive visits in office- and home-based settings, and; (5) lack of trust due to historical discrimination. Interventions to increase Medicare AWV uptake in Black and Hispanic patients must address and overcome barriers such as those identified in this study.
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Growing numbers of people live with multimorbidity, defined as 2 or more long-term health conditions. Health care delivery must adapt to manage the growing workload and complexity associated with multimorbidity. Research, practice, and policy have called for a shift to whole-person tailored primary care management of multimorbidity but have yet to adequately describe how this should be implemented. Here, we systematically identify the enablers and barriers to delivery of tailored care for people living with multimorbidity to develop a new model for implementation. We collected data across 5 UK general practitioner (GP) sites through 2 methods: ethnography and focus group discussions. Ethnographers observed 25 consultation sessions, 5 per site. Focus groups were held among primary care staff (n = 16, across 4 sessions) and patients and carers (n = 8, across 2 sessions). We analyzed integrated data using inductive thematic analysis to describe enablers/barriers to delivery of tailored care. We identified 3 elements needed to enable tailored management: (1) resources for tailored assessment of, and practical support for, tailored management of multimorbidities, (2) engagement of patients/carers with professional collaboration to cocreate tailored management plans, and (3) evaluation and development of the professional skills required to confidently work beyond traditional condition-focused models. Whole-person tailored care needs inclusion of more services in routine primary care and change of culture toward shared decision making among multidisciplinary health care teams, patients, and carers. Such approach needs flexible consultation models and data sources enforced through monitoring and continual learning.
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We aimed to evaluate the effectiveness and safety of Care Anywhere with Community Paramedics (CACP), a mobile community paramedic intervention delivering a broad range of clinical services in the home, in preventing or shortening hospitalizations. In this multicenter, pragmatic, randomized controlled trial, we randomized 240 adults from ambulatory, emergency department (ED), or hospital settings requiring acute care-administered services to CACP or usual care. The trial was conducted from January 2022 to March 2023. The primary outcome was days alive out of hospital/ED within 30 days. Secondary outcomes were 30-day ED and unplanned hospital use, death, health-related quality of life, program satisfaction, medication errors, and falls with injury. A total of 119 patients were randomized to CACP and 121 to usual care. Mean (SD) age was 68 (14) and 69 (15) years, respectively, 37% and 46% lived in rural areas, the mean (SD) Elixhauser comorbidity index was 10.0 (4.4) and 8.9 (3.7), and 84% and 86% had an unplanned hospitalization in the past 6 months. There was no difference between the CACP and usual care arms in the primary outcome (26.7 [6.6] vs 27.9 [4.2] days; P = .1) or secondary outcomes. The mean satisfaction score was greater for CACP (4.2 [0.8] vs 3.9 [0.9]; P = .02), and 94% were very/extremely likely to recommend CACP to others. The CACP program, which enrolled highly complex patients with heterogeneous care needs, did not decrease 30-day acute care use compared with alternative usual care pathways, but it improved patient satisfaction and was preferred by most participants. Future research is needed to better tailor community paramedic services to those most likely to benefit.
Vitreous floaters are often considered harmless. However, floaters might be the first and only alarm symptom for a retinal tear or early retinal detachment (RD). Data from ophthalmology practices show that experiencing new-onset floaters is more strongly associated with retinal tears than experiencing flashes, but these associations have not been studied in primary care. We aimed to calculate the absolute risk (AR) and relative risk (RR) of floaters for RD in primary care. We performed a retrospective cohort study of patients (aged ≥18 years) with new-onset floaters or flashes during the period 2012 to 2021 among 7 family practices in the Netherlands. Based on electronic health record reviews, cases (n = 1,181) were categorized into floaters, flashes and floaters, and flashes. The duration (acute, defined as ≤14 days) and number of floaters (many, defined as ≥10 floaters or a cloud/haze/curtain) were used as subgroups. We calculated the RR for flashes alone as the reference group. The incidence (1,000 patient-years) of floaters and flashes was 5.5 and 2.7, respectively. The AR of RD was 6.1% for floaters alone, 4.7% for flashes alone, and 8.4% for floaters and flashes. Both acute and many floaters increased AR. The RRs for acute floaters and flashes (2.39; 95% CI, 1.11-5.15), many floaters (4.20; 95% CI, 1.87-9.40), and many floaters and flashes (6.20; 95% CI, 2.47-15.55) were significantly increased compared with flashes alone. Data from primary care confirm that new-onset floaters confer increased risk of RD. Currently, family physicians use vision loss and flashes as important alarm symptoms for RD. Our primary care data revealed that floaters confer a greater risk of RD than flashes. This enables family physicians to make an evidence-based risk assessment for patients with floaters or flashes.