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Background Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Methods/design We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale –up. Discussion The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information – a critical gap for addressing a leading global cause of disability. Trial registration ClinicalTrials.gov NCT03466346 , registered March 15, 2018.

BACKGROUND Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed. AIM To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model. SETTING A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices. PARTICIPANTS Residents, faculty, and administrative staff. PROGRAM DESCRIPTION Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously. PROGRAM EVALUATION A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased ( p  = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting ( p  < 0.0001). Satisfaction with ambulatory training improved ( p  < 0.0001). Self-reported empanelment also increased ( p  < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites ( p  < 0.0001). DISCUSSION A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.

Background The COVID-19 pandemic has intensified the burden of noncommunicable diseases, particularly diabetes mellitus. This study aims to examine the impact of the COVID-19 pandemic on the trend of diabetic care and its indices in Iran by comparing the periods before and during the pandemic. Methods In this trend analysis study, we used data from the National Program for Prevention and Control of Diabetes (NPPCD) database from March 2017 to June 2021 alongside national data on COVID-19 infection and mortality from February 2020 to June 2021. The t-test and general linear models were used to compare diabetes care indices before and during the COVID-19 pandemic and to analyze the weekly and monthly trends of visits in relation to COVID-19 infection and mortality, respectively. Results The results of this study revealed significant disruptions in outpatient diabetic care during the COVID-19 pandemic. The average weekly visits to diabetes outpatient clinics showed an inverse trend to COVID-19 infections and deaths. Comparing the pre-pandemic to the pandemic period, a notable shift observed in the gender distribution toward an increase in male patients (from 32.82% pre-pandemic to 35.94% during the pandemic, p-value, 0.018). Smoking prevalence rose significantly from 4.65% to 5.86% (p-value = 0.001). Hyperlipidemia decreased from 54.36% to 46.77% (p-value < 0.001), and metabolic syndrome prevalence declined from 63.2% to 61.98% (p-value < 0.001). Cardiovascular disease decreased from 21.04% to 18.63% (p-value = 0.013), while hypertension increased from 35.61% to 38.54% (p-value = 0.023). Regarding glucose-lowering therapies, the use of oral medications dropped significantly from 83.73% pre-pandemic to 78.94% during the pandemic (p-value < 0.001), while insulin use increased from 38.91% to 46.75% (p-value < 0.001). Analysis of laboratory findings showed a significant reduction in LDL > 100 mg/dl (36.69% to 33.03%, p-value = 0.006) and TG > 150 mg/dl (49.59% to 48.79%, p-value = 0.006). However, no significant differences were observed in HbA1c > 7% or diabetic complications (p-value > 0.05). Conclusion The COVID-19 pandemic has profoundly impacted the care and management of diabetic patients in Iran, leading to contrasting trends in various diabetic care indices among diabetic patients who receive care in outpatient diabetes clinics. Notable improvements were observed in the prevalence of CVD, hyperlipidemia, and metabolic syndrome, while the prevalence of smoking and hypertension deteriorated. These findings underscore the need for adaptable healthcare strategies, especially for managing chronic conditions during health crises. Further studies are necessary to evaluate the long-term effects of the pandemic on diabetic care and patient outcomes.

A convenience sample of doctors working in UCCs since 1 July 2023 were invited to participate in an online survey. This was advertised through The Royal Australian College of General Practitioners (RACGP), The Royal New Zealand College of Urgent Care (RNZCUC), corporate general practices, UCC peer groups and LinkedIn.  RESULTS: A convenience sample of doctors working in UCCs since 1 July 2023 were invited to participate in an online survey. This was advertised through The Royal Australian College of General Practitioners (RACGP), The Royal New Zealand College of Urgent Care (RNZCUC), corporate general practices, UCC peer groups and LinkedIn.  DISCUSSION: Findings were compared with practices in other Western countries. This study highlights the potential for national standards to address unwarranted variation in health care delivery in Australian UCCs.

Background Previous studies have found that up to 15% of clinical encounters are experienced as difficult by clinicians. Objectives Explore patient and physician characteristics associated with being considered “difficult” and assess the impact on patient outcomes. Design Prospective cohort study. Participants Seven hundred fifty adults presenting to a primary care walk-in clinic with a physical symptom. Main Measures Pre-visit surveys assessed symptom characteristics, expectations, functional status (Medical Outcome Study SF-6) and the presence of mental disorders [Primary Care Evaluation of Mental Disorders, (PRIME-MD)]. Post-visit surveys assessed satisfaction (Rand-9), unmet expectations and trust. Two-week assessment included symptom outcome (gone, better, same, worse), functional status and satisfaction. After each visit, clinicians rated encounter difficulty using the Difficult Doctor-Patient Relationship Questionnaire (DDPRQ). Clinicians also completed the Physician’s Belief Scale, a measure of psychosocial orientation. Key Results Among the 750 subjects, 133 (17.8%) were perceived as difficult. “Difficult” patients were less likely to fully trust (RR = 0.88, 95% CI: 0.77–0.99) or be fully satisfied (RR = 0.78, 95% CI: 0.62–0.98) with their clinician, and were more likely to have worsening of symptoms at 2 weeks (RR = 0.75, 95% CI: 0.57–0.97). Patients involved in “difficult encounters” had more than five symptoms (RR = 1.8, 95% CI: 1.3–2.3), endorsed recent stress (RR = 1.9, 95% CI: 1.4–3.2) and had a depressive or anxiety disorder (RR = 2.3, 95% CI: 1.3–4.2). Physicians involved in difficult encounters were less experienced (12 years vs. 9 years, p = 0.0002) and had worse psychosocial orientation scores (77 vs. 67, p < 0.005). Conclusion Both patient and physician characteristics are associated with “difficult” encounters, and patients involved in such encounters have worse short-term outcomes.

The Accreditation Council for Graduate Medical Education (ACGME) requirement that internal medicine residents spend one-third of their training in an ambulatory setting has resulted in programmatic innovation across the country. The traditional weekly half-day clinic model has lost ground to the block or “X + Y” clinic model, which has gained in popularity for many reasons. Several disadvantages of the block model have been reported, however, and residency programs are caught between the threat of old and new challenges. We offer the perspectives of three large residency programs (University of Washington, Emory University, and Massachusetts General Hospital) that have successfully navigated scheduling challenges in our individual settings without implementing the block model. By sharing our innovative non-block models, we hope to demonstrate that programs can and should create the solution that fits their individual needs.

BACKGROUND Many have called for ambulatory training redesign in internal medicine (IM) residencies to increase primary care career outcomes. Many believe dysfunctional, clinic environments are a key barrier to meaningful ambulatory education, but little is actually known about the educational milieu of continuity clinics nationwide. OBJECTIVE We wished to describe the infrastructure and educational milieu at resident continuity clinics and assess clinic readiness to meet new IM-RRC requirements. DESIGN National survey of ACGME accredited IM training programs. PARTICIPANTS Directors of academic and community-based continuity clinics. RESULTS Two hundred and twenty-one out of 365 (62%) of clinic directors representing 49% of training programs responded. Wide variation amongst continuity clinics in size, structure and educational organization exist. Clinics below the 25th percentile of total clinic sessions would not meet RRC-IM requirements for total number of clinic sessions. Only two thirds of clinics provided a longitudinal mentor. Forty-three percent of directors reported their trainees felt stressed in the clinic environment and 25% of clinic directors felt overwhelmed. LIMITATIONS The survey used self reported data and was not anonymous. A slight predominance of larger clinics and university based clinics responded. Data may not reflect changes to programs made since 2008. CONCLUSIONS This national survey demonstrates that the continuity clinic experience varies widely across IM programs, with many sites not yet meeting new ACGME requirements. The combination of disadvantaged and ill patients with inadequately resourced clinics, stressed residents, and clinic directors suggests that many sites need substantial reorganization and institutional commitment.New paradigms, encouraged by ACGME requirement changes such as increased separation of inpatient and outpatient duties are needed to improve the continuity clinic experience.

The COVID-19 pandemic has disrupted health-care systems, leading to concerns about its subsequent impact on non-COVID disease conditions. The diagnosis and management of cancer is time sensitive and is likely to be substantially affected by these disruptions. We aimed to assess the impact of the COVID-19 pandemic on cancer care in India. We did an ambidirectional cohort study at 41 cancer centres across India that were members of the National Cancer Grid of India to compare provision of oncology services between March 1 and May 31, 2020, with the same time period in 2019. We collected data on new patient registrations, number of patients visiting outpatient clinics, hospital admissions, day care admissions for chemotherapy, minor and major surgeries, patients accessing radiotherapy, diagnostic tests done (pathology reports, CT scans, MRI scans), and palliative care referrals. We also obtained estimates from participating centres on cancer screening, research, and educational activities (teaching of postgraduate students and trainees). We calculated proportional reductions in the provision of oncology services in 2020, compared with 2019. Between March 1 and May 31, 2020, the number of new patients registered decreased from 112 270 to 51 760 (54% reduction), patients who had follow-up visits decreased from 634 745 to 340 984 (46% reduction), hospital admissions decreased from 88 801 to 56 885 (36% reduction), outpatient chemotherapy decreased from 173634 to 109 107 (37% reduction), the number of major surgeries decreased from 17 120 to 8677 (49% reduction), minor surgeries from 18 004 to 8630 (52% reduction), patients accessing radiotherapy from 51 142 to 39 365 (23% reduction), pathological diagnostic tests from 398 373 to 246 616 (38% reduction), number of radiological diagnostic tests from 93 449 to 53 560 (43% reduction), and palliative care referrals from 19 474 to 13 890 (29% reduction). These reductions were even more marked between April and May, 2020. Cancer screening was stopped completely or was functioning at less than 25% of usual capacity at more than 70% of centres during these months. Reductions in the provision of oncology services were higher for centres in tier 1 cities (larger cities) than tier 2 and 3 cities (smaller cities). The COVID-19 pandemic has had considerable impact on the delivery of oncology services in India. The long-term impact of cessation of cancer screening and delayed hospital visits on cancer stage migration and outcomes are likely to be substantial. None. For the Hindi translation of the abstract see Supplementary Materials section.

The coronavirus disease 2019 (COVID-19) pandemic has critically affected healthcare delivery in the United States. Little is known on its impact on the utilization of emergency department (ED) services, particularly for conditions that might be medically urgent. The objective of this study was to explore trends in the number of outpatient (treat and release) ED visits during the COVID-19 pandemic. We conducted a cross-sectional, retrospective study of outpatient emergency department visits from January 1, 2019 to August 31, 2020 using data from a large, urban, academic hospital system in Utah. Using weekly counts and trend analyses, we explored changes in overall ED visits, by patients' area of residence, by medical urgency, and by specific medical conditions. While outpatient ED visits were higher (+6.0%) in the first trimester of 2020 relative to the same period in 2019, the overall volume between January and August of 2020 was lower (−8.1%) than in 2019. The largest decrease occurred in April 2020 (−30.4%), followed by the May to August period (−12.8%). The largest declines were observed for visits by out-of-state residents, visits classified as non-emergent, primary care treatable or preventable, and for patients diagnosed with hypertension, diabetes, headaches and migraines, mood and personality disorders, fluid and electrolyte disorders, and abdominal pain. Outpatient ED visits for emergent conditions, such as palpitations and tachycardia, open wounds, syncope and collapse remained relatively unchanged, while lower respiratory disease-related visits were 67.5% higher in 2020 relative to 2019, particularly from March to April 2020. However, almost all types of outpatient ED visits bounced back after May 2020. Overall outpatient ED visits declined from mid-March to August 2020, particularly for non-medically urgent conditions which can be treated in other more appropriate care settings. Our findings also have implications for insurers, policymakers, and other stakeholders seeking to assist patients in choosing more appropriate setting for their care during and after the pandemic.

China's universal medical insurance system (UMIS) is designed to promote social fairness through improving access to medical services and reducing out-of-pocket (OOP) costs for all Chinese. However, it is still not known whether UMIS has a significant impact on the accessibility of medical service supply and the affordability, as well as the seeking-care choice, of patients in China. Segmented time-series regression analysis, as a powerful statistical method of interrupted time series design, was used to estimate the changes in the quantity and quality of medical service supply before and after the implementation of UMIS. The rates of catastrophic payments and seeking-care choices for UMIS beneficiaries were selected to measure the affordability and medical service flow of patients after the implementation of UMIS. China's UMIS was established in 2008. After that, the trending increase of the expenditure of the UMIS was higher than that of increase in revenue compared to previous years. Up to 2014, the UMIS had covered 97.5% of the entire population in China. After introduction of the UMIS, there were significant increases in licensed physicians, nurses, and hospital beds per 1000 individuals. In addition, hospital outpatient visits and inpatient visits per year increased compared to the pre-UMIS period. The average fatality rate of inpatients in the overall hospital and general hospital and the average fatality rate due to acute myocardial infarction (AMI) in general hospitals was significantly decreased. In contrast, no significant and prospective changes were observed in rural physicians per 1000 individuals, inpatient visits and inpatient fatality rate in the community centers and township hospitals compared to the pre-UMIS period. After 2008, the rates of catastrophic payments for UMIS inpatients at different income levels were declining at three levels of hospitals. Whichever income level, the rate of catastrophic payments for inpatients of Urban Employee's Basic Medical Insurance was the lowest. For the low-income patients, a single hospitalization at a tertiary hospital can lead to catastrophic payments. It is needless to say what the economic burden could be if patients required multiple hospitalizations within a year. UMIS beneficiaries showed the intention of growth to seek hospitalization services in tertiary hospitals. Introduction of the UMIS contributed to an increase in available medical services and the use thereof, and a decrease in fatality rate. The affordability of UMIS beneficiaries for medical expenses was successfully ameliorated. The differences in patients' affordability are mainly manifested in different medical insurance schemes and different seeking-care choices. The ability of the poor patients covered by UMIS to resist catastrophic medical payments is still relatively weak. Therefore, the current UMIS should reform the insurance payment model to promote the integration of medical services and the formation of a tiered treatment system. UMIS also should establish supplementary medical insurance packages for the poor.