Explore the vast range of titles available.

Background Practice facilitation (PF), a multifaceted approach in which facilitators (external health care professionals) help family physicians to improve their adoption of best practices, has been highly successful. Improved Delivery of Cardiovascular Care (IDOCC) was an innovative PF trial designed to improve evidence-based care for people who have, or are at risk of, cardiovascular disease (CVD). The intervention was found to be ineffective as assessed by a patient-level composite score based on chart reviews from a subsample of patients ( N  = 5292). Here, we used population-based administrative data to examine IDOCC’s effect on CVD-related hospitalizations. Methods IDOCC used a pragmatic, stepped wedge cluster randomized controlled design involving primary care providers recruited across Eastern Ontario, Canada. IDOCC’s effect on CVD-related hospitalizations was assessed in the 2 years of active intervention and post-intervention years. Marginal and mixed-effects regression analyses were used to account for the study design and to control for patient, physician, and practice characteristics. Secondary and subgroup analyses investigated robustness. Results Our sample included 262,996 patient/year observations representing 54,085 unique patients who had, or were at risk of, CVD, from 70 practices. There was a strong decreasing secular trend in CVD-related hospitalizations but no statistically significant effect of IDOCC. Relative to patients in the control condition, patients in the intervention condition were estimated to have 4 % lower odds of CVD-related hospitalizations (adjOR = 0.96, 99 % CI 0.83 to 1.11). The nonsignificant result persisted across robustness analyses. Conclusions Clinical outcomes from administrative databases were examined to form a more complete picture of the (in)effectiveness of a large-scale quality improvement intervention. IDOCC did not have a significant effect on CVD hospitalizations, suggesting that the results from the primary composite adherence score analysis were neither due to choice of outcome nor relatively short follow-up period. Trial registration ClinicalTrials.gov NCT00574808 , registered on 14 December 2007.

OBJECTIVE To assess the effect of a specialist telemedicine intervention for improving diabetes care using the chronic care model (CCM). PARTICIPANTS AND METHODS As part of the CCM, 97 primary care physicians at 6 primary care practices in Rochester, MN, referred 639 patients to an on-site diabetes educator between July 1, 2001, and December 31, 2003. On first referral, physicians were centrally randomized to receive a telemedicine intervention (specialty advice and evidence-based messages regarding medication management for cardiovascular risk) or no intervention, keeping outcome assessors and data analysts blinded to group assignment. After each subsequent clinical encounter, endocrinologists reviewed an abstract from the patient's electronic medical record and provided management recommendations and supporting evidence to intervention physicians via e-mail. Control physicians received e-mail with periodic generic information about cardiovascular risk reduction in diabetes. Outcome measures included diabetes care processes (diabetes test completion), outcomes (metabolic and cardiovascular risk factors, estimated coronary artery disease risk), and patient costs (payer perspective). RESULTS During the intervention, 951 (70%) of the 1361 endocrinology reviews detected performance gaps and resulted in a message; primary care physicians reported using 49% of messages in patient care. With a mean of 21 months' follow-up, the intervention, compared with control, did not significantly enhance metabolic outcomes or reduce estimated risk of coronary artery disease (adjusted mean difference, -1%; 95% confidence interval, -19% to 17%). The intervention group incurred lower costs ( P =.02) but not in diabetes-related costs. CONCLUSION Specialty telemedicine did not significantly enhance the value of CCM in primary care. Trial Registration: clinicaltrials.gov identifier: NCT00421850

ABSTRACT BACKGROUND/OBJECTIVES The impact of co-morbid illnesses on adherence to guideline recommendations in chronic illness is of growing concern. We tested a framework [Piette and Kerr, Diabetes Care. 29(3):725–31, 2006 ] of provider adherence to guidelines in the presence of co-morbid conditions, which suggests that the effect of co-morbid conditions depends on treatment recommendations for the co-morbid conditions and how symptomatic they are. METHODS We conducted an exploratory analysis to assess the framework using chart audit data for 1,240 post-acute myocardial infarction (AMI) Medicare beneficiaries in Alabama. We assessed level of guideline-adherent post-AMI care from chart-based quality indicators and constructed scores reflecting how much care for the co-morbid condition was similar to post-AMI care (concordance) and how symptomatic the co-morbid condition is, based on expert opinion. RESULTS Patients had a mean age of 74 years, mean co-morbidities of 2, and 61% were white. Both concordance and symptomatic scores were positively associated with guideline compliance, with correlations of 0.32 and 0.14, respectively (p < 0.001 for each). We found positive correlations between highly concordant co-morbid conditions and post-AMI quality scores and negative correlations between highly symptomatic conditions and post-AMI quality scores; both findings support the framework. However, the framework performed less well for conditions that were not highly concordant or highly symptomatic, and the magnitudes of the associations were not large. CONCLUSIONS The framework was related to the association of co-morbid conditions with adherence by providers to guideline-recommended treatment for post-AMI patients. The framework holds promise for evaluating and possibly predicting guideline adherence.

A randomized, blinded, multicenter, controlled study was undertaken to assess the impact of a multiyear continuing medical education (CME) initiative on physician knowledge and behavior in the treatment of erectile dysfunction (ED). The objective of this study was to assess the efficacy of CME and compare applied knowledge and attitude scores of participants in the Consortium for Improvement in Erectile Function (CIEF), to non-CIEF participants. Subjects were selected randomly and contacted anonymously, by mail, email and fax and requested to enroll in this study. A blinded, validated questionnaire and series of standardized patient (SP) case studies and attitude questions were given to CIEF participants, defined as those who showed an interest in learning more about ED and who took at least one CME-certified program on ED from the CIEF website and non-CIEF participants, defined as those who showed interest in learning more about ED and who took at least one CME-certified program on ED from any organization other than CIEF. The primary outcome was a comparison of subjects' scores who participated in at least one CIEF program to non-participants in CIEF programs. Subjects were also compared based on SP case scores, attitude scores, specialty, years in practice, age and gender. Answers were ranked from best to worst and assigned a corresponding value of 10…3, 2, 1 and 0 (10 being the best), assuming that there may be more than one correct answer to each question in clinical practice. SAS version 9.1 analysis of variance model was used by an independent consultant. A total of 120 physicians completed the questionnaire: 87 urologists (UROs) and 33 primary care physicians (PCPs). UROs scored higher on SP cases compared with PCPs ( P =0.0039); however, as a result of participating in CIEF programs, PCPs trended toward more comparable scores to UROs; P =0.23 for SP case 2 that was clinically less complex and P =0.19 for SP case 3 that was more complex. In the other two cases, the gap was reduced; however, UROs scored better than PCPs. PCPs in CIEF ( n =23) had significantly higher SP case scores compared with non-CIEF PCPs ( n =10); 216.6 vs 191.0, respectively ( P =0.0437). PCPs in CIEF also showed a significantly greater level in mean attitude scores compared with UROs, 10.82 vs 8.15, respectively ( P <0.0001). Both PCPs and UROs scored higher after participating in CIEF ED educational programs than those clinicians who participated in non-CIEF ED educational programs. In addition, clinicians participating in more CIEF programs scored higher than those participating in fewer CIEF programs. As expected, UROs consistently scored better than PCPs, indicating a higher baseline level of knowledge base about ED. However, this educational gap was significantly reduced in PCPs who participated in CIEF programs. The study demonstrated that PCPs who took more CIEF courses were almost as knowledgeable as UROs on the subject of ED. Longitudinal, disease-specific CME initiatives are valuable in that they positively impact the knowledge and thus the behavior of participating physicians, potentially conferring clinical benefits toward patient outcomes.

Childhood and adolescent immunizations compose a valuable public health tool to prevent infection, morbidity, and mortality. The American Academy of Family Physicians recommends that patients receive all recommended immunizations from their usual source of primary care and does not support nonmedical immunization exemptions. Maintaining high vaccination coverage is crucial for preventing outbreaks of vaccine-preventable diseases. Less than 70% of US children have received the full series of recommended vaccinations at 24 months of age. Using electronic health record reminders and creating standing orders to vaccinate according to protocol at every visit can address practice barriers to vaccination. Whereas most routine childhood immunizations have remained the same for the past 10 years, several considerable changes have occurred. With few exceptions, COVID-19 immunizations are recommended annually for all children to prevent disease and hospitalization and to decrease the risk of post–COVID-19 condition. New pneumococcal vaccine formulations that protect against more serotypes are recommended. Pneumococcal vaccination decreases the risk of meningitis, pneumonia, and possibly acute otitis media in children. Either respiratory syncytial virus immunization for the mother between 32 and 36 weeks of gestation from September to January or the monoclonal antibody nirsevimab for the infant from October to March are now recommended for all mother-infant dyads to prevent severe illness.

Digitalization and the increasing availability of online information have changed the way in which information is searched for and retrieved by the public and by health professionals. The technical developments in the last two decades have transformed the methods of information retrieval. Although systematic evidence exists on the general information needs of specialists, and in particular, family physicians (FPs), there have been no recent systematic reviews to specifically address the needs of FPs and any barriers that may exist to accessing online health information. This review aims to provide an up-to-date perspective on the needs of FPs in searching, retrieving, and using online information. This systematic review of qualitative and quantitative studies searched a multitude of databases spanning the years 2000 to 2020 (search date January 2020). Studies that analyzed the online information needs of FPs, any barriers to the accessibility of information, and their information-seeking behaviors were included. Two researchers independently scrutinized titles and abstracts, analyzing full-text papers for their eligibility, the studies therein, and the data obtained from them. The initial search yielded 4541 studies for initial title and abstract screening. Of the 144 studies that were found to be eligible for full-text screening, 41 were finally included. A total of 20 themes were developed and summarized into 5 main categories: individual needs of FPs before the search; access needs, including factors that would facilitate or hinder information retrieval; quality needs of the information to hand; utilization needs of the information available; and implication needs for everyday practice. This review suggests that searching, accessing, and using online information, as well as any pre-existing needs, barriers, or demands, should not be perceived as separate entities but rather be regarded as a sequential process. Apart from accessing information and evaluating its quality, FPs expressed concerns regarding the applicability of this information to their everyday practice and its subsequent relevance to patient care. Future online information resources should cater to the needs of the primary care setting and seek to address the way in which such resources may be adapted to these specific requirements.

OBJECTIVE:  To investigate the effects of exclusively physical presentation of depression on 1) depression management and outcomes under usual care conditions, and 2) the impact of an intervention to improve management and outcomes. DESIGN AND SETTING:  Secondary analysis of a depression intervention trial in 12 community‐based primary care practices. PARTICIPANTS:  Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS:  Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS:  Sixty‐six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physical presenters to complete an adequate trial of antidepressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physical symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P = .06), receipt of any antidepressant (63.0% vs 20.1%; P = .001), and an adequate antidepressant trial (34.9% vs 5.9%; P = .004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P = .01) and an adequate antidepressant trial (46.0% vs 23.8%; P = .004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS:  Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Objectives: To describe the current state of knowledge about detection and treatment of major depressive disorder (MDD) by family physicians (FPs), and to identify gaps in practice and current and future challenges. Methods: We reviewed the recent literature on MDD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, or International Classification of Diseases, Revision 10) in primary care, with an emphasis on systematic reviews and meta-analyses addressing prevalence, the impact of an aging population and of chronic disease on MDD rates in primary care, detection and treatment rates by FPs, adequacy of treatment, and interventions that could improve recognition and treatment. Results: About 10% of primary care patients are likely to meet criteria for MDD. The number of cases will increase as the baby boomer cohort ages and as the prevalence of chronic disease increases. The bidirectional relation between MDD and chronic disease is now firmly established. Detection and treatment rates in primary care remain low. Treatment quality is frequently inadequate in terms of follow-up and monitoring. Formal case management and collaborative care interventions are likely to provide some benefits. Conclusions: Low detection rates and low treatment rates need to be addressed. Planned reassessment may improve detection rates when the FP is uncertain whether MDD is present, but further research is needed to determine why FPs frequently do not initiate treatment, even when MDD is detected. A caring, attentive FP who monitors depressed patients is likely to have considerable placebo effect. Greater focus on integrated, concurrent treatment for MDD and chronic physical diseases in the middle-aged and elderly is also required.

Like many other family doctors from Hong Kong, we reminisce on the latest outbreak. Since that 2003 fatal outbreak, the role of family doctors in risk reduction and preparedness to medical emergency has gained recognition both locally and globally. Successive generations of family doctors continue to provide care and treatment. Family doctors empower the systems through training and new modes of practice In order to gain the trust of the public and other professionals, family doctors must demonstrate competency through continuous training and professional development.