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<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Antimicrobial resistance (AMR) is a global health warning that increases mortality, morbidity, and medical expenses. Effective AMR surveillance is essential to guide interventions and maintain treatment efficacy. While AMR surveillance is studied in various healthcare settings, data sources in primary care settings need to be evaluated.<div class="boxTitle">Aim</div>To identify the value of utilizing AMR surveillance data in primary care settings to inform community antimicrobial stewardship (AMS) practices.<div class="boxTitle">Methods</div>Eligibility criteria included primary studies, randomized and nonrandomised controlled trials, observational studies, surveys, qualitative studies, mixed-method studies, and grey literature in primary care published worldwide from 2001 to 2024.<div class="boxTitle">Results</div>Our review of 21 included studies emphasized the significance of utilizing AMR surveillance data to enhance clinical care. Clinicians need to better understand the local AMR pattern when prescribing primary care antibiotics. Despite limitations, educational interventions can change prescribing behaviour. AMR increased because local susceptibility data frequently did not inform empirical antibiotic treatment. Digital and geospatial platforms could enhance surveillance with institutional support and standardized data integration.<div class="boxTitle">Conclusion</div>This analysis highlights the need for user-friendly, real-time, and easily accessible data visualization platforms to improve AMR surveillance and AMS in primary care. Addressing data accessibility and providing training and education are crucial elements. Standardising data and utilizing digital technologies can improve decision-making and antibiotic prescribing. These elements must be incorporated into a consistent and adaptive plan for effective AMS interventions and public health outcomes.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Long working hours constitute a significant public health risk. They may induce psychological stress or lead to behavioral changes, which, in turn, can contribute to the development of cardiovascular diseases and metabolic disorders. This study investigated the association of working hours with visceral adiposity index, anthropometric indices, and weight management behaviors.<div class="boxTitle">Methods</div>In total, 32 373 adult workers were included in this cross-sectional study. Chinese Visceral Adiposity Index (CVAI), body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), and body roundness index (BRI) were assessed. Weight management behaviors over the past year, including exercise, diet control, and medication use, were self-reported. Linear or logistic regression analyses were performed. Regression models were adjusted for sex, age, education level, income level, marital status, occupation type, and survey year.<div class="boxTitle">Results</div>Among the sample, 19.4% of adults worked for ≥ 55 h per week. Compared to working 35–40 h per week, working ≥ 55 h per week was associated with higher values of 2.57 (95% confidence interval [CI:] 0.95, 4.19) in CVAI, 0.29 (95% CI: 0.14, 0.43) in BMI, 0.67 (95% CI: 0.29, 1.06) in WC, 0.47 (95% CI: 0.24, 0.69) in WHtR, and 0.09 (95% CI: 0.05, 0.14) in BRI, respectively. Working ≥ 55 h per week, in comparison with working 35–40 h per week, was linked to reduced odds of engaging in exercise for weight management (odds ratio: 0.76; 95% CI: 0.70, 0.83).<div class="boxTitle">Conclusions</div>Working hours are positively associated with CVAI, anthropometric indices, and a lower intention to engage in exercise for weight management.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Type 2 diabetes and obesity are lifelong conditions that require extensive lifestyle modifications. During the corona virus disease 19 (COVID-19) pandemic, in-person medical care was risky. Many patients suffered from isolation and loneliness. One remedy which would address both the need for obesity and diabetes-related self-management and social isolation is peer support groups. There is considerable evidence for the effectiveness of peer-led programs in weight management and in diabetes self-management. No prior study has evaluated the impact of a virtual peer support group for diabetes.<div class="boxTitle">Objectives</div>To determine the feasibility and acceptability of a virtual peer support group for patients with type 2 diabetes and obesity [body mass index (BMI) > 30 kg/m<sup>2</sup>].<div class="boxTitle">Methods</div>Patients at an urban, Midwestern healthcare system enrolled in an 18-month remote (Zoom) (November 2021–May 2023) peer support group. Weekly meetings featured peer discussions on topics related to diabetes self-management. Semi-structured interviews post-intervention underwent independent thematic analysis by two coders until a set of common themes emerged.<div class="boxTitle">Results</div>All participants expressed satisfaction and enjoyment with the study. The opportunity to connect with peers, increase awareness of the importance of diabetes management behaviors, and learn new skills were cited as meaningful. Many participants lived alone, making the social support offered by the group especially valuable.<div class="boxTitle">Conclusions</div>A long-term stand-alone virtual diabetes peer support group filled an important social and emotional need among its members, especially among those who were most isolated. To achieve long-term behavioral change and healthier outcomes, the support group may need to be paired with individual counseling.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>The war in Ukraine has led to an influx of Ukrainian refugees across Europe. Internationally, there is limited research into refugees’ experiences of accessing Primary Care. Furthermore, few studies have explored the experience of one homogenous refugee group. No study has explored the specific experience of Ukrainian refugees. To improve the care provided to this marginalized group it is important to understand the challenges they experience. The aim of this research is to identify the barriers Ukrainian refugees experience when accessing General Practice in Ireland.<div class="boxTitle">Methods</div>A 63-item questionnaire was distributed via Ukraine Action Ireland, a registered charitable organization, to Ukrainian refugees in Ireland. Qualitive comments were collected through free-text responses and were analysed using thematic analysis.<div class="boxTitle">Results</div>A total of 368 questionnaires were completed. About 75.4% of respondents reported that they were not asked about their mental health during consultations with their GP. About 25% of respondents could not attend GP due to transport difficulties. About 55% of respondents reported that a translator was needed but only one-third of respondents reported that one was offered. Self-reported health was relatively poor when compared with refugees in other countries and with Irish citizens. Three themes were developed; disparity in patient autonomy, perceived disregard for the refugee experience, and challenges in health care access.<div class="boxTitle">Conclusion</div>At a time of significant capacity challenges in General Practice it is paramount that resources are provided at a national level to address the challenges Ukrainian refuges currently experience.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background/objective</div>the determination of the carotid total plaque area (TPA) is an indicator of subclinical atherosclerosis and a useful tool in early cardiovascular prevention. Classically, diabetes has been considered the most atherogenic disease, even more so than hypertension, but the incidence of stroke and heart attack is higher in patients with hypertension than in patients with diabetes alone. Therefore, in this study, we compared hypertension and diabetes with regard to the burden of atherosclerosis.<div class="boxTitle">Methods</div>a cross-sectional observational study was carried out on adults (<span style="font-style:italic;">n</span> = 606). Those with a history of a cardiovascular event were excluded.<div class="boxTitle">Results</div>median age was 65 years (IQR 17), 58.6% women. People with diabetes and hypertension had the highest TPA (β exponent: 1.64; 95% CI 1.20–2.26), followed by people with hypertension alone (β exponent: 1.39; 95% CI 1.05–1.86), while people with diabetes alone had no differences (<span style="font-style:italic;">P</span> = .379) with respect to the control group.<div class="boxTitle">Conclusion</div>This cross-sectional study, though limited, emphasizes the need for larger prospective studies to validate the clinical significance of these findings and highlights the importance of routine monitoring of subclinical atherosclerosis in hypertensive patients to assess the effectiveness of preventive therapy.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Opioids are the primary contributor to overdose death in the USA and represent a major public health crisis despite the availability of highly effective evidence-based treatments. A co-occurring mental health disorder further complicates efforts to utilize effective treatments and leads to poorer outcomes. Collaborative care has shown promise in improving care for those with substance use disorders and those with mental health disorders. This study explores the experiences of providers participating in a randomized controlled trial of collaborative care for <span style="font-style:italic;">both</span> opioid use disorder (OUD) and co-occurring depression and/or posttraumatic stress disorder (COD).<div class="boxTitle">Methods</div>Semi-structured interviews were conducted with healthcare providers of collaborative care as part of a randomized controlled trial at two health systems. Interviewed participants included primary care providers, care coordinators, behavioral health providers, clinic administrators, and psychiatric consultants. Data was analyzed with content analysis to identify common themes and subthemes among experiences.<div class="boxTitle">Findings</div>Participants perceived differences between patients diagnosed with only OUD and those with COD, such as heightened stigma, greater symptom severity, and more barriers to treatment. They perceived the positive impacts of the collaborative care intervention for patients with COD and the clinics and providers caring for this population, and identified considerations for future implementation efforts.<div class="boxTitle">Conclusions</div>Although participants noted challenges in treating patients with COD compared to those with only OUD, they also perceived the benefits of using collaborative care in this complex population. Participants supported using collaborative care in the future, but noted important systems and policy suggestions needed for successful implementation.</span>
<span class="paragraphSection">Dear Editor, we wish to comment on the publication of “Case control study of access to medications during coronavirus disease 2019 (COVID-19) and longitudinal impact on health outcomes for primary care patients managing multiple chronic conditions [<a href="#CIT0001" class="reflinks">1</a>].” This study highlights risk factors and health consequences during the COVID-19. It also examines socioeconomic characteristics including income, housing, and food insecurity, adding to our understanding of health care access disparities. One weakness is the lack of specificity in defining and assessing “difficulty accessing medicines.”</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>In many high-income countries, nurses, including registered nurses (RNs), play a key role in primary care (PC), particularly in general practice. Their involvement enhances patients’ experiences, especially in terms of accessibility and comprehensiveness of care provided. To reinforce the provision of care and enhance patients’ experience in family medicine, RNs were integrated into eight private general practices in the canton of Vaud, Switzerland, creating interprofessional teams. This study assessed patients’ experiences with new nursing activities in general practices.<div class="boxTitle">Methods</div>A mixed-methods approach was used to assess patients’ experiences. Quantitative data were collected through a patient experience survey conducted before and after nursing follow-up, with descriptive and bivariate analyses performed. Qualitative data were obtained from interviews with ten patients.<div class="boxTitle">Results</div>A total of 109 patients completed the questionnaire before and after nursing follow-up. Descriptive analyses showed that several dimensions of patients’ experience improved with new nursing follow-up. Bivariate analyses revealed significant improvements in several areas, including unmet healthcare needs, accessibility to nursing care, preventive care, and information provided. Furthermore, patients reported positive changes in their health and lifestyle due to preventive care. Qualitative data supported these results, highlighting the importance of nurses’ accessibility and availability and the holistic nursing care provided.<div class="boxTitle">Conclusion</div>These findings highlight the potential of nurse-led case management to address gaps in PC delivery, particularly in managing chronic diseases. The integration of nurses into general practice settings improved the provision of preventive care, enhanced patient education, and increased accessibility to care.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Inappropriate antibiotic prescription for self-limiting respiratory tract infections (RTIs) by general practitioner (GP) registrars (trainees) is less common than by established GPs but still exceeds evidence-based benchmarks. A 2014 face-to-face educational intervention for registrars and supervisors reduced registrars’ acute bronchitis antibiotic prescription by 16% (absolute reduction). We aimed to establish the efficacy of an updated registrar/supervisor RTI-management intervention (delivered at distance) on antibiotic prescribing.<div class="boxTitle"> Methods</div>A non-randomized trial using a non-equivalent control-group nested within the ReCEnT cohort study. The intervention included online educational modules, registrar and supervisor webinars, and materials for registrar-supervisor in-practice educational sessions, and focussed on acute bronchitis as an exemplar RTI. The theoretical underpinning was the ‘capability, opportunity, and motivation’ (COM-B) framework. The intervention was delivered to registrars and supervisors of one large educational/training organization annually from mid-2021, with pre-intervention period from 2017, and with postintervention period ending 2023. Two other educational/training organizations served as controls. The primary outcome was antibiotics prescribed for acute bronchitis. Analyses used multivariable logistic regression with predictors of interest: time (before/after intervention), treatment group, and an interaction term for time-by-treatment group, adjusted for potential confounders. The interaction term <span style="font-style:italic;">P</span>-value was used to infer statistical significance of the intervention effect.<div class="boxTitle"> Results</div>Of 4612 acute bronchitis presentations, 70% were prescribed antibiotics. There was a 6.9% absolute reduction (adjusted) of prescribing in the intervention-group compared with the control-group. This was not statistically significant (<span style="font-style:italic;">P</span><sub>interaction</sub> = .22).<div class="boxTitle"> Conclusions</div>Failure to find a significant effect on prescribing suggests difficulties with scalability of this (and similar educational) innovations.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Purpose</div>Japan has insufficient palliative care specialists, so there are calls for a palliative care consultation system to aid primary care physicians. Community-based palliative care may require clarification on the division of tasks and responsibilities. Primary care physicians’ needs specific to palliative care are also ambiguous. We therefore aimed to elucidate the consultation needs of primary care physicians particular to palliative care in Japan.<div class="boxTitle">Methods</div>This analysis of a nationwide observational study was conducted between December 2023 and January 2024. We sent questionnaires to 1,100 Japanese board-certified primary care physicians based on the Palliative Care Difficulties Scale (range: 1–4). Comparisons were made by unpaired Student’s <span style="font-style:italic;">t</span> test and with a multivariate linear regression model according to workplace type (clinics and hospitals).<div class="boxTitle">Results</div>We obtained 548 replies (response rate: 50%), of which 540 had analyzable data. Primary care physicians in clinics required less consultation than those in hospitals on the choice of medication (<span style="font-style:italic;">P</span> = .019), opioids switching (<span style="font-style:italic;">P</span> = .018), prognosis estimates (<span style="font-style:italic;">P</span> < .001), decision support (<span style="font-style:italic;">P</span> = .016), and grief care (<span style="font-style:italic;">P</span> = .009). Those in clinics were less likely to have palliative care support from non-physician palliative care specialists (<span style="font-style:italic;">P</span> < .001) and information support (<span style="font-style:italic;">P</span> = .003). In multivariable analysis, being a clinic-based physician was inversely associated with the functioning of a decision-making support counseling system (<span style="font-style:italic;">R</span><sup>2</sup> = 0.527).<div class="boxTitle">Conclusions</div>The specific consultation needs of primary care physicians in Japan specific to palliative care differ by workplace. Our data suggest the need for clear national-level supporting guidelines and training toward primary care physicians’ involvement in palliative care and individualized end-of-life management.UMIN trial ID: UMIN000054985</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Cancer is a major global cause of death, and primary care is crucial for cancer prevention and early detection. However, there is conflicting information on the effectiveness, implementation, and sustainability of cancer control interventions in primary care.<div class="boxTitle">Objective</div>This study aimed to summarize the evidence for cancer control in primary care, focussing on identifying relevant factors for implementation and sustainability.<div class="boxTitle">Study setting and design</div>We conducted a narrative, mixed-methods review of systematic reviews, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Four databases were screened, and two independent reviewers selected studies reporting on cancer prevention, screening, or early detection in primary or community settings. We analysed findings using the extended Reach-Effectiveness-Adopt-Implementation-Maintenance (RE-AIM) Framework.<div class="boxTitle">Principal findings</div>From the 37 reviews that met the inclusion criteria, 6 focussed on primary prevention, 23 on screening, and 12 on early detection. Most reviews (78%) addressed intervention effectiveness, such as HPV vaccination, tobacco cessation, and cervical, breast, and colorectal screening. One-third of the reviews mentioned adoption and implementation factors, including barriers and facilitators to the implementation of cancer screening programs. Only one review addressed maintenance and sustainability factors, exploring continuous resources and funding strategies.<div class="boxTitle">Conclusion</div>While numerous interventions are effective for cancer prevention and detection in primary care, literature on implementation and sustainability strategies is lacking. Focusing on continuous resources and funding for cancer strategies in primary care may aid sustainability. Future research should prioritize reporting on implementation and sustainability factors to enhance cancer prevention and control in primary care settings.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>The quality of the doctor–patient relationship plays a crucial role in patients’ experiences with healthcare services, positively influencing clinical outcomes and satisfaction with care. The Patient–Doctor Relationship Questionnaire (PDRQ-9) is widely used to assess this relationship. However, there are no quality categories that can be derived from the instrument’s score to facilitate understanding and decision-making.<div class="boxTitle">Objectives</div>This study aims to establish categories of the quality of the relationship based on the PDRQ-9 score.<div class="boxTitle">Methods</div>A latent class analysis (LCA) was conducted using interviews with 6160 users of primary health care units throughout Brazil to define different homogeneous response profiles. The Youden index was used to determine the cut point between classes.<div class="boxTitle">Results</div>LCA identified the presence of two response profiles, one associated with a high evaluation of the quality of the doctor–patient relationship and another associated with a moderate evaluation. The cut point between classes, established through the Youden index, was 3.5 (on a possible score range of 1–5) or 31 (on a possible score range of 9–45). The cut point demonstrated high accuracy (0.94), sensitivity (0.96), and specificity (0.98).<div class="boxTitle">Conclusions</div>The categorization proposed in this study enhances the interpretability of PDRQ-9 results, providing a practical framework for assessing the quality of the doctor–patient relationship. By establishing actionable quality categories, this tool could support targeted interventions, such as performance feedback and training, aimed at fostering empathy, communication, and trust in healthcare settings.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Cannabinoid hyperemesis syndrome (CHS) is an increasingly recognized condition linked to chronic cannabis use, yet it remains frequently overlooked in clinical practice. The syndrome is characterized by cyclic episodes of severe nausea, vomiting, and abdominal pain, often relieved temporarily by hot showers or baths. With the rising prevalence of cannabis use following its legalization, the incidence of CHS has surged, presenting a significant challenge in both diagnosis and management within primary healthcare settings. Understanding the epidemiology, risk factors, and potential long-term sequelae of CHS is crucial for timely identification and intervention. This case report highlights the challenge of diagnosis and management of CHS in primary healthcare.<div class="boxTitle">Objective(s)</div>To emphasize the importance of proper counseling and the use of Rome IV criteria in diagnosing CHS. To illustrate how this may reduce patient suffering and unnecessary investigation.<div class="boxTitle">Case</div>A 22-year-old female with chronic, daily cannabis use presented with recurrent episodes of intense nausea, vomiting, and abdominal pain over a 2-year period. Extensive diagnostic evaluations were inconclusive. A tentative diagnosis of CHS was made by a medical student and family doctor based on published criteria. The Rome IV criteria were then applied for confirmation of diagnosis and management. In so doing, the patient was advised to cease cannabis use for a minimum of 3 months. Initially, symptom improvement was reported with cannabis cessation. However, symptoms recurred following a relapse in cannabis use.<div class="boxTitle">Conclusion</div>To confirm the diagnosis of CHS, counseling should specify the need for a minimum of 3 months of cannabis cessation to achieve symptom relief. Increased physician and patient awareness of this minimal time period for drug cessation can help to avoid unnecessary investigations, and prolonged patient suffering. This case emphasizes the need for vigilance in recognizing CHS and consideration of cannabis as a potential cause of cyclic vomiting.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>When research and management of Dupuytren’s disease (DD) shift from symptom relief to preventing contractures, general practitioner (GP) care may become more central to treatment. However, the presentation and course of DD in GP care are underexplored and this has been recognized as a knowledge gap that hinders effective treatment decisions. This study is the first to map the trajectory of DD patients in GP care.<div class="boxTitle">Methods</div>Using electronic health records from Dutch general practices in a regional research network, we conducted a registration-based cohort study in a dynamic population. Descriptive statistics detailed patient demographics, number of contacts, and symptoms per contact. The time and number of contacts before diagnosis were also analysed. Sankey diagrams illustrated the relationship between management options and symptoms.<div class="boxTitle">Results</div>Over a 16-year period, 84% of patients with a DD diagnosis had visited their GP for this reason, with 73% only having one GP contact. The diagnosis was made at first contact for 93% of patients. Initial contacts often reported a lump (57.3%), but this symptom was less frequent in subsequent visits. ‘Daily life impairment’ increased after the first contact. The most common management options were referral to secondary care (37.7%) and watchful waiting (35.1%).<div class="boxTitle">Conclusion</div>The diagnosis and management of DD in GP care are in line with the current guidelines. Less than half of the DD patients were referred to secondary care during follow-up. This may give room for preventive treatment that limits progression. Future studies should focus on the accuracy of diagnosis and the feasibility of effective treatments in GP care.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>The University of New Mexico School of Medicine established the combined baccalaureate/medical degree (BA/MD) program in response to critical physician shortages in New Mexico (NM). This 8-year program aims to improve health care in NM by expanding access to medical education for local students, particularly from rural and underserved communities and/or racial/ethnically underrepresented in medicine (URiM) in NM.<div class="boxTitle">Objectives</div>To describe the BA/MD program’s initial design, the impact of improvements on retention, and the outcomes in terms of physicians in practice, particularly in primary care specialties.<div class="boxTitle">Methods</div>The study reviews the BA/MD program’s progress from 2006 to 2023, focusing on curriculum and support enhancements. Retention rates and choice of primary care specialties were analyzed by geographic origin and racial/ethnic background.<div class="boxTitle">Results</div>From 2006 to 2023, the program graduated 81 physicians, with 53 practicing in 10 of NM’s 33 counties. Approximately two-thirds specialize in primary care, and a similar proportion are URiM. Students from 31 of NM’s 33 counties were admitted, with two-thirds coming from outside the state’s metropolitan area. Overall retention and retention across demographic groups improved significantly in the baccalaureate phase of the program due to changes in curriculum and support services.<div class="boxTitle">Conclusions</div>The program has effectively addressed physician shortages in NM, particularly in rural and underserved areas. Its success in training and retaining physicians from diverse backgrounds, with a focus on primary care, is crucial for improving health care access in the state. Ongoing improvements in the program are essential to sustaining and enhancing these outcomes.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Guidelines recommend follow-up within 2 weeks for patients starting medication for depression. Knowledge is lacking about how general practitioners’ (GPs) follow-up varies with patients’ sociodemographic characteristics.<div class="boxTitle">Objective</div>To describe follow-up by GP and specialist in mental healthcare provided to men and women with depression within 3 months of starting drug therapy. Furthermore, to examine whether follow-up varied according to patients’ age and education.<div class="boxTitle">Methods</div>Registry-based cohort study comprising all patients aged ≥18 years in Norway with a new depression episode in 2014 who started on antidepressants within 12 months from diagnosis. Patients’ age and educational level were the exposures. Outcomes were follow-up by GP and/or mental healthcare specialist, and talking therapy with GP, within 90 days of first prescription. Cox proportional hazard models were used to estimate the likelihood of having follow-up contacts. Log binomial regression analysis was performed to explore the likelihood of having talking therapy with a GP. Time to first contact was illustrated by Kaplan–Meier survival curves.<div class="boxTitle">Results</div>The study population comprised 17 000 patients, mean age 45.7 years, 60.6% women. Only 27.8% of the patients were followed up by GP and/or specialist within 2 weeks of the first drug dispensing, 67.1% within 90 days. Older or less educated men and women received less and later contacts than the younger or more highly educated.<div class="boxTitle">Conclusions</div>Differences in age and educational level were associated with follow-up of depressed patients who started medication. This may indicate unwarranted variation in depression care that GPs should consider when prescribing antidepressants.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Introduction</div>The evolving landscape of general practice (GP)/family medicine (FM) in the post-COVID-19 era, focussing on integrating telemedicine and remote consultations requires a new definition for this specialty. Hence, a broader consensus-based definition of post-COVID-19 GP/FM is warranted.<div class="boxTitle">Methods</div>This study involved a modified electronic Delphi technique involving 27 specialists working in primary care recruited via convenient and snowball sampling. The Delphi survey was conducted online between August 2022 and April 2023, utilizing the Google Forms platform. Descriptive statistics were employed to analyse consensus across Delphi rounds.<div class="boxTitle">Results</div>Twenty-six international experts participated in the survey. The retention rate through the second and third Delphi rounds was 96.2% (<span style="font-style:italic;">n</span> = 25). The broader consensus definition emphasizes person-centred care, collaborative patient-physician partnerships, and a holistic approach to health, including managing acute and chronic conditions through in-person or remote access based on patient preferences, medical needs, and local health system organization.<div class="boxTitle">Conclusion</div>The study highlights the importance of continuity of care, prevention, and coordination with other healthcare professionals as core values of primary care. It also reflects the role of GP/FM in addressing new challenges post-pandemic, such as healthcare delivery beyond standard face-to-face care (e.g. remote consultations) and an increasingly important role in the prevention of infectious diseases. This underscores the need for ongoing research and patient involvement to continually refine and improve primary healthcare delivery in response to changing healthcare landscapes.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Objectives</div>General practice plays a key role in end-of-life care, yet the extent of this remains largely unknown due to a lack of detailed clinical data. This study aims to describe the care provided by General Practitioners (GPs) for people with cancer in their last year of life.<div class="boxTitle">Methods</div>Retrospective cohort study using linked routine primary care and death certificate data in Victoria, Australia. Patients were included who died from cancer between 2008 and 2017.<div class="boxTitle">Results</div>In total 7025 cancer patients were included, mean age of 74.8 yrs. 95% of patients visited their GP in the last 6 months of life, with a median of 11 general practice contacts in this period. 72% of patients visited their GP in the second-last month prior to death, and 74% in the last month of life. The majority of patients (58%) were prescribed opioids, 19% anticipatory medications, 24% received a home visit, and a small proportion had imaging (6%) in the last month and pathology (6%) in the last fortnight. Patients in regional areas had more contact with general practices in the last year of life compared to metropolitan patients (median metropolitan = 16, inner regional = 25, and outer regional = 23, <span style="font-style:italic;">P</span> < .001). The use of GP services did not differ by cancer type.<div class="boxTitle">Conclusions</div>GP’s play a central role in end-of-life care provision for cancer patients, which intensifies in the last months of life. There is room for improvement, with a proportion having little or no engagement, and low rates of home visits and anticipatory medication prescribing.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>The primary cause of antimicrobial resistance is excessive and non-indicated antibiotic use.<div class="boxTitle">Aim</div>To evaluate the impact of a multifaceted intervention aimed at various healthcare professionals (HCPs) on antibiotic prescribing and dispensing for common infections.<div class="boxTitle">Design and setting</div>Before-and-after study set in general practice, out-of-hours services, nursing homes, and community pharmacies in France, Greece, Lithuania, Poland, and Spain.<div class="boxTitle">Methods</div>Following the Audit Project Odense method, HCPs from these four settings self-registered encounters with patients related to antibiotic prescribing and dispensing before and after an intervention (February–April 2022 and February–April 2023). Prior to the second registration, the HCPs undertook a multifaceted intervention, which included reviewing and discussing feedback on the first registration’s results, enhancing communication skills, and providing communication tools. Indicators to identify potentially unnecessary prescriptions and non-first-line antibiotic choices were developed, and the results of the two registrations were compared.<div class="boxTitle">Results</div>A total of 345 HCPs registered 10 744 infections in the first registration period and 10 207 infections in the second period. In general practice, participants showed a significant 9.8% reduction in unnecessary antibiotic prescriptions in the second period, whereas limited or no effect was observed in out-of-hours services and nursing homes (0.8% reduction and 4.5% increase, respectively). Pharmacies demonstrated an 18% increase in safety checks, and correct advice in pharmacies rose by 17%.<div class="boxTitle">Conclusion</div>External factors like COVID-19, antibiotic shortages, and a streptococcal epidemic impacted the intervention’s benefits. Despite this, the intervention successfully improved antibiotic use in both settings.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>This article aims to examine patient safety in general practice during COVID-19.<div class="boxTitle">Methods</div>In total, 5489 GP practices from 37 European countries and Israel filled in the online self-reported PRICOV-19 survey between November 2020 and December 2021. The outcome measures include 30 patient safety indicators on structure, process, and outcome.<div class="boxTitle">Results</div>The data showed that structural problems often impeded patient safety during COVID-19, as 58.6% of practices (3209/5479) reported limitations related to their building or infrastructure. Nevertheless, GP practices rapidly changed their processes, including the appointment systems. Implementation proved challenging as, although 76.1% of practices (3751/4932) developed a protocol to answer calls from potential COVID patients, only 34.4% (1252/3643) always used it. The proportion of practices reported having sufficient protected time in general practitioners’ schedules to review guidelines remained consistent when comparing the pre-COVID (34.2%,1647/4813) with the COVID period (33.2%,1600/4813). Overall, 42.8% of practices (1966/4590) always informed home care services when patients were diagnosed with COVID-19, while this decreased to 30.1% for other major infectious diseases (1341/4458). Most practices reported at least one incident of delayed care in patients with an urgent condition, most often because the patient did not come to the practice sooner (60.4%, 2561/4237). Moreover, 31.1% of practices (1349/4199) always organized a team discussion when incidents happened. Overall, large variations were found across countries and patient safety indicators.<div class="boxTitle">Conclusions</div>The results demonstrated that European GP practices adopted numerous measures to deliver safe care during COVID-19. However, multilayered interventions are needed to improve infection control and GP practice accessibility in future pandemics.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>There is a lack of evidence regarding the trajectories of type 2 diabetes until the first clinic visit, including the untreated period after diagnosis.<div class="boxTitle">Objective</div>We aimed to determine the real-world history of type 2 diabetes until the first clinic visit, including the untreated duration, and to assess the effective timing of the therapeutic intervention.<div class="boxTitle">Methods</div>A total of 23,622 nondiabetic Japanese workers with a mean (SD) age of 38.8 (11.5) years were retrospectively followed from 2008 to 2022 for annual health checkups. The trajectories of glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), and body mass index (BMI) until the first clinic visit in diabetes individuals were determined. ROC analysis was performed to assess the contribution of each measure to the first visit.<div class="boxTitle">Results</div>During a median follow-up of 12.0 years, 1,725 individuals developed type 2 diabetes, of whom 532 individuals visited clinics. HbA1c and FPG trajectories steeply rose in the year before the first clinic visit after their progressive upward trends. ROC analysis showed cutoff values for each measure. As the untreated duration increased, glycemia increased and BMI decreased among individuals who visited clinics.<div class="boxTitle">Conclusions</div>To prevent the initial worsening of diabetes, early therapeutic intervention is necessary during the increasing trends before the steep rise in glycemia, regardless of the degree of obesity. HbA1c ≥6.5% (47.5 mmol/mol) and an HbA1c ≥0.2% (2.2 mmol/mol)/year increase may be an effective timing for therapeutic intervention.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Promoting health via a community approach is one of the most effective strategies for reducing the current incidence of chronic diseases. Primary care (PC), through the implementation of community activities (CA), has the potential to achieve this goal. Yet the implementation of CA at health centers is not standardized and is often thanks only to the voluntariness of health professionals.<div class="boxTitle">Objective</div>To ascertain the knowledge, attitudes, and practices of PC professionals regarding the implementation of CA.<div class="boxTitle">Methods</div>We carried out a cross-sectional study by circulating a self-administered online questionnaire on CA, across the period December 2022 through June 2023 in Galicia (Spain). All health professionals working in the Galician Health Service PC setting were invited to participate.<div class="boxTitle">Results</div>A total of 521 health professionals participated in the study. They included all types of PC health professionals (physicians, general and specialist nurses -midwives, pediatrics, family and community, mental health- and social workers), including residents in training. Only 14.8% and 12.5% of professionals correctly identified CAs and social prescription (SPr) interventions, respectively. Furthermore, 93.9% recognized that the development of CA in health centers was deficient. Despite this, 76.5% showed a good attitude toward participation in CA.<div class="boxTitle">Conclusions</div>PC professionals find it difficult to identify CA and SPr interventions. Therefore, it is necessary to improve the training of these professionals in the implementation of CA with a view to enhancing population health, reducing the incidence of chronic diseases, and helping lessen the healthcare burden of the health system.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Collectively, rare diseases are common, affecting approximately 8% of the population in Canada and the USA. Therefore, the majority of primary care (PC) clinicians will care for patients who are affected or at risk for a genetic disease. Considering the increasing ways in which genetics is being implemented into all areas of healthcare, one way to address these needs and expand the capacity of the PC workforce is through the integration of genetic counselors (GCs) into PC multidisciplinary teams. GCs are Masters-educated allied health professionals with specialized training in molecular genetics, communication, and short-term psychotherapeutic counseling. The current models of GCs in PC mimic other multidisciplinary models. Complex tasks related to genetics, such as pre- and post-test counseling, genetic test selection, and results interpretation, are conducted by GCs, which, in turn, allows physicians, nurse practitioners, and other PC providers to work at the top of their scope of practice. Quality genetics services provided by GCs improve clinical outcomes for patients and their families; the simultaneous provision of genetic education and psychological support by a GC is associated with an increase in patient knowledge, perceived personal control, decrease in distress, and can lead to positive health behavior changes, all of which are aligned with the goals of primary healthcare. With their extensive training in clinical care, medical communication, and psychotherapeutic counseling, integrating GCs into PC care teams will improve the care patients receive and allow PC clinicians to ensure their patients are at the forefront of the personalized medicine revolution.</span>
<span class="paragraphSection">In the recent article ‘Temporal patterns of antibiotic prescribing for sore throat, otitis media, and sinusitis: a longitudinal study of general practitioner registrars’ by Turner <span style="font-style:italic;">et al</span>. [<a href="#CIT0001" class="reflinks">1</a>], the main message is the changing practice of Australian general practitioner (GP) registrars over a substantial period. Antimicrobial resistance continues to challenge public health [<a href="#CIT0002" class="reflinks">2</a>], and this study’s relevance is underscored by its findings on decreasing prescribing rates for respiratory conditions, although further interventions are needed.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Information and communication technologies (ICTs) can enable workers to structure work in novel ways, allow for better time management, and increase work scheduling autonomy. Time management and work scheduling are important factors in the field of clinical practice in primary care. Time limits on consultation are a key constraint on the delivery of good care since the length of patient–physician consultation impacts its quality.<div class="boxTitle">Objectives</div>This research aimed to examine the experiences of primary care physicians (PCPs) when using telemedicine technologies (TTs), a type of ICT, in their communication with patients.<div class="boxTitle">Methods</div>During 2023 in-depth interviews were conducted with 20 Israeli PCPs: family physicians and pediatricians.<div class="boxTitle">Findings</div>Perception and management of time emerged as a focal subject in the interviews. The PCPs interviewed described several effects of TTs on time management in primary care. They portrayed TTs as saving time for patients and having a mixed effect on the healthcare organization: both saving and wasting their work time. TTs were described as impacting their time management in the context of work-life balance, allowing them to manage their time during and between appointments.<div class="boxTitle">Discussion</div>For PCPs, TTs can be beneficial for managing time in the clinic, which can contribute to better healthcare. This article, concerning TTs as a type of ICT, contributes to the existing literature which suggests that ICTs can allow for better time management and increase work scheduling autonomy. It also presents several recommendations for better implementation of TTs in healthcare organizations.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Multiple studies have shown that physical activity improves cancer survivorship, by decreasing risk of second primary cancers and chronic conditions. However, cancer survivor physical activity levels remain low. General practice presents more opportunities for lifestyle interventions, such as increasing physical activity. We conducted a realist review of physical activity interventions relevant to general practice.<div class="boxTitle">Methods</div>A total of 9728 studies were obtained from a systematic search of the CINAHL, Embase, PsycINFO, PubMed, and SPORTDiscus databases from the inception of the electronic database to 21 June 2024. We focussed on intervention studies that improved physical activity among cancer survivors and were relevant to general practice. Data extraction focussed on: what makes physical activity interventions effective for cancer survivors <span style="font-style:italic;">(what works)</span> and what factors promote physical activity for cancer survivors <span style="font-style:italic;">(for whom it works).</span><div class="boxTitle">Results</div>Thirty-seven studies were used to generate themes on the components of physical activity interventions that are likely to work and for whom; these studies facilitated <span style="font-style:italic;">goal setting</span>, <span style="font-style:italic;">action planning</span>, <span style="font-style:italic;">self-monitoring</span>, <span style="font-style:italic;">social support,</span> and <span style="font-style:italic;">shaping of knowledge</span>; through delivering tailored motivational support, evoking a teachable moment, and promoting the use of self-monitoring tools. Interventions that were cost-effective and easily implementable improved sustainability, deployability, and uptake by cancer survivors. Cancer survivor psychological and physical factors, such as baseline motivational levels and post-treatment symptoms, influenced the uptake of physical activity interventions.<div class="boxTitle">Conclusion</div>Our realist review has highlighted opportunities for general practices to promote physical activity among cancer survivors through collaborative <span style="font-style:italic;">goal setting, action planning, self-monitoring, social support,</span> and <span style="font-style:italic;">shaping of knowledge.</span></span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Shoulder pain is common amongst adults, but little is known about patients’ preferences.<div class="boxTitle">Objective</div>The aim of this study was to determine patients’ preferences for treatment options offered for shoulder pain in primary care.<div class="boxTitle">Methods</div>A discrete choice experiment was used to investigate these preferences. Adults with shoulder pain were asked to make 12 choices between two treatment options, or to opt-out. The attributes of the 12 treatment options were presented as varying in: treatment effectiveness (50%, 70%, or 90%), risk of relapse (10%, 20%, or 30%), time to pain reduction (2 or 6 weeks), prevention of relapse (yes/no), requiring injection (yes/no), and including physiotherapy (none, 6, or 12 sessions). A conditional logit model with latent class analysis was used for the analysis and a class assignment model.<div class="boxTitle">Results</div>Three hundred and twelve participants completed the questionnaire with mean age of 52 ± 15.2 years. Latent class analysis revealed three groups. Group 1 preferred to opt-out, unless the attributes were highly favorable (90% effectiveness). Group 2 preferred treatment, but not an injection. Group 3 preferred to opt-out and did not opt for treatment. The likelihood of a participant belonging to one of these groups was 68.8%, 9.3%, and 21.9%, respectively. The class assignment was related to having previously received injection or physiotherapy, as they did not prefer that same treatment again.<div class="boxTitle">Conclusion</div>This study showed that most patients with shoulder pain prefer to opt-out, unless treatment attributes are highly favorable. Characteristics of influence on this decision was whether the patient had received an injection or physiotherapy before.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>Several articles have appeared in the medical literature on the use of ultrasound in primary care. Point-of-care ultrasound refers to ultrasound protocols performed at the bedside to evaluate many conditions such as aortic aneurysm or assessment of left ventricular function by estimation of ejection fraction. Primary care physicians can play a key role in evaluating such conditions for their patients. It should be considered that the use of ultrasound in general practice can not only be an aid to diagnosis but also an active screening tool, accessible even to those with basic training in ultrasound; the left ventricle and large abdominal vessels are indeed clearly visible with this technique, which with little training can become accessible to many. In a working organization, so few trained physicians would be sufficient to screen the target population of the entire group and extend the assessment to a large number of participants.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div>At the onset of the COVID-19 pandemic, the pressure on hospitals increased tremendously. To alleviate this pressure, a remote patient monitoring system called the COVID Box was developed and implemented in primary care. The aim was to assess whether the COVID Box in primary care could reduce emergency department (ED) referrals due to a COVID-19 infection. A matched cohort study was performed between December 2020 and June 2021. Patients with a COVID-19 infection in need of intensive monitoring based on the clinical judgement of their own general practitioner received the COVID Box in primary care combining home monitoring of vital parameters with daily video consultations. The control group was retrospectively matched by propensity score matching. We conducted a subgroup analysis in higher-risk patients with oxygen saturation measurements, considering oxygen saturation as a critical parameter for assessing the risk of a complicated infection. We included 205 patients, of whom 41 patients were monitored with the COVID Box (mean age 70 and 53.7% male) and 164 in the control group (mean age 71.5 and 53% male). No difference was found in ED referrals between the intervention and control groups in our primary analysis. In the subgroup analysis, we found a nonsignificant trend that remote monitoring could reduce the ED referrals. While the overall study found comparable ED referrals between groups, the subgroup analysis suggested a promising prospect in reducing ED referrals due to remote monitoring of higher-risk patients with acute respiratory disease in primary care.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Accreditation has been implemented in general practice in many countries as a tool for quality improvement. Evidence of the effects of accreditation is, however, lacking.<div class="boxTitle">Aim</div>To investigate the clinical effects of accreditation in general practice.<div class="boxTitle">Design and setting</div>A mandatory national accreditation programme in Danish general practice was rolled out from 2016 to 2018. General practices were randomized to year of accreditation at the municipality level.<div class="boxTitle">Methods</div>We conducted a pragmatic randomized controlled study with general practices randomized to accreditation in 2016 (intervention group) and 2018 (control group). Data on patients enlisted with these practices were collected at baseline in 2014 (before randomization) and at follow-up in 2017. We use linear and logistic regression models to compare differences in changes in outcomes from baseline to follow-up between the intervention and control groups. The primary outcome was the number of redeemed medications. Secondary outcomes were polypharmacy, nonsteroidal anti-inflammatory drugs (NSAIDs) without proton pump inhibitors, sleeping medicine, preventive home visits, annual controls, spirometry tests, and mortality.<div class="boxTitle">Results</div>We found statistically significant effects of accreditation on the primary outcome, the number of redeemed medications, and the secondary outcome, polypharmacy. No other effects were detected.<div class="boxTitle">Conclusion</div>In this first randomized study exploring the effects of accreditation in a primary care context, accreditation was found to reduce the number of redeemed medications and polypharmacy. We conclude that accreditation can be effective in changing behaviour, but the identified effects are small and limited to certain outcomes. Evaluations on the cost-effectiveness of accreditation are therefore warranted.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Healthcare globally is increasingly threatened by antibiotic resistance. Misunderstanding of the appropriate use of antibiotics is common within the general population, therefore patient education could be a useful tool to employ against antibiotic resistance. Patient satisfaction with healthcare is important, and antibiotic awareness is crucial to avoid disappointment when antibiotic stewardship is practiced.<div class="boxTitle">Aim</div>This review aims to identify whether patient education is an effective tool to improve knowledge and awareness of the appropriate use of antibiotics and whether it has an effect on expectations of or prescription rates of antibiotics.<div class="boxTitle">Method</div>Embase, Medline, Web of Science, PubMed, and Cochrane Library were searched to identify studies examining the impact of various forms of patient education on awareness of appropriate antibiotic use and antibiotic prescription rates. Reference lists of eligible studies were also screened.<div class="boxTitle">Results</div>Three hundred and fourteen unique studies were identified, of which 18 were eligible for inclusion. All studies were of good quality. Three studies examined public health campaigns, five examined leaflets, two examined posters, three examined videos, four used mixed interventions and one study examined a presentation. The results were too heterogenous to perform a meta-analysis.<div class="boxTitle">Conclusion</div>Patient education is an effective tool to increase public knowledge and awareness of the appropriate use of antibiotics, and can reduce the expectation of or prescription rates of antibiotics. The form of patient education matters, as interventions involving active learning and engagement demonstrate significant positive outcomes, whereas passive forms of learning do not appear to have any effect on understanding or prescriptions.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>A national policy in Norway demanding certificates for medical absences in upper secondary school was implemented in 2016, leading to an increase in general practitioner (GP) visits in this age group.<div class="boxTitle">Objectives</div>To assess the policy’s effect on the use of primary and specialist healthcare.<div class="boxTitle">Methods</div>A cohort study following all Norwegian youth aged 14–21 in the years 2010–2019 using a difference-in-differences approach comparing exposed cohorts expected to attend upper secondary school after the policy change in 2016 with previous unexposed cohorts. Data were collected from national registries.<div class="boxTitle">Results</div>The absence policy led to the increased number of contacts with GPs for exposed cohorts during all exposed years, with estimated incidence rate ratios (IRRs) in the range from 1.14 (95% confidence intervals [CI] 1.11–1.18) to 1.25 (95% CI 1.21–1.30). Consultations for respiratory tract infections increased during exposed years. However, there was no conclusive policy-related difference in mental health consultations with GPs. In specialist healthcare we did not find conclusive evidence of an effect of absence policy on the risk of any contact per school year, but there was a slightly increased risk of contacts with ear–nose–throat specialist services.<div class="boxTitle">Conclusions</div>We found an increase in general practice contacts attributable to the school absence policy. Apart from a possible increase in ear–nose–throat contacts, increased GP attention did not increase specialized healthcare.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Heart failure (HF) is the most frequent cardiovascular pathology in primary care. Echocardiography is the gold standard for diagnosis, follow-up, and prognosis of HF. Point-of-care ultrasound (POCUS) is of growing interest in daily practice.<div class="boxTitle">Aim</div>This study aimed to systematically review the literature to evaluate left ventricular ejection fraction (LVEF) assessment of unselected patients in primary care by non-expert physicians with cardiac POCUS (cPOCUS).<div class="boxTitle">Methods</div>We searched in Medline, Embase, and Pubmed up to January 2024 for interventional and non-interventional studies assessing LVEF with cPOCUS in unselected patients with suspected or diagnosed HF in hospital or outpatient settings, performed by non-expert physicians.<div class="boxTitle">Results</div>Forty-two studies were included, involving 6598 patients, of whom 60.2% were outpatients. LVEF was assessed by 351 non-expert physicians after an initial ultrasound training course. The LVEF was mainly assessed by visual estimation (90.2%). The most frequent views were parasternal long/short axis, and apical 4-chamber. The median time of cPOCUS was 8 minutes. A strong agreement was found (κ = 0.72 [0.63; 0.83]) compared to experts when using different types of ultrasound devices (hand-held and standard), and agreement was excellent (κ = 0.84 [0.71; 0.89]) with the same device. Training course combined a median of 4.5 hours for theory and 25 cPOCUS for practice.<div class="boxTitle">Conclusion</div>The use of cPOCUS by non-expert physicians after a short training course appears to be an accurate complementary tool for LVEF assessment in daily practice. Its diffusion in primary care could optimize patient management, without replacing specialist assessment.</span>
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