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Protocol for a pragmatic randomised controlled trial of Body Brain Life-General Practice and a Lifestyle Modification Programme to decrease dementia risk exposure in a primary care setting.
Kim, S, McMaster, M, Torres, S, Cox, KL, Lautenschlager, N, Rebok, GW, Pond, D, D'Este, C, McRae, I, Cherbuin, N, et al
BMJ open. 2018;(3):e019329
Abstract
INTRODUCTION It has been estimated that a 10%-25% reduction in seven key risk factors could potentially prevent 1.1-3.0 million Alzheimer's disease cases globally. In addition, as dementia is preceded by more subtle cognitive deficits which have substantial social and economic impact, effective preventative interventions would likely have more extensive benefits. The current study evaluates in primary care a multidomain risk-reduction intervention targeting adults with high risk of developing dementia. METHODS AND ANALYSIS A randomised controlled trial (RCT) is being conducted to evaluate three intervention programmes using a pragmatic approach suitable to the clinic: (1) a 12-week online and face-to-face dementia risk-reduction intervention (Body Brain Life-General Practice (BBL-GP)); (2) a 6-week face-to-face group lifestyle modification programme (LMP); and (3) a 12-week email-only programme providing general health information. We aim to recruit 240 participants, aged 18 and over, to undergo a comprehensive cognitive and physical assessment at baseline and follow-ups (postintervention, 18, 36 and 62 weeks). The primary outcome is dementia risk measured with the modified version of the Australian National University-Alzheimer's Disease Risk Index Short Form. Secondary outcomes are cognitive function measured with Trails A and B, and the Digit Symbol Modalities Test; physical activity with moderate-vigorous physical activity and the International Physical Activity Questionnaire; depression with the Centre for Epidemiological Studies Depression; cost evaluation with the 12-item Short Form Health Survey, Framingham Coronary Heart Disease Risk Score and Australian Type 2 Diabetes Risk Assessment Tool; diet quality with the Australian Recommended Food Score; and sleep quality with the Pittsburgh Sleep Quality Index. ETHICS AND DISSEMINATION This RCT is a novel pragmatic intervention applied in a primary care setting to reduce the dementia risk exposure in adults at high risk. If successful, BBL-GP and LMP will provide a versatile, evidence-based package that can be easily and quickly rolled out to other primary care settings and which can be scaled up at relatively low cost compared with other strategies involving intensive interventions. TRIAL REGISTRATION NUMBER ACTRN12616000868482.
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Use of a Mental Health Center Collaborative Care Team to Improve Diabetes Care and Outcomes for Patients With Psychosis.
Chwastiak, LA, Luongo, M, Russo, J, Johnson, L, Lowe, JM, Hoffman, G, McDonell, MG, Wisse, B
Psychiatric services (Washington, D.C.). 2018;(3):349-352
Abstract
OBJECTIVE This study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness (compared with usual care) of a collaborative care model to treat community mental health center (CMHC) patients with psychosis and poorly controlled diabetes. METHODS Stakeholder input was used to adapt a primary care-based collaborative care intervention for CMHC settings. Thirty-five adult CMHC clients with type II diabetes and hemoglobin A1c (HbA1c) >8% or blood pressure >140/90 were randomized to receive either collaborative care or usual care. Change in HbA1c was evaluated between baseline and three months. Paired t tests were used for within-group comparisons. RESULTS After three months, intervention participants had a statistically significant mean decrease in HbA1c of 1.1% (p=.049). There was no significant change in HbA1c in the usual-care group. CONCLUSIONS This pilot demonstrates the feasibility and acceptability of implementing collaborative care in CMHC settings and its preliminary effectiveness in improving glycemic control in a high-risk population.
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A pragmatic controlled trial to prevent childhood obesity within a risk group at maternity and child health-care clinics: results up to six years of age (the VACOPP study).
Mustila, T, Raitanen, J, Keskinen, P, Luoto, R
BMC pediatrics. 2018;(1):89
Abstract
BACKGROUND Obesity in childhood appears often during the toddler years. The prenatal environment influences obesity risk. Maternal gestational diabetes, the child's diet, and physical activity in the first few years have an important role in subsequent weight gain. A study was conducted to evaluate effectiveness of a primary health-care lifestyle counselling intervention in prevention of childhood obesity up to 6 years of age. METHODS The study was a controlled pragmatic trial to prevent childhood obesity and was implemented at maternity and child health-care clinics. The participants (n = 185) were mothers at risk of gestational diabetes mellitus with their offspring born between 2008 and 2010. The prenatal intervention, started at the end of the first trimester of pregnancy, consisted of counselling on diet and physical activity by municipal health-care staff. The intervention continued at yearly appointments with a public health-nurse at child health-care clinics. The paper reports the offspring weight gain results for 2-6 years of age. Weight gain up to 6 years of age was assessed as BMI standard deviation scores (SDS) via a mixed-effect linear regression model. The proportion of children at 6 years with overweight/obesity was assessed as weight-for-height percentage and ISO-BMI. Priority was not given to power calculations, because of the study's pragmatic nature. RESULTS One hundred forty seven children's (control n = 76/85% and intervention n = 71/56%) weight and height scores were available for analysis at 6 years of age. There was no significant difference in weight gain or overweight/obesity proportions between the groups at 6 years of age, but the proportion of children with obesity in both groups was high (assessed as ISO-BMI 9.9% and 11.8%) relative to prevalence in this age group in Finland. CONCLUSION As the authors previously reported, the intervention-group mothers had lower prevalence of gestational diabetes mellitus, but a decrease in obesity incidence before school age among their offspring was not found. The authors believe that an effective intervention should start before conception, continuing during pregnancy and the postpartum period through the developmentally unique child's first years. TRIAL REGISTRATION ClinicalTrials.gov NCT00970710 . Registered 1 September 2009. Retrospectively registered.
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Improving mental health through integration with primary care in rural Karnataka: study protocol of a cluster randomized control trial.
Srinivasan, K, Mazur, A, Mony, PK, Whooley, M, Ekstrand, ML
BMC family practice. 2018;(1):158
Abstract
BACKGROUND People who are diagnosed with both mental and chronic medical illness present unique challenges for the health care system. In resource-limited settings, such as rural India, people with depression and anxiety are often under-served, due to both stigma and lack of trained providers and resources. These challenges can lead to complications in the management of chronic disease as well as increased suffering for patients, families and communities. In this study, we evaluate the effects of integrating mental health and chronic disease treatment of patients in primary health care (PHC) settings using a collaborative care model to improve the screening, diagnosis and treatment of depression in rural India. METHODS This study is a multi-level randomized controlled trial among patients with depression or anxiety and co-morbid diabetes, or cardiovascular disease. Aim 1 examines whether patients screened at community health-fairs are more likely to be diagnosed and treated for these co-morbid conditions than patients screened after presenting at PHCs. Aim 2 evaluates the impact of collaborative care compared to usual care in a cluster RCT, randomizing at the level of the PHCs. Intervention arm PHC staff are trained in mental health diagnoses, treatment, and the collaborative care model. The intervention also involves community-based "Healthy Living groups" co-led by Ashas, using cognitive-behavioral strategies to promote healthy behaviors. The primary outcome is severity of common mental disorders, with secondary outcomes being diabetes and cardiovascular risk, staff knowledge and patient perceptions. DISCUSSION If effective, our results will contribute to the field in five ways: 1) expand on implementation research in low resource settings by examining how multiple chronic diseases can be treated using integrated low-cost, evidence-based strategies, 2) build the capacity of PHC staff to diagnose and treat mental illness within their existing clinic structure and strengthen referral linkages; 3) link community members to primary care through community-based health fairs and healthy living groups; 4) increase mental health awareness in the community and reduce mental health stigma; 5) demonstrate the potential for intervention scale-up and sustainability. TRIAL REGISTRATION http://Clinicaltrials.gov : NCT02310932 registered December 8, 2014 URL: https://clinicaltrials.gov/ct2/show/record/NCT02310932 ; Clinical Trials Registry India: CTRI/2018/04/013001 retrospectively registered on April 4, 2018.
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Effects of home telemonitoring on the control of high blood pressure: a randomised control trial in the Fangzhuang Community Health Center, Beijing.
Pan, F, Wu, H, Liu, C, Zhang, X, Peng, W, Wei, X, Gao, W
Australian journal of primary health. 2018;(5):398-403
Abstract
This study aimed to evaluate the effect of home telemonitoring on the control of high blood pressure in the Fangzhuang Community Health Center in Fengtai District, Beijing. A total of 110 hypertensive patients with uncontrolled high blood pressure were equally allocated to an intervention group and a control group randomly. The participants in the intervention group received home telemonitoring for blood pressure delivered by a team comprising a GP, a hypertension specialist, a general nurse and an information manager. The participants in the control group received the usual care. The levels of systolic and diabolic blood pressure of the participants were assessed on days 0 (baseline), 30, 90 and 180. On average, the intervention group had a greater reduction in blood pressure compared with the control by 6.6-8.0mmHg in systolic blood pressure and 0-3.0mmHg in diastolic blood pressure. Similarly, higher proportions of patients with normal blood pressure were achieved in the intervention group (63.6-71.2%) compared with the control (38.5-41.8%). The reduction in systolic blood pressure for the participants in the intervention group was positively correlated with the utilisation of the app (P<0.05). Home telemonitoring is effective in the control of high blood pressure.
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Dental Problems in Primary Care.
Stephens, MB, Wiedemer, JP, Kushner, GM
American family physician. 2018;(11):654-660
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Abstract
Oral health directly affects overall health and quality of life. More Americans lack dental insurance than medical insurance. Patients with poor oral health are more likely to have respiratory and cardiovascular diseases, adverse pregnancy outcomes, and diabetes mellitus. Early childhood caries is the most common chronic condition in American children. Certain illicit and prescription drugs increase the risk of enamel erosion and caries formation in adults. Incision and drainage is the treatment of choice for dental abscess. Risk factors for periodontal disease include smoking, diabetes, human immunodeficiency virus infection, use of certain medications, and genetic susceptibility. Patients with gingivitis typically present with swollen, erythematous gum tissue that bleeds easily with brushing or flossing. One in three children will have an injury to the primary teeth, and one in five 12-year-old children will have an injury to the permanent teeth. All dental fractures should be evaluated with imaging and managed in conjunction with a dental professional. Immediate reimplantation is the preferred treatment for avulsed permanent teeth. Primary care clinicians are well positioned to reduce rates of oral disease. Family physicians can incorporate oral health into routine practice through counseling about diet, oral hygiene, smoking cessation, and fluoride supplementation; application of fluoride varnish; and screening for dental disease.
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Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial.
Wu, S, Ell, K, Jin, H, Vidyanti, I, Chou, CP, Lee, PJ, Gross-Schulman, S, Sklaroff, LM, Belson, D, Nezu, AM, et al
Journal of medical Internet research. 2018;(4):e147
Abstract
BACKGROUND Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. OBJECTIVE The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. METHODS DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. RESULTS DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5.16; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.02); decreased prevalence of major depression (odds ratio, OR: supported care vs usual care=0.45, technology-facilitated care vs usual care=0.33; P value: supported care vs usual care=.02, technology-facilitated care vs usual care=.007); and reduced functional disability as measured by Sheehan Disability Scale scores (LSE: usual care=3.21, supported care=2.61, technology-facilitated care=2.59; P value: supported care vs usual care=.04, technology-facilitated care vs usual care=.03). Technology-facilitated care was significantly associated with depression remission (technology-facilitated care vs usual care: OR=2.98, P=.04); increased satisfaction with care for emotional problems among depressed patients (LSE: usual care=3.20, technology-facilitated care=3.70; P=.05); reduced total cholesterol level (LSE: usual care=176.40, technology-facilitated care=160.46; P=.01); improved satisfaction with diabetes care (LSE: usual care=4.01, technology-facilitated care=4.20; P=.05); and increased odds of taking an glycated hemoglobin test (technology-facilitated care vs usual care: OR=3.40, P<.001). CONCLUSIONS Both the technology-facilitated care and supported care delivery models showed potential to improve 6-month depression and functional disability outcomes. The technology-facilitated care model has a greater likelihood to improve depression remission, patient satisfaction, and diabetes care quality.
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Screening for familial hypercholesterolaemia in primary care: Time for general practice to play its part.
Brett, T, Qureshi, N, Gidding, S, Watts, GF
Atherosclerosis. 2018;:399-406
Abstract
Fifty per cent of first-degree relatives of index cases with familial hypercholesterolemia (FH) inherit the disorder. Despite cascade screening being the most cost-effective method for detecting new cases, only a minority of individuals with FH are currently identified. Primary care is a key target area to increase identification of new index cases and initiate cascade screening, thereby finding close relatives of all probands. Increasing public and health professional awareness about FH is essential. In the United Kingdom and in Australia, most of the population are reviewed by a General Practitioner (GP) at least once over a three-year period, offering opportunities to check for FH as part of routine clinical consultations. Such opportunistic approaches can be supplemented by systematically searching electronic health records with information technology tools that identify high risk patients. GPs can help investigate and implement results of this data retrieval. Current evidence suggests that early detection of FH and cascade testing meet most of the criteria for a worthwhile screening program. Among heterozygous patients the long latent period before the expected onset of coronary artery disease provides an opportunity for initiating effective drug and lifestyle changes. The greatest challenge for primary care is to implement an efficacious model of care that incorporates sustainable identification and management pathways.
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Vitamin D levels in a pediatric population of a primary care centre: a public health problem?
Fernández Bustillo, JM, Fernández Pombo, A, Gómez Bahamonde, R, Sanmartín López, E, Gualillo, O
BMC research notes. 2018;(1):801
Abstract
OBJECTIVE Vitamin D deficiency is a public health problem that occurs more frequently than expected. The aim of this study is to evaluate the vitamin D levels of children attending the paediatrics unit of the Bertamiráns primary care centre (A Coruña NW Spain). This is an observational study carried out during 1 year on a random sample of the pediatric population aged between 5 and 15 years. The levels of vitamin D (25(OH)D) were determined by immunoassay (ADVIA Centaur Vitamin D®). The results were classified as sufficient (> 20 ng/ml), insufficient (10-20 ng/ml) and deficient (< 10 ng/ml). RESULTS 153 analyses of vitamin D were carried out (58.2% in girls and 41.8% in boys), distributed in two age groups: 5-10 (62) and 10-15 (91). 66% of the total of the sample presented some degree of vitamin D deficit (60.1% insufficient (92) and 5.9% (11) deficient). In Galicia, there is a high prevalence of vitamin D deficiency/insufficiency in the healthy population, which increases if the patients present some kind of chronic pathology, thus leading to a public health problem. It is advisable to increase the consumption of fortified foods and/or to reconsider the administration of vitamin supplements.
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Management of bone health in patients with celiac disease: Practical guide for clinicians.
Duerksen, D, Pinto-Sanchez, MI, Anca, A, Schnetzler, J, Case, S, Zelin, J, Smallwood, A, Turner, J, Verdú, E, Butzner, JD, et al
Canadian family physician Medecin de famille canadien. 2018;(6):433-438
Abstract
OBJECTIVE To describe clinical issues related to bone health in patients with celiac disease (CD) and to provide guidance on monitoring bone health in these patients. SOURCES OF INFORMATION A PubMed search was conducted to review literature relevant to CD and bone health, including guidelines published by professional gastroenterological organizations. MAIN MESSAGE Bone health can be negatively affected in both adults and children with CD owing to the inflammatory process and malabsorption of calcium and vitamin D. Most adults with symptomatic CD at diagnosis have low bone mass. Bone mineral density should be tested at diagnosis and at follow-up, especially in adult patients. Vitamin D levels should be measured at diagnosis and annually until they are normal. In addition to a strict gluten-free diet, supplementation with calcium and vitamin D should be provided and weight-bearing exercises encouraged. CONCLUSION Bone health can be adversely affected in patients with CD. These patients require adequate calcium and vitamin D supplementation, as well as monitoring of vitamin D levels and bone mineral density with regular follow-up to help prevent osteoporosis and fractures.