To prevent being stressed-out: Allostatic overload and resilience of general practitioners in the era of COVID-19. A cross-sectional observational study

BackgroundResponsibility of general practitioners (GPs) in delivering safe and effective care is always high but during the COVID-19 pandemic they face even growing pressure that might result in unbearable stress load (allostatic overload, AO) leading to disease.ObjectivesWe aimed to measure AO of Hungarian GPs during the COVID-19 pandemic and explore their recreational resources to identify potential protective factors against stress load.MethodsIn a mixed-method design, Fava’s clinimetric approach to AO was applied alongside the Psychosocial Index (PSI); Kellner’s symptom questionnaire (SQ) to measure depression, anxiety, hostility and somatisation and the Public Health Surveillance Well-being Scale (PHS-WB) to determine mental, social, and physical well-being. Recreational resources were mapped. Besides Chi-square and Kruskal-Wallis tests, regression analysis was applied to identify explanatory variables of AO.ResultsData of 228 GPs (68% females) were analysed. Work-related changes caused the biggest challenges leading to AO in 60% of the sample. While female sex (OR: 1.99; CI: 1.06; 3.74, p = 0.032) and other life stresses (OR: 1.4; CI: 1.2; 1.6, p < 0.001) associated with increased odds of AO, each additional day with 30 min for recreation purposes associated with 20% decreased odds (OR: 0.838; CI: 0.72; 0.97, p = 0.020). 3–4 days a week when time was ensured for recreation associated with elevated mental and physical well-being, while 5–7 days associated with lower depressive and anxiety symptoms, somatisation, and hostility.ConclusionUnder changing circumstances, resilience improvement through increasing time spent on recreation should be emphasised to prevent GPs from the adverse health consequences of stress load.     

Primary care practice-based care management for chronically ill patients (PraCMan) in German healthcare: Outcome of a propensity-score matched cohort study

BackgroundGrowing prevalence of chronic diseases is a rising challenge for healthcare systems. The Primary Care Practice-Based Care Management (PraCMan) programme is a comprehensive disease management intervention in primary care in Germany aiming to improve medical care and to reduce potentially avoidable hospitalisations for chronically ill patients.ObjectivesThis study aimed to assess the effect of PraCMan on hospitalisation rate and related costs.MethodsA retrospective propensity-score matched cohort study was performed. Reimbursement data related to patients treated in general practices between 1st July 2013 and 31st December 2017 were supplied by a statutory health insurance company (AOK Baden-Wuerttemberg, Germany) to compare hospitalisation rate and direct healthcare costs between patients participating in the PraCMan intervention and propensity-score matched controls following usual care. Outcomes were determined for the one-year-periods before and 12 months after beginning of participation in the intervention.ResultsIn total, 6148 patients participated in the PraCMan intervention during the observation period and were compared to a propensity-score matched control group of 6148 patients from a pool of 63,446 eligible patients. In the one-year period after the intervention, the per-patient hospitalisation rate was 8.3% lower in the intervention group compared to control (p = 0.0004). Per-patient hospitalisation costs were 9.4% lower in favour of the intervention group (p = 0.0002).ConclusionThis study showed that the PraCMan intervention may be associated with a lower rate of hospital admissions and hospitalisation costs than usual care. Further studies may assess long-term effects of PraCMan and its efficacy in preventing known complications of chronic diseases.     

The effects of a mobile application for patient participation to improve patient safety

BackgroundPatient participation in patient safety activities in care processes is a fundamental element of safer care. Patients play an important role in preventing patient safety incidents and improving health outcomes. Therefore, healthcare providers need to develop and provide educational materials and actionable tools for patient participation.ObjectivesThis study aimed to develop a mobile application for health consumers'' participation and evaluate the effect of the mobile application on improving health consumers'' participation in patient safety.MethodsA quasi‐experimental design was adopted. We developed a mobile application on the basis of a needs assessment, literature review, compilation of patient safety topics, and validity testing of the application. The target population included Korean adults aged between 30 and 65 years who had visited a medical institution more than once within the most recent 6 months. The intervention group received patient participation training by using the mobile application, Application for Patient Participation in Safety Enhancement, for 2 months. The primary outcome variables were patient safety knowledge, self‐efficacy of participation, willingness to participate and experience of patient participation in patient safety activities. End‐user satisfaction was assessed using a questionnaire. To assess participants'' experiences with the intervention, qualitative data were collected through a focus group interview and open‐ended responses to an end‐user satisfaction survey.ResultsThe intervention group (n = 60) had significantly higher overall average scores than the control group (n = 37) with regard to patient safety knowledge (p < .001), self‐efficacy of participation (p = .001), willingness to participate (p = .010) and experience of participation (p = .038) in the post‐survey. The total mean end‐user satisfaction score was 3.56 ± 0.60. The participants expressed the realization that patients could play an important role in improving patient safety.ConclusionsThis study demonstrated that educating health consumers through a mobile application with useful information improves patient participation in patient safety activities. Educational materials and patient participation tools could motivate health consumers'' health‐related behaviours.Patient or Public ContributionPatients were involved during the programme development and evaluation.     

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

ObjectivesEngland has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.DesignHistorical cohort study.SettingA total of 330 English primary care practices, 2010–2017, using UK Clinical Practice Research Datalink.ParticipantsA total of 84,441 adults with type 2 diabetes.Main Outcome MeasuresThe primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission.ResultsThere were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89–0.92; p < 0.001 and 0.87; 95% CI 0.86–0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96–0.99; p = 0.001). Strong associations were found between completing 7–9 (vs. either 4–6 or 0–3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7–9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions.ConclusionsAttaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.     

The diversity of opinion among general practitioners regarding the threat and measures against COVID-19 – Cross-sectional survey

BackgroundAfter the ‘first wave’ in spring 2020, opinions regarding the threat and measures against COVID-19 seemed to vary among German general practitioners (GPs).ObjectivesTo systematically investigate opinions and to identify subgroups of GPs sharing similar views.MethodsA questionnaire was sent to all 210 practices accredited for undergraduate teaching of family medicine at the Medical Faculty of the Technical University of Munich. Questions addressed personal opinions regarding risks, dilemmas, restrictions and their relaxation associated with COVID-19, and personal fears, symptoms of depression and anxiety. Patterns of strong opinions (‘archetypes’) were identified using archetypal analysis, a statistical method seeking extremal points in the multidimensional data.ResultsOne hundred and sixty-one GPs sent back a questionnaire (response rate 77%); 143 (68%) with complete data for all 38 relevant variables could be included in the analysis. We identified four archetypes with subgroups of GPs tending in the direction of these archetypes: a small group of ‘Sceptics’ (n = 12/8%) considering threats of COVID-19 as overrated and measures taken as exaggerated; ‘Hardliners’ (n = 34/24%) considering threats high and supporting strong measures; ‘Balancers’ (n = 77/54%) who also rated the threats high but were more critical about potentially impairing the quality of life of elderly people and children; and ‘Anxious’ GPs (n = 20/14%) tending to report more fear, depressive and anxiety symptoms.ConclusionAmong the participants in this survey, opinions regarding the threat and the measures taken against COVID-19 during the ‘first wave’ in Germany in spring 2020 varied greatly.     

Healthcare needs,experiences and treatment burden in primary care patients with multimorbidity: An evaluation of process of care from patients' perspectives

BackgroundPatients with multimorbidity often experience treatment burden as a result of fragmented, specialist‐driven healthcare. The ‘family doctor team'' is an emerging service model in China to address the increasing need for high‐quality routine primary care.ObjectiveThis study aimed to explore the extent to which treatment burden was associated with healthcare needs and patients'' experiences.MethodsMultisite surveys were conducted in primary care facilities in Guangdong province, southern China. Interviewer‐administered questionnaires were used to collect data from patients (N = 2160) who had ≥2 clinically diagnosed long‐term conditions (multimorbidity) and had ≥1 clinical encounter in the past 12 months since enrolment registration with the family doctor team. Patients'' experiences and treatment burden were measured using a previously validated Chinese version of the Primary Care Assessment Tool (PCAT) and the Treatment Burden Questionnaire, respectively.ResultsThe mean age of the patients was 61.4 years, and slightly over half were females. Patients who had a family doctor team as the primary source of care reported significantly higher PCAT scores (mean difference 7.2 points, p < .001) and lower treatment burden scores (mean difference −6.4 points, p < .001) when compared to those who often bypassed primary care. Greater healthcare needs were significantly correlated with increased treatment burden (β‐coefficient 1.965, p < .001), whilst better patients'' experiences were associated with lower treatment burden (β‐coefficient −0.252, p < .001) after adjusting for confounders.ConclusionThe inverse association between patients'' experiences and treatment burden supports the importance of primary care in managing patients with multimorbidity.Patient ContributionPrimary care service users were involved in the instrument development and data collection.     

The results of cardiac surgery during the COVID-19 pandemic compared with previous years: a propensity weighted study of outcomes at six months

ObjectivesIn addition to excess mortality due to COVID-19, the pandemic has been characterised by excess mortality due to non-COVID diagnoses and consistent reports of patients delaying seeking medical treatment. This study seeks to compare the outcomes of cardiac surgery during and before the COVID-19 pandemic.DesignOur institutional database was interrogated retrospectively to identify all patients undergoing one of three index procedures during the first six months of the pandemic and the corresponding epochs of the previous five years.SettingA regional cardiothoracic centre.ParticipantsAll patients undergoing surgery during weeks #13-37, 2015-2020.Main outcome measuresPropensity score weighted analysis was employed to compare the incidence of major complications (stroke, renal failure, re-ventilation), 30-day mortality, six month survival and length of hospital stay between the two groups.ResultsThere was no difference in 30-day mortality (HR = 0.76 [95% CI 0.27-2.20], p = 0.6211), 6-month survival (HR = 0.94 [95% CI 0.44-2.01], p = 0.8809) and duration of stay (SHR = 1.00 (95% CI 0.90-1.12), p = 0.959) between the two eras. There were no differences in the incidence of major complications (weighted chi-square test: renal failure: p = 0.923, stroke: p = 0.991, new respiratory failure: p = 0.856).ConclusionsCardiac surgery is as safe now as in the previous five years. Concerns over the transmission of COVID-19 in hospital are understandable but patients should be encouraged not to delay seeking medical attention. All involved in healthcare and the wider public should be reassured by these findings.     

The impact of an intensive care unit admission on the health status of relatives of intensive care survivors: A prospective cohort study in primary care

BackgroundRelatives of intensive care unit (ICU) survivors may suffer from various symptoms after ICU admittance of their relative, known as post-intensive care syndrome-family (PICS-F). Studies regarding PICS-F have been performed but its impact in primary care is unknown.ObjectivesTo explore health problems of relatives of ICU survivors in primary care.MethodsThis is an exploratory prospective cohort study in which we combined data from two hospitals and a primary care research network in the Netherlands. ICU survivors who had been admitted between January 2005 and July 2017 were identified and matched by sex and age with up to four chronically ill (e.g. COPD, cardiovascular disease) patients. In both groups, relatives living in the same household were identified and included in this study. Primary outcome was the number of new episodes of care (International Classification of Primary Care-2) for up to five years. Hazard ratios (HRs) for the total number of new episodes were calculated.ResultsRelatives of ICU survivors (n = 267, mean age 38.1 years, 41.0% male) had significantly more new care episodes compared to the reference group (n = 705, mean age 36.3 years, 41.1% male) 1–2 years (median 0.11 vs. 0.08, HR 1.26; 95% confidence interval (CI) 1.03–1.54) and 2–5 years (median 0.18 vs. 0.13, HR 1.28; 95%CI 1.06–1.56) after ICU discharge. No differences were found in the period before ICU admission.ConclusionRelatives of ICU survivors present more morbidity in primary care than relatives of chronically ill patients up to five years after ICU discharge.     

Burnout of the US midwifery workforce and the role of practice environment

ObjectivesTo determine the prevalence of burnout among the midwifery workforce and the association between fixed personal and practice characteristics and modifiable organizational factors, specifically practice environment, to burnout among midwives in the United States.Data SourcePrimary data collection was conducted via an online survey of the complete national roster of certified nurse‐midwives and certified midwives over 3 weeks in April 2017.Study DesignThe study was a cross‐sectional observational survey consisting of 95 items about personal and practice characteristics, respondents'' practice environments, and professional burnout.Data Collection MethodsThe inclusion criterion was actively practicing midwifery in the United States. Data were analyzed with bivariate analyses to determine the association between personal and practice characteristics and burnout. A hierarchal multilinear regression evaluated the interrelationship between personal and practice characteristics, practice environment, and burnout.Principal FindingsOf the almost one third (30.9%) of certified nurse‐midwives and certified midwives who responded to the survey, 40.6% met criteria for burnout. Weak negative correlations existed between burnout and indicators of career longevity: age (r(2256) = −0.09, p < 0.01), years as a midwife (r(2267) = −0.07, p = 0.01), and years with employer (r(2271) = −0.05, p = 0.02). There were significant relationships between burnout score and patient workload indicators: patients per day in outpatient setting (F(5,2292) = 13.995, p < 0.01), birth volume (F(3,1864) = 8.35, p < 0.01), and patient acuity (F(2,2295) = 20.21, p < 0.01). When the practice environment was entered into the model with personal and practice characteristics, the explained variance increased from 6.4% to 26.5% (F(20,1478) = 27.98, p < 0.01).ConclusionsOur findings suggested that a key driver of burnout among US midwives was the practice environment, specifically practice leadership and participation and support for the midwifery model of care. Structural and personal characteristics contributed less to burnout score than the practice environment, implying that prevention of burnout may be achieved through organizational support and does not require structural changes to the provision of perinatal health.     

Appropriateness of COVID-19 public health guidelines for an Alberta First Nations community

ObjectivesThe First Nations people experience significant challenges that may influence the ability to follow COVID-19 public health directives on-reserve. This study aimed to describe experiences, perceptions and circumstances of an Alberta First Nations community, related to COVID-19 public health advice. We hypothesized that many challenges ensued when following and implementing advice from public health experts.MethodsWith First Nations leadership and staff, an online cross-sectional survey was deployed between April 24 and June 25, 2020. It assessed the appropriateness of public health advice to curb COVID-19 within this large First Nations community. Both quantitative and qualitative data were captured and described.ResultsA total of 106 adults living on-reserve responded; over 80% were female. Difficulty accessing food was significant by employment status (p = 0.0004). Those people with lower income found accessing food (p = 0.0190) and getting essential medical care (p = 0.0060), clothing (p = 0.0280) and transportation (p = 0.0027) more difficult. Some respondents described lost income associated with COVID-19 experiences, as well as difficulties accessing essential supplies. Respondents found “proper handwashing” most easy (98%) and “keeping a distance of 2 m from others” most difficult (23%). Many respondents found following public health advice within their personal domain easy and put “family safety” first but experienced some difficulties when navigating social aspects and obligations, particularly when unable to control the actions of others. People stated wanting clear information, but were sometimes critical of the COVID-19 response.ConclusionFirst Nations people face many additional challenges within the COVID-19 response, driven in part by ongoing issues related to significant societal, economic, and systemic factors.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00579-4.     

Treatment outcomes of acute streptococcal tonsillitis according to antibiotic treatment. A retrospective analysis of 242,366 cases treated in the community

BackgroundAcute upper respiratory infections are the most common reason for primary physician visits in the community. This study investigated whether the type of antibiotic used to treat streptococcal tonsillitis can reduce the burden by affecting the number of additional visits.ObjectivesTo assess the effect of different antibiotic treatments for tonsillitis on the number of additional primary physician visits and the development of infectious or inflammatory sequels.MethodsThis retrospective study included first cases of culture-confirmed streptococcal tonsillitis (n = 242,366, 55.3% females, 57.6% aged 3–15 years) treated in primary clinics throughout Israel between the years 2010 and 2019. Primary outcomes were the number of additional primary physician visits, due to any cause or due to specific upper airway infections. Secondary outcomes were the number of developed complications, such as peritonsillar abscess, post-streptococcal glomerulonephritis, rheumatic fever, post-streptococcal arthritis, chorea and death.ResultsCompared to penicillin-V, adjusted incidence rate ratios (IRR) for additional primary physician visits at 30–days were highest for IM benzathine-benzylpenicillin (IRR = 1.46, CI 1.33–1.60, p < .001) and cephalosporin treatment (IRR = 1.27, CI 1.24–1.30, p < .001). Similar results were noted for visits due to specific diagnoses such as recurrent tonsillitis, otitis media and unspecified upper respiratory tract infection. Amoxicillin showed decreased adjusted odds ratio (aOR) of developing complications (aOR = 0.68, CI 0.52–0.89, p < .01 for any complication. aOR = 0.75, CI 0.55–1.02, p = .07 for peritonsillar or retropharyngeal abscess).ConclusionPenicillin-V treatment is associated with fewer additional primary physician visits compared to other antibiotic treatments. Amoxicillin and penicillin-V are associated with fewer complications. These findings are limited by the retrospective nature of the study and lack of adjustment for illness severity. Further prospective studies may be warranted to validate results.     

Household- and employment-related risk factors for depressive symptoms during the COVID-19 pandemic

ObjectivesThe COVID-19 pandemic has generated multiple psychological stressors, which may increase the prevalence of depressive symptoms. Utilizing Canadian survey data, this study assessed household- and employment-related risk factors for depressive symptoms during the pandemic.MethodsA sample of 1005 English-speaking Canadian adults aged 18+ years completed a web-based survey after physical distancing measures were implemented across Canada. Hierarchical binary logistic regression analyses were conducted to examine the associations of depressive symptoms with household- (household size, presence of children, residence locale) and employment-related (job with high risk of COVID-19 exposure, working from home, laid off/not working, financial worry) risk factors, controlling for demographic factors (gender, age, education, income).ResultsAbout 20.4% of the sample reported depressive symptoms at least 3 days per week. The odds of experiencing depressive symptoms 3+ days in the past week were higher among women (AOR = 1.67, p = 0.002) and younger adults (18–29 years AOR = 2.62, p < 0.001). After adjusting for demographic variables, the odds of experiencing depressive symptoms were higher in households with 4+ persons (AOR = 1.88, p = 0.01), in households with children aged 6 to 12 years (AOR = 1.98, p = 0.02), among those with a job at high risk for exposure to COVID-19 (AOR = 1.82, p = 0.01), and those experiencing financial worry due to COVID-19 (‘very worried’ AOR = 8.00, p < 0.001).ConclusionPandemic responses must include resources for mental health interventions. Additionally, further research is needed to track mental health trajectories and inform the development, targeting, and implementation of appropriate mental health prevention and treatment interventions.     

Examining weather-related factors on physical activity levels of children from rural communities

ObjectiveThe objective was to examine the influence of weather on moderate-to-vigorous physical activity (MVPA) and light physical activity (LPA) levels of children aged 8–14 years from rural communities, an understudied Canadian population.MethodsChildren (n = 90) from four communities in rural Northwestern Ontario participated in this study between September and December 2016. Children’s MVPA and LPA were measured using an Actical accelerometer and demographic data were gathered from surveys of children and their parents. Weather data were collected from the closest weather station. Cross-classified regression models were used to assess the relationship between weather and children’s MVPA and LPA.ResultsBoys accumulated more MVPA than girls (b = 26.38, p < 0.01), children were more active on weekdays as compared with weekends (b = − 16.23, p < 0.01), children were less active on days with precipitation (b = − 22.88, p < 0.01), and higher temperature led to a significant increase in MVPA (b = 1.33, p  < 0.01). As children aged, they accumulated less LPA (b = − 9.36, p < 0.01) and children who perceived they had higher levels of physical functioning got more LPA (b = 25.18, p = 0.02). Similar to MVPA, children had higher levels of LPA on weekdays (b = − 37.24, p < 0.01) as compared to weekend days and children accumulated less LPA (b = −50.01, p < 0.01) on days with rain.ConclusionThe study findings indicate that weather influences rural children’s MVPA and LPA. Future research is necessary to incorporate these findings into interventions to increase rural children’s overall PA levels and improve their overall health.Electronic supplementary materialThe online version of this article (10.17269/s41997-020-00324-3) contains supplementary material, which is available to authorized users.     

Participation preferences of health service users in health care decision‐making regarding rehabilitative care in Germany—A cross‐sectional study

BackgroundInvolving patients and citizens in health care decision‐making is considered increasingly important in Germany. Participatory structures have been implemented, especially in rehabilitative care. However, it is unknown whether and to what extent German patients and citizens want to participate in decisions that exceed their own medical treatment.ObjectiveThis study aimed to survey participation preferences and associated factors of health service users in decisions regarding rehabilitative care at micro, meso and macro levels.MethodsA questionnaire was sent to 3872 former rehabilitants. We collected participation preferences using the Control Preference Scale or an adapted form. Possible influencing factors were examined using logistic regression models.ResultsThe response rate was 5.7% (n = 217). At all decision‐making levels, joint decision‐making was preferred. At the macro level, preferences for actively participating were the highest. Preferences were significantly interrelated between decision‐making levels. At the micro level, an orthopaedic indication significantly decreased the desire for participation compared to psychosomatic indications (odds ratio = 0.44, p = .019).DiscussionParticipants wanted to be equally involved in decision‐making as experts. Higher preferences for active participation at the macro level might be due to dissatisfaction with the current health care organisation and lack of trust in politicians. Compared to the general public, our study sample was older (73.3% between 50 and 69 years) and more often chronically ill—factors associated with increased participation preferences in the literature.ConclusionContrary to the identified preferences, participation opportunities in the German health care system are rare. Further research on participation preferences and structures that enable meaningful involvement are needed.     

Telemedicine to deliver diabetes care in low- and middle-income countries: a systematic review and meta-analysis

ObjectiveTo determine the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries.MethodsWe searched seven databases up to July 2020 for randomized controlled trials investigating the effectiveness of telemedicine in the delivery of diabetes care in low- and middle-income countries. We extracted data on the study characteristics, primary end-points and effect sizes of outcomes. Using random effects analyses, we ran a series of meta-analyses for both biochemical outcomes and related patient properties.FindingsWe included 31 interventions in our meta-analysis. We observed significant standardized mean differences of −0.38 for glycated haemoglobin (95% confidence interval, CI: −0.52 to −0.23; I² = 86.70%), −0.20 for fasting blood sugar (95% CI: −0.32 to −0.08; I² = 64.28%), 0.81 for adherence to treatment (95% CI: 0.19 to 1.42; I² = 93.75%), 0.55 for diabetes knowledge (95% CI: −0.10 to 1.20; I² = 92.65%) and 1.68 for self-efficacy (95% CI: 1.06 to 2.30; I² = 97.15%). We observed no significant treatment effects for other outcomes, with standardized mean differences of −0.04 for body mass index (95% CI: −0.13 to 0.05; I² = 35.94%), −0.06 for total cholesterol (95% CI: −0.16 to 0.04; I² = 59.93%) and −0.02 for triglycerides (95% CI: −0.12 to 0.09; I² = 0%). Interventions via telephone and short message service yielded the highest treatment effects compared with services based on telemetry and smartphone applications.ConclusionAlthough we determined that telemedicine is effective in improving several diabetes-related outcomes, the certainty of evidence was very low due to substantial heterogeneity and risk of bias.     

Geneva medical students increasingly identify primary care physicians as role models after introduction of a compulsory clerkship

BackgroundRole modelling is recognised as an important element in career choice. In strongly hospital-based medical education settings, students identify few primary care physicians as positive role models, which might impact their career plans and potentially contribute to primary care workforce shortage. At Geneva Faculty of Medicine (Switzerland), a compulsory final-year clerkship in primary care practices was introduced to strengthen primary care teaching in the curriculum.ObjectivesTo assess the proportion of graduating students identifying a primary care physician as positive role model, before and after the introduction of the clerkship.MethodsCross-sectional survey in four consecutive classes of graduating medical students one year before and three years after the introduction of the clerkship. The main outcome measure was the proportion of students in each class citing a primary care physician role model. Comparisons were analysed using Pearson’s Chi-square test and one-way ANOVA.ResultsThe total sample included 505 students. The proportion of students recalling a primary care physician role model increased steadily from 8% (before introduction of the clerkship) to 13, 16, and 21%, respectively, at 1, 2 and 3 years after the introduction of the clerkship (p = 0.03).ConclusionOur exploratory study suggests that introducing a compulsory primary care clerkship may have contributed to increasing the visibility of primary care physicians as role models. Future research should explore primary care physicians’ awareness of role modelling and its contribution to career choices.     

Home environment allergen exposure scale in older adult cohort with asthma

ObjectivesHome environmental exposures are a primary source of asthma exacerbation. There is a gap in decision support models that efficiently aggregate the home exposure assessment scores for focused and tailored interventions. Three development methods of a home environment allergen exposure scale for persons with asthma (weighted by dimension reduction, unweighted, precision biomarker-based) were compared, and racial disparity tested.MethodsBaseline measures from a longitudinal cohort of 187 older adults with asthma were analyzed using humidity and particulate matter sensors, allergy testing, and a home environment checklist. Weights for the dimension reduction scale were obtained from factor analysis, applied for loadings > 0.35. Scales were tested in linear regression models with asthma control and asthma quality of life outcomes. Racial disparities were tested using t tests. Scale performance was tested using unadjusted regression analyses with asthma control and asthma quality of life outcomes, separately.ResultsThe 7-item empirically weighted scale demonstrated best performance with asthma control associations (F = 4.65, p = 0.03, R² = .02) and quality of life (F = 6.45, p = 0.01, R² = .03) as follows: evidence of roach/mice, dust, mold, tobacco smoke exposure, properly venting bathroom fan, self-report of roach/mice/rats, and access to a HEPA filter vacuum. Pets indoors loaded on a separate scale. Racial differences were observed (t = − 3.09, p = 0.004).ConclusionThe Home Environment Allergen Exposure Scale scores were associated with racial disparities. Replicating these methods in populations residing in high-risk/low-income housing may generate a clinically meaningful, tailored assessment of asthma triggers. Further consideration for variables that address allergic reactivity and biomarker results is indicated to enhance the potential for a precision prevention score.Electronic supplementary materialThe online version of this article (10.17269/s41997-020-00335-0) contains supplementary material, which is available to authorized users.