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Transitional Care Management care team impact on no-show rates to hospital discharge appointments [Patient education/adherence]

Annals of Family Medicine

Context: The Transitional Care Management (TCM) clinic visit is a uniquely billed visit type to review a recently discharged patient’s hospital course, reconcile medications, and continue ongoing workup. Objective: Our objective was to improve the TCM clinic no-show rate and thereby improve patient outcomes.

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Implementation of a novel linkage of primary care electronic medical record data with hospital data in South Eastern Ontario [Big data]

Annals of Family Medicine

Context: Currently, primary care data, community data, and hospital data are not linked in Ontario, resulting in a disconnect in continuity of care. 1072 patients with COPD were identified within the merged dataset, 50% of whom visited the ED within two years. Following patient review by clinician, 77 patients were deemed eligible.

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Electronic Health Record Use and Patient-Centredness [Education and training]

Annals of Family Medicine

Context: Large-scale electronic health record (EHR) programs have reported a number of issues to their implementation in primary care including physician patient-centredness and clinical performance. Setting: An academic primary care clinic based in a hospital. Population: Ten resident physicians and six staff physicians.

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SGLT-2 inhibitor, cardiovascular risk and outcome in patients with comorbidity of hypertension and diabetes [Cardiovascular disease]

Annals of Family Medicine

Context Two thirds of diabetes patients complicated with hypertension, and comorbidity increase 4-fold risk of atherosclerotic cardiovascular disease (ASCVD). Outcome Measures Changes of China-PAR score and cardiovascular hospitalization events. Study design and analysis This is a multiple-center retrospective real-world cohort study.

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Outcomes of a virtual CGM initiation service (virCIS) for primary care patients with diabetes [Diabetes and endocrine disease]

Annals of Family Medicine

However, its adoption has been slower in primary care settings compared to endocrinology practices, resulting in unequal access for patients with diabetes. Implementation of a virtual CGM initiation service can be valuable for enhancing CGM access to primary care patients with diabetes. Setting: Primary care practices in Colorado.

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High use of the emergency department among patients in Krakow, Poland: An alternative to seeking primary care? [Acute and emergency care]

Annals of Family Medicine

Individuals who frequently attend the ED comprise up to 10% of patients, while accounting for a third of ED visits. Objective: To describe frequent ED use among patients in Krakow, Poland. Population Studied: Adult patients (≥18 years of age) with high ED use (≥5 visits per year) were included. median: 6, IQR: 2.0).

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Comparing impact of a holistic patient centered navigation model to an online navigation service on health care utilization [Population health and epidemiology]

Annals of Family Medicine

Population Primary care providers in 12 Ottawa and Sudbury (Ontario, Canada) practices referred their patients with health or social needs to access needed SP services. Dataset Of the 326 enrolled patients, 150 consented and had their data successfully linked to health administrative data housed at ICES (ARC=83, Ontario-211: 67).