primary health care

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has issued its 2023 annual report1. Compared with former versions, it has been significantly updated. Here, we summarize the most relevant changes for a Primary Care audience. The complete document can be downloaded for free from the GOLD web page (www.goldcopd.org), together with a “pocket guide” and a “teaching slide set”.

Background: Most patients with irritable bowel syndrome (IBS) are managed in primary care. When first-line therapies for IBS are ineffective, the UK National Institute for Health and Care Excellence guideline suggests considering low- dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown, and they are infrequently prescribed in this setting.

Methods: This randomised, double-blind, placebo-controlled trial (Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment [ATLANTIS]) was conducted at 55 general practices in England. Eligible participants were aged 18 years or older, with Rome IV IBS of any subtype, and ongoing symptoms (IBS Severity Scoring System [IBS-SSS] score ≥75 points) despite dietary changes and first-line therapies, a normal full blood count and C-reactive protein, negative coeliac serology, and no evidence of suicidal ideation. Participants were randomly assigned (1:1) to low-dose oral amitriptyline (10 mg once daily) or placebo for 6 months, with dose titration over 3 weeks (up to 30 mg once daily), according to symptoms and tolerability. Participants, their general practitioners, investigators, and the analysis team were all masked to allocation throughout the trial. The primary outcome was the IBS-SSS score at 6 months. Effectiveness analyses were according to intention-to-treat; safety analyses were on all participants who took at least one dose of the trial medication. This trial is registered with the ISRCTN Registry (ISRCTN48075063) and is closed to new participants.

Findings: Between Oct 18, 2019, and April 11, 2022, 463 participants (mean age 48·5 years [SD 16·1], 315 [68%] female to 148 [32%] male) were randomly allocated to receive low-dose amitriptyline (232) or placebo (231). Intention-to-treat analysis of the primary outcome showed a significant difference in favour of low-dose amitriptyline in IBS-SSS score between groups at 6 months (-27·0, 95% CI -46·9 to -7·10; p=0·0079). 46 (20%) participants discontinued low-dose amitriptyline (30 [13%] due to adverse events), and 59 (26%) discontinued placebo (20 [9%] due to adverse events) before 6 months. There were five serious adverse reactions (two in the amitriptyline group and three in the placebo group), and five serious adverse events unrelated to trial medication.

Interpretation: To our knowledge, this is the largest trial of a tricyclic antidepressant in IBS ever conducted. Titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes, and was safe and well tolerated. General practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial.

Funding: National Institute for Health and Care Research Health Technology Assessment Programme (grant reference 16/162/01).

Suicide prevention has been named a national priority and much work has been done to review existing evidence and identify gaps in how our nation’s mental health and health care systems address this public health challenge. A national task force that was part of the effort to update the national suicide prevention strategy reviewed research and best practices from the field and
concluded that suicide prevention could be improved in health care. The task force found three common characteristics among successful suicide prevention programs in health care settings. Health care staff in these organizations:
Believed that suicide can be prevented in the population they serve through improvements in service access and quality, and through systems of continuous improvement;
Created a culture that finds suicide unacceptable and sets and monitors ambitious goals to prevent suicide; and
Employed evidence-based clinical care practice, including standardized risk stratification, evidence-based interventions, and patient engagement approaches1.

The task force’s recommendations formed the foundation of the Zero Suicide Approach for health care organizations. The recommendations contained in this guide are based on those offered in the comprehensive Zero Suicide in Health and Behavioral Health Care Toolkit [http://zerosuicide.sprc.org/toolkit]. Here they have been adapted specifically for primary care organizations and clinicians who care for underserved populations.
The guide focuses on two core components:
1. Screening and assessment
2. Care management and referral processes
The final section contains some additional information on administrative and legal issues providers and leaders may find helpful to support integration of safer suicide care in practice. Many providers and clinical leaders erroneously assume if they discuss suicide with a patient they open up themselves to liability. Utilizing a patient safety approach, primary care organizations can
establish safer suicide care practices that deliver high quality care to patients and reduce risk to the organization.
In each section of this guide you will find:
Information summarized for providers, including some helpful provider communication tips.
A list of recommended trainings and resources to learn more.
Leadership actions organizations may wish to undertake to help providers reduce suicide in their organization’s
patient population, and
Relevant tools, templates and case studies.
This toolkit begins with a brief background on the impact of suicide and offers a case study illustrating how one federally qualified health center adopted a safer suicide care model.

Background: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care.

Methods: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content.

Results: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model (“Appointment system” and “Interprofessional practice”), 1 was merged with a revised pillar (“Develop contingency plans” with “Planning of needs and supply”) and 1 underwent major transformations (“Backlog reduction” to “Continuous adjustment”). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content.

Interpretation: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Timely access is a cornerstone of strong primary health care and a key component of a patient-centred medical home for ensuring population health.1 Numerous innovations have been implemented to improve timely access,2 with one of the most recommended around the world being the advanced access model, also called open access.2,3 Based on greater accessibility linked with patients’ relational and informational continuity with a primary health care professional or team, the advanced access model aims to ensure that patients obtain access to health care services at a time and date convenient for them when needed, regardless of the urgency of the demand.4 Originally developed in the United States in the early 2000s, advanced access is defined by Murray and Berwick as having 5 pillars: balance supply and demand, reduce the backlog of previously scheduled appointments, review the appointment system, integrate interprofessional practice and develop contingency plans.5,6 Several scientific papers on the foundations of advanced access have been published over the past 20 years, and its benefits have been reported in many countries, including the US, the United Kingdom and Canada.6–9

Over the last 2 decades, primary health care practice has evolved to increase interdisciplinarity in clinical teams. Thus, the need for a model that incorporates new practices and professionals has necessitated development of an updated advanced access model. Furthermore, advanced access was originally developed in a context that prioritized implementing a new way of doing, with less emphasis on the ongoing practice and sustainability of the model.10,11 However, changes in primary health care practice require revisions to the advanced access model to adapt it to the contemporary context.

In this study, we redefine the pillars and subpillars of the advanced access model by integrating an interdisciplinary team–based focus, while considering the integration of primary health care professionals, such as nurse practitioners, registered nurses, social workers and other allied professionals, in primary health care practices. The objective of this study was to revise and operationalize the pillars and subpillars of the advanced access model.