Rapid increases in technology and data motivate the application of artificial intelligence (AI) to primary care, but no comprehensive review exists to guide these efforts. Our objective was to assess ...the nature and extent of the body of research on AI for primary care.
We performed a scoping review, searching 11 published or gray literature databases with terms pertaining to AI (eg, machine learning, bayes* network) and primary care (eg, general pract*, nurse). We performed title and abstract and then full-text screening using Covidence. Studies had to involve research, include both AI and primary care, and be published in Eng-lish. We extracted data and summarized studies by 7 attributes: purpose(s); author appointment(s); primary care function(s); intended end user(s); health condition(s); geographic location of data source; and AI subfield(s).
Of 5,515 unique documents, 405 met eligibility criteria. The body of research focused on developing or modifying AI methods (66.7%) to support physician diagnostic or treatment recommendations (36.5% and 13.8%), for chronic conditions, using data from higher-income countries. Few studies (14.1%) had even a single author with a primary care appointment. The predominant AI subfields were supervised machine learning (40.0%) and expert systems (22.2%).
Research on AI for primary care is at an early stage of maturity. For the field to progress, more interdisciplinary research teams with end-user engagement and evaluation studies are needed.
Food insecurity is "the state of being without reliable access to a sufficient quantity of affordable, nutritious food". Observational studies have associated food insecurity with many negative ...health effects including the development and exacerbations of chronic diseases, higher health care use and increased mortality. Health care providers prescribing food is a growing area of interest and research, however it is not known how patients feel about receiving fruit and vegetable prescriptions (FVRx) from their health provider versus other means of food provision. This pilot study was conducted to explore the experiences and opinions of Canadian adults with food insecurity who were recipients of a FVRx box program prescribed by their health provider.
Potential participants were recruited to 3 focus groups using flyers included in their monthly food box. Questions were kept open to encourage participation of all group members. The focus groups were audiotaped, transcribed verbatim, and analyzed by the research team using descriptive qualitative research methodology.
Participants described shame and frustration trying to obtain enough food through local food banks. In comparison, they perceived their team dietitian, family physician or addictions physician as directly helping them with their health by prescribing food. The boxed fruit and vegetables were prepared in many ways and often shared to reduce waste and to reduce the food insecurity of extended family members. Positive effects of the FVRx on physical and mental health were reported. Participants believed that follow up with their health provider helped support them and their behavioural changes towards better nutrition. Limitations of the program included lack of choice, non-flexible pick-up times and the program being limited to 6 months. Being able to choose their own fruit and vegetables, instead of receiving a set box, was suggested by most to help meal planning and to increase autonomy.
Health providers prescribing FVRx boxes to adult patients with food insecurity was positively received in this study. Evaluation of similar programs in other regions in Canada and internationally, and comparison of food prescriptions to basic income guarantee programs is recommended.
Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality ...allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection.
Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income.
Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.
Maternal mortality is still a major risk for women of childbearing age in Nigeria. In 2008, Nigeria bore 14% of the global burden of maternal mortality. The national maternal mortality ratio has ...remained elevated despite efforts to reduce maternal deaths. Though health disparities exist between the North and South of Nigeria, there is a dearth of evidence on the estimates and determinants of maternal mortality for these regions.
This study aimed to assess differences in the levels and determinants of maternal mortality in women of childbearing age (15-49 years) in the North and South of Nigeria. The Nigeria Demographic and Health Surveys (2008 and 2013) were used. The association between maternal mortality (outcome) and relevant sociocultural, economic and health factors was tested using multivariable logistic regression in a sample of 51,492 living or deceased women who had given birth.
There were variations in the levels of maternal mortality between the two regions. Maternal mortality was more pronounced in the North and increased in 2013 compared to 2008. For the South, the levels slightly decreased. Media exposure and education were associated with maternal mortality in the North while contraceptive method, residence type and wealth index were associated with maternal death in the South. In both regions, age and community wealth were significantly associated with maternal mortality.
Differences in the levels and determinants of maternal mortality between the North and South of Nigeria stress the need for efforts to cut maternal deaths through new strategies that are relevant for each region. These should improve education of girls in the North and access to health information and services in the South. Overall, new policies to improve women's socioeconomic status should be adopted.
First-episode psychosis (FEP) can be quite variable in clinical presentation, and both sex and gender may account for some of this variability. Prior literature on sex or gender differences in ...symptoms of psychosis have been inconclusive, and a comprehensive summary of evidence on the early course of illness is lacking. The objective of this study was to conduct a systematic review and meta-analysis of the literature to summarize prior evidence on the sex and gender differences in the symptoms of early psychosis. We conducted an electronic database search (MEDLINE, Scopus, PsycINFO, and CINAHL) from 1990 to present to identify quantitative studies focused on sex or gender differences in the symptoms of early psychosis. We used random effects models to compute pooled standardized mean differences (SMD) and risk ratios (RR), with 95% confidence intervals (CI), for a range of symptoms. Thirty-five studies met the inclusion criteria for the systematic review, and 30 studies were included in the meta-analysis. All studies examined sex differences. Men experienced more severe negative symptoms (SMD = − 0.15, 95%CI = − 0.21, − 0.09), whereas women experienced more severe depressive symptoms (SMD = 0.21, 95%CI = 0.14, 0.27) and had higher functioning (SMD = 0.16, 95%CI = 0.10, 0.23). Women also had a lower prevalence of substance use issues (RR = 0.65, 95%CI = 0.61, 0.69). Symptoms of early psychosis varied between men and women; however, we were limited in our ability to differentiate between biological sex and gender factors. These findings may help to inform early detection and intervention efforts to better account for sex and gender differences in early psychosis presentation.
Multimorbidity is a complex issue in modern medicine and a more nuanced understanding of how this phenomenon occurs over time is needed.
To determine the prevalence, characteristics, and patterns of ...patients living with multimorbidity, specifically the unique combinations (unordered patterns) and unique permutations (ordered patterns) of multimorbidity in primary care.
A retrospective cohort analysis of the prospectively collected data from 1990 to 2013 from the Canadian Primary Care Sentinel Surveillance Network electronic medical record database.
Adult primary care patients who were aged ≥18 years at their first recorded encounter were followed over time. A list of 20 chronic condition categories was used to detect multimorbidity. Computational analyses were conducted using the Multimorbidity Cluster Analysis Tool to identify all combinations and permutations.
Multimorbidity, defined as two or more and three or more chronic conditions, was prevalent among adult primary care patients and most of these patients were aged <65 years. Among female patients with two or more chronic conditions, 6075 combinations and 14 891 permutations were detected. Among male patients with three or more chronic conditions, 4296 combinations and 9716 permutations were detected. While specific patterns were identified, combinations and permutations became increasingly rare as the total number of chronic conditions and patient age increased.
This research confirms that multimorbidity is common in primary care and provides empirical evidence that clinical management requires a tailored, patient-centred approach. While the prevalence of multimorbidity was found to increase with increasing patient age, the largest proportion of patients with multimorbidity in this study were aged <65 years.
While maternal mortality has declined worldwide in the past 25 years, this is not the case for Cameroon. Since there is a predominantly young population in this country, high maternal mortality ...ratios may persist. Maternal mortality ratios vary within countries, yet it is unknown if the North and South, the most distinct parts of Cameroon, differ in terms of ratios and determinants of maternal mortality.
This study explored ratios and determinants of maternal mortality in women of childbearing age (15-49 years) and assessed differences between the North and South. We used the Cameroon Demographic and Health Surveys (2004 and 2011) to extract a sample of 18,665 living or deceased women who had given birth. Multivariable logistic regression was used to explore the relationship between maternal mortality and sociocultural, economic and healthcare factors.
Maternal mortality ratios were different for the two regions and increased in the North in 2011 compared to 2004. In the North, any level of education and being Muslim were protective against maternal mortality. Meanwhile, the odds of maternal mortality decreased with increasing age, and having secondary or higher education in the South. Domestic violence and ethnicity were associated with maternal death in the South. Increasing parity was protective of maternal death in both the North and South.
Maternal mortality ratios and determinants varied between women of childbearing age in the North and South of Cameroon. These reinforce recommendations for region specific strategies that will improve health communication, community education programs, curb domestic violence and train more community health workers to connect pregnant women with the health system. Programs to reduce maternal death among women with low parity and little or no education should be national priority.
To determine factors associated with having a focused practice among a sample of family medicine graduates in Canada and to assess the characteristics of FPs with focused practices and the range of ...services provided by these FPs in relation to the full scope of office-based care.
Secondary analyses of cross-sectional data from the 2013-2014 Western Family Medicine Resident Follow-Up Survey.
Western University in London, Ont.
Western University family medicine residency graduates who completed the program between 1985 and 2012.
Physician and practice characteristics and the clinical services that survey participants provide.
Completion of postgraduate third-year (PGY3) training was associated with having a focused practice. Focused practice FPs were more likely to be remunerated by fee-for-service, alternative payment plans, or alternative funding plans compared with non-focused practice FPs, who were more likely to participate in group payment models. Focused practice FPs appeared to be a heterogeneous group who were distinguished by being either an office-based focused practice FP (OBFFP) or a non-office-based focused practice FP (NOBFFP). Office-based focused practice FPs were less likely than NOBFFPs to have completed PGY3 training and more likely to work under a fee-for-service or group payment model. Further, the OBFFP group offered a greater variety of primary care services than the NOBFFP group, but offered less variety than non-focused practice FPs.
Completion of PGY3 training and payment through certain remuneration models were both associated with focused practice. Important differences exist between OBFFPs and NOBFFPs. The overall service provision of focused practice FPs was centred on specialized areas, especially among those practising in non-office-based settings. Novel findings from this study provide insights for family medicine education, work force planning, and policy making in the Canadian health system.
Summary
Background
: Artificial intelligence (AI) is heralded as an approach that might augment or substitute for the limited processing power of the human brain of primary health care (PHC) ...professionals. However, there are concerns that AI-mediated decisions may be hard to validate and challenge, or may result in rogue decisions.
Objective
: To form consensus about perceptions, issues, and challenges of AI in primary care.
Method
: A three-round Delphi study was conducted. Round 1 explored experts’ viewpoints on AI in PHC (n=20). Round 2 rated the appropriateness of statements arising from round one (n=12). The third round was an online panel discussion of findings (n=8) with the members of both the International Medical Informatics Association and the European Federation of Medical Informatics Primary Health Care Informatics Working Groups.
Results
: PHC and informatics experts reported AI has potential to improve managerial and clinical decisions and processes, and this would be facilitated by common data standards. The respondents did not agree that AI applications should learn and adapt to clinician preferences or behaviour and they did not agree on the extent of AI potential for harm to patients. It was more difficult to assess the impact of AI-based applications on continuity and coordination of care.
Conclusion
: While the use of AI in medicine should enhance healthcare delivery, we need to ensure meticulous design and evaluation of AI applications. The primary care informatics community needs to be proactive and to guide the ethical and rigorous development of AI applications so that they will be safe and effective.
Objectives: To determine the efficacy of reductions in long acting and basal insulin to prevent lows in T1D sports campers. The Sam Fuld’s T1D Sports Camp is a camp for children with T1D taking place ...each February. It involves high-intensity exercise for up to six hours in a day. We began adjusting our insulin dosing recommendation in 2017 to prevent incidence of hypoglycemia and ensure more campers are able to fully participate.
Methods: We compared incidence of hypo and hyperglycemic events at camp from 2016-2019. Using bg data recorded for all T1D campers. Starting in 2017, we recommended MDI campers decrease long acting insulin by 30% the night before camp and pump users decrease basal rates by 30% beginning at breakfast prior to camp. In 2019, meal boluses for lunch were also cut by 50%.
Results: From 2016 to 2018 there was a 40% decrease in campers with low bgs, and an expected increase in hyperglycemic values. In 2019, we saw an increase in lows compared with 2018 with lower overall prevalence than seen in prior years and fewer hyperglycemic events than in 2018.
Of those campers who followed the recommendations, in 2017, no incidents of hypo or hypoglycemia occurred, in 2018 there were just three incidents of hyperglycemia and in 2019, one bg value < 50 mg/dL and 8 bg values > 250 mg/dL (mostly in the morning).
Conclusion: More research is needed to determine the best dosing guidelines for intense exercise in children with T1D.
Disclosure
A.M. Terry: None. S. Bollepalli: None. L. Smith: None. H. Rodriguez: Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Bristol-Myers Squibb Company, Daiichi Pharm Corp, MannKind Corporation, Medtronic MiniMed, Inc. Research Support; Spouse/Partner; Medtronic MiniMed, Inc. Research Support; Self; Takeda Pharmaceutical Company Limited. Other Relationship; Self; Merck & Co., Inc., Novartis Pharmaceuticals Corporation, Novo Nordisk Inc.
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