OBJECTIVE: This article aims to provide a primary care update on the maintenance or discontinuation of antidepressant medication for the treatment of moderate-to-severe depression in adults. To this end, we performed a qualitative narrative review and provide commentary on recent research and systematic reviews.
DISCUSSION: In primary care, recent research has shown that there are substantial risks of depressive relapse resulting from antidepressant discontinuation. For a first episode of moderate-to-severe depression, antidepressants should be continued for 9-12 months after remission. Systematic reviews indicate that, overall, there is limited evidence of benefits from ceasing antidepressant treatment for recurrent depression. The existing evidence base on antidepressant withdrawal is limited in quality and extent, providing some evidence of harms, such as relapse, and not necessarily any gains, although reducing the burden of adverse effects is a consideration. There is a benefit-to-risk ratio in any decision to continue or withdraw antidepressant treatment.
METHODS: This qualitative exploration study. All healthcare providers who were involved in EnPHC at the intervention clinics were selected as participants. In-depth interviews and focus group discussions were carried out among healthcare providers working in the intervention clinic. Thematic analysis was used to categorize data, based on the consolidated framework for implementation research (CFIR) theoretical framework domains.
RESULTS: A total of 61 healthcare providers participated. All 5 domains with 19 CFIR constructs emerged from the analysis. Inner setting played a significant role in facilitating CC intervention, in which culture, networking, and collaboration and leadership engagement played an essential role in supporting CC activities. Although CC tasks are complex, concerns of losing clinical skill and resource constraints were identified as potential barriers in CC implementations. Criteria for appointing new CCs emerged from the characteristics of individual constructs, in which the individual must be familiar and interested in community health, have good communication skills, and at least 3 years' experience in the primary healthcare setting.
CONCLUSION: The implementation of the CC intervention faces varying challenges in different settings. This is partially resolved through teamwork, guidance from mentors, and support from superiors. The complexity of the responsibility of the CC intervention is perceived as both a validation and a burden. Above all, it is seen as paramount in EnPHC intervention.
METHODS: The study applied mixed-method embedded design to analyze both quantitative and qualitative data. Quantitative approach was used to evaluate sustainability perception from 20 intervention clinics via self-reported assessment form whereas qualitative data were obtained through in-depth interview (IDI) and focus group discussions (FGDs) 14 health care professionals participated in IDI session and were either care coordinators, liaison officers (LOs)/clinic managers, or medical officers-in-charge for the clinic's intervention. Nine FGDs conducted comprised 58 HCPs from various categories.
RESULTS: HCPs from all the 20 clinics involved responded to each listed Enhanced Primary Healthcare (EnPHC) intervention components as being implemented but the perceived sustainability of these implementation varies between them. Quantitative feedback showed sustainable interventions included risk stratification, non-communicable disease (NCD) screening form, referral within clinics and hospitals, family health team (FHT), MTAC services and mechanisms and medical adherence status. Qualitative feedback highlighted implementation of each intervention components comes with its challenges, and most of it are related to inadequate resources and facilities in clinic. HCPs made initiatives to adapt based on clinical setting to implement the interventions at best level possible, whereby this seems to be one of the core values for sustainability.
CONCLUSION: Overall perceptions among HCPs on sustainability of EnPHC interventions are highly influenced by current experiences with existing resources. Components perceived to have inadequate resources are seen as a challenge to sustain. It's crucial for stakeholders to understand implications affecting implementation process if concerns raised are not addressed and allocation of needed resources to ensure overall successfulness and long term sustainability.
BACKGROUND: In 2014, almost two-thirds of Malaysia's adult population aged 18 years or older had T2DM, hypertension or hypercholesterolaemia. An analysis of health system performance from 2016 to 2018 revealed that the control and management of diabetes and hypertension in Malaysia was suboptimal with almost half of the patients not diagnosed and just one-quarter of patients with diabetes appropriately treated. EnPHC framework aims to improve diagnosis and effective management of T2DM, hypertension or hypercholesterolaemia and their risk factors by increasing prevention, optimising management and improving surveillance of diagnosed patients.
METHODS: This is a quasi-experimental controlled study which involves 20 intervention and 20 control clinics in two different states in Malaysia, namely Johor and Selangor. The clinics in the two states were matched and randomly allocated to 'intervention' and 'control' arms. The EnPHC framework targets different levels from community to primary healthcare clinics and integrated referral networks.Data are collected via a retrospective chart review (RCR), patient exit survey, healthcare provider survey and an intervention checklist. The data collected are entered into tablet computers which have installed in them an offline survey application. Interrupted time series and difference-in-differences (DiD) analyses will be conducted to report outcomes.
METHODS: In-depth interviews and focus group discussions were conducted with the intervention design team, healthcare providers and patients in two rounds during the implementation period. A total of 121 individuals in the two rounds, split into different groups, where some of the participants of the FGD were also interviewed individually. Data were analysed using a thematic analysis, with codes being organised into larger themes.
RESULTS: Themes that emerged from the data were around the process of FHT implementation and the advantages of the FHT, which included continuity of health care and improved quality of care. Patients and health care providers were receptive to the FHT concept, and took the effort to adapt the concept in the local settings.
CONCLUSIONS: The FHT concept implemented at 20 public primary health clinics has benefits appreciated by health care providers and patients. Addressing the viable shortcomings would better prepare the current primary healthcare system to scale up the FHT concept nationwide and enhance its feasibility and sustainability.
TRIAL REGISTRATION: The study is registered with the National Medical Research Register, Ministry of Health Malaysia ( NMRR-17-295-34711 ).
OBJECTIVES: To provide an overview of reviews describing task shifts from physicians to allied healthcare workers in primary care and its impact on clinical outcomes.
METHODS: Six electronic databases were searched up to 15 December 2020, to identify reviews describing task shifting in primary care. Two reviewers independently screened the references for relevant studies, extracted the data and assessed the methodological quality of included reviews using AMSTAR-2.
RESULTS: Twenty-one reviews that described task shifting in primary care were included. Task shifted include provision of care for people with chronic conditions, medication prescribing, and health education. We found that task shifting could potentially improve several health outcomes such as blood pressure, HbA1c, and mental health while achieving cost savings. Key elements for successful implementation of task shifting include collaboration among all parties, a system for coordinated care, provider empowerment, patient preference, shared decision making, training and competency, supportive organisation system, clear process outcome, and financing.
CONCLUSION: Evidence suggests that allied healthcare workers such as pharmacists and nurses can potentially undertake substantially expanded roles to support physicians in primary care in response to the changing health service demand. Tasks include providing care to patients, independent prescribing, counselling and education, with comparable quality of care.
METHODS: Using systematic review methodology, 5 databases were searched using keywords relating to adults, CP, and primary care, relating to quantitative studies (January 2000-July 2024). Data was extracted, collated, and analyzed descriptively, with additional meta-analyses to estimate proportion of GP visits.
RESULTS: Fifteen studies were included describing GP access by 6231 adults with CP. The proportion annually accessing a GP was 78% (95% CI = 69%-85%). The frequency of GP access ranged from 1.76 to 11.7 visits per year, increased with advancing age and disability severity. Comorbid intellectual disability and pain also increased GP attendance. Limited data was available reporting healthcare needs prompting GP access, and no interventions were described.
CONCLUSIONS: Advancing age, greater disability severity, comorbid intellectual disability, and pain may prompt increased GP access by adults with CP. Identification of reasons for seeking primary care, and interventions provided are required through data linkage studies to enhance lifespan care.