Literature Collection

BACKGROUND: Intrinsic capacity (IC) co-exists with frailty and multimorbidity in primary care and guidelines recommend screening for IC and frailty to improve health outcomes. To inform effective implementation of such screening, this study aimed to understand the association between IC and frailty, and the discriminative ability of IC for frailty in older adults with multimorbidity. METHOD: A cross-sectional study was conducted across three primary care clinics from August to October 2022. The participants were multimorbid older adults who had the triad of diabetes mellitus, hypertension and hyperlipidemia and who could walk independently. Data collected included sociodemographic factors, Integrated Care Older People Screening Tool (ICOPE), social vulnerability, chronic conditions, functional impairment, modified Frailty Phenotype (mFP), and Clinical Frailty Scale (CFS). Multinomial logistic regression was used to assess the association between IC and frailty while area under the curve of the receiver operating characteristic (AUC-ROC), sensitivity, specificity, and false positive result were used to assess the discriminative ability of IC for frailty. RESULTS: 411 participants were included in the study and the mean age was 69.9 (± 6.2) years. 11.9% of the participants were mFP frail while 7.5% were CFS frail, and almost all the participants (98.0%) had reduced IC. Higher composite IC score was associated with reduced odds of frailty (OR 0.39 (mFP) and OR 0.45 (CFS), p ≤ 0.05). The IC domains associated with frailty depended on the frailty measure used and socio-cultural factors. An IC cut-off score of 2 had AUC-ROC, sensitivities, specificities, and false positive results of 0.72, 59.2%, 77.9% and 22.1% respectively for mFP; and 0.74, 61.3%, 76.3% and 23.7% respectively for CFS. CONCLUSIONS: In a primary care population with multimorbidity, IC screening inadequately discriminates for frailty and functional impairment with insufficient sensitivity and high false positive results. In view of the very high prevalence of IC losses, IC screening followed by frailty screening of selected patients with IC losses may not be feasible and other approaches should be considered to optimise screening.

BACKGROUND: Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care. OBJECTIVE: To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs). DESIGN: As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted. PARTICIPANTS: Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine. APPROACH: Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework. KEY RESULTS: Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment. CONCLUSIONS: Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.