Relationships Matter: Primary Care Physicians and Usual Sources of Care.

There are benefits to having a primary care physician or a usual source of care. Adults with a primary care physician have higher rates of preventive care, have improved communication with their care team, and receive more attention to social needs.1-3 Yet, not all individuals have equitable access to a primary care physician. The overall percentage of U.S. patients who reported having a usual source of care declined from 84% in 2000 to 74% in 2019, with wide variations across states, patient race, and insurance status.

An Estimate of the US Rate of Overuse of Screening Colonoscopy: a Systematic Review.

BACKGROUND: This study aims to assess the rate at which screening colonoscopy is performed on patients younger or older than the age range specified in national guidelines, or at shorter intervals than recommended. Such non-indicated use of the procedure is considered low-value care, or overuse. This study is the first systematic review of the rate of non-indicated completed screening colonoscopy in the USA. METHODS: PubMed and Embase were queried for relevant studies on overuse of screening colonoscopy published from January 1, 2002, until January 23, 2019. English-language studies that were conducted for screening colonoscopy after 2001 for average-risk patients were included. Studies must have followed national guidelines for detecting rates of overuse. We followed methods outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the reporting recommendations of the Meta-analysis of Observational Studies in Epidemiology group (MOOSE). RESULTS: A total of 772 papers were reviewed for inclusion; 42 were reviewed in full text. Of those reviewed, six studies met eligibility criteria, including a total of 459,503 colonoscopies of which 242,756 were screening colonoscopies. The rate of overuse ranged credibly from 17 to 25.7%. DISCUSSION: This study demonstrates that screening colonoscopy is regularly performed in the USA more often, and in populations older or younger, than recommended by national guidelines. Such overuse wastes resources and places patients at unnecessary risk of harm. Efforts to reduce non-indicated screening colonoscopy are needed.

Using State All-Payer Claims Data to Identify the Active Primary Care Workforce: A Novel Study in Virginia.

PURPOSE: Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association's Masterfile, but these data have limitations that overestimate the workforce. METHODS: We present a pragmatic, systematic, and more accurate method for identifying primary care physicians using the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD). Between 2015 and 2019, we identified all Virginia physicians and their specialty through the NPPES. Active physicians were defined by at least 1 claim in the VA-APCD. Specialty was determined hierarchically by the NPPES. Wellness visits were used to identify non-family medicine physicians who were providing primary care. RESULTS: In 2019, there were 20,976 active physicians in Virginia, of whom 5,899 (28.1%) were classified as providing primary care. Of this primary care physician workforce, 52.4% were family medicine physicians; the remaining were internal medicine physicians (18.5%), pediatricians (16.8%), obstetricians and gynecologists (11.8%), and other specialists (0.5%). Over 5 years, the counts and relative percentages of the workforce made up by primary care physicians remained relatively stable. CONCLUSIONS: Our novel method of identifying active physicians with a primary care scope provides a realistic size of the primary care workforce in Virginia, smaller than some previous estimates. Although the method should be expanded to include advanced practice clinicians and to further delineate the scope of practice, this simple approach can be used by policy makers, payers, and planners to ensure adequate primary care capacity.

Health Equity: The Only Path Forward for Primary Care.

The 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report on Implementing High-Quality Primary Care identifies 5 high-level objectives regarding payment, access, workforce development, information technology, and implementation. Nine junior primary care leaders (3 internal medicine, 3 family medicine, 3 pediatrics) invited from broad geographies, practice settings, and academic backgrounds used appreciative inquiry to identify priorities for the future of primary care. Highlighting the voices of these early career clinicians, we propose a response to the report from the perspective of early career primary care physicians. Health equity must be the foundation of the future of primary care. Because Barbara Starfield's original 4 Cs (first contact, coordination, comprehensiveness, and continuity) may not be inclusive of the needs of under-resourced communities, we promote an extension to include 5 additional Cs: convenience, cultural humility, structural competency, community engagement, and collaboration. We support the NASEM report's priorities and its focus on achieving health equity. We recommend investing in local communities and preparatory programs to stimulate diverse individuals to serve in health care. Finally, we support a blended value-based care model with risk adjustment for the social complexity of our patients.Appeared as Annals "Online First" article.

Practice facilitation to promote evidence-based screening and management of unhealthy alcohol use in primary care: a practice-level randomized controlled trial.

BACKGROUND: Unhealthy alcohol use is the third leading cause of preventable death in the United States. Evidence demonstrates that screening for unhealthy alcohol use and providing persons engaged in risky drinking with brief behavioral and counseling interventions improves health outcomes, collectively termed screening and brief interventions. Medication assisted therapy (MAT) is another effective method for treatment of moderate or severe alcohol use disorder. Yet, primary care clinicians are not regularly screening for or treating unhealthy alcohol use. METHODS AND ANALYSIS: We are initiating a clinic-level randomized controlled trial aimed to evaluate how primary care clinicians can impact unhealthy alcohol use through screening, counseling, and MAT. One hundred and 25 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be engaged; each will receive practice facilitation to promote screening, counseling, and MAT either at the beginning of the trial or at a 6-month control period start date. For each practice, the intervention includes provision of a practice facilitator, learning collaboratives with three practice champions, and clinic-wide information sessions. Clinics will be enrolled for 6-12 months. After completion of the intervention, we will conduct a mixed methods analysis to identify changes in screening rates, increase in provision of brief counseling and interventions as well as MAT, and the reduction of alcohol intake for patients after practices receive practice facilitation. DISCUSSION: This study offers a systematic process for dissemination and implementation of the evidence-based practice of screening, counseling, and treatment for unhealthy alcohol use. Practices will be asked to implement a process for screening, counseling, and treatment based on their practice characteristics, patient population, and workflow. We propose practice facilitation as a robust and feasible intervention to assist in making changes within the practice. We believe that the process can be replicated and used in a broad range of clinical settings; we anticipate this will be supported by our evaluation of this approach. TRIAL REGISTRATION: ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT04248023, Registered 5 February 2020.

Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership.

BACKGROUND: Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022. METHODS: Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed. RESULTS: 526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001). The percent of practices reporting any major stressor increased from 34% to 53% (P < .0001). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician (P < .0001). CONCLUSIONS: Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care.

Screening for Unhealthy Alcohol Use Among Patients With Multiple Chronic Conditions in Primary Care.

Introduction: Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions. Methods: The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services' chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force-recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years. Results: Within a final cohort of n=11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force-recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; p=0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force-recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; p=0.0014 and 95% CI=1.2, 1.8; p=0.0003). Conclusions: Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force-recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.

Practice Facilitation to Address Unhealthy Alcohol Use in Primary Care: A Cluster Randomized Clinical Trial.

Importance: Unhealthy alcohol use (UAU) is the fourth most preventable cause of death in the US. The US Preventive Services Task Force recommends that primary care clinicians routinely screen all adults 18 years and older for UAU; however, this preventive service is poorly implemented. Objective: To determine if practice facilitation improved delivery of the recommended care for UAU compared to usual care. Design, Setting, and Participants: This practice-level cluster randomized clinical trial was conducted across diverse and representative primary care practices throughout Virginia. A total of 76 primary care practices enrolled between October 2019 and January 2023. Intervention: Practices received immediate (intervention) or 6-month delayed (control) practice facilitation, which included tailored educational sessions, workflow management, and tools for addressing UAU. Main Outcomes and Measures: Outcomes included the increase in recommended screening for UAU, brief interventions, referral for counseling, and medication treatment. Data were collected via medical record review (structured and free text data) and transcripts of practice facilitator sessions and exits interviews. Results: Of the 76 primary care practices enrolled, 32 were randomized to intervention and 35 to control; 11 789 patients (mean [SD] age, 50.1 [16.3] years; 61.1% women) were randomly selected for analysis, with patient demographics similar to Virginia at large. From baseline to 6 months after intervention, screening with a validated instrument increased from 2.1% (95% CI, 0.5%-8.4%) to 35.5% (95% CI, 11.5%-69.9%) in the intervention group compared to 0.4% (95% CI, 0.1%-1.8%) to 1.4% (95% CI, 0.3%-5.8%) in the control group (P < .001). Brief office-based interventions for the intervention group increased from 26.2% (95% CI, 14.2%-45.8%) to 62.6% (95% CI, 43.6%-78.3%) vs 45.5% (95% CI, 28.0%-64.1%) to 55.1% (95% CI, 36.5%-72.3%) in the control group (P = .008). Identification of UAU, referral for counseling, and medication treatment had similar changes for both groups. Qualitative analyses of transcripts revealed that few clinicians understood the preventive service prior to practice facilitation, but at the end most felt much more competent and confident with screening and brief intervention for UAU. Conclusions and Relevance: This cluster randomized clinical trial demonstrated that practice facilitation can help primary care practices to better implement screening and counseling for UAU into their routine workflow. Effective primary care practice implementation interventions such as this can have a profound effect on the health of communities. Given the number of people that the participating practices care for, this intervention resulted in an additional 114 604 patients being screened annually for UAU who would not have been otherwise. Trial Registration: ClinicalTrials.gov Identifier: NCT04248023.

Concordance of Primary Human Papillomavirus Testing Among Clinicians and Patients: A Systematic Review.

Objective: Primary high risk human papilloma virus (hrHPV) testing is recommended as first-line screening for cervical cancer. Testing involves either a clinician-collected or a self-collected cervicovaginal swab. This study examines concordance between methods of collection of primary HPV testing. Methods: Ovid MEDLINE, Ovid Embase, and Cochrane were searched for relevant studies on self-collected and clinician-collected primary HPV testing published before December 31, 2022. English-language studies for primary HPV testing of average-risk patients were included. Studies conducted in screening settings rather than colposcopy clinics, that used standard devices for HPV collection, and that directly compared methods of collection were included. Outcomes were concordance and kappa between paired samples, and rate of HPV detection in self-collected and clinician-collected samples. Results: A total of 2381 studies were screened, of which 228 were included for full-text evaluation. Thirty-six studies, including 23,328 individuals screened, met the inclusion criteria. The rate of HPV detection ranged from 4.7% to 63% for self-collection and from 3.7% to 62% for clinician-collection. The concordance ranged from 78.2% to 96.9%, and kappa had substantial agreement for 26 of the 36 studies and moderate agreement for 7 of the 36 studies. Conclusions: This study directly compares clinician-collected and self-collected primary HPV screening rates. Studies were conducted in methods which are widely reproducible in the primary care setting. Primary HPV self-collection is a reliable and accurate method for cervical cancer screening.

An Estimate of Severe Harms Due to Screening Colonoscopy: A Systematic Review.

OBJECTIVE: This study aims to comprehensively assess the direct, severe harms of screening colonoscopy in the United States. Whereas other investigators have completed systematic reviews estimating the harms of all types of colonoscopy, this analysis focuses on screening colonoscopies that had adequate follow up to avoid undercounting delayed harms. DATA SOURCES: PubMed and Embase were queried for relevant studies on screening colonoscopy harms published between January 1, 2002, and April 1, 2022. STUDY SELECTION: English-language studies of screening colonoscopy for average risk patients were included. Studies must have followed patients for adequate time post procedure, defined as 30 days after colonoscopy. MAIN OUTCOMES: The primary outcome was the number of severe bleeding events and gastrointestinal (GI) perforations within 30 days of screening colonoscopy. RESULTS: A total of 1951 studies were reviewed for inclusion; 94 were reviewed in full text. Of those reviewed in full, 6 studies, including a total of 467,139 colonoscopies, met our inclusion criteria and were included in our analysis of harms related to screening colonoscopies. The rate of severe bleeding ranged credibly from 16.4 to 36.18 per 10,000 colonoscopies; the rate of perforation ranged credibly from 7.62 to 8.50 per 10,000 colonoscopies. CONCLUSIONS: This study is the first to estimate direct harms from screening colonoscopy, including harms that occur up to 30 days after the procedure. The risk of harm subsequent to screening colonoscopy is higher than previously reported and should be discussed with patients when engaging in shared decision making.

Use of population health data to promote equitable recruitment for a primary care practice implementation trial addressing unhealthy alcohol use.

Background: Recruiting underrepresented people and communities in research is essential for generalizable findings. Ensuring representative participants can be particularly challenging for practice-level dissemination and implementation trials. Novel use of real-world data about practices and the communities they serve could promote more equitable and inclusive recruitment. Methods: We used a comprehensive primary care clinician and practice database, the Virginia All-Payers Claims Database, and the HealthLandscape Virginia mapping tool with community-level socio-ecological information to prospectively inform practice recruitment for a study to help primary care better screen and counsel for unhealthy alcohol use. Throughout recruitment, we measured how similar study practices were to primary care on average, mapped where practices' patients lived, and iteratively adapted our recruitment strategies. Results: In response to practice and community data, we adapted our recruitment strategy three times; first leveraging relationships with residency graduates, then a health system and professional organization approach, followed by a community-targeted approach, and a concluding approach using all three approaches. We enrolled 76 practices whose patients live in 97.3% (1844 of 1907) of Virginia's census tracts. Our overall patient sample had similar demographics to the state for race (21.7% vs 20.0% Black), ethnicity (9.5% vs 10.2% Hispanic), insurance status (6.4% vs 8.0% uninsured), and education (26.0% vs 32.5% high school graduate or less). Each practice recruitment approach uniquely included different communities and patients. Discussion: Data about primary care practices and the communities they serve can prospectively inform research recruitment of practices to yield more representative and inclusive patient cohorts for participation.

Reallocating Cervical Cancer Preventive Service Spending from Low- to High-Value Clinical Scenarios.

Timely follow-up care after an abnormal cervical cancer screening test result is critical to the prevention and early diagnosis of cervical cancer. The current inadequate and inequitable delivery of these potentially life-saving services is attributed to several factors, including patient out-of-pocket costs. Waiving of consumer cost-sharing for follow-up testing (e.g., colposcopy and related cervical services) is likely to improve access and uptake, especially among underserved populations. One approach to defray the incremental costs of providing more generous coverage for follow-up testing is reducing expenditures on "low-value" cervical cancer screening services. To explore the potential fiscal implications of a policy that redirects cervical cancer screening resources from potentially low- to high-value clinical scenarios, we analyzed 2019 claims from the Virginia All-Payer Claims Database to quantify (i) total spending on low-value cervical cancer screening and (ii) out-of-pocket costs associated with colposcopy and related cervical services among commercially insured Virginians. In a cohort of 1,806,921 female patients (ages 48.1 ± 24.8 years), 295,193 claims for cervical cancer screening were reported, 100,567 (34.0%) of which were determined to be low-value ($4,394,361 total; $4,172,777 for payers and $221,584 out-of-pocket [$2/patient]). Claims for 52,369 colposcopy and related cervical services were reported ($40,994,016 total; $33,457,518 for payers and $7,536,498 out-of-pocket [$144/patient]). These findings suggest that reallocating savings incurred from unnecessary spending to fund more generous coverage of necessary follow-up care is a feasible approach to enhancing cervical cancer prevention equity and outcomes. PREVENTION RELEVANCE: Out-of-pocket fees are a barrier to follow-up care after an abnormal cervical cancer screening test. Among commercially insured Virginians, out-of-pocket costs for follow-up services averaged $144/patient; 34% of cervical cancer screenings were classified as low value. Reallocating low-value cervical cancer screening expenditures to enhance coverage for follow-up care can improve screening outcomes. See related Spotlight, p. 363.

The Current State of Alcohol Screening and Management in Virginia Primary Care Practices: An Evaluation of Preventive Service Use.

The US Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling for adults over 18 years for unhealthy alcohol use. Recommended screening instruments include the Alcohol Use Disorders Identification Test-Concise and or Single Alcohol Screening Question. Behavioral counseling is feasible in primary care, taking on average 30 minutes. Baseline data for a practice facilitation trial demonstrated clinicians appropriately screened only 10.8% of patients and only identified 9.6% as having risky drinking. Yet, 24% of patients reported risky drinking on a survey, demonstrating the implementation gap of the USPSTF recommendation and opportunity to improve health.

Primary Care: A Critical Stopgap of Mental Health Services During the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic resulted in a worsening mental health crisis, while also dramatically reducing access to in-person primary care services. Primary care, an essential provider of mental health services, rapidly adopted telemedicine to address behavioral health needs. Here we examine the provision of mental health services by primary care during the pandemic, including the essential use of telemedicine. METHODS: Data were collected via a series of national, cross-sectional surveys of primary care clinicians in November 2020 by the Larry A. Green Center. The survey was distributed through a network of partner organizations and subscribers. Descriptive and chi squared analysis were utilized. RESULTS: Among 1,472 respondents, 88% reported increased mental health needs and 37% reported higher rates of substance use among patients. Most (65%) clinicians became more involved in providing mental health support, and 64% reported using telemedicine to provide behavioral health services. Phone-based care was more common for care delivery among patients who were uninsured (60% vs 42%, P < .01), Medicare beneficiaries (45% vs 36%, P < .05), non-English speaking (67% vs 40%, P < .001), and racial and ethnic minorities (58% vs 34%, P < .001). CONCLUSIONS: Primary care is a leading provider of mental health services and has played a critical role during the pandemic. Primary care clinicians have strong relationships with their patients as well as outreach within communities that may otherwise struggle to access mental health services. The use of telemedicine in primary care, and specifically phone-based services, has been an essential tool to providing equitable access to mental health services.

Women's Health and Gender-Specific Considerations.

Women's health is largely influenced by cultural beliefs, local traditions, and access to care across the world. Immigrant and refugee women experience health in varied ways; prior experiences with health care and beliefs about health should be explored with women on their arrival to the United States. Topics that should be discussed include menstrual practices, contraception and beliefs about family planning, prior screening for preventable diseases, pregnancies and experiences with childbirth, sexual assault and trauma, and history of traditional practices, including female genital mutilation (dependent on area of origin).

Stakeholder input on a care planning tool to address unhealthy behaviors, mental health needs, and social risks: The value of different stakeholder perspectives.

This report describes how stakeholder groups informed a web-based care planning tool's development for addressing root causes of poor health. Stakeholders included community members (n = 6), researchers (n = 6), community care providers (n = 9), and patients (n = 17). Feedback was solicited through focus groups, semi-structured interviews, and user experience observations and then qualitatively analyzed to identify themes. Each group contributed a unique perspective. Researchers wanted evidence-based content; community members and providers focused on making goals manageable; patients wanted care team support and simple action-oriented language. Our findings highlight the benefits of stakeholder input. Blending perspectives from multiple groups results in a more robust intervention design.

Understanding the Value of the Wellness Visit: A Descriptive Study.

INTRODUCTION: Clinical preventive services can reduce mortality and morbidity, but Americans receive only half of the recommended care. Although wellness visits protect time for clinicians to review needs and discuss care with patients, studies have not shown that having a wellness visit improves health outcomes. This study seeks to understand the types of discussions and volume of care delivered during wellness visits. METHODS: Using a sample of 1,008 patients scheduled for a wellness visit from 22 primary care clinicians across 3 states from 2018 to 2019, electronic health records were reviewed, and a subset of visits was audio recorded. The discussion and delivery of clinical preventive services, as recommended by the U.S. Preventive Services Task Force, were measured, and new diagnoses were identified from the clinical preventive services. Analyses were completed in 2020. RESULTS: Even though patients were up to date with 80% of the recommended clinical preventive services 3 months after the visit, only 0.5% of patients were up to date with all the recommended clinical preventive services. On average, 6.9 clinical preventive service discussions occurred during each wellness visit on the basis of electronic health records review, and 7.7 clinical preventive services discussions occurred on the basis of audio recordings. An average of 0.4 new diagnoses was identified, including cancer diagnoses, cardiovascular risks, and infections. CONCLUSIONS: Wellness visits are an important time for patients and clinicians to discuss prevention strategies and to deliver recommended clinical preventive services, leading to the identification of previously unrecognized diagnoses. This will improve patients' health. Policies and incentives that promote wellness visits are important, and efforts are needed to deliver them to those most in need.