Post-COVID-19 neurologic syndrome: Another legacy of the pandemic.

ABSTRACT: COVID-19 quickly escalated to a global pandemic in 2020. As research on the topic continues, the medical community has found that this acute illness can cause a new chronic illness: postacute sequelae of SARS-CoV-2 (PASC). Some patients with PASC develop predominately neurologic sequelae (post-COVID-19 neurologic syndrome or PCNS). This article describes PASC and PCNS, their proposed pathogenicity and possible neurovirulence mechanisms, symptoms, and treatment recommendations.

Development and Early Experience of a Primary Care Learning Collaborative in a Large Health Care System.

INTRODUCTION: Primary care clinicians are presented with hundreds of new clinical recommendations and guidelines. To consider practice change clinicians must identify relevant information and develop a contextual framework. Too much attention to information irrelevant to one's practice results in wasted resources. Too little results in care gaps. A small group of primary care clinicians in a large health system sought to address the problem of vetting new information and providing peer reviewed context. This was done by engaging colleagues across the system though a primary care learning collaborative. METHODS: The collaborative was a grass roots initiative between community and academic-based clinicians. They invited all the system's primary care clinicians to participate. They selected new recommendations or guidelines and used surveys as the principal communication instrument. Surveys shared practice experience and also invited members to give narrative feedback regarding their acceptance of variation in care relate to the topic. A description of the collaborative along with its development, processes, and evolution are discussed. Process changes to address needs during the COVID-19 pandemic including expanded information sharing was necessary. RESULTS: Collaborative membership reached across 5 states and included family medicine, internal medicine, and pediatrics. Members found involvement with the collaborative useful. Less variation in care was thought important for public health crises: the COVID pandemic and opioid epidemic. Greater practice variation was thought acceptable for adherence to multispecialty guidelines, such as diabetes, lipid management, and adult ADHD care. Process changes during the pandemic resulted in more communications between members to avoid practice gaps. CONCLUSION: An internet-based learning collaborative in a health system had good engagement from its members. Using novel methods, it was able to provide members with feedback related to the importance of new practice recommendations as perceived by their peers. Greater standardization was thought necessary when adopting measures to address public health crisis, and less necessary when addressing multispecialty guidelines. By employing a learning collaborative, this group was able to keep members interested and engaged. During the first year of the COVID pandemic the collaborative also served as a vehicle to share timely information.

One year of COVID: primary care learning experiences in a health system.

Context: Patients and communities consider their primary care clinicians (PCC's) to be their most trusted source of information. During the first 12 months of the COVID pandemic, initially reliable, accurate information was scare, evolving, and at times conflicting. From testing, public health prevention, treatment, and vaccinations clinicians had to learn, apply, and convey this information honestly and openly. Objective: This was a survey of a health system's PCC's after the first year of the pandemic. The objective was to determine the clinical, educational, and advisory roles performed by PCC's and the sources of from which PCC's obtained the information necessary to fulfill these roles. Study Design: An intranet survey was sent to members of the system's primary care learning collaborative. Questions were multiple answer with options for open-ended answers. Setting: Large health system. Population: Learning collaborative membership consisting of physicians, nurse practitioners (NP), and physician assistants (PA). Instrument: Brief intranet survey. Outcome measures: Identify clinical and educational roles for PCC. Results: 192 surveys were sent; 109 responses; 72% physicians, 28% NP/PA. 25 unique clinical roles were identified. Most common: discuss vaccine (94%), work excuse/return to work (88%), outpatient care (87%), virtual assessment for COVID (74%). 14 unique educational or advisory roles were identified; the most common being teaching residents (45%) or students (42%), lecture/discussion on COVID (20%) or vaccines (22%) or advising community groups (18%). Sources of information related to COVID were diverse. When asked to identify the three most relied on sources, system (internal COVID website or disseminated by system) (83%), colleagues (34%), and consultants (33%), were the most common source. CME was the least relied upon (7%). Frequently the system utilized information from CDC, state/local health department information along with national organizations. Conclusions: During the pandemic, primary care clinicians provided a broad array of clinical services, and are a source of information for colleagues, patients, and communities. They rely on a broad array of sources for reliable information, mostly relationship-based, not formal CME. The trusted relationships primary care clinicians have with others throughout their communities was essential in promulgating accurate reliable information during the first year of the pandemic.

Patients' experience with virtual care during COVID-19 pandemic in primary care practice.

Context: The advent of COVID-19 pandemic in March of 2020 galvanized primary care practices into adopting telemedicine to be able to continue delivering care to patients safely. As recipients of care delivered virtually, capturing patients' experience is key to evaluating its success and shortcomings. Objective: To describe patients' experience and perceptions with virtual care during COVID-19 pandemic. Study Design/Population: A survey was distributed to 900 adult patients across primacy care practices in MW Minnesota and Arizona from September through October, 2020. Questions asked included: mode of virtual care received (virtual visit, phone visit, secured patient on-line portal or POL), device used, and likelihood of using virtual care for different visit reasons (acute visit, persistent problem, routine/wellness visit or chronic care). Results: Five hundred ninety surveys (65.5%) were returned. Majority (72%) of responders' experience with virtual care was through use of POL to view test results or messages from their care team; 43% of responders also sought clinic advice though this avenue. Thirty percent (n=177) had phone visits compared to 26% video visits. Those over 64 years had more phone than video visits. This age group which comprised 23 % (n=139) of responders, reported more negative experience with video visits compared to other age groups. Only five percent of all responders had negative experience with POL for clinical communications. Across all age groups, responders were "very likely" to engage in virtual visits for routine/wellness care such as medication refills; those in 30-64 age groups were more likely to utilize virtual visits from mental health and chronic disease care than the younger (18-29 years) and older (65 and up) groups. Interestingly, 84% (n=496) of responders had smart phones and only 28% had computers with video cameras. Conclusion: Patients have varying experiences in virtual care which should be taken into consideration as this method of care delivery becomes more integrated into primary care practice. Majority of patients surveyed had access to smartphones than computers with video camera which creates an opportunity for exploring the use of this modality to expand care delivered through telemedicine.

Does the "office nurse" level of training matter in the family medicine office?

BACKGROUND: The "office nurse" or clinical associate (registered nurse [RN], licensed practical nurse[LPN], or medical assistant [MA]) is a key member of the family medicine care team, but little is known about the influence of their level of training on team performance. METHODS: The performance of the clinical dyad (clinician and associate) was studied in relation to the level of training of the nurse. The dyad's performance was measured by the performance indicators of diabetes scores, patient satisfaction, and productivity. RESULTS: Dyads with a RN scored higher in meeting all 5 of the diabetes quality indicators (27.8%) than those with a LPN (19.3%) or an MA (14.7%). For patient satisfaction, the RN dyads also scored higher than the other dyad groups (positive responses: RN, 96.8%; LPN, 95.5%; MA, 94.6%). Productivity was the same in all groups. Better diabetes performance was seen in those practices with fewer competing demands: nonrural versus rural (22.2% vs 15.1%, respectively), and those not doing obstetrics versus those doing obstetrics (20.3% vs 15.1%, respectively), and for physicians versus associate providers (18.8% vs 15.1%, respectively). Higher patient satisfaction was observed in those dyads who were nonrural verus rural (96.6 vs 94.1%), among those doing obstetrics (96.0% vs 94.9%), and in physicians verus associate providers (95.7% vs 93.2%). The number of years working with the same clinician was twice as high for RNs (6.63) and LPNs (6.57) than for MAs (3.29). CONCLUSIONS: A higher level of education of the clinical associate seems to confer skills that enhance the care team's management of chronic illness such as diabetes. This could potentially decrease the practice burden on other team members while facilitating the team's objectives in meeting quality indicators.

How many problems do family physicians manage at each encounter? A WReN study.

PURPOSE: The number of problems managed concurrently by family physicians during patient encounters has not been fully explored despite the implications for quality assessment, guideline implementation, education, research, administration, and funding. Our study objective was to determine the number of problems physicians report managing at each visit and compare that with the number reflected in the chart and the bill. METHODS: Twenty-nine members of the Wisconsin Research Network reported on encounters with 572 patients using a physician problem log. The patient chart notes and the diagnoses submitted for billing from the encounters were compared with the information in these logs. RESULTS: The physicians reported managing an average of 3.05 problems per encounter and recorded 2.82 in the chart and 1.97 on the bill. For all patients, 37% of encounters addressed more than 3 problems, and 18% addressed more than 4. For patients older than 65 years, there was an average of 3.88 problems at each visit, and for diabetic patients there was an average of 4.60. There was evidence for the selective omission of mental health and substance problems from the diagnoses used for billing. CONCLUSIONS: Family medicine involves the concurrent care of multiple problems, which billing data do not adequately reflect. Our findings suggest a mismatch between family medicine and current approaches to quality assessment, guideline implementation, education, research, administration, and funding. Activities in all these areas need to address the physician's task of prioritizing and integrating care for multiple problems concurrently.