Telemedicine Adoption During COVID-19 Pandemic: Perspectives from Primary Care Clinicians in Safety-Net Settings.

OBJECTIVE: The objective of this study is to describe the facilitators and barriers of telemedicine during the COVID-19 pandemic for primary care clinicians in safety-net settings. METHODS: We selected 5 surveys fielded between September 2020 and March 2023 from the national "Quick COVID-19 Primary Care Survey" by the Larry A. Green Center, with the Primary Care Collaborative. We used an explanatory sequential mixed method approach. We compared safety-net practices (free & charitable organization, federally qualified health center (FQHC), clinics with a 50% or greater Medicaid) to all other settings. We discuss: 1) telemedicine services provided; 2) clinician motivations; 3) and telemedicine access. RESULTS: All clinicians were similarly motivated to implement telemedicine. Safety-net clinicians were more likely to report use of phone visits. These clinicians felt less "confident in my use of telemedicine" (covariate-adjusted OR = 0.611, 95% CI 0.43 - 0.87) and were more likely to report struggles with televisits in March 2023 (covariate-adjusted OR = 1.73, 95% CI 1.16 - 2.57), particularly with physical examinations. Safety-net clinicians were more likely to endorse reductions in no-shows (covariate-adjusted OR = 1.77, 95% CI 1.17 - 2.68). Telemedicine increased access and new patient-facing demands including portal communications. CONCLUSIONS: This study enhances our understanding of the use of telemedicine within the safety-net setting. Clinician perceptions are important for identifying barriers to telemedicine following the end of the Federal COVID-19 Public Health Emergency. Clinicians highlighted significant limitations to its use including clinical appropriateness, quality of physical examinations, and added patient-facing workload.

You Cannot Function in "Overwhelm": Helping Primary Care Navigate the Slow End of the Pandemic.

GOAL: This study was developed to explicate underlying organizational factors contributing to the deterioration of primary care clinicians' mental health during the COVID-19 pandemic. METHODS: Using data from the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good's national survey of primary care clinicians from March 2020 to March 2022, a multidisciplinary team analyzed more than 11,150 open-ended comments. Phase 1 of the analysis happened in real-time as surveys were returned, using deductive and inductive coding. Phase 2 used grounded theory to identify emergent themes. Qualitative findings were triangulated with the survey's quantitative data. PRINCIPAL FINDINGS: The clinicians shifted from feelings of anxiety and uncertainty at the start of the pandemic to isolation, lack of fulfillment, moral injury, and plans to leave the profession. The frequency with which they spoke of depression, burnout, and moral injury was striking. The contributors to this distress included crushing workloads, worsening staff shortages, and insufficient reimbursement. Consequences, both felt and anticipated, included fatigue and demoralization from the inability to manage escalating workloads. Survey findings identified responses that could alleviate the mental health crisis, namely: (1) measuring and customizing workloads based on work capacity; (2) quantifying resources needed to return to sufficient staffing levels; (3) promoting state and federal support for sustainable practice infrastructures with less administrative burden; and (4) creating patient visits of different lengths to rebuild relationships and trust and facilitate more accurate diagnoses. PRACTICAL APPLICATIONS: Attention to clinicians' mental health should be rapidly directed to on-demand, confidential mental health support so they can receive the care they need and not worry about any stigma or loss of license for accepting that help. Interventions that address work-life balance, workload, and resources can improve care, support retention of the critically important primary care workforce, and attract more trainees to primary care careers.

Is primary care ready for a potential new public health emergency in the wake of the COVID-19 pandemic, now subsided?

INTRODUCTION: The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity. METHODS: From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions. RESULTS: An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had. CONCLUSION: These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs.

Telemedicine in Primary Care: Lessons Learned About Implementing Health Care Innovations During the COVID-19 Pandemic.

PURPOSE: During the COVID-19 pandemic, telemedicine emerged as an important tool in primary care. Technology and policy-related challenges, however, revealed barriers to adoption and implementation. This report describes the findings from weekly and monthly surveys of primary care clinicians regarding telemedicine during the first 2 years of the pandemic. METHODS: From March 2020 to March 2022, we conducted electronic surveys using convenience samples obtained through social networking and crowdsourcing. Unique tokens were used to confidentially track respondents over time. A multidisciplinary team conducted quantitative and qualitative analyses to identify key concepts and trends. RESULTS: A total of 36 surveys resulted in an average of 937 respondents per survey, representing clinicians from all 50 states and multiple specialties. Initial responses indicated general difficulties in implementing telemedicine due to poor infrastructure and reimbursement mechanisms. Over time, attitudes toward telemedicine improved and respondents considered video and telephone-based care important tools for their practice, though not a replacement for in-person care. CONCLUSIONS: The implementation of telemedicine during COVID-19 identified barriers and opportunities for technology adoption and highlighted steps that could support primary care clinics' ability to learn, adapt, and implement technology.

Measuring Primary Care Across 35 OECD Countries.

PURPOSE: To examine the psychometric properties and scores of the Person-Centered Primary Care Measure (PCPCM) in 28 languages and 35 Organisation for Economic Co-operation and Development (OECD) countries. METHODS: Using a paid online sampling service, we requested age- and sex-representative samples of 360 adults in each country. We administered the Person-Centered Primary Care Measure-a previously validated 11-item, patient-reported measure that was developed using what patients and clinicians said is most important about primary care. We also assessed construct validity through associations with demographics, the Patient-Enablement Instrument, number of years the person had been with their primary care physician and practice, whether the patient thought the doctor knowing the results would improve their care, and whether it was hard to complete the survey. We assessed the psychometric properties of the PCPCM in each country and report the summative and item-specific PCPCM scores for each country. RESULTS: The PCPCM exhibited solid psychometric properties across all languages and countries, with Cronbach's alphas ranging from 0.88 to 0.95, and corrected item-total correlations ranging from 0.47 to 0.81, with the vast majority of countries ranging from the low 0.50s to the high 0.70s. Multiple analyses showed strong evidence of concurrent validity. With a potential range from a low of 1 to a high of 4, the overall mean score was 2.74, with a standard deviation of 0.19. Mean PCPCM scores ranged from the lowest in Sweden (2.28) to the highest in Turkey (3.08), with Germany ranking second (3.01), and the United States third (2.99). CONCLUSION: The internal consistency and concurrent validity of the PCPCM across multiple countries provides strong evidence of the coherence of the breadth of primary care functions that patients and clinicians say are important. The diversity of total and item-specific scores across countries provokes interesting hypotheses about the influence of each different country's policies, practices, demographics, and culture on primary care, and provides a strong impetus for further ecological and individual data analyses using the Person-Centered Primary Care Measure. Annals "Online First" article.

Low-Intensity Intervention Supports Diabetes Registry Implementation: A Cluster-Randomized Trial in the Ambulatory Care Outcomes Research Network (ACORN).

BACKGROUND: Previous research demonstrated that registries are effective for improving clinical guideline adherence for the care of patients with type 2 diabetes. However, registry implementation has typically relied on intensive support (such as practice facilitators) for practice change and care improvement. OBJECTIVE: To determine whether a remotely delivered, low-intensity organizational change intervention supports implementation and use of diabetes registries in primary care. DESIGN: Cluster-randomized controlled effectiveness trial of providing limited external support leveraging internal practice resources and problem-solving capacities for driving diabetes registry implementation in 32 practices in Virginia. INTERVENTION: All practices identified local implementation champions who participated in an in-person education session on the value and use of diabetes registries, while intervention practices were also paired with peer mentors and had access to a physician informaticist, who worked remotely to assist practices with implementation. MAIN MEASURES: Practice champions reported progress on registry implementation milestone achievement, and reported practice-level organizational capacity by using a modified version of the Assessment of Chronic Illness Care (ACIC). KEY RESULTS: Intervention practices were significantly more likely to have implemented a registry (44% vs 6%, P = .04) and to have achieved more implementation milestones (5.5 vs 2.6, P < .0001) than control practices. Baseline ACIC scores indicated room for organizational improvement with regard to chronic illness care (overall median, 6.4; range, 3.8 to 10.8) and clinical information systems use (median, 6.0; range, 0 to 11) with no significant differences between intervention and control practices. CONCLUSIONS: Remotely provided guidance paired with limited in-person assistance can support rapid implementation of diabetes registries in typical primary care practices.

Coyote (Canis latrans) in South America: potential routes of colonization.

During the last century, the coyote (Canis latrans) has increased its distribution in Central America. Before the 1980s, it had not been recorded in Panama. New records show that coyotes have crossed the Panama Canal, indicating that continues to expand; therefore, there is a possibility that it will reach northern South America. Our objectives were to identify potential coyote colonization routes to South America, and the variables that favor its expansion. We hypothesized that habitat fragmentation benefits coyote expansion. We applied 7 algorithms to model the potential distribution of the coyote, using 196 presence records and 12 variables. The models with better performance were used to generate a consensus model. Using our consensus model and the areas with highest probability of presence, a potential colonization route was generated between Central America and northern South America. This route lies through southern Costa Rica, along the Pacific coast of Panama to the south, to the Andean mountains in northern Colombia. The variables that explained potential coyote distribution were human population density, altitude, and percentage of crops with positive influence, and tropical broadleaf forests with negative influence. These results indicate that human activities and deforestation are related to coyote distribution expansion. Actions can be implemented within the identified route to improve environmental management, in order to avoid the presence of the coyote in the ecosystems of northern South America.

What Is the Impact on Rural Area Residents When the Local Physician Leaves?

BACKGROUND AND OBJECTIVES: Scarce evidence exists in the medical literature describing the attitudes of rural community residents about the impact of losing their local physician. This pilot study explores aspects of access to care, both within and outside of primary care settings, that result from loss of a rural family physician. METHODS: We selected study participants through convenience and snowball sampling, and we conducted in-person interviews of up to 60 minutes. We audio recorded and transcribed the interviews (May to August, 2018), then analyzed transcripts using immersion crystallization and managed within Atlas.ti 7.0 software (Berlin, Germany). RESULTS: We interviewed 18 participants, some of whom interviewed as pairs. Our analysis revealed three significant themes: rurally-specific access to care concerns, relationships valued for being both community and care based, and loss felt specific to the integrated community leadership roles occupied by family physicians. In addition, participants identified social challenges they associated with losing their "country doctor," such as withering community cohesion. CONCLUSIONS: Our findings suggest that rural physicians offer tremendous value to their communities, both inside and beyond their clinic walls. Issues of social cohesion and local health leadership affected by physician loss should be addressed by policy makers and educators charged with designing patient-centered solutions to improve health outcomes in rural communities. Current health and medical education reforms would benefit from greater focused attention on these issues.

A New Comprehensive Measure of High-Value Aspects of Primary Care.

PURPOSE: To develop and evaluate a concise measure of primary care that is grounded in the experience of patients, clinicians, and health care payers. METHODS: We asked crowd-sourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts in a 2½ day international conference to provide additional insights. A multidisciplinary team conducted a qualitative analysis of the combined data to develop a parsimonious set of patient-reported items. We evaluated items using factor analysis, Rasch modeling, and association analyses among 2 online samples and 4 clinical samples from diverse patient populations. RESULTS: The resulting person-centered primary care measure parsimoniously represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, advocacy, community context, comprehensiveness, continuity, coordination, family context, goal-oriented care, health promotion, integration, and relationship. Principal axes factor analysis identified a single factor. Factor loadings and corrected item-total correlations were >0.6 in online samples (n = 2,229) and >0.5 in clinical samples (n = 323). Factor scores were fairly normally distributed in online patient samples, and skewed toward higher ratings in point-of-care patient samples. Rasch models showed a broad spread of person and item scores, acceptable item-fit statistics, and little item redundancy. Preliminary concurrent validity analyses supported hypothesized associations. CONCLUSIONS: The person-centered primary care measure reliably, comprehensively, and parsimoniously assesses the aspects of care thought to represent high-value primary care by patients, clinicians, and payers. The measure is ready for further validation and outcome analyses, and for use in focusing attention on what matters about primary care, while reducing measurement burden.