Primary Care Enhanced Access Services and the Association With Nonurgent Pediatric Emergency Department Utilization and Child Opportunity Index.

OBJECTIVES: This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits. METHODS: We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles. RESULTS: We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores. CONCLUSIONS: Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.

Pediatric Primary Care Clinicians' Perspectives on Telemedicine Use, 2020 Versus 2021.

Objective: We examined the change in pediatric primary care clinician attitudes and perceptions about telemedicine after one year of telemedicine use. Methods: We administered a survey to pediatric primary care clinicians across 50 primary care practices in Pennsylvania in 2020 and 2021. Surveys were linked using a combination of deterministic and probabilistic matching. We used McNemar's test to compare change in responses from 2020 to 2021. Results: Among pediatric primary care clinicians surveyed in 2020 and 2021 (n = 101), clinicians agreed that telemedicine could always or usually deliver high-quality care for mental health (80% in 2020 and 78% in 2021), care coordination (77% in 2020 and 70% in 2021), acute care (33% in 2020 and 34% in 2021), or preventive care (25% in 2020 and 18% in 2021) and this did not significantly change. Clinician perceptions of usability, while high, declined over time with fewer endorsing ease of use (93% in 2020 and 80% in 2021) and reliability (14% in 2020 and 0% in 2021) over time. Despite this, 62% of clinicians agreed that they were satisfied with their use of telemedicine at both time points. Respondents anticipated positive impact on equity and timeliness of care from telemedicine use but did not anticipate positive impact across child health, health care delivery, or clinician experience. Perceptions across these domains did not change over time. Conclusions: With one year of telemedicine experience, primary care clinicians maintained beliefs that telemedicine could deliver high-quality care for specific clinical needs but had worsening perceptions of usability over time.

Access to What for Whom? How Care Delivery Innovations Impact Health Equity.

Achieving health equity (where every person has the opportunity to attain their full health potential) requires the removal of obstacles to health, including barriers to high-quality medical care. Innovations in service delivery can inadvertently maintain, worsen, or introduce inequities. As such, implementation of innovations must be accompanied by a dual commitment to evaluate impact on marginalized groups and to restructure systems that obstruct people from health and healthcare. Understanding the impact innovations have on access to high-quality care is central to this effort. In this Perspective, we join conceptual models of healthcare access and quality with health equity frameworks to conceptualize healthcare receipt as a series of interactions between people and systems unfolding over time. This synthesized model is applied to illustrate the effects of telemedicine on patient, population, and system outcomes. Telemedicine may improve or worsen health equity by altering access to care and by altering quality of care once it is accessed. Teasing out these varied effects is complex and requires considering multilevel influences on the outcome of a care-seeking episode. This synthesized model can be used to inform research, practice, and policy surrounding the equity implications of care delivery innovations more broadly.

Scheduled and attended pediatric primary care telemedicine appointments during COVID-19.

BACKGROUND: The aim of this study was to examine pediatric primary care telemedicine visit scheduling and attendance during the first year of telemedicine. METHODS: Using electronic health record data from two academic pediatric primary care practices between April 2020-March 2021, we used Pearson χ2 tests and logistic regression models to identify child-, family-, and appointment-level characteristics associated with scheduled and attended telemedicine appointments. RESULTS: Among 5178 primary care telemedicine appointments scheduled during the 12-month period, the proportion of appointments scheduled differed over time for children in families with a language preference other than English or Spanish (4% quarter 1 vs. 6% in quarter 4, p = 0.01) and residing in ZIP codes with the lowest household technology access (24% in quarter 1 vs. 19% in quarter 3 (p = 0.01). Four thousand one hundred and forty-eight of 5178 scheduled telemedicine appointments were attended. Likelihood of attending a telemedicine appointment was highest for children in families with a language preference other than English or Spanish (90%, 95% CI 86-94% compared to Spanish 74%, 95% CI 65-84%), and same-day appointments (86%, 95% CI 85-87%). Attendance among families preferring Spanish language was higher in later months compared to earlier months. CONCLUSIONS: We found disparities in scheduling and attending telemedicine appointments, but signs of greater language equity over time.

General and subspecialist pediatrician perspectives on barriers and strategies for referral: a latent profile analysis.

BACKGROUND: Children in need of pediatric subspecialty care may encounter multiple barriers, and multiple strategies have been suggested to improve access. The purpose of this study was to describe the perceptions of general and subspecialty pediatric physicians regarding barriers to subspecialty care and the value of strategies to improve subspecialty access. METHODS: We surveyed a national sample of 1680 general pediatricians and pediatric subspecialists in May and June 2020 regarding 11 barriers to subspecialty care and 9 strategies to improve access to subspecialty care, selected from recent literature. Using latent profile analysis, respondents were grouped according to the degree to which they believed each of the barriers impacted access to subspecialty care. Using chi-squared tests, we compared the profiles based on respondent characteristics and perspectives on strategies to improve access. RESULTS: The response rate was 17%. In 263 responses completed and eligible for inclusion, the barriers most frequently described as "major problems" were wait times (57%), lack of subspecialists (45%) and difficulty scheduling (41%). Respondents were classified into 4 profiles: "Broad concerns," "Subspecialist availability concerns," "Clinician communication concerns," and "Few concerns." These profiles varied significantly by respondent specialty (p < .001, with medical subspecialists overrepresented in the "Clinician communication" profile, psychiatrists in the "subspecialist availability" profile, and surgeons in the "few concerns" profile); and by respondents' typical wait time for appointments (p < .001, with physicians with the longest wait times overrepresented in the "subspecialist availability" profile). CONCLUSIONS: We found specific profiles in clinician views regarding barriers to subspecialty care which were associated with perspectives on strategies aimed at overcoming these barriers. These results suggest that health systems aiming to improve subspecialty access should first identify the barriers and preferences specific to local clinicians.

Parent-Reported Use of Pediatric Primary Care Telemedicine: Survey Study.

BACKGROUND: Telemedicine delivered from primary care practices became widely available for children during the COVID-19 pandemic. OBJECTIVE: Focusing on children with a usual source of care, we aimed to examine factors associated with use of primary care telemedicine. METHODS: In February 2022, we surveyed parents of children aged ≤17 years on the AmeriSpeak panel, a probability-based panel of representative US households, about their children's telemedicine use. We first compared sociodemographic factors among respondents who did and did not report a usual source of care for their children. Among those reporting a usual source of care, we used Rao-Scott F tests to examine factors associated with parent-reported use versus nonuse of primary care telemedicine for their children. RESULTS: Of 1206 respondents, 1054 reported a usual source of care for their children. Of these respondents, 301 of 1054 (weighted percentage 28%) reported primary care telemedicine visits for their children. Factors associated with primary care telemedicine use versus nonuse included having a child with a chronic medical condition (87/301, weighted percentage 27% vs 113/753, 15%, respectively; P=.002), metropolitan residence (262/301, weighted percentage 88% vs 598/753, 78%, respectively; P=.004), greater internet connectivity concerns (60/301, weighted percentage 24% vs 116/753, 16%, respectively; P=.05), and greater health literacy (285/301, weighted percentage 96% vs 693/753, 91%, respectively; P=.005). CONCLUSIONS: In a national sample of respondents with a usual source of care for their children, approximately one-quarter reported use of primary care telemedicine for their children as of 2022. Equitable access to primary care telemedicine may be enhanced by promoting access to primary care, sustaining payment for primary care telemedicine, addressing barriers in nonmetropolitan practices, and designing for lower health-literacy populations.

Patient and Family Factors Associated with Use of Telemedicine Visits for Pediatric Acute Respiratory Tract Infections, 2018-2019.

Background: Pediatric acute respiratory tract infections (ARTIs) were a common reason for commercial direct-to-consumer (DTC) telemedicine use before the COVID-19 pandemic, but the factors associated with this use are unknown. Objective: To identify child and family factors associated with use of commercial DTC telemedicine for ARTIs in 2018-2019. Methods: We performed a retrospective cohort analysis of claims data from the Optum Clinformatics® Data Mart Database. Among children with ARTI visits, we fitted logit models to examine child and family characteristics associated with DTC telemedicine use. Results: Of 660,725 children with ARTI visits, 12,944 (2.0%) had ≥1 commercial DTC telemedicine encounter. The odds of DTC telemedicine use were higher for children with age ≥12 years, lower parent educational attainment, higher household income, white non-Hispanic race/ethnicity, and residency in the West South Central census division. Conclusion: In 2018-2019, commercial DTC telemedicine use varied with child age, child race/ethnicity parent educational attainment, household income, and geography.

Use of and Attitudes About Telelactation Services among New Parents.

Background: We conducted a national, cross-sectional survey among new parents to explore use and acceptability of telelactation. Methods: Recruitment occurred between October 2021 and January 2022 on Ovia's parenting mobile phone application. Poststratification survey weights were used, and logistic and linear regression models estimated associations between demographics and telelactation use. Results: Among 1,617 respondents, 33.8% had at least one telelactation visit. Odds of any telelactation visit(s) were greater for parents who gave birth in 2021 versus 2019 (odds ratio [OR]: 1.69, 95% confidence interval [CI]: 1.26-2.25), insured by Medicaid (OR: 1.43, 95% CI: 1.02-2.02), and younger parents (OR: 2.07, 95% CI: 1.32-3.34). In total, 56.0% agreed that they would be comfortable breastfeeding over video to get help, and 27.6% agreed that lactation support over video is as good as in-person support. Conclusions: Telelactation is increasingly common and acceptable to many parents.

School Nurse Perspectives on Addressing Chronic Absenteeism.

Chronic absenteeism is associated with poor health and educational outcomes. School nurses have great potential to address the health and educational needs that contribute to absenteeism. Through qualitative analysis of interviews with school nurses, we characterize their current role in reducing absenteeism and identify barriers 3 that limit their capacity to meet this goal, organized by the Framework for 21st Century School Nursing Practice. Interviewees (n = 23) identified actions perceived to reduce absenteeism aligned with domains of care coordination, leadership, quality improvement, and community and public health. Barriers perceived to limit the capacity of school nurses to address absenteeism were identified within these domains and ranged from student- and family-level to federal-level barriers. Specific healthcare system-level barriers included insufficient communication with community-based healthcare teams and the need for coordinated approaches across health and education sectors to address absenteeism. Strategic opportunities exist to address barriers to comprehensive school nursing practice and reduce absenteeism.

Healthcare Experiences of Gender Diverse Youth Across Clinical Settings.

We explored gender diverse youth's experiences seeking and receiving gender-affirming care in various health system locations. Results provide evidence for system-, clinic-, and provider-level improvements to promote the development of affirming environments and to improve health outcomes for gender diverse youth.

Perceived Usefulness of Increased Telemedicine Use by Pediatric Subspecialists: A National Survey.

Introduction: Although many studies have explored the perceived ease-of-use of telemedicine, the perceived usefulness of telemedicine for pediatric subspecialty care is less clear. Methods: We invited a national sample of 840 general pediatricians and 840 pediatric subspecialists to participate in a survey fielded in May-June 2020. Respondents ranked perceptions of usefulness of telemedicine for pediatric subspecialty care on a 5-point Likert scale and prioritization of potential strategies to support telemedicine use on a 4-point scale. Results: Of 285 respondents (18% response rate), physicians perceived that increased telemedicine use by pediatric subspecialists would modestly improve child health (mean = 3.5, standard deviation [SD] = 0.7), and access to care (mean = 3.9, SD = 0.6), but would slightly worsen the clinician experience (mean = 2.8, SD = 0.8). Most respondents highly prioritized payment-related strategies to support use of telemedicine. Conclusions: Pediatric clinicians anticipated that increased telemedicine use by pediatric subspecialists would improve child health and health care access but would worsen clinician experience.

Association of a Clinician's Antibiotic-Prescribing Rate With Patients' Future Likelihood of Seeking Care and Receipt of Antibiotics.

BACKGROUND: One underexplored driver of inappropriate antibiotic prescribing for acute respiratory illnesses (ARI) is patients' prior care experiences. When patients receive antibiotics for an ARI, patients may attribute their clinical improvement to the antibiotics, regardless of their true benefit. These experiences, and experiences of family members, may drive whether patients seek care or request antibiotics for subsequent ARIs. METHODS: Using encounter data from a national United States insurer, we identified patients <65 years old with an index ARI urgent care center (UCC) visit. We categorized clinicians within each UCC into quartiles based on their ARI antibiotic prescribing rate. Exploiting the quasi-random assignment of patients to a clinician within an UCC, we examined the association between the clinician's antibiotic prescribing rate to the patients' and their spouses' rates of ARI antibiotic receipt in the subsequent year. RESULTS: Across 232,256 visits at 736 UCCs, ARI antibiotic prescribing rates were 42.1% and 80.2% in the lowest and highest quartile of clinicians, respectively. Patient characteristics were similar across the four quartiles. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics (+3.0 fills/100 patients (a 14.6% difference), 95% CI 2.2-3.8, P < 0.001,) versus those seen by the lowest-prescribing clinicians. The increase in antibiotics was also observed among the patients' spouses. The increase in patient ARI antibiotic prescriptions was largely driven by an increased number of ARI visits (+5.6 ARI visits/100 patients, 95% CI 3.6-7.7, P < 0.001), rather than a higher antibiotic prescribing rate during those subsequent ARI visits. CONCLUSIONS: Receipt of antibiotics for an ARI increases the likelihood that patients and their spouses will receive antibiotics for future ARIs.

Low-Value Diagnostic Imaging in Children with Medicaid.

OBJECTIVES: To estimate rates and settings of low-value imaging among pediatric Medicaid beneficiaries and estimate the associated expenditures. STUDY DESIGN: Retrospective longitudinal cohort study from 2014 to 2016 of children <18 years enrolled in Pennsylvania Medicaid. Outcomes were rates of low-value imaging for 5 conditions identified by diagnosis codes, healthcare settings of imaging performance, and cost based on paid amounts. RESULTS: Of the 645 767 encounters for the 5 conditions, there were 37 525 (5.8%) low-value imaging services. Per 1000 encounters, there were 246.0 radiographs for bronchiolitis, 174.0 head computed tomography (CT) studies for minor head trauma, 155.0 and 33.3 neuroimaging studies for headache and simple febrile seizure, respectively, and 19.5 abdominal CT scans (without prior ultrasound examination) for abdominal pain. Rates of low-value imaging were highest in non-Hispanic White children and those in rural areas. In adjusted analysis, non-Hispanic White children were more likely to receive a CT scan for abdominal pain, and Black children were more likely to have imaging for bronchiolitis and minor head trauma. For individual conditions, up to 87.9% of low-value imaging (CT scan for minor head trauma) was in the emergency department (ED), with most imaging across all conditions occurring in nonpediatric EDs, up to 42.2% was in the outpatient setting (neuroimaging for headache), and up to 20.7% was during inpatient encounters (neuroimaging for febrile seizure). Outpatient and ED low-value imaging resulted in more than $7 million in Medicaid expenditures. CONCLUSIONS: Among the studied conditions, more than 1 in 20 encounters included low-value imaging, mostly in nonpediatric EDs and for bronchiolitis, head trauma, and headache. Interventions are needed to decrease the future performance of these low-value services.

Pediatric non-urgent emergency department visits and prior care-seeking at primary care.

BACKGROUND: We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits. METHODS: We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics. RESULTS: Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit. CONCLUSIONS: Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.

Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016.

Background: Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline. Objective: To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. Design: Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends. Setting: National, population-based. Participants: Adult health plan members aged 18 to 64 years. Measurements: PCP visit rates per 100 member-years. Results: In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%). Limitation: Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions. Conclusion: Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care. Primary Funding Source: None.

Parent Perspectives on Family-Centered Pediatric Electronic Consultations: Qualitative Study.

BACKGROUND: Electronic consultations, which use store-and-forward transfer of clinical information between a primary care physician and a specialist, improve access to specialty care. Adoption of electronic consultations is beginning in pediatric health care systems, but little is known about parent perspectives, informational needs, and preferences for interaction with this new model of care. OBJECTIVE: This study aimed to examine parent perspectives about electronic consultations, including perceived benefits and risks, anticipated informational needs, and preferences for parent engagement with electronic consultations. METHODS: We recruited caregivers of pediatric patients (aged 0-21 years) attending visits at an academic primary care center. Caregivers were eligible if their child had ever been referred for in-person specialty care. Caregivers participated in a semistructured interview about electronic consultations, including general perspectives, desired information, and preferences for parental engagement. Interviews were transcribed and qualitatively analyzed to identify parent perspectives on electronic consultations in general, information parents would like to receive about electronic consultations, and perspectives on opportunities to enhance parent engagement with electronic consultations. RESULTS: Interviewees (n=20) anticipated that electronic consultations would reduce the time burden of specialty care on families and that these had the potential to improve the integrity and availability of clinical information, but interviewees also expressed concern about data confidentiality. The most detailed information desired by interviewees about electronic consultations related to data security, including data confidentiality, availability, and integrity. Interviewees expressed concern that electronic consultations could exclude parents from their child's health care decisions. Interviewees saw value in the potential ability to track the consultation status or to participate in the consultation dialogue, but they were more ambivalent about the idea of read-only access to consultation documentation. CONCLUSIONS: Parents identified the potential risks and benefits of pediatric electronic consultations, with implications for communication with families about electronic consultations and for incorporation of features to enhance parent engagement.

Practice-Level Variation in Telemedicine Use in a Pediatric Primary Care Network During the COVID-19 Pandemic: Retrospective Analysis and Survey Study.

BACKGROUND: Telehealth, the delivery of health care through telecommunication technology, has potential to address multiple health system concerns. Despite this potential, only 15% of pediatric primary care clinicians reported using telemedicine as of 2016, with the majority identifying inadequate payment for these services as the largest barrier to their adoption. The COVID-19 pandemic led to rapid changes in payment and regulations surrounding telehealth, enabling its integration into primary care pediatrics. OBJECTIVE: Due to limited use of telemedicine in primary care pediatrics prior to the COVID-19 pandemic, much is unknown about the role of telemedicine in pediatric primary care. To address this gap in knowledge, we examined the association between practice-level telemedicine use within a large pediatric primary care network and practice characteristics, telemedicine visit diagnoses, in-person visit volumes, child-level variations in telemedicine use, and clinician attitudes toward telemedicine. METHODS: We analyzed electronic health record data from 45 primary care practices and administered a clinician survey to practice clinicians. Practices were stratified into tertiles based on rates of telemedicine use (low, intermediate, high) per 1000 patients per week during a two-week period (April 19 to May 2, 2020). By practice tertile, we compared (1) practice characteristics, (2) telemedicine visit diagnoses, (3) rates of in-person visits to the office, urgent care, and the emergency department, (4) child-level variation in telemedicine use, and (5) clinician attitudes toward telemedicine across these practices. RESULTS: Across pediatric primary care practices, telemedicine visit rates ranged from 5 to 23 telemedicine visits per 1000 patients per week. Across all tertiles, the most frequent telemedicine visit diagnoses were mental health (28%-36% of visits) and dermatologic (15%-28%). Compared to low telemedicine use practices, high telemedicine use practices had fewer in-person office visits (10 vs 16 visits per 1000 patients per week, P=.005) but more total encounters overall (in-office and telemedicine: 28 vs 22 visits per 1000 patients per week, P=.006). Telemedicine use varied with child age, race and ethnicity, and recent preventive care; however, no significant interactions existed between these characteristics and practice-level telemedicine use. Finally, clinician attitudes regarding the usability and impact of telemedicine did not vary significantly across tertiles. CONCLUSIONS: Across a network of pediatric practices, we identified significant practice-level variation in telemedicine use, with increased use associated with more varied telemedicine diagnoses, fewer in-person office visits, and increased overall primary care encounter volume. Thus, in the context of the pandemic, when underutilization of primary care was prevalent, higher practice-level telemedicine use supported pediatric primary care encounter volume closer to usual rates. Child-level telemedicine use differed by child age, race and ethnicity, and recent preventive care, building upon prior concerns about differences in access to telemedicine. However, increased practice-level use of telemedicine services was not associated with reduced or increased differences in use, suggesting that further work is needed to promote equitable access to primary care telemedicine.

National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015.

PURPOSE: Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice-including the use and content of primary care visits-may have contributed. METHODS: We analyzed nationally representative data of adult visits to primary care physicians (PCPs) and physician practice characteristics from 2007-2016 (National Ambulatory Medical Care Survey). United States census estimates were used to calculate visits per capita. Measures included visit rates per person year; visit duration; number of medications, diagnoses, and preventive services per visit; percentage of visits with scheduled follow-up; and percentage of physicians with practice capabilities including an electronic medical record (EMR). RESULTS: Our weighted sample represented 3.2 billion visits (83,368 visits, unweighted). Visits per capita declined by 20% (-0.25 visits per person, 95% CI, -0.32 to -0.19) during this time, while visit duration increased by 2.4 minutes per visit (95% CI, 1.1-3.8). Per visit, PCPs addressed 0.30 more diagnoses (95% CI, 0.16-0.43) and 0.82 more medications (95% CI, 0.59-1.1), and provided 0.24 more preventive services (95% CI, 0.12-0.36). Visits with scheduled PCP followup declined by 6.0% (95% CI, -12.4 to 0.46), while PCPs reporting use of EMR increased by 44.3% (95% CI, 39.1-49.5) and those reporting use of secure messaging increased by 60.9% (95% CI, 27.5-94.3). CONCLUSION: From 2008 to 2015, primary care visits were longer, addressed more issues per visit, and were less likely to have scheduled follow-up for certain patients and conditions. Meanwhile, more PCPs offered non-face-to-face care. The decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non-face-to-face care.

Validation of use of billing codes for identifying telemedicine encounters in administrative data.

BACKGROUND: Telemedicine is the use of telecommunication technology to remotely provide healthcare services. Evaluation of telemedicine use often relies on administrative data, but the validity of identifying telemedicine encounters in administrative data is not known. The objective of this study was to assess the accuracy of billing codes for identifying telemedicine use. METHODS: In this retrospective study of encounters within a large integrated health system from January 2016 to December 2017, we examined the accuracy of billing codes for identifying live-interactive and store-and-forward telemedicine encounters compared to manual chart review. To further examine external validity, we applied these codes and assessed patient and visit characteristics for identified live-interactive telemedicine encounters and store-and-forward telemedicine encounters in a second data set. RESULTS: In manual review of 390 encounters, 75 encounters were live-interactive telemedicine and 158 were store-and-forward telemedicine. In weighted analysis, the presence of the GT modifier in the absence of the GQ modifier or CPT code 99444 yielded 100% sensitivity and 99.99% specificity for identification of live-interactive telemedicine encounters. The presence of either the GQ modifier or the CPT code 99444 had 100% sensitivity and 100% specificity for identification of store-and-forward telemedicine encounters. Applying these algorithms to a second data set (n = 5,917,555) identified telemedicine encounters with expected patient and visit characteristics. CONCLUSIONS: These findings provide support for use of CPT codes to perform telemedicine research in administrative data, aiding ongoing work to understand the role of non-face-to-face care in optimizing health care delivery.

Telelactation via Mobile App: Perspectives of Rural Mothers, Their Care Providers, and Lactation Consultants.

Background: Rural-urban disparities exist in breastfeeding rates and availability of lactation support. Direct-to-consumer (DTC) telelactation that uses two-way video through personal devices has the potential to increase access to international board-certified lactation consultants (IBCLCs) in rural settings that lack them. This study describes the feasibility and acceptability of DTC telelactation for rural mothers.Methods: We conducted semi-structured interviews among various stakeholders involved in a study exploring the impact of telelactation through mobile phone app in rural Pennsylvania. Interviewees included mother participants assigned to receive telelactation (n = 17), IBCLCs employed by the telelactation vendor (n = 7), and nurses (n = 2) and physicians (n = 1) caring for mother participants at the recruitment hospital. Thematic content analysis was used to analyze qualitative data.Results: Interviewees reported that telelactation was convenient and efficient, provided a needed service in rural areas lacking breastfeeding support services, and increased maternal breastfeeding confidence. Telelactation was noted to have several advantages over in-person and telephone-based support. Barriers to use included maternal reluctance to conduct video calls with an unknown provider, preference for community-based breastfeeding resources, and technical issues including limited WiFi in rural areas.Conclusions: Among rural women who experience inequitable access to qualified breastfeeding support resources, DTC telelactation appears to be an acceptable delivery model for lactation assistance.