Perceived Impact of Virtual Visits on Access to Care in Family Medicine During the COVID-19 Pandemic: A Qualitative Study of Benefits and Challenges.

BACKGROUND: The COVID-19 pandemic in 2020 led to the rapid adoption of telemedicine, including virtual visits, to minimize face-to-face contact between clinicians and patients. Family medicine clinics across the nation had to transform how they provided primary care while maintaining the core values of family medicine. The objective of this study was to analyze how family medicine faculty perceived the impact of virtual visits on patient access to care. METHODS: This qualitative study took place in an academic primary care setting. We interviewed clinical faculty who utilized virtual visits about their experiences from June to December 2020. We used qualitative content analysis to evaluate the results of the interviews. RESULTS: The study included a total of 20 participants. The mean age was 43.4 years, and 85% of participants were female. Researchers developed 3 themes, "Logistics of virtual visits," "reigniting the concept of home visits," and "barriers and benefits that affect specific patient populations" that describe how virtual visits have impacted patients' access to care. The results highlight how virtual visits improve access to care by increasing flexibility for patients and providers and provide a new perspective into a patient's home life. Challenges of virtual visits include language barriers, technological issues, and issues unique to vulnerable patient populations. CONCLUSION: Virtual visits can enhance family medicine's ability to provide accessible care, but there are concerns it may worsen health disparities. Further research and quality improvement projects are needed to examine ways to implement innovative care delivery solutions to avoid further exacerbating these disparities.

Cumulative Incidence of All-Cause Knee Injury, Concussion, and Stress Fracture among Transgender Patients on Gender-Affirming Hormone Therapy: An Exploratory Retrospective Cohort Study.

Previous research has shown a discrepancy in incidences of knee injuries, stress fractures, and concussions between cisgender men and women. Little is known regarding the incidence of musculoskeletal injuries among patients on gender-affirming hormone therapy (GAHT). This retrospective cohort study examines cumulative incidence of knee injuries, concussions, and stress fracture injuries among transgender patients on GAHT at one health system from 2011-2020. Using relevant ICD-9 and 10 codes, incidences of knee injury, concussion, and stress fracture were calculated. Cohorts included 1971 transgender and 3964 cisgender patients. Transgender patients had significantly higher incidence of all-cause knee injuries over the study period, 109 (5.5%) versus 175 (4.4%) (p < 0.001; OR: 2.14, 95% CI [1.17-3.92]). Subgroup analysis showed significantly higher incidence of knee injuries among cisgender men (5.6%) versus cisgender women (4.1%) (p = 0.042) and among transgender women (6.6%) versus cisgender women (4.1%) (p = 0.005). There were no significant differences between incidences of concussion and stress fracture between groups. This sample showed that patients on GAHT had increased cumulative incidences of all-cause knee injury compared to controls but similar cumulative incidences of concussion and bone-stress injuries. Transgender women on exogenous estrogen had significantly higher cumulative incidences of all-cause knee injuries compared to cisgender women.

We Cannot Put This Genie Back in the Bottle: Qualitative Interview Study Among Family Medicine Providers About Their Experiences With Virtual Visits During the COVID-19 Pandemic.

BACKGROUND: When a genie is freed from its bottle, things cannot be restored to the way they were before. At the beginning of the global COVID-19 pandemic, health care systems adjusted how they delivered care overnight. Primary care practices switched from seeing patients in person to virtual care applications, including video and phone visits, e-visits, e-consults, and messaging with clinicians. Prior to the pandemic, these applications were not as widely used, but discussions around their advantages and disadvantages in some settings were being explored. Emergency regulatory changes spurred by the pandemic freed this virtual care "genie" from its bottle. Wide-scale adoption of virtual care in family medicine has much potential, as primary care services are often a patient's first point of contact with the health care system. OBJECTIVE: This study aims to analyze family medicine providers' experiences using virtual visits during the pandemic, perceived outcomes of the shift to virtual visits, and discusses its implications for the future of family medicine. METHODS: This qualitative study took place at 3 academic primary care clinics between June and December 2020. Data were collected through one-on-one Zoom (version 5.2.1) interviews with family medicine clinical faculty who experienced the rapid transition of in-person visits to mostly "virtual" visits. The interviews were recorded, deidentified, and transcribed. We adopted a constructivist approach to qualitative content analysis to evaluate the results. RESULTS: In total, 25 participants were eligible, and 20 individuals participated in this study (80% participation rate). The mean age was 43.4 years, and 85% (17/20) of the participants were female. We identified 3 main themes: the care process, patient engagement, and team-based care. CONCLUSIONS: This study highlights the transition from in-person to virtual visits during the pandemic from the perspective of family medicine providers. Generally, family medicine providers' perceptions of the shift to virtual visits were positive, especially regarding team-based care. Challenges involved virtual inhibition, particularly for providers. Providers described ways they integrated virtual care with aspects of in-person care, creating a hybrid environment. The genie is out of the bottle-things will not be the same-but family medicine now has the opportunity to evolve.

Does platelet-rich plasma improve patellar tendinopathy symptoms?

IT'S UNCLEAR. High-quality data have not consistently established the effectiveness of platelet-rich plasma (PRP) injections to improve symptomatic recovery in patellar tendinopathy, compared to placebo (strength of recommendation [SOR]: A, based on 3 small randomized controlled trials [RCTs]). The 3 small RCTs included only 111 patients, total. One found no evidence of significant improvement with PRP compared to controls. The other 2 studies showed mixed results, with different outcome measures favoring different treatment groups and heterogeneous results depending on follow-up duration.

Does Anesthetic Relief Correspond to Future Pain Relief?: A Prospective Trial Examining Future Pain Relief for Ultrasound-Guided Corticosteroid-Anesthetic Injections.

OBJECTIVES: The aim of the study was to prospectively evaluate the association between immediate pain relief from injections of local anesthetic with corticosteroid and subsequent pain relief up to 3 mos. The secondary aim was to examine the time until subjective pain relief after these injections. DESIGN: This was a single-center, prospective study of patients undergoing ultrasound-guided corticosteroid injections for musculoskeletal pain. Subjects completed follow-up surveys at 2 wks, 1 mo, and 3 mos postinjections. χ 2 tests and sensitivity analysis were used to examine the primary outcome, at least 50% relief from the injection. Regression modeling examined the effects of demographic and injection-related variables on outcome measures. RESULTS: A total of 132 patients were enrolled (55% female, mean age 52 yrs). Response rates were 87.1% at 2 wks and 77.2% at 3 mos. The positive likelihood ratios from 50% initial pain relief ranged from 1.22 to 1.29 at the three time points, whereas the negative likelihood ratios ranged from 0.54 to 0.63. More than 75% of participants reported subjective pain relief by day 4 after injection. CONCLUSIONS: The predictive value of immediate pain relief for subsequent longer-term pain relief from corticosteroid-anesthetic injections is not particularly high. Most patients will obtain pain relief within 4 days of a corticosteroid injection.

Which injections are effective for lateral epicondylitis?

Placebo injections actually improve lateral epicondylitis at high rates. No other injections convincingly improve it better than placebo.Corticosteroid injection is not superior to saline or anesthetic injection (strength of recommendation [SOR] A, systematic review of randomized controlled trials [RCTs]). Platelet-rich plasma (PRP) injection is not superior to saline injection (SOR A, meta-analysis of RCTs).Botulinum toxin injection, compared to saline injection, modestly improved pain in lateral epicondylitis, but with short-term grip-strength weakness (SOR A, meta-analysis of RCTs). Prolotherapy injection, compared to saline injection, improved pain at 16-week, but not at 8-week, follow-up (SOR B, one small pilot RCT).Hyaluronic acid injection, compared to saline injection, resulted in a statistically significant pain reduction (6%) but did not achieve the minimum clinically important difference (SOR B, single RCT).Autologous blood injection, compared to saline injection, did not improve disability ratings (SOR B, one small RCT).

Implementing an Anonymous Closed-Loop Feedback Process and Associations With ACGME Annual Survey Scores in a Family Medicine Residency.

BACKGROUND AND OBJECTIVES: The annual Accreditation Council for Graduate Medical Education (ACGME) survey evaluates numerous variables, including resident satisfaction with the training program. We postulated that an anonymous system allowing residents to regularly express and discuss concerns would result in higher ACGME survey scores in areas pertaining to program satisfaction. METHODS: One family medicine residency program implemented a process of quarterly anonymous closed-loop resident feedback and discussion in academic year 2012-2013. Data were tracked longitudinally from the 2011-2019 annual ACGME resident surveys, using academic year 2011-2012 as a baseline control. RESULTS: For the survey item "Satisfied that evaluations of program are confidential," years 2013-2014, 2014-2015, and 2018-2019 showed a significantly higher change from baseline. For "Satisfied that program uses evaluations to improve," year 2018-2019 had a significantly higher percentage change from baseline. For "Satisfied with process to deal with problems and concerns," year 2018-2019 showed significantly higher change. For "Residents can raise concerns without fear," years 2013-2014 and 2018-2019 saw significantly higher changes. CONCLUSIONS: These results suggest that this feedback process is perceived by residents as both confidential and promoting a culture of safety in providing feedback. Smaller changes were seen in residents' belief that the program uses evaluations to improve, and in satisfaction with the process to deal with problems and concerns.

Increasing Chlamydia Testing Rates via Targeted Outreach.

BACKGROUND AND OBJECTIVES: Chlamydia trachomatis is the most prevalent bacterial sexually transmitted infection (STI) in the United States. Annual chlamydia screening of asymptomatic, sexually active women age 16 to 24 years and in older women who are at increased risk for infection is recommended. This study built on prior work in which our university-based family medicine clinic implemented quality improvement (QI) interventions in 2016 and 2017 to increase our chlamydia screening rate. Our primary aim in the current study was to increase the screening rate by 10%. Our secondary aim was to determine the number of patient contacts that yielded maximum test rates. METHODS: For the most recent QI cycle, we conducted a prospective cohort study from December 2017 through March 2018. Using the FOCUS-PDSA model, a resident-led, interdisciplinary QI team developed the aims and implemented an intervention to streamline patient outreach. We also retrospectively analyzed data from the previous QI cycle to determine the number of tests obtained after each patient contact. RESULTS: Chlamydia testing increased from 54% to 56.3% between December 2017 and March 2018. The majority of tests were completed by four patient contacts; additional contacts yielded few additional tests. CONCLUSIONS: Persistent outreach increases chlamydia screening rates. This QI project could be replicated in other clinical settings to improve the screening of chlamydia or other diseases.

Assessing Symptoms in Adolescents Following Sport-Related Concussion: A Comparison of Four Different Approaches.

This study compared post-concussion symptom endorsements on the Post-Concussion Symptom Scale (PCSS) between a clinical open-ended interview, clinician-guided PCSS, parent-report PCSS, and computer-based PCSS in youth athletes with sport-related concussion (SRC). Participants included 54 patients aged 13-17 years (M = 15.19, SD = 1.29, 51.8% male) with a diagnosed SRC seen at a concussion clinic. Participants were administered a computer-based version (COMP) of the PCSS followed by clinical open-ended symptom interview (OPEN) and clinician-guided PCSS (GUIDED). Participants' parents concurrently and independently endorsed their children's symptoms by completing the PCSS in the waiting room (PARENT). Total number of symptoms reported and total symptom severity score were analyzed and compared across the four PCSS administration methods. Results revealed significantly lower total number of symptoms for OPEN compared to GUIDED (p = .002), PARENT (p < .001), and COMP (p = .006); and significantly lower total severity score for OPEN compared to GUIDED (p = .04) and PARENT (p < .001). These data support using the PCSS as a structured method of assessing post-concussion symptoms and question the utility of unstructured interview methods for assessing symptoms in youth athletes with SRC.

Outcomes of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemoperfusion in Patients with High-Grade, High-Volume Disseminated Mucinous Appendiceal Neoplasms.

BACKGROUND: High-grade (HG) mucinous appendiceal neoplasms (MAN) have a worse prognosis than low-grade histology. Our objective was to assess the safety and efficacy of cytoreductive surgery with hyperthermic intraperitoneal chemoperfusion (CRS/HIPEC) in patients with high-grade, high-volume (HG-HV) peritoneal metastases in whom the utility of this aggressive approach is controversial. METHODS: Prospectively collected perioperative data were compared between patients with peritoneal metastases from HG-HV MAN, defined as simplified peritoneal cancer index (SPCI) ≥12, and those with high-grade, low-volume (HG-LV; SPCI <12) disease. Kaplan-Meier curves and multivariate Cox regression models identified prognostic factors affecting oncologic outcomes. RESULTS: Overall, 54 patients with HG-HV and 43 with HG-LV peritoneal metastases underwent CRS/HIPEC. The HG-HV group had longer operative time, increased blood loss/transfusion, and increased intensive care unit length of stay (p < 0.05). Incomplete macroscopic cytoreduction (CC-1/2/3) was higher in the HG-HV group compared with the HG-LV group (68.5 vs. 32.6 %; p = 0.005). Patients with HG-HV disease demonstrated worse survival than those with HG-LV disease (overall survival [OS] 17 vs. 42 m, p = 0.009; time to progression (TTP) 10 vs. 14 m, p = 0.024). However, when complete macroscopic resection (CC-0) was achieved, the OS and progression-free survival of patients with HG-HV disease were comparable with HG-LV disease (OS 56 vs. 52 m, p = 0.728; TTP 20 vs. 19 m, p = 0.393). In a multivariate Cox proportional hazard regression model, CC-0 resection was the only significant predictor of improved survival for patients with HG-HV disease. CONCLUSIONS: Although patients with HG-HV peritoneal metastases from MAN have worse prognosis compared with patients with HG-LV disease, their survival is comparable when complete macroscopic cytoreduction is achieved.

Institutional learning curve of cytoreductive surgery and hyperthermic intraperitoneal chemoperfusion for peritoneal malignancies.

BACKGROUND: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemoperfusion (HIPEC) is routinely used to treat certain peritoneal carcinomatoses (PC), but it can be associated with relatively high complication rates, prolonged hospital length of stay, and potential mortality. Our objective was to determine the learning curve (LC) of CRS/HIPEC in our high-volume institution. METHODS: A total of 370 patients with PC from mucinous appendiceal neoplasms (MAN = 282), malignant peritoneal mesothelioma (MPM = 60), and gastric cancer (GC = 24) were studied. Outcomes analyzed included incomplete cytoreduction (IC), severe morbidity (SM), 60-day mortality, progression-free survival (PFS), and overall survival (OS). Risk-adjusted sequential probability ratio test (RA-SPRT) was employed to assess the LC of CRS/HIPEC for IC and SM using prespecified odds ratio (OR) boundaries derived from previously published data. Risk adjusted-cumulative average probability (RA-CAP) was used to analyze 1-year PFS and 2-year OS. RESULTS: Complete cytoreduction, severe morbidity, and 60-day mortality were 84.2, 30, and 1.9 % respectively. Higher simplified peritoneal cancer index was the major independent risk factor for IC, whereas high-grade histology, IC, and diagnosis of MPM and GC (compared with MAN) were predictors of SM after CRS/HIPEC (p < 0.05). RA-SPRT showed that approximately 180 cases are needed to achieve the lowest risk of IC and SM. Ninety cases were needed to achieve a steady 1-year PFS and 2-year OS in RA-CAP plots. CONCLUSIONS: The completeness of cytoreduction, morbidity, and mortality rates for CRS/HIPEC at our institution are comparable to previously reported data. Approximately 180 and 90 procedures are required to improve operative and oncologic outcomes respectively.