The Disproportionate Impact of Primary Care Disruption and Telehealth Utilization During COVID-19.

PURPOSE: The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected. METHODS: We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation. RESULTS: Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%). CONCLUSIONS: Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions.

Physician-Level Continuity of Care and Patient Outcomes in All-Payer Claims Database.

INTRODUCTION: Being one of the few existing measures of primary care functions, physician-level continuity of care (Phy-CoC) is measured by the weighted average of patient continuity scores. Compared with the well-researched patient-level continuity, Phy-CoC is a new instrument with limited evidence from Medicare beneficiaries. This study aimed to expand the patient sample to include patients of all ages and all types of insurance and reassess the associations between full panel-based Phy-CoC scores and patient outcomes. METHODS: Cross-sectional analysis at patient-level using Virginia All-Payer Claims Database (VA-APCD). Phy-CoC scores were calculated by averaging patient's Bice-Boxerman Index scores and weighted by the total number of visits. Patient outcomes included total cost and preventable hospitalization. RESULTS: In a sample of 1.6 million Virginians, patients who lived in rural areas or had Medicare as primary insurance were more likely to be attributed to physicians with the highest Phy-CoC scores. Across all adult patient populations, we found that being attributed to physicians with higher Phy-CoC was associated with 7%-11.8% higher total costs, but was not associated with the odds of preventable hospitalization. Results from models with interactions revealed nuanced associations between Phy-CoC and total cost with patient's age and comorbidity, insurance payer, and the specialty of their physician. CONCLUSIONS: In this comprehensive examination of Phy-CoC using all populations from the VA-APCD, we found an overall positive association of higher full panel-based Phy-CoC with total cost, but a non-significant association with the risk of preventable hospitalization. Achieving higher full panel-based Phy-CoC may have unintended cost implications.

Addressing Social Determinants of Health in Family Medicine Practices.

Primary care practices are under pressure to address patients' social determinants of health (SDOH). However, the extent to which these practices have this ability remains unknown. The objective of this study was to examine the association between physician, practice, and community characteristics and the ability of family medicine practices to address patients' SDOH. This cross-sectional study used data from the American Board of Family Medicine Continuing Certification Questionnaire from 2017 to 2019, with a 100% response rate. Respondents rated their practice's ability to address SDOH, which was dichotomized as high or low. Sequential multivariate logistic regression determined the association of the reported ability to address SDOH with physician, practice, and community characteristics. Among 19,300 respondents, 55.6% reported a high ability to address patients' SDOH. Across models controlling for different groups of variables, characteristics persistently positively associated with ability to address SDOH included employment at a federally qualified health center (Odds Ratios [OR] = 2.111-3.012), federally funded clinic (OR = 1.999-2.897), managed care organization (OR = 2.038-2.303), and working collaboratively with a social worker (OR = 2.000-2.523) or care coordinator (OR = 1.482-1.681). Characteristics persistently negatively associated with the ability to address SDOH were practicing at an independently owned (OR = 0.726-0.812) or small practice (OR = 0.512-0.863). While results varied across models, these findings are important for developing evidence-based policies and recommendations for resource sharing and allocation in clinics and communities. Ensuring availability and access to allied health professionals and community resources may be key components in Family Medicine clinics addressing SDOH.

Maternity Access in Rural America: The Role of Family Physicians in Providing Access to Cesarean Sections.

INTRODUCTION: As an increasing number of rural hospitals close their maternity care units, many of the approximately 28 million reproductive-age women living in rural America do not have local access to obstetric services. We sought to describe the characteristics and distribution of cesarean section-providing family physicians who may provide critical services in maintaining obstetric access in rural hospitals. METHODS: Using a cross-sectional study design, we linked data from the 2017 to 2022 American Board of Family Medicine's Continuting Certification Questionnaire on provision of cesarean sections as primary surgeon and practice characteristics to geographic data. Logistic regression determined associations with provision of cesarean sections. RESULTS: Of 28,526 family physicians, 589 (2.1%) provided cesarean sections as primary surgeon. Those who provided cesarean sections were more likely to be male (odds ratio (OR) = 1.573, 95% confidence limits (CL) 1.246-1.986), and work in rural health clinics (OR = 2.157, CL 1.397-3.330), small rural counties (OR = 4.038, CL 1.887-8.642), and in counties without obstetrician/gynecologists (OR = 2.163, CL 1.440-3.250). DISCUSSION: Although few in number, family physicians who provide cesarean sections as primary surgeon disproportionately serve rural communities and counties without obstetrician/gynecologists, suggesting that they provide access to obstetric services in these communities. Policies that support family physician training in cesarean sections and facilitate credentialing of trained family physicians could reverse the trend of closing obstetric units in rural communities and reduce disparities in maternal and infant health outcomes.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act.

PURPOSE: The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA. METHODS: Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation. RESULTS: Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation. CONCLUSIONS: Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Challenges Meeting Training Requirements in the Care of Children in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVE: In 2014, the Accreditation Council for Graduate Medical Education (ACGME) implemented numeric requirements for family medicine (FM) pediatric patient encounters. Impact on residency programs is unclear. We aimed to identify any difficulties faced by FM program directors (PDs) meeting these numeric requirements. METHODS: Questions about pediatric training in family medicine residencies were included in a survey of PDs conducted by the Council of Academic Family Medicine Educational Research Alliance (CERA). We performed univariate analysis of the demographic and program characteristics. We then used χ2 tests of independence to test for bivariate associations between these characteristics and our primary outcome: the most difficult ACGME pediatric care requirement to meet. RESULTS: Most programs reported the hospital as the primary location of training (n=131, 46%) and their family medicine practice (FMP) patient population consisted of over 20% pediatric patients (n=153, 56%). Over 80% of program directors reported challenges meeting FM requirements for the care of children. Challenges meeting pediatric requirements were associated with fewer than 20% FMP patients under 19 years of age (P<.0001), fewer than 50% of core FM faculty caring for sick children (P=.0128), and primary location of pediatric training in a family health center (P=.0006). CONCLUSION: Difficulty meeting ACGME requirements for the care of children in FM residency programs is common, especially for programs with fewer than 20% FMP patients under 19 years of age. Further research is needed to determine how best to assure FM resident competencies in the care of children and adolescents.

A Match Made in Rural: Interpreting Match Rates and Exploring Best Practices.

BACKGROUND AND OBJECTIVES: Although rural family medicine residency programs are effective in placing trainees into rural practice, many struggle to recruit students. Lacking other public measures, students may use residency match rates as a proxy for program quality and value. This study documents match rate trends and explores the relationship between match rates and program characteristics, including quality measures and recruitment strategies. METHODS: Using a published listing of rural programs, 25 years of National Resident Matching Program data, and 11 years of American Osteopathic Association match data, this study (1) documents patterns in initial match rates for rural versus urban residency programs, (2) compares rural residency match rates with program characteristics for match years 2009-2013, (3) examines the association of match rates with program outcomes for graduates in years 2013-2015, and (4) explores recruitment strategies using residency coordinator interviews. RESULTS: Despite increases in positions offered over 25 years, the fill rates for rural programs have improved relative to urban programs. Small rural programs had lower match rates relative to urban programs, but no other program or community characteristics were predictors of match rate. Match rates were not indicative of any of five measures of program quality nor of any single recruiting strategy. CONCLUSIONS: Understanding the intricacies of rural residency inputs and outcomes is key to addressing rural workforce gaps. Match rates likely reflect challenges of rural workforce recruitment generally and should not be conflated with program quality.

Academic Achievement and Competency in Rural and Urban Family Medicine Residents.

BACKGROUND AND OBJECTIVES: The quality of training in rural family medicine (FM) residencies has been questioned. Our objective was to assess differences in academic performance between rural and urban FM residencies. METHODS: We used American Board of Family Medicine (ABFM) data from 2016-2018 residency graduates. Medical knowledge was measured by the ABFM in-training examination (ITE) and Family Medicine Certification Examination (FMCE). The milestones included 22 items across six core competencies. We measured whether residents met expectations on each milestone at each assessment. Multilevel regression models determined associations between resident and residency characteristics milestones met at graduation, FMCE score, and failure. RESULTS: Our final sample was 11,790 graduates. First-year ITE scores were similar between rural and urban residents. Rural residents passed their initial FMCE at a lower rate than urban residents (96.2% vs 98.9%) with the gap closing upon later attempts (98.8% vs 99.8%). Being in a rural program was not associated with a difference in FMCE score but was associated with higher odds of failure. Interactions between program type and year were not significant, indicating equal growth in knowledge. The proportions of rural vs urban residents who met all milestones and each of six core competencies were similar early in residency but diverged over time with fewer rural residents meeting all expectations. CONCLUSIONS: We found small, but persistent differences in measures of academic performance between rural- and urban-trained FM residents. The implications of these findings in judging the quality of rural programs are much less clear and warrant further study, including their impact on rural patient outcomes and community health.

Rural Versus Urban Family Medicine Residency Scope of Training and Practice.

BACKGROUND AND OBJECTIVES: Little is known about how rural and urban family medicine residencies compare in preparing physicians for practice. This study compared the perceptions of preparation for practice and actual postgraduation scope of practice (SOP) between rural and urban residency program graduates. METHODS: We analyzed data on 6,483 early-career, board-certified physicians surveyed 2016-2018, 3 years after residency graduation, and 44,325 later-career board-certified physicians surveyed 2014-2018, every 7 to 10 years after initial certification. Bivariate comparisons and multivariate regressions of rural and urban residency graduates examined perceived preparedness and current practice in 30 areas and overall SOP using a validated scale, with separate models for early-career and later-career physicians. RESULTS: In bivariate analyses, rural program graduates were more likely than urban program graduates to report being prepared for hospital-based care, casting, cardiac stress tests, and other skills, but less likely to be prepared in some gynecologic care and pharmacologic HIV/AIDS management. Both early- and later-career rural program graduates reported broader overall SOPs than their urban-program counterparts in bivariate analyses; in adjusted analyses this difference remained significant only for later-career physicians. CONCLUSIONS: Compared with urban program graduates, rural graduates more often rated themselves prepared in several hospital care measures and less often in certain women's health measures. Controlling for multiple characteristics, only rurally trained, later-career physicians reported a broader SOP than their urban program counterparts. This study demonstrates the value of rural training and provides a baseline for research exploring longitudinal benefits of this training to rural communities and population health.

Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals.

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities.

Exploring the Association Between Physician Continuity of Care and Diagnosing Hypertension.

Context. The American Board of Family Medicine was funded by the Gordon Betty Moore Foundation to study the association between physician continuity of care, a clinical quality measure, and its impact on accurate, timely, efficient, and cost-effective diagnosis of target conditions that contribute to cardiovascular disease. In this exploratory analysis, we used electronic health records data from the PRIME registry to examine the association of continuity with factors leading to a hypertension diagnosis. Objective. 1) to determine the rate and timeliness of hypertension diagnosis, 2) to investigate the number of hypertension-level blood pressure (BP) readings in the 12 months prior to the diagnosis, and 3) to explore the association between physician continuity of care and these variables. Study Design and Population Studied. In this cohort study, we created two patient cohorts. Our prospective cohort consisted of patients who had 2 or more BP readings greater than SBP of 130 or DBP of 80 mm Hg in 2017-2018 and who did not have a hypertension diagnosis prior to the date of the second reading. Our retrospective cohort consisted of patients who had a hypertension diagnosis in 2018-2019. Dataset. Electronic health records extracted from the PRIME registry Outcome Measures. The rate of diagnosis was calculated by dividing the number of patients with a hypertension diagnosis by the number of patients whose BP readings exceeded the thresholds for hypertension per clinical guidelines. We investigated the timeliness of diagnosis by counting the average days between the second reading and the diagnosis dates. We also identified the number of hypertension-level BP readings in the past 12 months for patients diagnosed with hypertension. Results. Of 7,615 eligible patients from 4 pilot practices, the rate of hypertension diagnosis varied from 39.6% (solo practice) to 11.5% (large practice). The average days until diagnosis ranged from 142 days (solo practice) to 247 days (medium practice). Among patients diagnosed with hypertension (n=104,727), 25.7% had 0, 39.8% had 1, 14.7% had 2 and 19.7 had 3 or more hypertension-level BP readings in the 12 months prior to the diagnosis. We found no significant association between physician continuity of care and the rate or timeliness of the hypertension diagnosis. Conclusions. Factors leading to a hypertension diagnosis may be influenced more by other unobserved variables than by physician continuity of care.

Pandemic Disruption in Residency Did Not Alter Trends in Intended Scope of Practice.

We found the intended scope of practice remained unchanged in graduating family medicine residents between pre-pandemic and pandemic period. Tracking these trends with later cohorts will fully assess the pandemics' impact on training so that residencies can adjust their education accordingly.

Family Physician Income Disparities by Race and Gender.

A race and gender salary gap has been well-documented throughout the U.S. economy, but little described in primary care. Using self-reported data on the most widely distributed primary care physician specialty, we reveal lower incomes and hourly wages among Black/African American and female family physicians. The clear gradient in family physician compensation by race and gender demands further study and action to better understand and address the underlying sources of these differences.

Racial/Ethnic Group Trajectory Differences in Exam Performance Among US Family Medicine Residents.

BACKGROUND AND OBJECTIVES: Racial/ethnic score disparities on standardized tests are well documented. Such differences on the American Board of Family Medicine (ABFM) certification examination have not been previously reported. If such differences exist, it could be due to differences in knowledge at the beginning of residency or due to variations in the rate of knowledge acquisition during residency. Our objective was to examine the residents' mean initial scores and score trajectories using the In-Training Examination (ITE) and certification examination. METHODS: A total of 17,275 certification candidates from 2014 to 2019 were included in this study. Annual ITE scores and certification examination scores are reported on the same scale and serve as the outcome. We conducted multilevel longitudinal regression to determine initial knowledge and growth in knowledge acquisition during residency by race/ethnicity categories. RESULTS: The mean postgraduate year 1 (PGY-1) ITE score was 393.3, with minority residents scoring 16.2 to 36.0 points lower compared to White residents. The mean increase per year in exam performance from PGY-1 ITE to the certification exam was 39.9 points (95% CI, 38.7, 41.1) with additional change among race/ethnicity categories per year of -3.2 to 1.9 points. CONCLUSIONS: This study found that there were initial score disparities across race/ethnicity groups in PGY-1, and these disparities continued at the same rate throughout residency training, suggesting equality in acquisition of knowledge during family medicine residency training but with a persistent gap throughout training.

Family Physicians Increasingly Deliver Care in Diverse Languages.

The proportion of family physicians reporting provision of patient care in Spanish changed little between 2013 to 2020 but rose substantially for care delivered in other non-English languages. Physician-patient language concordance is associated with better clinical outcomes and higher patient satisfaction, serves as a proxy indicator for workforce diversity, and should be monitored and encouraged as the US population continues to diversify.

Racial and Ethnic Diversity of Family Physicians Delivering Maternity Care.

BACKGROUND: Maternal and birth outcomes represent some of the most profound racial and ethnic disparities in health in the USA, and are, in part, attributed to a lack of diversity in the maternity care workforce. Family physicians are an often-overlooked part of the maternity care workforce, yet frequently provide care to underserved populations. This study aims to characterize the family physician workforce providing obstetric care in terms of race/ethnicity. METHODS: In this cross-sectional study, we used data collected via the American Board of Family Medicine Exam Registration Questionnaire from 2017 to 2019. Respondents included family physicians seeking to continue their certification in those years. We conducted bivariate tests and an adjusted analysis using logistic regression to examine associations with providing obstetric deliveries. Variables included race, ethnicity, age, gender, degree type, international medical graduate status, practice site, and rurality. RESULTS: Of 20,820 family physicians in our sample, those identifying as Black/African American (OR 0.55, CI 0.41 to 0.74) and Asian (OR 0.40, CI 0.31 to 0.51) had significantly lower odds of including obstetrics in their practice than those identifying as White. We found no significant difference in practicing obstetrics between Hispanic and non-Hispanic family physicians (OR 0.94, CI 0.73 to 1.20). Asian (OR 0.40, CI 0.31 to 0.51) and Black/African American (OR 0.55, CI 0.41 to 0.74) physicians still have significantly lower odds of providing obstetric care than White physicians after controlling for rurality. CONCLUSIONS: Family physicians who identified as Black/African American or Asian are less likely to include obstetrics in their practice. A diverse and racially/ethnically representative maternity care workforce, including family physicians, may help to ameliorate disparities in maternal and birth outcomes. Enhanced efforts to diversify the family physician maternity care workforce should be implemented.

Racial and ethnic disparities in access to primary care during COVID-19.

Context: Early evidence suggests that many patients chose to forgo or delay necessary medical care during the COVID-19 pandemic. Existing and well-documented racial and ethnic disparities in access to care were exacerbated by the pandemic for many reasons, potentially including the additional barriers involved in a rapid shift to telehealth for certain groups of patients. Objectives: 1) Examine changes in primary care visit volume and telehealth during the COVID-19 pandemic. 2) Test for racial and ethnic differences in primary care in-person and telehealth visits during the pandemic relative to pre-pandemic levels. Study design: Longitudinal. Datasets: EHR data including patient visits, procedures, and demographics captured in the American Board of Family Medicine's PRIME Registry. Population studied: 2,966,859 patients seeing 1,477 primary care clinicians enrolled in the PRIME Registry. Outcome measures: 7-day average of weekly visits per clinician, both in-person and telehealth, tracking trends in the volume of care provided before and during the pandemic by patient race/ethnicity. We defined telehealth conversion ratio (TCR) as the number of telehealth visits during the pandemic divided by the total number of pre-pandemic visits. We calculated TCR and visit volume changes from March 15 through the end of 2020 relative to the same period in 2019. Results: During the pandemic we observed decreases of 12% and 22% in the average number of total and in-person visits, respectively, as well as a 10% TCR. Total visits reached a nadir in April 2020 with a 29% decrease from the same point in 2019. Telehealth visits peaked the following week with 23% of that week's total visits, and 139 times more than 2019. Total visits decreased and telehealth visits increased for patients of all races/ethnicities. The magnitude of these changes differed, with Black (5% decline, 15% in-person decline, 10% TCR) and Hispanic (9%, 24%, 15%) patients seeing less of a decrease in total visits than White (12%, 21%, 9%) and Asian (16%, 30%, 14%) patients. Conclusion: Declines in primary care visits during the pandemic were partially offset by an increase in telehealth use. Utilization in our sample suggests less decline in Black and Hispanic patient primary care utilization during the pandemic than expected, in contrast to Asian patients, who demonstrated the largest declines. This metric and these results are novel and foundational for ongoing & further study using other data sources.

rmc-discord: reverse Monte Carlo refinement of diffuse scattering and correlated disorder from single crystals.

A user-friendly program has been developed to analyze diffuse scattering from single crystals with the reverse Monte Carlo method. The approach allows for refinement of correlated disorder from atomistic supercells with magnetic or structural (occupational and/or displacive) disorder. The program is written in Python and optimized for performance and efficiency. Refinements of two user cases obtained with legacy neutron-scattering data demonstrate the effectiveness of the approach and the developed program. It is shown with bixbyite, a naturally occurring magnetic mineral, that the calculated three-dimensional spin-pair correlations are resolved with finer real-space resolution compared with the pair distribution function calculated directly from the reciprocal-space pattern. With the triangular lattice Ba3Co2O6(CO3)0.7, refinements of occupational and displacive disorder are combined to extract the one-dimensional intra-chain correlations of carbonate molecules that move toward neighboring vacant sites to accommodate strain induced by electrostatic interactions. The program is packaged with a graphical user interface and extensible to serve the needs of single-crystal diffractometer instruments that collect diffuse-scattering data.