Virtual Care: Perspectives From Family Physicians.

BACKGROUND: During the COVID-19 pandemic, virtual care expanded rapidly at Michigan Medicine and other health systems. From family physicians' perspectives, this shift to virtual care has the potential to affect workflow, job satisfaction, and patient communication. As clinics reopened and care delivery models shifted to a combination of in-person and virtual care, the need to understand physician experiences with virtual care arose in order to improve both patient and provider experiences. This study investigated Michigan Medicine family medicine physicians' perceptions of virtual care through qualitative interviews to better understand how to improve the quality and effectiveness of virtual care for both patients and physicians. METHODS: We employed a qualitative descriptive design to examine physician perspectives through semistructured interviews. We coded and analyzed transcripts using thematic analysis, facilitated by MAXQDA (VERBI) software. RESULTS: The results of the analysis identified four major themes: (a) chief concerns that are appropriate for virtual evaluation, (b) physician perceptions of patient benefits, (c) focused but contextually enriched patient-physician communication, and (d) structural support needed for high-quality virtual care. CONCLUSIONS: These findings can help further direct the discussion of how to make use of resources to improve the quality and effectiveness of virtual care.

Identifying Inequities in Video and Audio Telehealth Services for Primary Care Encounters During COVID-19: Repeated Cross-Sectional, Observational Study.

BACKGROUND: The COVID-19 pandemic resulted in rapid changes in how patient care was provided, particularly through the expansion of telehealth and audio-only phone-based care. OBJECTIVE: The goal of this study was to evaluate inequities in video and audio-only care during various time points including the initial wave of the COVID-19 pandemic, later stages of the pandemic, and a historical control. We sought to understand the characteristics of care during this time for a variety of different groups of patients that may experience health care inequities. METHODS: We conducted a retrospective analysis of electronic health record (EHR) data from encounters from 34 family medicine and internal medicine primary care clinics in a large, Midwestern health system, using a repeated cross-sectional, observational study design. These data included patient demographic data, as well as encounter, diagnosis, and procedure records. Data were obtained for all in-person and telehealth encounters (including audio-only phone-based care) that occurred during 3 separate time periods: an initial COVID-19 period (T2: March 16, 2020, to May 3, 2020), a later COVID-19 period (T3: May 4, 2020, to September 30, 2020), and a historical control period from the previous year (T1: March 16, 2019, to September 30, 2019). Primary analysis focused on the status of each encounter in terms of whether it was completed as scheduled, it was canceled, or the patient missed the appointment. A secondary analysis was performed to evaluate the likelihood of an encounter being completed based on visit modality (phone, video, in-person). RESULTS: In total, there were 938,040 scheduled encounters during the 3 time periods, with 178,747 unique patients, that were included for analysis. Patients with completed encounters were more likely to be younger than 65 years old (71.8%-74.1%), be female (58.8%-61.8%), be White (75.6%-76.7%), and have no significant comorbidities (63.2%-66.8%) or disabilities (53.2%-61.1%) in all time periods than those who had only canceled or missed encounters. Effects on different subpopulations are discussed herein. CONCLUSIONS: Findings from this study demonstrate that primary care utilization across delivery modalities (in person, video, and phone) was not equivalent across all groups before and during the COVID-19 pandemic and different groups were differentially impacted at different points. Understanding how different groups of patients responded to these rapid changes and how health care inequities may have been affected is an important step in better understanding implementation strategies for digital solutions in the future.

Equity in virtual care: A mixed methods study of perspectives from physicians.

BACKGROUND: Virtual care expanded rapidly during the COVID-19 pandemic, and how this shift affected healthcare disparities among subgroups of patients is of concern. Racial and ethnic minorities, older adults, individuals with less education, and lower-income households have lower rates of home broadband, smartphone ownership, and patient portal adoption, which may directly affect access to virtual care. Because primary care is a major access point to healthcare, perspectives of primary care providers are critical to inform the implementation of equitable virtual care. OBJECTIVE: The aim of this mixed methods study was to explore primary care physician experiences and perceptions of barriers and facilitators to equitable virtual care. DESIGN: We used an explanatory sequential mixed methods design, which consists of first collecting and analyzing quantitative survey data, then using those results to inform a qualitative follow-up phase to explain and expand on results. PARTICIPANTS: Primary care physicians in a family medicine department at an academic medical center responded to surveys (n = 38) and participated in interviews (n = 16). APPROACH: Participants completed a survey concerning frequency and preferences about video visits, pros and cons of video visits, communication aspects, and sufficiency of the technology. A purposeful sample of participants completed semi-structured interviews about their virtual care experiences with a focus on equity for subpopulations. KEY RESULTS: The results indicated that physicians have observed equity issues for unique patient populations. The results add to the understanding of nuanced ways in which virtual care can increase and decrease healthcare access for unique populations. Patients with limited English proficiency were particularly affected by inequity in virtual care access. CONCLUSION: Additional research and interventions are needed to improve portal access for those with limited English proficiency. Improvements should focus on health system interventions that expand access without requiring increased patient burden.

Telehealth Considerations for the Adolescent Patient.

Recent rapid expansion of telemedicine services has included delivery of those services to adolescents and young adults. Telemedicine can be used to provide a wide array of health services to adolescent and young adult (AYA) including the treatment of mental health and substance use disorders, gender-affirming services, contraception, acute care, and health education. Special attention to minor consent laws which vary by state and country should help inform the health system and practice decisions for patient portal access, delivery of confidential care, and care for which the consent of a guardian or parent is required. For AYA with limited transportation options or who are geographically distant from specialty care, telemedicine helps expand access to those services.

Video Visits: Family Physician Experiences With Uptake During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: With the emergence of COVID-19, telemedicine use has increased dramatically as clinicians and patients have looked for alternatives to face-to-face care. Prior research has shown high levels of patient satisfaction and comparable quality of care. Video visits have been hypothesized to be one way to reduce burnout among clinicians, but there has been minimal research on physician views of virtual care. We sought to measure family physician experience with video visits at the start of the COVID-19 pandemic. METHODS: We identified all faculty and resident physicians at a large academic department of family medicine who had conducted a video visit in the prior month and conducted an anonymous online 12-question survey about their experiences, satisfaction, and barriers with care. RESULTS: Most eligible physicians responded (102/109, 94%), of whom half (52%) reported this was their first month trying a video visit. There was very high satisfaction (91% very or somewhat satisfied). The majority of respondents felt that video visits were shorter (54%) or took the same amount of time (38%) as in-person visits. There was concern that many physicians had experienced a visit in which they felt video was not the appropriate platform given patient concerns. CONCLUSIONS: This study is among the first to assess physician experience with video visits. As the visits are perceived as shorter, they may offer a unique opportunity to address clinician burnout. There was a high level of satisfaction at our institution despite multiple technical challenges.

The Adolescent "Expanded Medical Home": School-Based Health Centers Partner with a Primary Care Clinic to Improve Population Health and Mitigate Social Determinants of Health.

INTRODUCTION: Access to high-quality health care is a crucial social determinant of health. We describe the implementation of an "expanded medical home" partnering a primary care practice (the Ypsilanti Health Center [YHC]) with local school-based health centers (the Regional Alliance for Healthy Schools [RAHS]), and to assess whether this model improves access to and quality of care for shared patients. METHODS: Using the Consolidated Framework for Implementation Research, we define the steps in, barriers to, and facilitating factors in implementing the expanded medical home model. Visits and quality measures were assessed for patients seen by YHC only versus YHC/RAHS at baseline and during the intervention. RESULTS: At baseline, patients seen at YHC/RAHS had higher compliance with most quality metrics compared with those seen at YHC only. The proportion of shared patients significantly increased because of the intervention (P < .001). Overall, patients seen in the expanded medical home had a higher likelihood of receiving quality metric services than patients in YHC only (odds ratio, 1.8; 95% confidence interval, 1.57-2.05) across all measures. CONCLUSIONS: Thoughtful and intentional implementation of an expanded medical home partnership between primary care physicians and school-based health centers increases the number of shared high-risk adolescent patients. Shared patients have improved compliance with quality measures, which may lead to long-term improved health equity.

Validity of the brief inpatient screen for intimate partner violence among adult women.

BACKGROUND: Identifying intimate partner violence in healthcare settings is becoming the standard of care. The Brief Inpatient Screen was designed to assess recent emotional, physical, and sexual abuse in a general inpatient medical-surgical setting and compared to the Composite Abuse Scale. METHODS: Researchers matched "cases" (inpatients screening Brief Inpatient Screen-positive) to up to four "controls" (inpatients screening Brief Inpatient Screen-negative). Forty-six female hospital inpatients ages 18-64 years completed a self-administered survey. The sensitivity and specificity of the Brief Inpatient Screen and its subscales were compared to the Composite Abuse Scale. Researchers examined the performance of the Brief Inpatient Screen when used as a verbal screen versus an anonymous written screen. RESULTS: Twelve of 46 participants (26%) had a positive screen. Compared to the Composite Abuse Scale, the overall sensitivity and specificity of the verbal Brief Inpatient Screen were 52.6% (95% CI 28.9-75.6) and 92.6% (95% CI 75.7-99.1), respectively. The written Brief Inpatient Screen showed improved sensitivity overall (68.4%, 95% CI 43.5-87.4) for the most severe intimate partner violence. Subscale analysis revealed greater sensitivity for emotional and severe combined intimate partner violence. CONCLUSIONS: The verbal Brief Inpatient Screen, when compared to the Composite Abuse Scale, was limited in its ability to identify intimate partner violence. An anonymous written format improved sensitivity. Future research should optimize intimate partner violence screening among inpatients.

Of broken bonds and bondage: an analysis of loss in the Slave Narrative Collection.

Relatively few scholars have made use of the Slave Narrative Collection, a collection of more than 2,300 autobiographical narratives detailing the lives of people who had been born into slavery. Housed at the Library of Congress, the Collection was gathered during the 1930s under the direction of the Federal Writers Project. Research derived from the Collection thus far has dealt primarily with the experience of slavery as a whole. The present study focuses on loss as it was experienced by former slaves. This qualitative study used a grounded theory approach to analyze 48 narratives. Results culminated in a core category or central theme that for former slaves loss was both a cause and a consequence of dehumanization. Findings also suggested that people experienced loss as a result of witnessing or experiencing violence and of living in deprivation and fear. Other losses included losses of hope and identity. Losses associated with the pain and suffering of family members were hardest to bear.

African Americans in bereavement: grief as a function of ethnicity.

Few empirical studies have explored the grieving process among different ethnic groups within the United States, and very little is known about how African Americans and Caucasians may differ in their experience of loss. The purpose of this study was to examine the African-American experience of grief, with particular emphasis on issues of identity change, interpersonal dimensions of the loss, and continuing attachments with the deceased. Participants were 1,581 bereaved college students (940 Caucasians and 641 African Americans) attending classes at a large southern university. Each participant completed the Inventory of Complicated Grief-Revised, the Continuing Bonds Scale, and questions regarding the circumstances surrounding his or her loss. Results revealed that African Americans experienced more frequent bereavement by homicide, maintenance of a stronger continuing bond with the deceased, greater grief for the loss of extended kin beyond the immediate family, and a sense of support in their grief, despite their tendency to talk less with others about the loss or seek professional support for it. Overall, African Americans reported higher levels of complicated grief symptoms than Caucasians, especially when they spent less time speaking to others about their loss experience. Implications of these findings for bereavement support services for African Americans were briefly noted.