Impact of a Remote Primary Care Telehealth Staffing Model on Primary Care Access in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) implemented the Clinical Resource Hub (CRH) program to fill staffing gaps in primary care (PC) clinics via telemedicine and maintain veterans' healthcare access. OBJECTIVE: To evaluate PC wait times before and after CRH implementation. DESIGN: Comparative interrupted time series analysis among a retrospective observational cohort of PC clinics who did and did not use CRH during pre-implementation (October 2018-September 2019) and post-implementation (October 2019-February 2020) periods. PARTICIPANTS: Clinics completing ≥10 CRH visits per month for 2 consecutive months and propensity matched control clinics. MAIN MEASURES: Two measures of patient access (i.e., established, and new patient wait times) and one measure of clinic capacity (i.e., third next available appointment) were assessed. Clinics using CRH were 1:1 propensity score matched across clinical and demographic characteristics. Comparative interrupted time series models used linear mixed effects regression with random clinic-level intercepts and triple interaction (i.e., CRH use, pre- vs. post-implementation, and time) for trend and point estimations. KEY RESULTS: PC clinics using CRH (N = 79) were matched to clinics not using CRH (N = 79). In the 12-month pre-implementation, third next available time increased in CRH clinics (0.16 days/month; 95% CI = [0.07, 0.25]), and decreased in the 5 months post-implementation (-0.58 days/month; 95% CI = [-0.90, -0.27]). Post-implementation third next available time also decreased in control clinics (-0.48 days/month; 95% CI = [-0.81, -0.17]). Comparative differences remained non-significant. There were no statistical differences in established or new patient wait times by CRH user status, CRH implementation, or over time. CONCLUSIONS: In a national VHA telemedicine program developed to provide gap coverage for PC clinics, no wait time differences were observed between clinics using and not using CRH services. This hub-and-spoke telemedicine service is an effective model to provide gap coverage while maintaining access. Further investigation of quality and long-term access remains necessary.

Quantifying the Digital Divide: Associations of Broadband Internet with Tele-mental Health Access Before and During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, telemedicine quickly expanded. Broadband speeds may impact equitable access to video-based mental health (MH) services. OBJECTIVE: To identify access disparities in Veterans Health Administration (VHA) MH services based on broadband speed availability. DESIGN: Instrumental variable difference-in-differences study using administrative data to identify MH visits prior to (October 1, 2015-February 28, 2020) and after COVID-19 pandemic onset (March 1, 2020-December 31, 2021) among 1176 VHA MH clinics. The exposure is broadband download and upload speeds categorized as inadequate (download ≤25 Megabits per second - Mbps; upload ≤3 Mbps), adequate (download ≥25 Mbps and <100 Mbps; upload ≥5 Mbps and <100 Mbps), or optimal (download and upload ≥100/100 Mbps) based on data reported to the Federal Communications Commission at the census block and spatially merged to each veteran's residential address. PARTICIPANTS: All veterans receiving VHA MH services during study period. MAIN MEASURES: MH visits were categorized as in-person or virtual (i.e., telephone or video). By patient, MH visits were counted quarterly by broadband category. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband speed category and quarterly MH visit count by visit type, adjusted for patient demographics, residential rurality, and area deprivation index. KEY RESULTS: Over the 6-year study period, 3,659,699 unique veterans were seen. Adjusted regression analyses estimated the change after pandemic onset versus pre-pandemic in patients' quarterly MH visit count; patients living in census blocks with optimal versus inadequate broadband increased video visit use (incidence rate ratio (IRR) = 1.52, 95% CI = 1.45-1.59; P < 0.001) and decreased in-person visits (IRR = 0.92, 95% CI = 0.90-0.94; P < 0.001). CONCLUSIONS: This study found patients with optimal versus inadequate broadband availability had more video-based and fewer in-person MH visits after pandemic onset, suggesting broadband availability is an important determinant of access-to-care during public health emergencies requiring remote care.

A Novel Gap Staffing Metric for Primary Care in the Veterans Health Administration and Implications for Rural and Urban Clinics.

Primary care providers (PCPs), including physicians and advanced practice providers, are the front line of medical care. Patient access must balance PCP availability and patient needs. This work develops a new PCP staffing metric using panel size and full-time equivalent data to determine whether a clinic is adequately staffed and describes variation by clinic rurality. Data were from the Veterans Health Administration, 2017-2021. Results describe the gap staffing metric, provide summary graphics, and compare the gap staffing between rural and urban clinics. This novel gap staffing metric can inform strategic clinic staffing in health care systems.

Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic.

Importance: Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access. Objective: To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality. Design, Setting, and Participants: This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021). Exposures: Federal Communications Commission-reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran's home address using US Census Bureau shapefiles. Main Outcomes and Measures: All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates. Results: In primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients' quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46; P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84; P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09). Conclusions and Relevance: This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.

Are Perceived Stress and Cytokine Genotypes Clinically Feasible as Predictors of Psychoneuroimmune Symptoms in Advanced Cancer?

CONTEXT: Genetic variability and perceived stress have been identified as likely predictors of psychoneuroimmune (PNI) symptoms in patients with cancer. In the clinical setting, the ability to identify the patients at greatest risk of development of severe PNI symptoms continues to be elusive. OBJECTIVE: To evaluate the feasibility of cytokine genes and perceived stress scores as clinical predictors of PNI symptom severity in patients with a new diagnosis of advanced cancer compared with cancer-free controls (CFCs). DESIGN: Patients with advanced-stage cancer beginning chemotherapy and CFCs completed questionnaires at 6 time points during 24 weeks and provided blood samples for genotyping. MAIN OUTCOME MEASURES: Associations between single-nucleotide polymorphisms in cytokine genotypes and perceived stress scores with PNI symptom severity were evaluated using bivariate analysis. RESULTS: Forty-two participants were recruited (21 patients with cancer and 21 CFCs). Patients with cancer and CFCs were demographically similar and had similar allele frequencies for 15 of 16 single-nucleotide polymorphisms. Cancer-affected patients reported higher perceived stress and PNI symptom severity. Associations were found between several single-nucleotide polymorphisms and PNI symptoms, but no clear pattern emerged across time. Perceived stress was associated with PNI symptom severity for memory problems and fatigue at all 6 time points. CONCLUSION: Perceived stress performed better than cytokine genotypes as a clinical predictor of PNI symptoms in this small-scale study. Assessing perceived stress is an easy and low-cost approach that can be used to identify patients at high risk of PNI symptom development.

Testing the Theory of Resilience and Relational Load (TRRL) in Families with Type I Diabetes.

The theory of resilience and relational load was tested with 60 couples and their adolescent children (ages 11-18) with type I diabetes (T1D). The couples participated in a stress-inducing conversation task in their home, followed by a random assignment to a two-week intervention designed to increase their relationship maintenance. Before the intervention, stronger communal orientation predicted greater maintenance for husbands and wives, but maintenance only reduced T1D stress for wives. The wives' and adolescents' T1D stress were also correlated, but the husbands' T1D stress was not significantly associated with either of them. Better maintenance was associated with less conflict during couples' conversations. Maintenance was also directly associated with less perceived and physiological stress (cortisol) from the conversation. Finally, wives in the intervention reported the most thriving, communal orientation and the least loneliness. The intervention also reduced adolescents' general life stress, but it did not influence their T1D stress or thriving.

The Functionality of Communal Coping in Chronic Uncertainty Environments: The Context of Palestinian Refugees in Lebanon.

Most research suggests that communal coping, where a group of people own and act upon a shared stressor or uncertainty together, enhances mental health and fosters coping efficacy. The majority of this research, however, has been conducted in the United States in contexts where stress and uncertainty are relatively short-lived and with samples that are economically secure and moderately to highly educated. The purpose of this study was to understand how socio-emotional conditions, such as exposure to trauma and interparental conflict, influence the functionality of communal coping for adolescents in Palestinian refugee camps in Lebanon, where chronic uncertainty is normative. One hundred eighty-five Palestinian adolescents (M age = 15.75) residing in two refugee camps in Beirut, Lebanon completed a cross-sectional survey. The results showed that communal coping with immediate family members was only beneficial for adolescents' mental health and hopelessness when their parents had moderate to little conflict and not high levels of conflict. Similarly, when adolescents had experienced trauma, engaging in high levels of communal coping accentuated, as opposed to buffered, the harmful effects of uncertainty on mental health.

Determinants of Rectal Cancer Patients' Decisions on Where to Receive Surgery: a Qualitative Analysis.

BACKGROUND: Current literature suggests surgeons who perform large volumes of rectal cancer resections achieve superior outcomes, but only about half of rectal cancer resections are performed by high-volume surgeons in comprehensive hospitals. Little is known about the considerations of patients with rectal cancer when deciding where to receive surgery. METHODS: A purposive sample of stage II/III rectal adenocarcinoma survivors diagnosed 2013-2015 were identified through the Iowa Cancer Registry and interviewed by telephone about factors influencing decisions on where to receive rectal cancer surgery. RESULTS: Fifteen survivors with an average age of 63 were interviewed: 60% were male, 53% resided in non-metropolitan areas, and 60% received surgery at low-volume facilities. Most patients considered surgeon volume and experience to be important determinants of outcomes, but few assessed it. Recommendation from a trusted source, usually a physician, appeared to be a main determinant of where patients received surgery. Patients who chose low-volume centers noted comfort and familiarity as important decision factors. CONCLUSION: Most rectal cancer patients in our sample relied on physician referrals to decide where to receive surgery. Interventions facilitating more informed decision-making by patients and referring providers may be warranted.