Disparities in Video-Based Primary Care Use Among Veterans with Cardiovascular Disease.

BACKGROUND: Cardiovascular disease (CVD) is prevalent among Veterans, and video care enhances access to CVD care. However, it is unknown which patients with CVD conditions receive video care in primary care clinics, where a large proportion of CVD services is delivered. OBJECTIVE: Characterize use of VA video primary care for Veterans with two common CVDs, heart failure and hypertension. DESIGN: Retrospective cohort study. PATIENTS: Veterans seen in VA primary care with diagnoses of heart failure and/or hypertension in the year prior to the COVID-19 pandemic and for the first two pandemic-years. MAIN MEASURES: The primary outcome was use of any video-based primary care visits. Using multilevel regressions, we examined the association between video care use and patient sociodemographic and clinical characteristics, controlling for time and adjusting for patient- and site-level clustering. KEY RESULTS: Of 3.8M Veterans with 51.9M primary care visits, 456,901 Veterans had heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average age of 71.6 years. 2.9% were female, and 34.8% lived in rural settings. Patients who were male, aged 75 or older, or rural-dwelling had lower odds of using video care than female patients, 18-44-year-olds, and urban-dwellers, respectively (male patients' adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72-0.74; 75 years or older, AOR 0.38, 95% CI 0.37-0.38; rural-dwellers, AOR 0.71, 95% CI 0.70-0.71). Veterans with heart failure had higher odds of video care use than those with hypertension only (AOR 1.05, 95% CI 1.04-1.06). CONCLUSIONS: Given lower odds of video primary care use among some patient groups, continued expansion of video care could make CVD services increasingly inequitable. These insights can inform equitable triage of patients, for example by identifying patients who may benefit from additional support to use virtual care.

Overcoming Obstacles: Barriers to Virtual Care Use Among Video-Enabled Tablet Recipients in the Veterans Health Administration.

INTRODUCTION: The Veterans Health Administration (VHA) distributes video-enabled tablets to individuals with barriers to accessing care. Data suggests that many tablets are under-used. We surveyed Veterans who received a tablet to identify barriers that are associated with lower use, and evaluated the impact of a telephone-based orientation call on reported barriers and future video use. METHODS: We used a national survey to assess for the presence of 13 barriers to accessing video-based care, and then calculated the prevalence of the barriers stratified by video care utilization in the 6 months after survey administration. We used multivariable modeling to examine the association between each barrier and video-based care use and evaluated whether a telephone-based orientation modified this association. RESULTS: The most prevalent patient-reported barriers to video-based care were not knowing how to schedule a visit, prior video care being rescheduled/canceled, and past problems using video care. Following adjustment, individuals who reported vision or hearing difficulties and those who reported that video care does not provide high-quality care had a 19% and 12% lower probability of future video care use, respectively. Individuals who reported no interest in video care, or did not know how to schedule a video care visit, had an 11% and 10% lower probability of being a video care user, respectively. A telephone-based orientation following device receipt did not improve the probability of being a video care user. DISCUSSION: Barriers to engaging in virtual care persist despite access to video-enabled devices. Targeted interventions beyond telephone-based orientation are needed to facilitate adoption and engagement in video visits.

Research Priorities to Expand Virtual Care Access for Patients in the Veterans Affairs Health Care System.

The rapid expansion of virtual care is driving demand for equitable, high-quality access to technologies that are required to utilize these services. While the Department of Veterans Affairs (VA) is seen as a national leader in the implementation of telehealth, there remain gaps in evidence about the most promising strategies to expand access to virtual care. To address these gaps, in 2022, the VA's Health Services Research and Development service and Office of Connected Care held a "state-of-the-art" (SOTA) conference to develop research priorities for advancing the science, clinical practice, and implementation of virtual care. One workgroup within the SOTA focused on access to virtual care and addressed three questions: (1) Based on the existing evidence about barriers that impede virtual care access in digitally vulnerable populations, what additional research is needed to understand these factors? (2) Based on the existing evidence about digital inclusion strategies, what additional research is needed to identify the most promising strategies? and (3) What additional research beyond barriers and strategies is needed to address disparities in virtual care access? Here, we report on the workgroup's discussions and recommendations for future research to improve and optimize access to virtual care. Effective implementation of these recommendations will require collaboration among VA operational leadership, researchers, Human Factors Engineering experts and front-line clinicians as they develop, implement, and evaluate the spread of virtual care access strategies.

Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis.

BACKGROUND: Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs. OBJECTIVE: The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs. DESIGN: Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score. PARTICIPANTS: Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit. INTERVENTION: PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services. MAIN OUTCOMES AND MEASURES: Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date. KEY RESULTS: Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM. CONCLUSIONS AND RELEVANCE: VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes. TRIAL REGISTRATION: PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

Patterns and predictors of mental health service use among older veterans with alcohol use disorder who received a video-enabled tablet.

Objectives: Video-based telehealth may expand access to mental health services among older veterans with alcohol use disorder (AUD). We examined the modalities through which mental health services were rendered, and predictors of video visits before and after video-enabled tablet receipt from the Veterans Health Administration. Method: 11,210 veterans aged 60 or older with a diagnosis of AUD who received a tablet between 1 April 2020 and 25 October 2021 were identified. The electronic health record was used to characterized encounters by modality of mental health care delivery in the six months pre/post tablet receipt. Logistic regression examined predictors of a video visit for mental health. Results: Phone was the most common modality; however, the proportion of video encounters increased from 8.7% to 26.2% after tablet receipt. Individuals who were older, male, and had more physical health conditions, were less likely to have a video visit. Individuals who were married, resided in urban areas, had a history of housing instability, and had more mental health conditions, were more likely to have a video visit. Conclusion: Video-enabled tablets may help older adults with AUD overcome access barriers to mental health services, although targeted support for certain groups may be necessary.

Adoption and Sustained Use of Primary Care Video Visits Among Veterans with VA Video-Enabled Tablets.

In 2020, the U.S. Department of Veterans Affairs (VA) expanded an initiative to distribute video-enabled tablets to Veterans with limited virtual care access. We examined patient characteristics associated with adoption and sustained use of video-based primary care among Veterans. We conducted a retrospective cohort study of Veterans who received VA-issued tablets between 3/11/2020-9/10/2020. We used generalized linear models to evaluate the sociodemographic and clinical factors associated with video-based primary care adoption (i.e., likelihood of having a primary care video visit) and sustained use (i.e., rate of video care) in the six months after a Veteran received a VA-issued tablet. Of the 36,077 Veterans who received a tablet, 69% had at least one video-based visit within six months, and 24% had a video-based visit in primary care. Veterans with a history of housing instability or a mental health condition, and those meeting VA enrollment criteria for low-income were significantly less likely to adopt video-based primary care. However, among Veterans who had a video visit in primary care (e.g., those with at least one video visit), older Veterans, and Veterans with a mental health condition had more sustained use (higher rate) than younger Veterans or those without a mental health condition. We found no differences in adoption of video-based primary care by rurality, age, race, ethnicity, or low/moderate disability and high disability priority groups compared to Veterans with no special enrollment category. VA's tablet initiative has supported many Veterans with complex needs in accessing primary care by video. While Veterans with certain social and clinical challenges were less likely to have a video visit, those who adopted video telehealth generally had similar or higher rates of sustained use. These patterns suggest opportunities for tailored interventions that focus on needs specific to initial uptake vs. sustained use of video care.

Associations Between Social Risks and Primary Care Utilization Among Medically Complex Veterans.

BACKGROUND: Social risks contribute to poor health outcomes, especially for patients with complex medical needs. These same risks may impact access to primary care services. OBJECTIVE: To study associations between social risks and primary care utilization among patients with medical complexity. DESIGN: Prospective cohort study of respondents to a 2018 mailed survey, followed up to 2 years after survey completion. PARTICIPANTS: Nationally representative sample of 10,000 primary care patients in the Veterans Affairs (VA) health care system, with high (≥ 75th percentile) 1-year risk of hospitalization or death. MAIN MEASURES: Survey-based exposures were low social support, no family member/friend involved in health care, unemployment, transportation problem, food insecurity, medication insecurity, financial strain, low medical literacy, and less than high school graduate. Electronic health record-based outcomes were number of primary care provider (PCP) encounters, number of primary care team encounters (PCP, nurse, clinical pharmacist, and social worker), and having ≥ 1 social work encounter. KEY RESULTS: Among 4680 respondents, mean age was 70.3, 93.7% were male, 71.8% White non-Hispanic, and 15.8% Black non-Hispanic. Unemployment was associated with fewer PCP and primary care team encounters (incident rate ratio 0.77, 95% CI 0.65-0.91; p = 0.002 and 0.75, 0.59-0.95; p = 0.02, respectively), and low medical literacy was associated with more primary care team encounters (1.17, 1.05-1.32; p = 0.006). Among those with one or more social risks, 18.4% had ≥ 1 social work encounter. Low medical literacy (OR 1.95, 95% CI 1.45-2.61; p < 0.001), transportation problem (1.42, 1.10-1.83; p = 0.007), and low social support (1.31, 1.06-1.63; p = 0.01) were associated with higher odds of  ≥ 1 social work encounter. CONCLUSIONS: We found few differences in PCP and primary care team utilization among medically complex VA patients by social risk. However, social work use was low, despite its central role in addressing social risks. More work is needed to understand barriers to social work utilization.

Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form.

BACKGROUND: Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted. OBJECTIVE: To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a). DESIGN: Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores. PARTICIPANTS: National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder). MAIN MEASURES: Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence. KEY RESULTS: Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%. CONCLUSIONS: The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

Types of Engagement Strategies to Engage High-Risk Patients in VA.

BACKGROUND: Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging. OBJECTIVE: To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program. METHODS: We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. RESULTS: The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change. CONCLUSION: We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

Incorporating TechQuity in Virtual Care Within the Veterans Health Administration: Identifying Future Research and Operations Priorities.

BACKGROUND: The Covid-19 pandemic dramatically changed healthcare delivery, driving rapid expansion of synchronous (i.e., real-time) audio-only and video telehealth, otherwise known as virtual care. Yet evidence describes significant inequities in virtual care utilization, with certain populations more dependent on audio-only virtual care than video-based care. Research is needed to inform virtual care policies and processes to counteract current inequities in access and health outcomes. OBJECTIVE: Given the importance of incorporating equity into virtual care within the Veterans Health Administration (VHA), we convened a Think Tank to identify priorities for future research and virtual care operations focused on achieving equitable implementation of virtual care within the VHA. METHODS: We used participatory activities to engage clinicians, researchers, and operational partners from across the VHA to develop priorities for equitable implementation of virtual care. We refined priorities through group discussion and force-ranked prioritization and outlined next steps for selected priorities. KEY RESULTS: Think Tank participants included 43 individuals from the VHA who represented diverse geographical regions, offices, and backgrounds. Attendees self-identified their associations primarily as operations (n = 9), research (n = 28), or both (n = 6). We identified an initial list of 63 potential priorities for future research and virtual care operations. Following discussion, we narrowed the list to four priority areas: (1) measure inequities in virtual care, (2) address emerging inequities in virtual care, (3) deploy virtual care equitably to accommodate differently abled veterans, and (4) measure and address potential adverse consequences of expanded virtual care. We discuss related information, data, key partners, and outline potential next steps. CONCLUSIONS: This Think Tank of research and operational partners from across the VHA identified promising opportunities to incorporate equity into the design and implementation of virtual care. Although much work remains, the priorities identified represent important steps toward achieving this vital goal.

Opportunities to Enhance the Implementation of Veterans Affairs Video-Based Care: Qualitative Perspectives of Providers from Diverse Specialties.

BACKGROUND: Increasing the adoption of digital care tools, including video visits, is a long-term goal for the US Department of Veterans Affairs (VA). While previous work has highlighted patient-specific barriers to the use of video visits, few have examined how clinicians view such barriers and how they have overcome them during the rapid uptake of web-based care. OBJECTIVE: This study sought input from providers, given their role as critical participants in video visit implementation, to qualitatively describe successful strategies providers used to adapt their practices to a web-based care setting. METHODS: We conducted interviews with 28 VA providers (physicians and nurse practitioners) from 4 specialties that represent diverse clinical services: primary care (n=11), cardiology (n=7), palliative care (n=5), and spinal cord injury (n=5). All interviews were audio recorded and transcribed, and transcripts were reviewed and coded according to an iteratively created codebook. To identify themes, codes were grouped together into categories, and participant comments were reviewed for repetition and emphasis on specific points. Finally, themes were mapped to Expert Recommendations for Implementing Change (ERIC) strategies to identify evidence-based opportunities to support video visit uptake in the VA. RESULTS: Interviewees were mostly female (57%, 16/28), with an average age of 49 years and with 2-20 years of experience working in the VA across 16 unique VA facilities. Most providers (82%, 23/28) worked in urban facilities. Many interviewees (78%, 22/28) had some experience with video visits prior to the COVID-19 pandemic, though a majority (61%, 17/28) had conducted fewer than 50 video visits in the quarter prior to recruitment. We identified four primary themes related to how providers adapt their practices to a web-based care setting: (1) peer-based learning and support improved providers' perceived value of and confidence in video visits, (2) providers developed new and refined existing communication and clinical skills to optimize video visits, (3) providers saw opportunities to revisit and refine team roles to optimize the value of video visits for their care teams, and (4) implementing and sustaining web-based care requires institutional and organizational support. We identified several ERIC implementation strategies to support the use of video visits across the individual-, clinic-, and system-levels that correspond to these themes: (1) individual-level strategies include the development of educational materials and conducting education meetings, (2) clinic-level strategies include identifying champions and revising workflows and professional roles, and (3) system-level strategies include altering incentive structures, preparing implementation blueprints, developing and implementing tools for quality monitoring, and involving executive leadership to encourage adoption. CONCLUSIONS: This work highlights strategies to support video visits that align with established ERIC implementation constructs, which can be used by health care systems to improve video visit implementation.

Overcoming Access Barriers for Veterans: Cohort Study of the Distribution and Use of Veterans Affairs' Video-Enabled Tablets Before and During the COVID-19 Pandemic.

BACKGROUND: During the COVID-19 pandemic, as health care services shifted to video- and phone-based modalities for patient and provider safety, the Veterans Affairs (VA) Office of Connected Care widely expanded its video-enabled tablet program to bridge digital divides for veterans with limited video care access. OBJECTIVE: This study aimed to characterize veterans who received and used US Department of VA-issued video-enabled tablets before versus during the COVID-19 pandemic. METHODS: We compared sociodemographic and clinical characteristics of veterans who received VA-issued tablets during 6-month prepandemic and pandemic periods (ie, from March 11, 2019, to September 10, 2019, and from March 11, 2020, to September 10, 2020). Then, we examined characteristics associated with video visit use for primary and mental health care within 6 months after tablet shipment, stratifying models by timing of tablet receipt. RESULTS: There was a nearly 6-fold increase in the number of veterans who received tablets in the pandemic versus prepandemic study periods (n=36,107 vs n=6784, respectively). Compared to the prepandemic period, tablet recipients during the pandemic were more likely to be older (mean age 64 vs 59 years), urban-dwelling (24,504/36,107, 67.9% vs 3766/6784, 55.5%), and have a history of housing instability (8633/36,107, 23.9% vs 1022/6784, 15.1%). Pandemic recipients were more likely to use video care (21,090/36,107, 58.4% vs 2995/6784, 44.2%) and did so more frequently (5.6 vs 2.3 average encounters) within 6 months of tablet receipt. In adjusted models, pandemic and prepandemic video care users were significantly more likely to be younger, stably housed, and have a mental health condition than nonusers. CONCLUSIONS: Although the COVID-19 pandemic led to increased distribution of VA-issued tablets to veterans with complex clinical and social needs, tablet recipients who were older or unstably housed remained less likely to have a video visit. The VA's tablet distribution program expanded access to video-enabled devices, but interventions are needed to bridge disparities in video visit use among device recipients.

Moving beyond inquiry: a secondary qualitative analysis on promoting racial justice in clinical care.

BACKGROUND: Anti-Black racism is prevalent in medicine, and anti-racism training is needed in medical education. One such training is the Presence 5 for Racial Justice (P5RJ) Curriculum which covers evidence-based anti-racism communication strategies that promote health equity for Black patients. The P5RJ Curriculum was developed using feedback from clinicians and trainees with diversity, equity, and inclusion (DEI) experience. In this study, we identify themes in recommended anti-racism language and phrases that surveyed clinicians and trainees use to promote racial justice and health equity in clinical care for Black patients. METHODS: Secondary analysis of survey responses to identify themes in qualitative data. DATASET: Survey responses of specific phrases for anti-racism communication based on P5RJ Curriculum feedback. POPULATION STUDIED: N = 50 respondents (27 clinicians, 17 medical trainees, 6 unreported) recruited through convenience sampling and listservs of clinicians with DEI experience. An inductive qualitative analysis was performed on survey responses to identify emerging themes. RESULTS: Emerging themes from survey responses reflected four communication practices: "Inquiry" was the predominant practice (59%), followed by "Empathy" (25%), "Statements of Allyship" (9%), and "Self-Accountability" (8%). CONCLUSION: Inquiry and empathy may be predominant communication practices when addressing anti-Black racism in medicine. There is an opportunity to expand anti-racism communication tools with statements of self-accountability and allyship. Future research is necessary to analyze the patient voice on clinician communication practices that promote anti-racism in clinical care.

Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans.

BACKGROUND: Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE: To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN: Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS: 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES: The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS: In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS: Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.

Clinical Outcome and Utilization Profiles Among Latent Groups of High-Risk Patients: Moving from Segmentation Towards Intervention.

BACKGROUND: The ability of latent class models to identify clinically distinct groups among high-risk patients has been demonstrated, but it is unclear how healthcare data can inform group-specific intervention design. OBJECTIVE: Examine how utilization patterns across latent groups of high-risk patients provide actionable information to guide group-specific intervention design. DESIGN: Cohort study using data from 2012 to 2015. PATIENTS: Participants were 934,787 patients receiving primary care in the Veterans Health Administration, with predicted probability of 12-month hospitalization in the top 10th percentile during 2014. MAIN MEASURES: Patients were assigned to latent groups via mixture-item response theory models based on 28 chronic conditions. We modeled odds of all-cause mortality, hospitalizations, and 30-day re-hospitalizations by group membership. Detailed outpatient and inpatient utilization patterns were compared between groups. KEY RESULTS: A total of 764,257 (81.8%) of patients were matched with a comorbidity group. Groups were characterized by substance use disorders (14.0% of patients assigned), cardiometabolic conditions (25.7%), mental health conditions (17.6%), pain/arthritis (19.1%), cancer (15.3%), and liver disease (8.3%). One-year mortality ranged from 2.7% in the Mental Health group to 14.9% in the Cancer group, compared to 8.5% overall. In adjusted models, group assignment predicted significantly different odds of each outcome. Groups differed in their utilization of multiple types of care. For example, patients in the Pain group had the highest utilization of in-person primary care, with a mean (SD) of 5.3 (5.0) visits in the year of follow-up, while the Substance Use Disorder group had the lowest, with 3.9 (4.1) visits. The Substance Use Disorder group also had the highest rates of using services for housing instability (25.1%), followed by the Liver group (10.1%). CONCLUSIONS: Latent groups of high-risk patients had distinct hospitalization and utilization profiles, despite having comparable levels of predicted baseline risk. Utilization profiles pointed towards system-specific care needs that could inform tailored interventions.

Black patient perceptions of COVID-19 vaccine, treatment, and testing.

Context: The Presence for Racial Justice project leverages the Stanford Presence 5 framework to present anti-racism communication practices that promote clinician trust-building for Black patients in primary care. With the racial/ethnic disparities in COVID-19 infection rates, an assessment of Black patients' perspectives around COVID-19 care is required to promote health equity in current and future health crises. Objective: To compile clinician communication strategies for promotion of patient understanding and agency concerning Black patients' perceptions of COVID-19 vaccine, treatment and testing. Study design: Qualitative study employing inductive and deductive thematic analysis. Setting: Four primary care clinics primarily serving Black patients in Oakland, CA; Rochester, NY; Leeds, AL; and Memphis, TN. Population Studied: 37 Black patients, recruited through convenience sampling by their primary care clinician for 45-minute semi-structured audio-recorded interviews. Outcome Measures: Emergent themes around Black patient perceptions and motivations for seeking/delaying COVID-19 vaccine, treatment, and testing, and their ideal medical guidance on COVID-19 care. Results: Due to historic mistreatment of Black patients within the healthcare system, medicine, and research, there is a high prevalence of mistrust amongst the Black patient interviewees towards the safety, efficacy, and equitable distribution of the COVID-19 vaccine compared to existing vaccines. Patients feared racial discriminatory treatment and intended to wait for the general population, authority figures, and White patients to receive the vaccine first. Many patients believed personal protective behaviors (e.g., mask wearing, staying home, taking supplements) would be more effective than receiving the COVID-19 vaccine. They expressed a preference for receiving COVID-19 medical care in the comfort of their homes due to high costs and risks of maltreatment, death, and loneliness. Conclusion: Black patients hinged their vaccination decisions on having enough time to observe vaccine rollout and discussion with their clinicians. Relating new medical interventions (ie., COVID-19 vaccine) to accept medical approaches (ie., Flu vaccine) and being aware of historical distrust in medicine can inform clinician efforts to empower and provide excellent care for Black patients moving forward.

PPE portraits: patient and clinician experiences at a COVID-19 testing site.

Context: The COVID-19 pandemic mandated personal protective equipment (PPE) in healthcare settings, obscuring clinician faces and expressions, and depersonalizing patient care experiences. PPE Portraits (affixing a clinician's photo to the front of PPE) was first introduced in 2015 during the West Africa Ebola epidemic, and has been shown to help maintain patient-provider connection at times when patients may be fearful, isolated, and unable to identify clinicians caring for them. Objective: To evaluate patient and clinician experiences with PPE Portraits. Study Design: Implementation pilot with mixed methods evaluation. Setting: A drive-thru COVID-19 testing site affiliated with a large academic medical center. Population studied: Patients (n=18) and clinicians (n=6) interviewed in March-April 2020. Clinicians were recruited through convenience sampling. Clinicians answered questions via recorded interviews or email. Patients were interviewed by phone through random sampling stratified by date of service. Patients were sent a post-visit survey. Intervention: Health workers affixed a PPE Portrait in order to connect better with individuals in their care. Outcome Measures: Patient and clinician experiences with PPE Portraits (assessed through inductive coding of qualitative data) and patient experiences with fear (assessed through survey). Results: Patient surveys indicated varying levels of fear, including mild (16%), moderate (66%), and severe (18%). Patients reported that seeing the PPE Portrait was comforting; four patients stated that it did not impact their care because they already trusted the facility. Clinicians corroborated patient sentiments, reporting that the intervention humanized both the testing experience for patients and also the interactions among patients and clinicians. They noted that patients seemed more at ease and that portraits fostered connection and trust, thereby reducing anxiety and fear and signaling to patients that they were being given holistic, optimal care. A majority of clinicians felt this intervention should be replicated, and they recommended having surplus portrait supplies on site to facilitate ad hoc portrait creation. Conclusion: PPE Portraits humanized the COVID-19 testing experiences for patients and clinicians during a time of fear. Clinicians recommended PPE Portraits for other healthcare settings that require PPE. Future research could assess how PPE Portraits promote patient-provider connection and trust.

Presence for racial justice: disrupting racism through physician-patient communication.

Context: Anti-Black racism is firmly rooted in US healthcare, but many clinicians do not have the tools and language to question their biases and address racism in clinical practice, eg biased communication practices such as "non-compliance" in medical documentation. Objective: Presence 5 for Racial Justice (P5RJ) leverages the Presence 5 patient-provider communication framework to identify anti-racism communication practices that support trusting relationships between physicians and Black patients and empower Black individuals in clinical care. Study design: For this multi-phased community-based participatory research (CBPR) overseen by an advisory board of clinicians and patients at four community clinics, we conducted a literature review, interviews with Black patients, clinician small-group discussions, and design thinking interviews with non-medical professionals. We mapped emergent communication practices to Presence 5 domains to create P5RJ. Setting: Four primary care clinics primarily serving Black patients in Oakland CA; Rochester NY; Leeds AL; Memphis TN. Population Studied: Total 113 participants (40 non-medical interviews, 37 Black patients interviewed, 12 advisory board members, 24 clinicians in discussion); 30 reviewed articles. Outcomes: Strategies on how providers, through communication and connection in the clinical visit, can navigate and address structural, institutional, and personally mediated forms of racism faced by Black patients. Results: P5RJ practices included: 1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address emergent bias and social determinants of health; 2) Listen intently and completely by using focused interpersonal listening without interruption and deep listening for racism impacts; give patients time and space to tell their story; 3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort, consent, and referral planning; 4) Connect with the patient's story by acknowledging socio-political factors influencing patient health and focusing on positive efforts/events to encourage patient agency; 5) Explore emotional cues by noticing and naming patient emotions and considering how racial trauma might influence these emotions. Conclusion: P5RJ practices offer strategies to reflect on clinician biases, address racism and known gaps in care for Black patients and promote health equity in their clinical care.

Factors Influencing How Providers Assess the Appropriateness of Video Visits: Interview Study With Primary and Specialty Health Care Providers.

BACKGROUND: The rapid implementation of virtual care (ie, telephone or video-based clinic appointments) during the COVID-19 pandemic resulted in many providers offering virtual care with little or no formal training and without clinical guidelines and tools to assist with decision-making. As new guidelines for virtual care provision take shape, it is critical that they are informed by an in-depth understanding of how providers make decisions about virtual care in their clinical practices. OBJECTIVE: In this paper, we sought to identify the most salient factors that influence how providers decide when to offer patients video appointments instead of or in conjunction with in-person care. METHODS: We conducted semistructured interviews with 28 purposefully selected primary and specialty health care providers from the US Department of Veteran's Affairs health care system. We used an inductive approach to identify factors that impact provider decision-making. RESULTS: Qualitative analysis revealed distinct clinical, patient, and provider factors that influence provider decisions to initiate or continue with virtual visits. Clinical factors include patient acuity, the need for additional tests or labs, changes in patients' health status, and whether the patient is new or has no recent visit. Patient factors include patients' ability to articulate symptoms or needs, availability and accessibility of technology, preferences for or against virtual visits, and access to caregiver assistance. Provider factors include provider comfort with and acceptance of virtual technology as well as virtual physical exam skills and training. CONCLUSIONS: Providers within the US Department of Veterans Affairs health administration system consider a complex set of factors when deciding whether to offer or continue a video or telephone visit. These factors can inform the development and further refinement of decision tools, guides, and other policies to ensure that virtual care expands access to high-quality care.

Organizational and External Factors Associated with Video Telehealth Use in the Veterans Health Administration Before and During the COVID-19 Pandemic.

Objectives: To identify organizational and external factors associated with medical center video telehealth uptake (i.e., the proportion of patients using telemedicine) before and early in the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: We conducted a retrospective, observational study using cross-sectional data for all 139 U.S. Veterans Affairs Medical Centers (VAMCs). We used logistic regression analyses to identify factors that predicted whether a VAMC was in the top quartile of VA Video Connect (VVC) telehealth uptake for primary care and mental health care. Results: All 139 VAMCs increased their VVC uptake at least 2-fold early in the pandemic, with most increasing uptake between 5- and 10-fold. Pre-COVID-19, higher VVC uptake in primary care was weakly and positively associated with having more high-risk patients, negatively associated with having more long-distance patients, and positively associated with the prior fiscal year's VVC uptake. During COVID-19, the positive association with high-risk patients and the negative association with long-distance patients strengthened, while weaker broadband coverage was negatively associated with VVC uptake. For mental health care, having more long-distance patients was positively associated with higher VVC uptake pre-COVID-19, but this relationship reversed during COVID-19. Discussion: Despite the marked increase in VVC uptake early in the COVID-19 pandemic, significant VAMC-level variation indicates that VVC adoption was more difficult for some medical centers, particularly those with poorer broadband coverage and less prior VVC experience. Conclusions and Relevance: These findings highlight opportunities for medical centers, VA Central Office, and other federal entities to ensure equitable access to video telehealth.