Improving the Development of Public Health Emergency Preparedness and Response System via Reinforcing Primary Care in Pandemic and Non-pandemic Periods

Objective-The federal government boosted support for community health centers in medically underserved areas in 2002-2007.This investigation compared trends in behavioral health services provided by community health centers nationwide during the first several years of that initiative with immediately prior trends.Methods-Data were extracted from the Health Resources and Services Administration's Uniform Data System on community health centers for 1998-2007 (2007, N=1,067).Regression analyses revealed trends in individual community health centers' likelihood of providing on-site specialty mental health care, crisis services, and substance abuse treatment.Aggregate data were used to show national trends in numbers of behavioral health encounters, patients, and encounters per patient.Results-The number of federally funded community health centers increased 43% between 2001 and 2007, from 748 to 1,067, over twice the annual growth rate between 1998 and 2001.However, trends in individual community health centers' likelihood of providing different types of behavioral health care were generally consistent across the two time periods.In 2007, 77% of community health centers offered specialty mental health services, 20% offered 24-hour crisis intervention services, and 51% offered substance abuse treatment.The mean number of mental health encounters per mental health patient at community health centers in 2007 was 2.9.Conclusions-The behavioral health care safety net has widened through rapid recent growth in the number of community health centers as well as a continuing increase in the proportion offering specialty mental health services.Access to behavioral health care remains a major public health concern in the United States (1-4), most acutely affecting people who have low income or are uninsured (5-7).One

Changes in medicine domestically and globally are transforming primary care in the United States. Many have suggested that primary care is in crisis or at least at a crossroads in the United States. The Annals of Internal Medicine recently devoted much of one issue to this topic.1 Primary care for children and adolescents, however, was not addressed specifically. This article focuses on pediatrics and identifies potential roles and new models for primary care pediatrics. The Institute of Medicine has defined primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”2 Starfield3 has defined 4 attributes of primary care including first-contact care, longitudinality, comprehensiveness, and coordination. September 11, 2001, the anthrax scare, and emerging threats such as severe acute respiratory syndrome (SARS) have brought a new focus on the importance of individual-level contacts in addressing population-level threats. Before these world events, however, primary care pediatrics was already grappling with its identity and responding to significant changes in medical systems, science, and family needs. The pace and scope of these changes are such that primary care pediatricians of the future will not be performing the same role as today. Historically, American medicine has tended to be reactive rather than proactive in defining its roles in society. However, dynamic change demands collective reflection; it is time to be proactive in assessing the needs of patients, exploring potential roles as health care providers, and developing the mechanisms to redefine the primary care pediatrician of the future. Projecting future trends requires reflection on the history of the profession of preventive pediatrics. In the 1800s, few physicians in the United States routinely … Address correspondence to Tina L. Cheng, MD, MPH, Johns Hopkins University Department of Pediatrics, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu

Barriers to expanding primary care roles for chiropractors: the role of chiropractic as primary care gatekeeper

Purpose: The primary aim of thşis study was to evaluate difference in the number of patients with tru-cut biopsies to diagnose breast lesions between non-pandemic and pandemic periods. Materials and Methods: In this study, the nonpandemic period and the pandemic period were compared, the periods for the pandemic times, between March 1, 2018, and 29 February 2020, and for the nonpandemic period, 1 March 2020 to 12 March 2022 to 12 March 2022. In each period, we have included all the tru-cut biopsies for suspected breast cancer. During the pandemic and non-pandemic period, the number of tru-cut biopsies BI-RADS and histopathological findings of the patients who experienced tru-cut biopsies were compared. Results: The number of tru-cut biopsies performed during the nonpandemic and pandemic period was similar (1596, 1599). In the pandemic period, tru-cut biopsy histopathologic reports revealed that benign and high-risk cases decreased statistically, while invasive carcinoma cases increased by 1.9 (95% CI 1.6-2.2) times. During the pandemic period, US-guided BI-RADS 3 and BI-RADS 4a cases decreased statistically significantly, BBI-RADS 4b cases increased 1.4 (95% CI 1.1-2.2) times, BI-RADS 4c cases 1.7 (95% CI 1.2-2.2), BI-RADS 5 cases increased 2.1 (95% CI 1.4-3.1) times Conclusion: There was no significant change in tru-cut biopsy numbers compared to the period of the pandemic and the non-pandemic period. However, the stage of the cancers captured during the period of the pandemic was higher.

Health centers provide primary and behavioral health care to the nation's safety net population. Many health centers served on the frontlines of the COVID-19 pandemic, which brought major changes to health center care delivery. To elucidate primary care and behavioral health service delivery patterns in health centers before and during the COVID-19 public health emergency (PHE). We compared annual and monthly patients from 2019 to 2022 for new and established patients by visit type (primary care, behavioral health) and encounter visits by modality (in-person, telehealth) across 218 health centers in 13 states. There were 1581,744 unique patients in the sample, most from health disparate populations. Review of primary care data over 4 years show that health centers served fewer pediatric patients over time, while retaining the capacity to provide to patients 65+. Monthly data on encounters highlights that the initial shift in March/April 2020 to telehealth was not sustained and that in-person visits rose steadily after November/December 2020 to return as the predominant care delivery mode. With regards to behavioral health, health centers continued to provide care to established patients throughout the PHE, while serving fewer new patients over time. In contrast to primary care, after initial uptake of telehealth in March/April 2020, telehealth encounters remained the predominant care delivery mode through 2022. Four years of data demonstrate how COVID-19 impacted delivery of primary care and behavioral health care for patients, highlighting gaps in pediatric care delivery and trends in telehealth over time.

Will Community Health Centers Survive COVID‐19?

New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care. We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management. Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians. The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario's CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality.

Using the PHQ-9 for Depression Screening and Treatment Monitoring for Chinese Americans in Primary Care

Review Question: This review aims to answer the following specific question: What are nurses’ experiences of preparing for and managing the ethical challenges posed by catastrophic public health emergencies and health care disasters? Review Purpose/Objectives: The purpose of this systematic review is to systematically review and synthesise research literature reporting nurses’ experiences of ethical preparedness for dealing with catastrophic public health emergencies and health care disasters and the ethical quandaries that may arise during such events. INCLUSION CRITERIA: Types of Participants: The review will consider publications that include nurses registered or authorised under a given country’s state of emergency provisions to practice in jurisdictions in which a public health emergency (e.g. pandemic influenza) or sudden‐onset mass casualty health care disaster (e.g. flood, hurricane, earthquake, tsunami, volcanic eruption, terrorist attack) have occurred, or may occur. Phenomena of interest: This review will examine the phenomenon of nurses’ experiences of preparing for and/or managing ethical issues arising during a public health emergency or health care disaster. Consideration will be given to, but not be limited to nurse preparation for and management of ethical issues associated with: development of local public health emergency (including pandemic influenza) and sudden‐onset health care disaster plans provision of first health care contact for the general public personal protection and correct use of safety equipment providing front line clinical care providing community and primary health care assistance with containment measures triaging in a range of settings, including general practices, community health centres, and local hospitals maintaining infection control vaccinations informing the public work attendance.

To evaluate the effects of inadequate antenatal care (ANC) caused by the COVID-19 pandemic on pregnant women. In this retrospective study, pregnant women were divided into two groups as those presenting during the pandemic and non-pandemic periods. The pandemic period was selected as March 11, 2020- December 10, 2020 and the pre-pandemic period as March 11, 2019- December 10, 2019 corresponding to the same period a year earlier. Pregnant women receiving ANC three times or less was defined as inadequate ANC. The pregnant women were evaluated in terms of obstetric complications, including premature rupture of membranes, premature birth, placental abruption. gestational diabetes mellitus (GDM), preeclampsia, fetal or neonatal death, and maternal death. The study included 276 patients presenting during the pandemic period and 229 patients presenting during the non-pandemic period. When the pandemic and non-pandemic periods were compared, it was determined that the rates of fetal death, preeclampsia and GDM statistically significantly increased in the former. The rate of adequate ANC was 72.5% (n=166) in the non-pandemic period and 58.3% (n=161) in the pandemic period. When pregnancy complications were compared according to ANC during the pandemic, it was observed that the rates of fetal death, preeclampsia and GDM were higher among the pregnant women with inadequate ANC. Complications due to inadequate ANC may have more significant consequences than complications caused by a possible COVID-19 infection. During the pandemic period, healthcare professionals should ensure that women receive safe and effective care during both pregnancy and childbirth.

The Reply:

Teaching Health Centers Can Meet Objectives for State Medicaid Innovation.

Nowadays there is a renewed interest in the role of primary care as an essential component of the delivery of health care. Cueto’s article on the role of the World Health Organization (WHO) in the emergence of primary health care1 is timely indeed and stimulates discussion about this dimension of health care. We wish to direct attention to an approach not mentioned in Cueto’s article that is taught, practiced, and written about extensively—the community-oriented primary care (COPC) model. The recent application and evaluation of COPC in various countries was reported in several articles published in the November 2002 issue of the Journal. The conceptual roots of COPC were introduced and developed in the 1940s by Sidney Kark and Emily Kark in a rural area of South Africa. As family physicians, the Karks implemented a comprehensive approach to care, taking into account the socioeconomic and cultural determinants of health, identifying health needs, and providing health care to the total community. Their pioneering work, integrating preventive and curative care with significant community involvement, created a service network of a kind scarcely known then in that continent, with more than 40 community health centers established in different regions of the country.2 The Karks and their team developed this approach further at the Community Health Center of the Hadassah School of Public Health and Community Medicine in Jerusalem.3 In Sidney Kark’s book Epidemiology and Community Medicine (published in 1974, before Alma Ata), he speaks of “community medicine and primary health care as a unified practice.”4(p7) This approach, which later was denominated COPC,5 is considered an expression of the Alma Ata spirit.6,7 In our COPC teaching,8 we have had frequent discussions with international public health students, mainly Africans, concerning the similarities and differences between COPC and the primary health care approach of WHO. As an explicit expression of the role played by COPC in the development of the WHO primary health care approach, Litsios notes (also in the November 2004 issue of the Journal) that there is evidence of “many similarities between primary health care and Kark’s work in Africa.”9(p1890) The renewed interest in primary care is particularly appropriate because primary care is the component of health services that addresses most of the health problems arising in a community, and when it is enhanced by a community orientation, it can be considered public health at the local level.10

During the COVID-19 pandemic, misinformation and distrust exacerbated disparities in vaccination rates by race and ethnicity throughout the United States. Primary care, public health systems, and community health centers have shifted their vaccination outreach strategies toward these disparate, unvaccinated populations. To support primary care, we developed the SAVE Sprint model for implementing rapid-cycle change to improve vaccination rates by overcoming community outreach barriers and workforce limitations. Participants were recruited for the 10-week SAVE Sprint program through partnerships with the National Association of Community Health Centers (NACHC) and the Resilient American Communities (RAC) Initiative. The majority of the participants were from community health centers. Data were evaluated during the program through progress reports and surveys, and interviews conducted three months post-intervention were recorded, coded, and analyzed. The SAVE Sprint model of rapid-cycle change exceeded participants’ expectations and led to improvements in patient education and vaccination among their vulnerable populations. Participants reported building new skills and identifying strategies for targeting specific populations during a public health emergency. However, participants reported that planning for rapid-pace change and trust-building with community partners prior to a health care crisis is preferable and would make navigating an emergency easier.

Changes in frequency of urology clinic visits and diagnosis of erectile dysfunction in Germany before and during COVID-19