Academic Primary Care Practice Research Articles

Physicians' lifelong learning journeys: A narrative analysis of continuing professional development struggles.

Despite tenacious efforts of continuing professional development (CPD) developers and educators, physician engagement in CPD is fraught with challenges. Research suggests that these educational interventions and the maintenance of professional competence systems that mandate them are often seen as impractical, decontextualized and check-box activities by participants. This study explores physicians' learning post graduate medical education (GME) training across their CPD journey to understand how they (a) conceive of themselves as learners and (b) engage in lifelong learning across the course of their professional careers. Using narrative inquiry and holistic narrative analysis situated within a social constructivist orientation, we carried out individual interviews with physicians from across a large children's hospital network including academic hospitals, community hospitals and primary care practices. Timelines and story arcs were used to support the narrative analysis's re-storying. Twelve physicians from six different sub-specialties were interviewed. We identified three noteworthy challenges as particularly salient across participants' re-storied narratives: (i) train-on-a-track to treading water, (ii) learning takes a backseat, and (iii) learning through foraging or hunting and gathering. Participants described significant change when transitioning from GME to CPD learning. While participants identified as learners, they described the disorienting impact of losing GME's formal supports and structures. They articulated that patient care trumped learning as their top priority. They lamented having limited insight into their learning needs (e.g. little feedback data) and so resorted to engaging in CPD activities that were readily at hand-but not necessarily relevant-and to finding learning resources that might not be formally recognised for CPD credit. Physicians' learning journeys post-GME are challenging, and the systems created to support that learning are ill equipped to meet the needs of physicians transitioning from GME to CPD. To encourage meaningful learning, the complex interplay of factors impeding CPD engagement should inform future innovations.

Validation of adult asthma case definitions for primary care sentinel surveillance.

Most asthma diagnoses and patient care take place in primary care settings. Electronic medical records (EMRs) offer an opportunity to utilize technology to improve asthma diagnosis and care. The purpose of this study was to create and validate separate case definitions for suspected and confirmed asthma in primary care EMRs, to enable surveillance, benchmarking, and quality improvement in primary care settings. The objective of this study was to develop a case definition for suspected and confirmed asthma for use in a primary care sentinel surveillance system. A single chart abstractor conducted a manual audit of 776 randomly selected patient charts from an academic primary care practice EMR in Kingston, Ontario. Following the single chart abstractor classification, a consensus on chart classification as "not asthma", "suspected asthma", or "confirmed asthma" was achieved between the abstractor, a family physician, and a respirologist using Canadian Thoracic Society (CTS) criteria. Case definition algorithms based on billing codes, clinical data elements and medications were applied to the site's Canadian Primary Care Sentinel Surveillance Network (CPCSSN) data for the same charts and compared to abstractor classifications to determine each algorithm's measurement properties. The prevalence of suspected and confirmed asthma were 7.3% (n = 54) and 2.4% (n = 18), respectively. None of the proposed case definitions could differentiate between suspected and confirmed asthma. One algorithm consisting of billing, clinical, and medication elements had the highest Youden's Index for either suspected or confirmed asthma. The algorithm had a sensitivity of 81%, a specificity of 96%, positive predictive value of 71%, negative predictive value of 98%, and a Youden's Index of 0.77 for combined suspected or confirmed asthma cases. An EMR case definition for suspected or confirmed adult asthma has been validated for use in CPCSSN. Implementation of this case definition will enable the development of a surveillance electronic tool (eTool) for adult asthma that can foster quality improvement.

Patient perspectives of health-related social needs screening in an urban academic adult primary care practice

Patient perspectives of health-related social needs screening in an urban academic adult primary care practice

Effect of Automated and Personalized Outreach Messages on Well-Child Visit Catch Up: A Randomized Clinical Trial

ObjectiveTo determine the effectiveness of text/telephone outreach messages and personal contact attempts on well-child care (WCC) scheduling and completion and measles, mumps, and rubella (MMR) vaccine receipt. MethodsWe conducted an intent-to-treat, 2 × 2 factorial randomized clinical trial with 3 replications at 3 academic pediatric primary care practices from September 27, 2020 to August 6, 2021. We randomized participants to 1 of 4 groups: 1 automated message (group 1), 2 automated messages (group 2), 1 automated message plus personal contact attempts (group 3), or 2 automated messages plus personal contact attempts (group 4). Outcomes included: 1) scheduled WCC within 2 weeks (secondary outcome), 2) completed WCC within 8 weeks (secondary outcome), 3) receipt of first MMR by 15 months of age or second MMR within 3 months of first message for 4-year-olds (primary outcome). ResultsWe randomized 1312 patients (mean [SD] age = 38.8 [19.3] months, 53.5% male, 72.8% non-Hispanic Black, 86.9% Medicaid-enrolled). Scheduling rates were significantly higher in groups with personal contact attempts compared to those without (1 = 15.2%, 2 = 12.5%, 3 = 29.3%, and 4 = 31.5%). WCC completion rates also differed across groups: 1 = 27.4%, 2 = 22.3%, 3 = 32.0%, and 4 = 29.4%, with groups 3 and 4 having significantly higher rates than group 2. Similarly, groups 3 (30.2%) and 4 (31.8%) had significantly higher rates of receiving the MMR vaccine compared to group 2 (23.5%) but not group 1 (28.0%). ConclusionsOutreach messages that were followed by personal contact attempts increased the rates of scheduling and completing WCCs and receiving the MMR vaccine, providing a useful tool to re-engage at-risk populations.

Low Rate of Completion of Recommended Tests and Referrals in an Academic Primary Care Practice with Resident Trainees

A frequent, preventable cause of diagnostic errors involves failure to follow up on diagnostic tests, referrals, and symptoms-termed "failure to close the diagnostic loop." This is particularly challenging in a resident practice where one third of physicians graduate annually, and rates of patient loss due to these transitions may lead to more opportunities for failure to close diagnostic loops. The aim of this study was to determine the prevalence of failure of loop closure in a resident primary care clinic compared to rates in the faculty practice and identify factors contributing to failure. This retrospective cohort study included all patient visits from January 1, 2018, to December 31, 2021, at two academic medical center-based primary care practices where residents and faculty practice in the same setting. The primary outcome was prevalence of failure to close the loop for (1) dermatology referrals, (2) colonoscopy, and (3) cardiac stress testing. The primary predictor was resident vs. faculty status of the ordering provider. The authors present an unadjusted analysis and the results of a multivariable logistic regression analysis incorporating all patient factors to determine their association with loop closure. Of 12,282 orders for referrals and tests for the three studied areas, 1,929 (15.7%) were ordered by a resident physician. Of resident orders for all three tests, 52.9% were completed within the designated time vs. 58.4% for orders placed by attending physicians (p < 0.01). In an unadjusted analysis by test type, a similar trend was seen for colonoscopy (51.4% completion rate for residents vs. 57.5% for attending physicians, p < 0.01) and for cardiac stress testing (55.7% completion rate for residents vs. 61.2% for attending physicians), though a difference was not seen for dermatology referrals (64.2% completion rate for residents vs. 63.7% for attending physicians). In an adjusted analysis, patients with resident orders were less likely than attendings to close the loop for all test types combined (odds ratio 0.88, 95% confidence interval 0.79-0.98), with low rates of test completion for both physician groups. Loop closure for three diagnostic interventions was low for patients in both faculty and resident primary care clinics, with lower loop closure rates in resident clinics. Failure to close diagnostic loops presents a safety challenge in primary care and is of particular concern for training programs.

Burden of unmet health-related social needs in an academic adult primary care practice in San Francisco California.

Unmet health-related social needs can influence health outcomes and increase healthcare utilization. There is growing interest in integrating social needs care into healthcare delivery. We conducted an assessment of health-related social needs in an academic adult primary care practice in San Francisco, California. We recruited a random convenience sample of adult English-, Chinese- or Spanish-speaking patients from clinic waiting rooms at the study sites to complete a self-administered, anonymous survey. We used the Accountable Health Communities Health-Related Social Needs Screening Tool for these domains: housing instability, food insecurity, transportation problems, utility help needs, interpersonal safety, financial strain, and family/community support. We conducted univariate and multivariate analyses adjusting for age, sex and survey language. 679 patients completed the survey. Respondents were 57% female and mean age of 58 ± 18 years old. 54% of patients had at least one unmet health-related social need. The most prevalent health-related social needs were financial strain (35%), at least one issue with housing conditions (27%), and food insecurity (23%). Respondents completing the survey in Spanish had significantly higher odds of reporting food insecurity (AOR 3.97, 95%CI 1.86, 8.46), transportation problems (AOR 3.13, 95%CI 1.32, 7.43), and need for support with activities of daily living (AOR 4.58, 95%CI 2.04, 10.25) than respondents completing the survey in English. The burden of unmet health-related social needs was considerable in this adult primary care practice. These findings can support a case for integrating health-related social need screening and social care in the delivery of primary care in the United States to advance health equity.

Timely adherence to follow-up after high-risk lung cancer screenings.

To achieve the lung cancer screening (LCS) mortality benefit in clinical trials, timely, real-world follow-up of abnormal test results is necessary. Presently, annual LCS rates are lower than in trials, and adherence to follow-up after suspicious findings has not been well studied. This study examined timely adherence to follow-up recommendations after positive low-dose computed tomography (LDCT) screenings. This retrospective study included individuals from two academic primary care practices in New York City who met United States Preventative Services Task Force LCS eligibility and had a positive LDCT scan between 2013 and 2020. They were recommended for shorter interval follow-up repeat computed tomography (CT), CT biopsy, or positron emission tomography/CT. Adherence was completion of the prescribed imaging by 15 days after the recommended 7-, 30-, and 90-day follow-up and by 30 days after the 180-day recommended follow-up. Among 106 individuals with a positive LDCT scan, 64 (60%) were adherent to follow-up recommendations. Adherence was 72%, 63%, and 42% for recommended follow-ups of 30, 90, and 180 days, respectively. Being male was a predictor of a lower adherence rate. Among 23 individuals newly diagnosed with lung cancer after a positive LDCT scan, 83% were adherent to follow-up testing and 82% of cancers were Stage 1A or limited stage. There was variable adherence to the LCS follow-up recommendations despite positive screening CT, suggesting that even in a well-established screening program there may not be an efficient, systematic approach for follow-up. The delays in repeat testing potentially undermine the benefits of early detection.

Scheduled and attended pediatric primary care telemedicine appointments during COVID-19.

The aim of this study was to examine pediatric primary care telemedicine visit scheduling and attendance during the first year of telemedicine. Using electronic health record data from two academic pediatric primary care practices between April 2020-March 2021, we used Pearson χ2 tests and logistic regression models to identify child-, family-, and appointment-level characteristics associated with scheduled and attended telemedicine appointments. Among 5178 primary care telemedicine appointments scheduled during the 12-month period, the proportion of appointments scheduled differed over time for children in families with a language preference other than English or Spanish (4% quarter 1 vs. 6% in quarter 4, p = 0.01) and residing in ZIP codes with the lowest household technology access (24% in quarter 1 vs. 19% in quarter 3 (p = 0.01). Four thousand one hundred and forty-eight of 5178 scheduled telemedicine appointments were attended. Likelihood of attending a telemedicine appointment was highest for children in families with a language preference other than English or Spanish (90%, 95% CI 86-94% compared to Spanish 74%, 95% CI 65-84%), and same-day appointments (86%, 95% CI 85-87%). Attendance among families preferring Spanish language was higher in later months compared to earlier months. We found disparities in scheduling and attending telemedicine appointments, but signs of greater language equity over time.

Evaluation of Reading Level of Result Letters Sent to Patients from an Academic Primary Care Practice.

In primary care, low health literacy, particularly reading ability, is associated with worse health outcomes. Most physicians do not receive feedback on the reading levels of written communication that they may provide to patients, including result letters. Our study compares the readability of result letters, written by resident versus attending physicians, to patients with positive or negative screens for reading ability, as determined by the single-item literacy screener (SILS). Result letters to 50 patients at high risk and 50 patients at low risk of low reading ability were randomly selected starting from January 1st, 2020 at Albany Medical Center. Flesch-Kincaid Grade Level (FKGL), Gunning Fog Index (GFI), Coleman-Liau Index (CLI), Simple Measure of Gobbledygook (SMOG), and Flesch Reading Ease (FRE) were used to compare the readability of resident versus attending result letters. For all SILS levels, attending physicians wrote result letters at a lower grade level than resident physicians based on the FKGL, GFI, and SMOG indices. The FKGL, GFI, and SMOG readability scores of result letters written to patients with SILS 3-5 were also lower when written by attending physicians compared to resident physicians. Result letters written by attending physicians may be easier to read than result letters written by resident physicians, especially for patients with low reading ability. Future electronic health record (EHR) software should give physicians and providers feedback on the reading level of their written communication.

Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time.

Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.

Effect of Electronic Outreach Using Patient Portal Messages on Well Child Care Visit Completion

Outreach messages to patients overdue for well child care (WCC) can be delivered different ways (ie, telephone calls and text messages). Use of electronic health record patient portals is increasingly common but their effectiveness is uncertain. To determine the effectiveness of patient portal outreach messages, with and without the date of the last WCC, on the scheduling and completion of WCC visits and completion of vaccinations. An intention-to-treat, multigroup, randomized clinical trial was conducted at 3 academic primary care practices from July 30 to October 4, 2021. The population included predominantly non-Hispanic Black, low-income children (age, 6-17 years) whose parent had an active portal account. Participants were randomized to the standard message, tailored message, or no message (control) group. Two messages were delivered to those in the message groups. Outcomes included WCC visit scheduled within 2 weeks of the first intervention message, WCC visit completed within 8 weeks (primary outcome), and receipt of COVID-19 vaccine within 8 weeks. Nine hundred forty-five patients participated (mean [SD] age, 9.9 [3.3] years, 493 [52.2%] girls, 590 [62.4%] non-Hispanic Black, 807 [85.4%] publicly insured). Scheduling rates were 18.4% in the standard message group (adjusted risk ratio [aRR], 1.97; 95% CI, 1.32-2.84) and 14.9% in the tailored message group (aRR, 1.57; 95% CI, 1.02-2.34) compared with the control group (9.5%). Well child care visit completion rates were 24.1% in the standard message group (aRR, 1.92; 95% CI, 1.38-2.60) and 19.4% in the tailored message group (aRR, 1.52; 95% CI, 1.06-2.13) compared with the control group (12.7%). Among eligible children, rates of receiving the COVID-19 vaccine were 16.7% in the standard message group compared with 4.8% in the tailored message (aRR, 3.41; 95% CI, 1.14-9.58) and 3.7% in the control groups (aRR, 4.84; 95% CI, 1.44-15.12). In this randomized clinical trial, outreach messages delivered via electronic health record patient portals increased the rates of scheduling and completing WCC visits and receiving the COVID-19 vaccine, providing a useful tool to help restore WCC in populations whose care was delayed during the pandemic. ClinicalTrials.gov Identifier: NCT04994691.

The effect of remote scribes on primary care physicians’ wellness, EHR satisfaction, and EHR use

BackgroundPhysician burnout is a major problem in the United States. Small studies suggest scribes can improve clinician satisfaction, but scribe programs have not been evaluated using separate control groups or structured measures of electronic health record (EHR) use. MethodsWe conducted a pre-post, non-randomized controlled evaluation of a remote scribe pilot program introduced in September 2019 in an academic primary care practice. Scribes were paired with physicians via an audio-only cellphone connection to hear and document in real-time. Physician wellness was measured with the 10-item Mini-Z and 16-item Professional Fulfillment Index. EHR use was measured using vendor-derived platforms that provide routine EHR-related data. Results37 of 38 scribe users (97.4%) and 68 of 160 potential control physicians (42.5%) completed both pre and post intervention questionnaires. Compared with controls, scribe users had improvements in Mini-Z wellness metrics including Joyful Workplace (mean improvement 2.83, 95%CI 0.60, 5.06) and a single-item dichotomized burnout measure (OR 0.15, 95%CI 0.03, 0.71). There were significant reductions among scribe users compared to controls in total EHR time per 8 scheduled hours (−1.14 h, 95%CI -1.55, −0.72), and an increase in the percentage of orders with team contribution (10.4%, 95%CI 5.2, 15.6). These findings remained significant in adjusted analyses. Conclusions/implicationsA remote scribe program was associated with improvements in physician wellness and reduced EHR use. Healthcare organizations can consider scribe programs to help improve wellness among their physician workforce.

A Mixed-Methods Assessment of Coronavirus Disease of 2019–Era Telehealth Acute Care Visits in the Medical Home

To compare acute care virtual visits with in-person visits with respect to equity of access, markers of quality and safety, and parent and provider experience, before and during the coronavirus disease 2019 pandemic. We compared patient demographics, antimicrobial prescribing rates, emergency department (ED) use, and patient-experience scores for virtual visits and in-person care at 2 academic pediatric primary care practices using χ2 testing and interrupted time series analyses. Parent and provider focus groups explored themes related to virtual visit experience and acceptability. We compared virtual acute care visits conducted in March 2020-February 2021 (n=8868) with in-person acute care visits conducted in February 2019-March 2020 (n=24 120) and March 2020-February 2021 (n=6054). There were small differences in patient race/ethnicity across the different cohorts (P<.01). Virtual visits were associated with a 9.6% (-11.5%, -7.8%, P<.001) decrease in all antibiotic prescribing and a 13.2% (-22.1%, -4.4%, P<.01) decrease in antibiotic prescribing for acute respiratory tract infections. Unanticipated visits to the ED did not significantly differ among visit types. Patient experience scores were significantly greater (P<.05) for virtual acute care in overall rating of care and likelihood to recommend. Focus group themes included safety, distractibility, convenience, treatment, and technology. Providers were broadly accepting of virtual care while parental views were more mixed. Telehealth acute care visits may not have negative effects on quality and safety, as measured by antimicrobial prescribing and unanticipated ED visit rates. Efforts to increase parental acceptance and avoid creating disparities in access to virtual care will be essential to continued success of telehealth acute care visits.

Evaluation of an Automated Text Message–Based Program to Reduce Use of Acute Health Care Resources After Hospital Discharge

Posthospital contact with a primary care team is an established pillar of safe transitions. The prevailing model of telephone outreach is usually limited in scope and operationally burdensome. To determine whether a 30-day automated texting program to support primary care patients after hospital discharge is associated with reductions in the use of acute care resources. This cohort study used a difference-in-differences approach at 2 academic primary care practices in Philadelphia from January 27 through August 27, 2021. Established patients of the study practices who were 18 years or older, were discharged from an acute care hospitalization, and received the usual transitional care management telephone call were eligible for the study. At the intervention practice, 604 discharges were eligible and 430 (374 patients, of whom 46 had >1 discharge) were enrolled in the intervention. At the control practice, 953 patients met eligibility criteria. The study period, including before and after the intervention, ran from August 27, 2020, through August 27, 2021. Patients received automated check-in text messages from their primary care practice on a tapering schedule during the 30 days after discharge. Any needs identified by the automated messaging platform were escalated to practice staff for follow-up via an electronic medical record inbox. The primary study outcome was any emergency department (ED) visit or readmission within 30 days of discharge. Secondary outcomes included any ED visit or any readmission within 30 days, analyzed separately, and 30- and 60-day mortality. Analyses were based on intention to treat. A total of 1885 patients (mean [SD] age, 63.2 [17.3] years; 1101 women [58.4%]) representing 2617 discharges (447 before and 604 after the intervention at the intervention practice; 613 before and 953 after the intervention at the control practice) were included in the analysis. The adjusted odds ratio (aOR) for any use of acute care resources after implementation of the intervention was 0.59 (95% CI, 0.38-0.92). The aOR for an ED visit was 0.77 (95% CI, 0.45-1.30) and for a readmission was 0.45 (95% CI, 0.23-0.86). The aORs for death within 30 and 60 days of discharge at the intervention practice were 0.92 (95% CI, 0.23-3.61) and 0.63 (95% CI, 0.21-1.85), respectively. The findings of this cohort study suggest that an automated texting program to support primary care patients after hospital discharge was associated with significant reductions in use of acute care resources. This patient-centered approach may serve as a model for improving postdischarge care.

Use of the Electronic Health Record During Clinical Encounters: An Experience Survey.

Use of the electronic health record (EHR) during face-to-face clinical encounters affects communication, and prior research has been inconclusive regarding its effect. This survey study assessed health care practitioner use of EHR-specific communication skills and patient and practitioner experiences and attitudes regarding EHR use during clinical encounters. For this US-based study, we distributed previously validated surveys to practitioners and adult patients (aged >18 years) at academic primary care practices from July 1, 2018 through August 31, 2018. The electronic practitioner survey was completed first; a paper survey was administered to patients after appointments. Descriptive statistics were calculated, and the Cochran-Armitage test was used to assess for associations between key variables. The practitioner response was 72.9% (43/59); patient response, 45.2% (452/1,000). Practitioners reported maintaining less eye contact (79.1%), listening less carefully (53.5%), focusing less on patients (65.1%), and visits feeling less personal (62.8%). However, patients reported that practitioners provided sufficient eye contact (96.8%) and listened carefully (97.0%); they disagreed that practitioners focused less on them (86.7%) or that visits felt less personal (87.2%). Patients thought EHR use was positive (91.7%); only one-third of practitioners (37.2%) thought that patients would agree with that statement. Practitioners reported stress, burnout, and a lack of sufficient time for EHR documentation. A discrepancy existed in this study between patient and practitioner experiences and attitudes about EHR use, which appeared to negatively affect the experience of health care practitioners but not patients. Organizations should adopt formal strategies to improve practitioner experiences with EHR use.

How the Novel Person-Centered Primary Care Measure Performs in Canada.

The Person-Centered Primary Care Measure (PCPCM) is a relatively new and concise yet comprehensive measure of primary care quality. The objectives of this study are to administer the PCPCM in Canada and to understand whether there is an association between the PCPCM and sociodemographic and patient experience measures. The PCPCM was added to the routine patient experience survey administered at a multi-site academic primary care practice in Toronto, Canada. The survey was administered to patients with an e-mail on file and included questions on demographics, timely access, patient-centeredness, care continuity, and the PCPCM. Descriptive statistics were used to summarize the PCPCM. We used 1-way analysis of variance to determine whether there was an association between the PCPCM and patient demographics and patient experience measures at the team level. We analyzed 2581 survey responses. The mean PCPCM score was 3.47. The PCPCM was higher for people with better health status (P < .001), those born in Canada (P = .036), those with higher educational attainment (P = .003), and those who knew their provider for longer (P < .001). There was no significant association between PCPCM and income quintile (P = .417). The PCPCM was significantly associated with all 9 patient experience measures related to access, patient-centeredness, and care continuity (P < .001). The 11-item PCPCM is a feasible and meaningful measure that reflects patient-reported access, continuity, and patient-centeredness and can be incorporated into primary care patient experience surveys to evaluate and improve quality of care.

Association of Telehealth with Short-Interval Follow-Up.

The COVID-19 pandemic led to wide adoption of telehealth in primary care. The impact of telehealth on subsequent follow-up visit volume is mixed. This study examines the association of newly expanded telehealth with short-interval follow-up visits during the COVID-19 pandemic in an academic primary care practice. Scheduling data were used to compare rates of 0 to 60-day follow-up visits after telehealth and in-person visits before and after onset of the COVID-19 pandemic. Compared with in-person visits, telehealth visits were associated with significantly higher rates of total short-interval follow-ups and higher rates of first short-interval follow-ups occurring in 0 to 15 days. Higher rates of short-interval follow-up may be due to inefficiencies created by rapid expansion of telehealth including suboptimal scheduling algorithms, pandemic-related safety considerations, and discomfort with the visit modality. Short-interval follow-ups have potential negative impacts on practice access, patient-centered outcomes, and sustainability of telehealth in primary care. Newly expanded telehealth visits conducted in the year after the onset of the COVID-19 pandemic resulted in higher rates and sooner first occurrence of short-interval follow-up visits. Future research should identify optimal scheduling processes for telehealth visits to minimize short-interval follow-ups.

A Qualitative Study of Caregiver Perspectives on Health Policy Discussions Initiated by Pediatricians.

Prior studies suggest that pediatricians believe discussing health policy issues with families is important. Caregiver preferences on these discussions, however, have not been examined. We explored circumstances in which caregivers may be receptive to discussing health policy issues with pediatricians. We conducted 26 semistructured interviews with mostly Black female caregivers at 3 urban academic pediatric primary care practices. Using both structured and open response questions, we explored 4 primary content areas: 1) caregivers' perspectives on discussing health policy issues in pediatricians' offices; 2) which health policy topics caregivers may prefer to discuss; 3) factors that render policy discussions in the clinic inappropriate to caregivers; and 4) which communication modalities caregivers prefer. Interview transcripts were coded and analyzed using content analysis. Themes that emerged from interviews included: 1) pediatricians are perceived as trusted information sources on health policy; 2) caregivers want to talk with pediatricians about children's health insurance policy changes; 3) time constraints are a barrier to health policy discussions; 4) caregivers prefer to discuss health policy topics during well-child visits; 5) caregivers want the option to opt-out of these conversations; 6) preferred modalities for communicating about health policy issues, including printed materials and health fairs or educational events. Caregivers expressed a satisfactory view of pediatricians discussing directly relevant health policy issues, including congressional debates on health insurance, in the primary care setting. Our findings highlight other caregiver preferences for engaging families in health policy discussions, including the timing of these conversations.

Is Primary Care Physician Involvement Associated with Earlier Advance Care Planning?: A Study of Patients in an Academic Primary Care Setting.

Background: Advance care planning (ACP) is important to improving end-of-life care. Few studies have examined the impact of primary care physician (PCP) involvement in ACP. Objectives: To determine whether complete ACP, defined as health care proxy (HCP), provider orders for life-sustaining treatment (POLST), and documented goals-of-care (GOC) conversations, would occur earlier when the PCP was involved in POLST and/or GOC conversations. Design: Charts of deceased patients from 2015 to 2017 in a U.S. academic primary care practice were reviewed. Demographic factors, mortality risk scores, palliative care involvement, and visits within the last year of life to PCPs and specialists were collected. Poisson models with robust variance estimators were used to estimate the likelihood of PCP involvement being associated with earlier complete ACP after adjusting for confounders and accounting for clustering by PCP. Due to high rates of HCP documentation at the institution, 10 patients without HCP were excluded from the review. Results: Of 403 decreased patients, 71 (18%) met criteria for complete ACP and 214 (53%) had HCP only; the remaining 118 patients had partial (2/3 components) ACP. Of the 71 patients with complete ACP, 40.1% had ACP earlier than three months of death (early) and 59.2% had ACP within three months of death (late). PCP involvement was associated with early ACP compared with late ACP and HCP only for both PCP completion of the POLST (risk ratio [RR]: 4.7; 95% confidence interval [CI]: 1.3-17.1) and for PCP documentation of GOC conversation (RR: 4.6; 95% CI: 1.2-17.1) after adjustment for clustering by PCP and other relevant variables. Conclusion: This retrospective cohort study suggests that PCP involvement in ACP correlates with earlier completion. This finding highlights the importance of educating and encouraging PCPs on completing ACP with their patients.

Patient engagement in an academic community-based primary care practice’s management committee: A case study

Patient engagement in primary care has been the focus of many studies; however, little research has evaluated its added value to organisational management in an academic community-based primary care practice (ACBPCP). In 2017, managers of an ACBPCP in Montreal, Canada, decided to integrate patients into the organization’s management committee to enhance the quality and relevance of decision-making for clinical services, education and research.