Non-primary Care Research Articles

A survey of essential anatomy from the perspective of anesthesiology, emergency medicine, obstetrics and gynecology, and orthopedics resident physicians

BackgroundRecent changes in anatomy curricula in undergraduate medical education (UME), including pedagogical changes and reduced time, pose challenges for foundational learning. Consequently, it is important to ask clinicians what anatomical content is important for their clinical specialty, which when taken collectively, can inform curricular development.MethodsThis study surveyed 55 non-primary care residents in anesthesiology (AN; N = 6), emergency medicine (EM; N = 15), obstetrics and gynecology (OB; N = 13), and orthopedics (OR; N = 21) to assess the importance of 907 anatomical structures across all anatomical regions. Survey ratings by participants were converted into a post-hoc classification system to provide end-users of this data with an intuitive and useful classification system for categorizing individual anatomical structures (i.e., essential, more important, less important, not important).ResultsSignificant variability was observed in the classifications of essential anatomy: 29.1% of all structures were considered essential by OB residents, 37.6% for AN residents, 41.6% for EM residents, and 72.0% for OR residents. Significant differences (with large effect sizes) were also observed between residency groups: OR residents rated anatomy of the back, limbs, and pelvis and perineum anatomy common to both sexes significantly higher, whereas OB residents rated the pelvis and perineum anatomy common to both sexes and anatomy for individuals assigned female at birth highest. Agreement in classifications of importance among residents was observed for selected anatomical structures in the thorax, abdomen, pelvis and perineum (assigned male at birth-specific anatomy), and head and neck. As with the ratings of anatomical structures, OR residents had the highest classification across all nine tissue types (p < 0.01).ConclusionsThe present study created a database of anatomical structures assessed from a clinical perspective that may be considered when determining foundational anatomy for UME curriculum, as well as for graduate medical education.

15 Predictive validity of two developmental screening tools at the 18-month visit and neurodevelopmental consultation at an average age of 8 years

Abstract Background The Canadian Paediatric Society (CPS) recommends an enhanced 18-month well-baby visit incorporating a developmental screening tool to stimulate discussion with parents, and notes that a widely used tool is the Nipissing District Developmental Screen (NDDS). For early detection of autism spectrum disorder, the CPS notes that a commonly used screening tool is the Infant Toddler Checklist (ITC). Objectives To examine the predictive validity of the ITC and NDDS at the 18-month visit using later neurodevelopmental consultation as the criterion measure; and examine whether positive developmental screening was associated with health care utilization (HCU). Design/Methods Using a prospective design, parents completed the ITC and the NDDS at the 18-month visit in primary care practices. Seven types of HCU were collected from health administrative databases, via linkage using the child’s health insurance number, including: neurodevelopmental consultation, special paediatric consultation, scheduled primary care visit billings, unscheduled primary care or minor visit billings, other non-primary care visit billings, hospitalizations, and emergency department visits. Covariates included child and family characteristics. We calculated screening test properties (using neurodevelopmental consultation as the criterion) and used multivariable negative binomial regression to estimate rate ratios (RR) for each of the 7 types of HCU. Results For both the ITC (n=1460) and NDDS (n=802) cohorts, mean age at screening was 18 months and mean age at follow up was 8 years. Of the ITC cohort, 11% were screen positive, 2.6% had a neurodevelopmental consultation. A positive ITC had 40% sensitivity (95% CI 24%-57%), 90% specificity (95% CI 88%-91%), 10% false positive rate (95% CI 9%-12%). A positive ITC was associated with 6 of 7 types of HCU, including neurodevelopmental consultation (RR=2.78, 95% CI 1.37-5.67). Of the NDDS cohort, 36% were screen positive, 2.5% had a neurodevelopmental consultation. A positive NDDS had a sensitivity of 50% (95% CI 27%-73%), specificity of 65% (95% CI 61%-68%), false positive rate of 35% (95% CI 31%-40%). A positive NDDS was associated with only 1 of 7 types of HCU: unscheduled primary care or minor visit billings 1.24 (95% CI 1.01, 1.53, p=0.04). Conclusion The predictive validity of the ITC was stronger than the NDDS due to high specificity and low false positive rates. The low sensitivity of the ITC is similar to other screening tools used at 18 months, highlighting the importance of ongoing developmental surveillance. The false positive rate of the NDDS is unacceptably high for a screening tool.

Effects of Citizenship Status on International Medical Graduate Specialty Choice and Practice Location.

The number of both US citizen and noncitizen international medical graduates (IMGs) practicing in the United States has grown substantially over the last two decades, but little is known about how these groups differ in clinical specialty and practice location. To evaluate the effects of citizenship status on IMG specialty choice (primary care vs nonprimary care) and practice location (rural and health professional shortage areas [HPSAs]). To analyze the retrospective, cross sectional data between 2010 and 2019, we estimated a series of multivariate logistic regressions with year fixed effects after assessing trends in new physician specialty choice and practice location. Survey of Residents Completing Training in New York, the largest publicly available annual survey of graduating residents and fellows in the US. 15,133 new physicians who accepted a job offer in our study period, including 8,177 US medical graduates (USMGs), 2,753 US citizen IMGs, 1,057 permanent resident IMGs, and 3,146 noncitizen non-permanent resident (NCNP) IMGs. IMG and Citizenship status. Whether a new physician chose to practice primary care; whether a new primary care physician chose to work in a rural area; whether a new primary care physician chose to work in a HPSA. Compared to 2010, there were 20% fewer NCNP IMGs entering primary care in 2019. Our logistic analysis found that US citizen IMGs were five times, permanent resident IMGs seven times, and NCNP IMGs nine times more likely to enter primary care compared to USMGs. Among new primary care physicians, NCNP IMGs were more likely to work in a rural area compared to USMGs while US citizen IMGs and permanent resident IMGs acted similarly to USMGs. NCNP IMGs were five times more likely to work in a HPSA while US citizen IMGs and permanent resident IMGs were less likely, compared to USMGs. There was a declining proportion of NCNP IMGs entering primary care; citizenship status affected IMGs' specialty and practice location choices with NCNP IMGs more likely to choose primary care and work in rural areas and HPSAs.

Differences in the clinical management of shoulder pain by physician specialty: data from the 2007–2019 National Ambulatory Medical Care Survey

ObjectivesThe aim of this study was to identify the differences in the clinical management of shoulder pain by primary care physicians (PCPs) and non-primary care physicians (non-PCPs) from the National Ambulatory Medical Care Survey (NAMCS) dataset.MethodsThis cross-sectional study included ambulatory care visits for shoulder pain by using NAMCS data from 2007 to 2019. Descriptive statistics were presented to assess patient-level and visit-level characteristics of the sampled visits. By controlling for patient-level and visit-level covariates, we conducted a multivariable logistic regression to evaluate the influence of primary care physician status on the utilization of health services (pain medications, PT referral, health education/counseling, and diagnostic imaging) for shoulder pain.ResultsThere were 74.43 million ambulatory care visits by adults with shoulder pain during the study period, and nearly one-third of these shoulder visits were made to PCPs. As compared with non-PCPs, PCPs had higher adjusted odds of prescribing narcotic analgesics (adjusted odds ratio [OR] = 1.62, 95% confidence interval [CI]: 1.04–2.51), skeletal muscle relaxants (adjusted OR = 2.71, 95% CI: 1.65–4.45), other pain medications (adjusted OR = 1.87, 95% CI: 1.13–3.07), and lower odds of prescribing PT (adjusted OR = 0.34, 95% CI: 0.21–0.55) and MRI (adjusted OR = 0.46, 95% CI: 0.25–0.84).ConclusionWe observed significant differences in the services ordered or provided by PCPs versus non-PCPs for shoulder pain in ambulatory care settings. These results may reveal the higher reliance of pharmacological approaches, coupled with the potential under-utilization of PT during the ambulatory shoulder care provided by PCPs compared to non-PCPs in the United States.

Improving influenza vaccine uptake in clinical risk groups: patient, provider and commissioner perspectives on the acceptability and feasibility of expanding delivery pathways in England

BackgroundPeople under the age of 65 in clinical risk groups are at increased risk of severe complications and death from influenza. In England, influenza vaccine coverage rates in this cohort...

Factors Influencing Primary Care Career Choice: A Multi-Institutional Cross-sectional Survey of Internal Medicine Primary Care Residency Graduates.

Although primary care is associated with population health benefits, the supply of primary care physicians continues to decline. Internal medicine (IM) primary care residency programs have produced graduates that pursue primary care; however, it is uncertain what characteristics and training factors most affect primary care career choice. To assess factors that influenced IM primary care residents to pursue a career in primary care versus a non-primary care career. Multi-institutional cross-sectional study. IM primary care residency graduates from seven residency programs from 2014 to 2019. Descriptive analyses of respondent characteristics, residency training experiences, and graduate outcomes were performed. Bivariate logistic regression analyses were used to assess associations between primary care career choice with both graduate characteristics and training experiences. There were 256/314 (82%) residents completing the survey. Sixty-six percent of respondents (n = 169) practiced primary care or primary care with a specialized focus such as geriatrics, HIV primary care, or women's health. Respondents who pursued a primary care career were more likely to report the following as positive influences on their career choice: resident continuity clinic experience, nature of the PCP-patient relationship, ability to care for a broad spectrum of patient pathology, breadth of knowledge and skills, relationship with primary care mentors during residency training, relationship with fellow primary care residents during training, and lifestyle/work hours (all p < 0.05). Respondents who did not pursue a primary care career were more likely to agree that the following factors detracted them from a primary care career: excessive administrative burden, demanding clinical work, and concern about burnout in a primary care career (all p < 0.05). Efforts to optimize the outpatient continuity clinic experience for residents, cultivate a supportive learning community of primary care mentors and residents, and decrease administrative burden in primary care may promote primary care career choice.

P-wave duration and interatrial block as predictors of ischemic stroke: a systematic review and meta-analysis

Abstract Introduction Ischemic stroke-risk has been associated with clinical characteristics, atrial remodeling and P- wave changes, like P-wave duration (PWD) or interatrial block (IAB). Despite the increasing evidence though, their use in risk-stratification remains limited. Purpose The aim of this review and meta-analysis was to examine the predictive value of PWD/IAB for stroke and offer practical implications. Methods Publication databases were systematically searched and studies reporting PWD and/or morphology at baseline and thromboembolic events (TEs) during follow-up (FUP) were included. IAB was defined as partial (pIAB) if PWD≥120 ms or advanced (aIAB) if the P-wave was biphasic in the inferior leads. After quality assessment and data extraction, random-effects analysis calculated odds ratio (OR) and confidence intervals (CI). Subgroup-analysis was performed to address heterogeneity. Results Among 180.997 patients (17 studies, mean 66 years old), including primary care patients (n=152.759), 15.578 (9%) had a new TE during 4 years of FUP. The pIAB was significant TE-risk predictor for non-primary care patients (OR:1.7; 95% CI:1.4-2.1) and those with prior TE (OR:1.8; 95% CI:1.4-2.2), but not for primary-care (OR:1.0) or those without prior TE (OR:1.3). The aIAB was significant TE-risk predictor both for primary (OR:1.6; 95% CI:1.4-1.9) and nonprimary care (OR:2.5; 95% CI:1.8-3.4) as well as those without (OR:2.2; 95% CI:1.1-4.4) or with prior TE (OR:2.6; 95% CI:1.4-4.7). There was heterogeneity but no publication bias in the subgroup-analysis. Conclusion Interatrial block is an independent predictor of TE-risk. The association is stronger for non-primary care patients or those with prior TE. Thus, PWD and IAB could be used as selection criteria for intensive screening, follow-up or interventions.

Quantifying the impact of telemedicine and patient medical advice request messages on physicians' work-outside-work

The COVID-19 pandemic has boosted digital health utilization, raising concerns about increased physicians’ after-hours clinical work ("work-outside-work”). The surge in patients’ digital messages and additional time spent on work-outside-work by telemedicine providers underscores the need to evaluate the connection between digital health utilization and physicians’ after-hours commitments. We examined the impact on physicians’ workload from two types of digital demands - patients’ messages requesting medical advice (PMARs) sent to physicians’ inbox (inbasket), and telemedicine. Our study included 1716 ambulatory-care physicians in New York City regularly practicing between November 2022 and March 2023. Regression analyses assessed primary and interaction effects of (PMARs) and telemedicine on work-outside-work. The study revealed a significant effect of PMARs on physicians’ work-outside-work and that this relationship is moderated by physicians’ specialties. Non-primary care physicians or specialists experienced a more pronounced effect than their primary care peers. Analysis of their telemedicine load revealed that primary care physicians received fewer PMARs and spent less time in work-outside-work with more telemedicine. Specialists faced increased PMARs and did more work-outside-work as telemedicine visits increased which could be due to the difference in patient panels. Reducing PMAR volumes and efficient inbasket management strategies needed to reduce physicians’ work-outside-work. Policymakers need to be cognizant of potential disruptions in physicians carefully balanced workload caused by the digital health services.

Utilization, quality, and spending for pediatric Medicaid enrollees with primary care in health centers vs non-health centers

BackgroundLimited research has explored the performance of health centers (HCs) compared to other primary care settings among children in the United States. We evaluated utilization, quality, and expenditures for pediatric Medicaid enrollees receiving care in HCs versus non-HCs.MethodsThis national cross-sectional study utilized 2012 Medicaid Analytic eXtract (MAX) claims to examine children 0–17 years with a primary care visit, stratified by whether majority (> 50%) of primary care visits were at HCs or non-HCs. Outcome measures include utilization (primary care visits, non-primary care outpatient visits, prescription claims, Emergency Department (ED) visits, hospitalizations) and quality (well-child visits, avoidable ED visits, avoidable hospitalizations). For children enrolled in fee-for-service Medicaid, we also measured expenditures. Propensity score-based overlap weighting was used to balance covariates.ResultsA total of 2,383,270 Medicaid-enrolled children received the majority of their primary care at HCs, while 18,540,743 did at non-HCs. In adjusted analyses, HC patients had 20% more primary care visits, 15% less non-primary care outpatient visits, and 21% less prescription claims than non-HC patients. ED visits were similar across the two groups, while HC patients had 7% lower chance of hospitalization than non-HC. Quality of care outcomes favored HC patients in main analyses, but results were less robust when excluding managed care beneficiaries. Total expenditures among the fee-for-service subpopulation were lower by $239 (8%) for HC patients.ConclusionsIn this study of nationwide claims data to evaluate healthcare utilization, quality, and spending among Medicaid-enrolled children who receive primary care at HCs versus non-HCs, findings suggest primary care delivery in HCs may be associated with a more cost-effective model of healthcare for children.

A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Using a Virtual Simulation Workshop to Teach Interns Evidence-Based Feedback Techniques.

Background TheAccreditation Council for Graduate Medical Education requires residents to demonstrate competence in integrating feedback into their daily practice. With the shift to virtual medical education during the pandemic, the need for new skills in delivering effective feedback through virtual media has emerged. Methodology This study aimed to assess the feasibility of a virtual bootcamp for interns, utilizing virtual simulation workshops to teach effective feedback skills. The curriculum employed a situated learning-guided participation framework. Virtual standardized students participated, and interns engaged in activities such as providing virtual feedback, completing self-assessments, and receiving instruction on feedback principles, including the one-minute preceptor's five micro-skills. Interns repeated the feedback process, with virtual students providing assessments. Data were collected from 105 incoming interns at Arrowhead Regional Medical Center in June 2021 and June 2022, using Zoom® as the online platform. Results Competency assessments revealed a significant post-training increase in proficiency/expert milestones (88% versus 47%, p = 0.007). Interns' self-assessments also significantly improved (18.02 versus 16.74, p = 0.001), particularly for previously trained interns (18.27 versus 16.7). Non-primary care interns outperformed primary care interns in milestone scores. The majority of interns (80%) reported valuable learning experiences during the workshop, with 70% expressing confidence in using the one-minute preceptor technique during residency. The one-minute preceptor step "reinforce what was right" was deemed the easiest, while "obtain commitment" and "explore emotional reaction" presented significant challenges. Conclusions This study demonstrates the potential of virtual workshops to enhance intern competency in delivering effective feedback through formal processes and the one-minute preceptor. These virtual approaches offer innovative alternatives to in-person teaching, enabling evaluation at higher levels of Miller's pyramid of clinical competence.

Fighting Fires and Battling the Clock: Advance Care Planning in Family Medicine Residency.

Few family physicians treating patients with life-limiting illness report regularly initiating advance care planning (ACP) conversations about illness understanding, values, or care preferences. To better understand how family medicine training contributes to this gap in clinical care, we asked how family medicine residents learn to engage in ACP in the workplace. We coded semistructured interviews with family medicine residents (n=9), reflective memos (n=9), and autoethnographic field notes (n=37) using a constructivist-grounded theory approach. We next used the constant comparative method of grounded theory to develop two composite narratives describing participants' experiences that we then member-checked with participants. We identified six core categories of social process to describe how participants were taught to engage in advance care planning. These social processes included previously unidentified barriers to ACP that were specific to their role as learners. These barriers appeared to lead to cultural avoidance of prognosis, conflation of ACP and goals of care (GOC) conversations, and deferral of difficult conversations to nonprimary care settings. Family medicine educators should consider developing interventions such as flexible clinic schedules, dedicated ACP time, deliberate observed practice, and structured teaching to address potential barriers identified in this exploratory research. Family medicine leaders may wish to consider directly teaching residents and preceptors about crucial differences between ACP and GOC discussions. Shifting curricular focus toward eliciting values and illness understanding during ACP could help resolve a cultural avoidance of prognosis that limits family medicine residents' attempts to engage in ACP.

Longitudinal Patterns in Testosterone Prescribing After US FDA Safety Communication in 2014.

The objective of this study was to describe changes in testosterone prescribing following a 2014 US Food and Drug Administration (FDA) safety communication and how changes varied by physician characteristics. Data were extracted from a 20% random sample of Medicare fee-for-service administrative claims data from 2011 through 2019. The sample included 1,544,604 unique male beneficiaries who received evaluation and management (E&M) services from 58,819 unique physicians that prescribed testosterone between 2011 and 2013. Patients were categorized based on presence of coronary artery disease (CAD) and non-age-related hypogonadism. Physician characteristics were identified in the OneKey database and included specialty and affiliations with teaching hospitals, for-profit hospitals, hospitals in integrated delivery networks, and hospitals in the top decile of case mix index. Linear segmented models described how testosterone prescriptions changed following a 2014 FDA safety communication and how changes were associated with physician and organizational characteristics. Among 65,089,560 physician-patient-quarter-year observations, mean (standard deviation) age ranged from 72.16 (5.84) years for observations without CAD or non-age-related hypogonadism to 75.73 (6.92) years with CAD and without non-age-related hypogonadism. Following the safety communication, immediate changes in off-label testosterone prescription levels fell by 0.22 percentage points (pp) (95% confidence interval [CI] -0.33 to -0.11) for patients with CAD and by -0.16 pp (95% CI -0.19 to -0.16) for patients without CAD. A similar change was noticed in on-label prescribing levels. Off-label testosterone prescription quarterly trend, however, increased for patients with CAD and without CAD; on-label testosterone prescription trends declined for both groups. Declines in off-label prescribing were larger when treated by primary care physicians vs. non-primary care physicians, and physicians affiliated with teaching compared to nonteaching hospitals. Physician and organizational characteristics were not associated with changes in on-label prescribing. On-label and off-label testosterone therapy declined following the FDA safety communication. Certain physician characteristics were associated with changes in off-label, but not on-label, prescribing.

Mammography Screening Outreach Through Non-Primary Care–Based Services

ObjectiveTo estimate the proportion of patients visiting urgent care centers or emergency departments or being hospitalized who were not up to date with recommended mammography screening to assess the potential impact of non-primary care–based cancer screening interventions. MethodsAdult participants from the 2019 National Health Interview Survey were included. Among participants not up to date with breast cancer screening guidelines based on ACR recommendations, the proportion of patients reporting an urgent care, emergency department visit, or hospitalization within the last year was estimated accounting for complex survey sampling design features. Multiple variable logistic regression analyses were then conducted to evaluate the association between sociodemographic characteristics and mammography screening adherence. ResultsThe study included 9,139 women between the ages of 40 and 74 years without history of breast cancer. Of these respondents, 44.9% did not report mammography screening within the last year. Among participants who did not report mammography screening, 29.2% reported visiting an urgent care center, 21.8% reported visiting an emergency room, and 9.6% reported being hospitalized within the last year. The majority of patients receiving non-primary care–based services, who were not up to date with mammography screening, were from historically underserved groups including Black and Hispanic patients. ConclusionNearly 10% to 30% of participants who have not obtained recommended breast cancer screening have visited non-primary care–based services including urgent care centers or emergency rooms or have been hospitalized within the last year.

Prescription Patterns of New Use of Fixed-Dose Combination Inhalers in Patients with Chronic Obstructive Pulmonary Disease: Long-Acting β2 Agonists Plus Long-Acting Muscarinic Antagonists versus Long-Acting β2 Agonists Plus Inhaled Corticosteroids.

The clinical guideline recommends use of long-acting β2 agonists/long-acting muscarinic antagonists (LABA/LAMA) or long-acting β2 agonists/inhaled corticosteroids (LABA/ICS) combination therapies for patients with severe chronic obstructive pulmonary disease (COPD). The fixed-dose combination (FDC) inhalers of LABA/LAMA and LABA/ICS were reimbursed in Taiwan in 2015 and in 2002, respectively. This study aimed to examine prescription patterns of new use of either FDC therapy in real-world practice. We identified COPD patients who initiated LABA/LAMA FDC or LABA/ICS FDC between 2015 and 2018 from a population-based Taiwanese database with 2 million, randomly sampled beneficiaries enrolled in a single-payer health insurance system. We compared number of LABA/LAMA FDC and LABA/ICS FDC initiators in each calendar year, from different hospital accreditation levels, and cared for by different physician specialties. We also compared baseline patient characteristics between LABA/LAMA FDC and LABA/ICS FDC initiators. A total of 12,455 COPD patients who initiated LABA/LAMA FDC (n=4019) or LABA/ICS FDC (n=8436) were included. Number of LABA/LAMA FDC initiators increased apparently (n=336 in 2015 versus n=1436 in 2018), but number of LABA/ICS FDC initiators decreased obviously (n=2416 in 2015 versus n=1793 in 2018) over time. The preference of use of LABA/LAMA FDC varied across clinical environments. The proportions of LABA/LAMA FDC initiators were more than 30% in the setting of non-primary care clinics (eg, medical centers) and in the services of chest physicians; but were only less than 10% in primary care clinics and non-chest physicians' services (eg, family medicine physicians). LABA/LAMA FDC initiators appeared to be older, male, to have more comorbidities, and to utilize resources more frequently compared to LABA/ICS FDC initiators. This real-world study found evident temporal trends, variations in healthcare provider, and differences in patient characteristics among COPD patients who initiated LABA/LAMA FDC or LABA/ICS FDC.

Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico

BackgroundIdentifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses.MethodsThis cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios.ResultsOver two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%).ConclusionsUniversal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.

Building a Data Bridge: Policies, Structures, and Governance Integrating Primary Care Into the Public Health Response to COVID-19.

The effective integration of primary care into public health responses to the COVID-19 pandemic, particularly through data sharing, has received some attention in the literature. However, the specific policies and structures that facilitate this integration are understudied. This paper describes the experiences of clinicians and administrators in Alberta, Canada as they built a data bridge between primary care and public health to improve the province's community-based response to the pandemic. Fifty-seven semistructured qualitative interviews were conducted with a range of primary care and public health stakeholders working inside the Calgary Health Zone. Interpretive description was used to analyze the interviews. SARS-CoV-2 test results produced by the local public laboratory were, initially, only available to central public health clinicians and not independent primary care physicians. This enabled centrally managed contact tracing but meant primary care physicians were unaware of their patients' COVID-19 status and unable to offer in-community follow-up care. Stakeholders from both central public health and independent primary care were able to leverage a policy commitment to the Patient Medical Home (PMH) care model, and a range of existing organizational structures, and governance arrangements to create a data bridge that would span the gap. Primary care systems looking to draw lessons from the data bridge's construction may consider ways to: leverage care model commitments to integration and adjust or create organization and governance structures which actively draw together primary care and non-primary care stakeholders to work on common projects. Such policies and structures develop trusting relationships, open the possibility for champions to emerge, and create the spaces in which integrative improvisation can take place.

First-Year Resident Perceptions of Virtual Interviewing

Virtual interviews (VI) for residency programs present a relatively new paradigm for recruitment. To date, studies have been small, largely descriptive, and focused on surgical and subspecialty areas. The purpose of the study was to assess residents' perceptions about their VI experience and to compare those in primary care versus non-primary care specialties. An electronic survey was sent to 35 designated institutional officials in Illinois with a resulting snowball sample to assess first-year residents' perceptions of their virtual interviewing experience. A total of 82 postgraduate year-1 residents responded to the survey. We used descriptive analysis and χ2 tests to analyze results. Respondents were mostly female (52.4%), White (79%), non-Hispanic (76%), attending a university residency program (76.3%), and in a primary care specialty (61.7%). In general, most respondents (54.8%-75.3%) felt their VI accurately portrayed their residency program experience. Resident morale, resident-faculty camaraderie, and educational opportunities were perceived as being best portrayed in the VI. Compared to non-primary care residents, primary care residents felt that their program's VI more accurately portrayed the patient population served (P=.0184), resident morale in the program (P=.0038), and the overall residency experience (P=.0102). Still, 25.7% of respondents felt they were not accurately represented in the VI. Respondents reported that the VI portrays the residency experience fairly well, yet there is opportunity to improve the overall experience. The more difficult experiences to convey (morale, camaraderie, and the overall resident experience) may be areas in which primary care programs are outpacing other training programs.

Outpatient secondary care pathways for head and neck cancer referral result in patient delays for cancer treatment.

The majority of head and neck cancer referrals are received through primary care. A proportion of cancer referrals are received through secondary care specialties. Local delivery plan (LDP) targets in Scotland for cancer investigation are set at 31 days for diagnosis and 62 days to start treatment. The aim was to audit referrals made through non-primary care pathways compared with the standard primary care pathways against LDP targets. New head and neck cancer patients between 1 January 2014 and 1 January 2019 were included. Pathway points were recorded between referral to outpatient clinic, time to multidisciplinary team discussion (MDT) and finally MDT to treatment. 1,276 new patient referrals were received over a 5-year period. Of these, 136 (10%) were referred via non-primary care pathways. The mean time for urgent suspicion of cancer (USoC) referrals to start treatment was 77 days (15 days over target) and for outpatient secondary care referrals was 102 days (40 days over target) (p<0.05). When treatment intent was considered, 841/1,131 (75%) of patients referred via primary care were treated curatively compared with 49/99 (49%) (p<0.05) of patients referred through the secondary outpatient pathway. Patients with head and neck cancer referred from other outpatient specialties face delays commencing cancer treatment and are also associated with a greater likelihood of being treated with palliative intent.

Assessing patient, physician, and practice characteristics predicting the use of low-value services.

To examine characteristics of beneficiaries, physicians, and their practice sites associated with greater use of low-value services (LVS) using LVS measures that reflect current care practices. This study was conducted in the context of a large, nationwide primary care redesign initiative (Comprehensive Primary Care Plus), using Medicare claims data in 2018. We examined beneficiary-level total counts of LVS based on the existing 31 claims-based measures updated by excluding three services provided with diminishing frequency to Medicare beneficiaries and by replacing these with more recently identified LVS. We estimated hierarchical linear models with an extensive list of beneficiary, physician, and practice site characteristics to examine the contribution of characteristics at each level in predicting greater use of LVS. We also examined the proportion of variation in LVS use attributable to the set of characteristics at each level. The study included 5,074,642 Medicare fee-for-service beneficiaries attributed to 32,406 primary care physicians in 11,009 primary care practice sites. Patients with disabilities, end-stage renal disease, and those in regions with higher poverty rates receive 10 (standard error [SE]=3.0), 80 (SE=14.0), and 10 (SE=1.0) more LVS per 1000 beneficiaries across all 31 measures combined than patients without such attributes, respectively. Greater physician comprehensiveness and an increase in the number of primary care practitioners at a practice were associated with 40 (SE=20.0) and 20 (SE=6.0) fewer LVS per 1000 beneficiaries, respectively. Yet, the explanatory variables we examined only account for 11 percent of the variation in LVS use, with most of the variation (87 percent) being due to unobserved differences at the beneficiary level. Unexplained residual variation, from underlying patient preferences and behavior of non-primary care providers, could be important determinants of LVS use.