Primary Care Delivery Research Articles

Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: A survey study

IntroductionThe COVID-19 pandemic has had a profound impact on the delivery of primary care around the world. In Ireland, the use of technologies such as virtual consultations and the electronic transfer of prescriptions became widespread in order to deliver care to patients while minimising infection risk. The impact of these changes on medication safety is not yet known. ObjectivesThe aims of this survey study were to investigate 1) the changes that have occurred in Irish primary care since the start of the COVID-19 pandemic and 2) the impact of these changes on medication safety. MethodsAnonymous, online surveys were distributed to general practitioners (GPs) and pharmacists from August–September 2021. Surveys contained quantitative (multiple-choice, Likert scale) and qualitative (free-text) questions concerning workflow changes, medication safety incidents and near misses, and GP/pharmacist perspectives on medication safety and COVID-19. Reported medication safety incidents and near misses were categorised according to the WHO Conceptual Framework for the International Classification for Patient Safety. ResultsIn total, there were 251 responses to the survey, comprising of 211 pharmacists and 40 GPs. The most significant workflow changes during the pandemic were the widespread use of a secure clinical email service (Healthmail) that facilitates electronic prescription transfer and communication (75.3% of respondents) and the increased use of telephone consultations (49%). Overall, Healthmail was widely perceived to have had a positive impact on medication safety. Most GPs did not perceive a change in the frequency of medication safety incidents during the pandemic, while most pharmacists reported a slight increase in incidents. Survey participants highlighted pressure, patient expectations, and patient monitoring as significant challenges encountered during the pandemic. ConclusionsDuring the pandemic, a number of significant changes occurred in primary care in Ireland, particularly involving communication of healthcare information, with varying impacts on workflow and medication safety. Future research should focus on the optimisation of electronic prescribing and telemedicine services in Ireland, patient perspectives on the changes in primary care, and interventions to improve medication safety in primary care.

Coordination between Primary Care Teams and Family Health Support Units and influence on Primary Care delivery.

This article aims to compare the implementation of coordinated actions by family health/primary care (FH/PC) teams and extended family health and primary care units (NASF-ABs) in the Northeast and rest of Brazil, and the influence of implementation on collaborative working. The independent variables were 19 coordinated actions assessed by Module II of the 3rd Cycle of the National Program for Improving Primary Care Access and Quality (PMAQ-AB). The three collaborative working outcomes were "FH/PC team readiness to work jointly with the NASF-AB", "support received by the FH/PC team from the NASF-AB", and "The NASF-AB's contribution to resolving patients" needs. The implementation of coordinated actions by the Northeast and at national level was compared using the two-proportions z-test and the influence of these actions on the outcomes was assessed using hierarchical linear regression models: The Northeast implemented more actions that at national level (p<0.05). The implemented actions that had the most positive influence on the three outcomes were "Case conferences", "Joint development of singular therapy plans for complex cases", "Shared appointments" and "Results monitoring". The Northeast implemented more actions and the implemented actions had a positive influence on collaborative working.

The PA profession in the 1990s.

History is rarely linear, and nowhere is this more evident than the US physician assistant/associate (PA) movement (1965-2021). The 1990s stand out as pivotal years for the PA profession, marked by advances that shaped the profession, experiments in primary care delivery, sex equity, the Balanced Budget Act, and national policy errors in predicting a physician surplus. Rapid growth followed program expansion, doubling from 57 in 1993 to 120 by 1999. By the end of the decade, all states had advanced PA-enabling legislation with broad-based prescribing. During this era, PA-focused research moved from descriptive to predictive, an official journal emerged in 1988, the Accreditation Review Commission on Education for the Physician Assistant became independent, and the American Academy of Physician Associates helped shape federal health policy. Also during this period, the profile of PAs shifted from older males to younger females with important sociological implications in leadership and career development. Notable milestones included national recognition of PAs as Medicare-eligible providers, direct commissioning in the military, and employment surges in the Veterans Health Administration and US Public Health Service. Not least of all this was a time of role shifts toward specialized medicine and surgery.

Preparedness for and impact of COVID-19 on primary health care delivery in urban and rural Malawi: a mixed methods study

ObjectiveAcross Africa, the impact of COVID-19 continues to be acutely felt. This includes Malawi, where a key component of health service delivery to mitigate against COVID-19 are the primary healthcare...

Vertical integration of GP practices with acute hospitals in England and Wales: rapid evaluation

Background Vertical integration refers to merging organisations that operate at different stages along the patient pathway. An organisation running an acute hospital and also operating primary care medical practices (i.e. general medical practitioner practices, also known as ‘general practices’) is an example of vertical integration. Evidence is limited concerning the advantages and disadvantages of different arrangements for implementing vertical integration, their rationale and their impact. Objectives Our aim was to (1) understand the rationale for, and early impact of, vertical integration in the NHS in England and Wales and (2) develop a theory of change for vertical integration. Design We carried out a rapid qualitative cross-comparative case study evaluation at three sites in England (n = 2) and Wales (n = 1), which comprised three work packages: (1) a rapid review of literature, telephone scoping interviews and a stakeholder workshop; (2) interviews with stakeholders across case study sites, alongside observations of strategic meetings and analysis of key documents from the sites; and (3) development of a theory of change for each site and for vertical integration overall. Results We interviewed 52 stakeholders across the three case study sites; however, gaining access to and arranging and completing non-participant observations proved difficult. The single most important driver of vertical integration proved to be the maintenance of primary care local to where patients live. Vertical integration of general practices with organisations running acute hospitals has been adopted in some locations in England and Wales to address the staffing, workload and financial difficulties faced by some general practices. The opportunities created by vertical integration’s successful continuation of primary care, namely to develop patient services in primary care settings and better integrate them with secondary care, were exploited to differing degrees across the three sites. There were notable differences between the sites in organisational and clinical integration. Closer organisational integration was attributed to previous good relationships between primary and secondary care locally, and to historical planning and preparation towards integrated working across the local health economy. The net impact of vertical integration on health system costs is argued by local stakeholders to be beneficial. Limitations Across all three case study sites, the study team was unable to complete the desired number of non-participant observations. The pace of data collection during early interviews and documentary analysis varied. Owing to the circumstances of the COVID-19 pandemic during project write-up, the team was unable to undertake site-specific workshops during data analysis and an overall workshop with policy experts. Conclusions The main impact of vertical integration was to sustain primary medical care delivery to local populations in the face of difficulties with recruiting and retaining staff, and in the context of rising demand for care. This was reported to enable continued patient access to local primary care and associated improvements in the management of patient demand. Future work The patient experience of vertical integration, effectiveness of vertical integration in terms of impact on secondary care service utilisation (e.g. accident and emergency attendances, emergency admissions and length of stay) and patient access (e.g. general practitioner and practice nurse appointments) to primary care requires further evaluation. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 17. See the NIHR Journals Library website for further project information.

"Beyond Just a Supplement": Administrators' Visions for the Future of Virtual Primary Care Services.

The COVID-19 pandemic resulted in unprecedented adoption and implementation of virtual primary care services, and little is known about whether and how virtual care services will be provided after the pandemic ends. We aim to identify how administrators at health care organizations perceive the future of virtual primary care services. In March-April of 2021, we conducted semistructured qualitative phone interviews with administrators at 17 health care organizations that ranged from multi-state nonfederal delivery systems to single-site primary care practices. Organizations differed in size, structure, ownership, and geography. We explore how health care administrators anticipate their organization will offer virtual primary care services after the COVID-19 pandemic subsides. All interviewed administrators expected virtual primary care services to persist after the pandemic. We categorize expected impact of future virtual services as limited (n = 4); targeted to a narrow set of clinical encounters (n = 5); and a major shift in primary care delivery (n = 8). The underlying motivation expressed by administrators for providing virtual care services was to remain financially stable and competitive. This motivation can be seen in the 3 main goals described for their anticipated use of virtual services: (1) optimizing medical services; (2) enhancing the patient experience; and (3) increasing loyalty among patients. Health care organizations are considering how virtual primary care services can be used to improve patient outcomes, access to care, and convenience of care. To implement and sustain virtual primary care services, health care organizations will need long-term support from regulators and payers.

How do diverse low-income and middle-income countries implement primary healthcare team integration to support the delivery of comprehensive primary health care? A mixed-methods study protocol from India, Mexico and Uganda

IntroductionAttainment of universal health coverage is feasible via strengthened primary health systems that are comprehensive, accessible, people-centred, continuous and coordinated. Having an adequately trained, motivated and equipped primary healthcare workforce...

Telemedicine in Primary Care: Qualitative Work Towards a Framework for Appropriate Use.

Telemedicine has been implemented in many health systems by necessity, yet evidence is sparse about its appropriate use for the delivery of primary care. We sought to understand what clinicians and patients consider to be appropriate use of telemedicine in primary care to inform future development of a framework that should be valuable to diverse stakeholders. We conducted in-depth, structured interviews of patients, clinicians who deliver primary care, and other select informants. They were asked to discuss optimal, acceptable, and suboptimal uses of telemedicine for delivering care relative to in-person care delivery. Audio was transcribed and paired reviewers analyzed the content to identify the key concepts that motivated the informants. The reviewers did thematic analysis to organize the concepts into unifying themes. Our 18 key informants generated 103 unique concepts. The unique concepts aggregated into themes suggesting the clinical situations in which telemedicine is appropriately used in primary care and clinical situations in which it should be avoided. We also learned of motivators toward expanded, or at least continued, use of telemedicine and motivators away from telemedicine's continued use. The informants expressed their expectations regarding decision making about telemedicine use and who should make these decisions. These key concepts and themes are expected to be a valuable starting point for the development of a framework to inform appropriate use of telemedicine in primary care.

Working Framework for Appropriate Use of Virtual Care in Primary Care.

Given the absence of guidelines for use of virtual visits for primary care delivery, a framework is needed to inform the most appropriate use of virtual visits. We conducted in-depth, structured interviews of 18 patients, primary care clinicians, and other select informants. They were asked to discuss optimal, acceptable, and suboptimal uses of telemedicine for delivering care relative to in-person care delivery. The concepts expressed informed our development of a framework about appropriate use of virtual visits. The 103 concepts supported 5 main themes that emerged as a framework: clinical situations which are optimal for in-person care; situations optimal for virtual visits; situations that might be exchangeable between sites; contextual factors favoring in-person care; and contextual factors favoring virtual visits. After further validation, we expect that this framework may guide future research and practice: it may be valuable for clinical practice redesign, for designing evaluations of the outcomes of virtual visits, for outcomes research, for patient education, for triage, and possibly for reimbursement considerations.

Rethinking Primary Care Delivery Models: Can Integrated Primary Care Teams Improve Care Experience?

Background:Integrated Primary Care Teams (IPCTs) have four key characteristics (intensive interdisciplinary practice; advanced nursing practice with an expanded role; group practice; increased proximity and availability) aimed at strengthening primary care in Quebec, Canada. The purpose of this paper is to examine the care experience over time of patients who have an IPCT as their primary source of care.Methods:We used a quasi-experimental longitudinal design based on a pre-and-post administered survey at a 2-year interval without a control group. We measured patient-reported accessibility, continuity, comprehensiveness, responsiveness and outcomes of care.Results:Results showed that patients who were newly registered with an IPCT had a significant increase in reported care experience, whereas patients who have been registered with an IPCT for 2 years prior to the first round of data collection had already high reported care experience that was maintained over time. Moreover, linear regression models showed statistically significant different increases in the dimensions of care experience by site and patients’ characteristics.Conclusions:Our results suggest that the IPCT model is tailored to the needs of its target populations, resulting in improved Patient Reported Experience Measures. These results imply that broader implementation of innovative and flexible community-based care models should be considered by policymakers.

Analysis of the role of General Practice in preventing Avoidable Hospitalisation through a multilevel approach

&#x0D; Objective. To examine the relationship between Avoidable Hospitalisation (AH) and the activities of General Practitioners (GPs). The study was carried out in the Lazio Region (Italy) within different organizational models of primary care (PC) delivery.&#x0D; Methods: Secondary data of a set of GP activities delivered to the Lazio population as listed in the Lazio GPs in 2008, were used. For each GP a set of health services delivered to the patients on their practice lists were measured. The relation between the rates of AH, acute and chronic conditions separately, and the rates of such health services were analyzed through the use of a multilevel Poisson regression model, adjusted according to patients’ health status.&#x0D; Results: The study included data from all the active GPs (4,837) in the Lazio Region and their 4,666,037 registered patients. The overall AH rate of the registered patients was 7.7 per 1,000, 2.2 for acute and 5.5 for chronic conditions. The diagnostics prescription by GPs is associated with a 7% (IRR=0.93;95% C.I.:0.89-0.97) reduction of the chronic AH rate. Patients registered at GPs working within a team practice resulted in a hospitalisation rate decrease of 5% (IRR= 0.95; 95% C.I.:0.91-0.99) for avoidable acute conditions.&#x0D; Conclusion: The study showed that the role of GPs in preventing AH is substantial, particularly when team practice is performed and specifically when additional diagnostics are prescribed. The study is further evidence in favor of the validity of AH as an outcome measure of quality and accessibility of primary care.&#x0D;

Provider supply and access to primary care.

Resource-constrained delivery systems often have access issues, causing patients to wait a long time to see a provider. We develop theoretical and empirical models of wait times and apply them to primary care delivery by the U.S. Veterans Health Administration (VHA). Using instrumental variables to handle simultaneity issues, we estimate the effect of clinician supply on new patient wait times. We find that it has a sizable impact. A 10% increase in capacity reduces wait times by 2.1%. Wait times are also associated with clinician productivity, scheduling protocols, and patient access to alternative sources of care. The VHA has adopted our models to identify underserved areas as specified by the MISSION Act of 2018.

Effectiveness of registered nurses on system outcomes in primary care: a systematic review

BackgroundInternationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care.MethodsA systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken.ResultsSeventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support).ConclusionsThe findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs.Protocol registration IDPROSPERO: International prospective register of systematic reviews. 2018. ID=CRD42018090767.

An exploration of general practitioners’ and pharmacists’ views and experiences of integrating a pharmacist into general practice: a qualitative study

Abstract Introduction Practice-based pharmacists (PBPs) have been introduced into general practice across the United Kingdom (UK) to relieve some of the pressures within primary care (1,2). However, there is little existing UK literature that has explored healthcare professionals’ (HCPs’) views about PBP integration and how this role has evolved. Aim To explore the views and experiences of general practitioners (GPs), PBPs, and community pharmacists (CPs) about PBPs’ integration into general practice and their impact on primary healthcare delivery. Methods Purposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in one region in the UK to participate in one-to-one semi-structured interviews. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. The interview topic guides were developed based on the published literature, and through discussion within the research team; they were piloted with two GPs, two PBPs, and two pharmacists. Due to the Covid-19 pandemic, interviews were conducted via telephone or Microsoft Teams platform. All interviews were recorded, transcribed verbatim, and analysed using inductive thematic analysis. Results Eleven triads were recruited from across the five administrative areas. Analysis of interview transcripts is ongoing. Findings to date have revealed four main themes in relation to PBPs’ integration into general practices (Table): evolution of the role, PBP attributes, collaboration and communication, and impact on care. A number of areas for development were identified such as patient awareness of the role and communication pathways between PBPs and CPs. Many saw PBPs as a ‘central hub-middleman’ between general practice and community pharmacies and between primary and secondary care. Conclusion Participants reported that PBPs had integrated well, and perceived a positive impact on primary health care delivery. Although recruitment was limited to one UK geographical region, the triad approach provided a more comprehensive overview of the working relationships between the three HCP groups. Further work is needed to increase patient awareness of the PBP role. References (1) Strategic Leadership Group for Pharmacy. Practice-based pharmacists’ statement. 2016. (Online) Available at: https://www.health-ni.gov.uk/sites/default/files/publications/health/practice-based-pharmacists.pdf (accessed 06 Oct 2021). (2) NHS England. Clinical pharmacists in general practice. 2015. (Online) Available at: https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/ (accessed 06 Oct 2021).

Queueing Information Management of Primary Care Delivery With E-Visits

The goal of this work is to investigate the system configuration and information management of primary care delivery with electronic visits (e-visits). We consider a medical institution employing primary care physicians and other clinicians that offer office visits (in-person) and e-visits (through secure messaging from patient portals), and where different queue-joining behaviors: denoted as the mixed strategy, the duplication strategy and the threshold strategy are adopted by flexible patients based on different system configurations. Different queueing models are developed to capture flexible patients' queue-joining behaviors according to queueing information provision. In particular, we develop the equilibrium behavior of a dual server system where state information is available for one of the servers and the flexible patient exhibits a utility-maximizing behavior, which extends the literature on the analysis of queueing systems with strategic customers. The duplication strategy with deletion offers the least expected waiting time for the patients, and the threshold strategy provides the next best performance which is superior to the mixed strategy, which demonstrates the value of information. IEEE

Supporting goal-oriented care using mobile technology: Findings from the mixed-methods trial of the ePRO tool.

Context: Goal-oriented models of care are becoming more widely used as part of primary care delivery for older adults with multimorbidity and complex care needs. While these models hold promise, implementation remains challenging. Digital health solutions may improve adoption however, they require evaluation to determine feasibility and impact. Objective: This study evaluates the implementation and effectiveness of the electronic Patient Reported Outcome (ePRO) mobile application and portal system, designed to enable goal-oriented care delivery in inter-professional primary care practices. Study design: Multi-method pragmatic randomized control trial using a stepped-wedge design and ethnographic case studies over a 15-month period. Setting: 6 comprehensive primary care practices across Ontario. Population studied: Older adults with complex care needs; target sample 176 patients. Intervention: Patient and provider participants used the ePRO tool in addition to usual care. The 6 practices randomized into either early (3-month control; 12-month intervention) or late (6-month control; 9-month intervention) groups. Outcome measures: The Assessment of Quality of Life-4D collected at baseline and 3-month intervals. Ethnographic data (observations and interviews) collected at mid-point and end of the intervention. Outcome data were analyzed using linear models. Ethnographic data was analyzed using qualitative description and framework analysis methods, guided by Normalization Process Theory. Results: The trial experienced recruitment challenges resulting in fewer sites (n=6) and participants (n=45) than expected. As such the impact of ePRO on quality of life could not be definitively assessed; analysis trends suggest decreased quality of life for patients over both the control and intervention periods. Ethnographic data reveals a complex implementation process, in which the meaningfulness (or coherence) of the technology to individuals lives, relationships and approach chronic disease management drove adoption and perceived value or irrelevance of ePRO. Conclusions: Implementation challenges were broad and largely unexpected. The difficultly in aligning meaningfulness of a complex intervention across diverse user groups over time, suggests the intervention may not be sufficiently adaptable, or that more dynamic trial methods may be required. Including ethnographic data collection reveals critical underlying mechanisms driving digital health innovations.

Universal Health Coverage and the Pacific Islands: An Overview of Senior Leaders' Discussions, Challenges, Priorities and Solutions, 2015-2020.

In 1995, Pacific Health Ministers articulated their vision of a healthy Pacific as ‘a place where children are nurtured in body and mind; environments invite learning and leisure; people work and age with dignity; where ecological balance is a source of pride; and where the ocean is protected.’ Central to this vision is the achievement of universal health coverage (UHC). To provide an indication of the UHC-related priorities of Pacific health authorities and promote alignment of domestic and international investments in health sector development, we thematically analyzed the discussion, resolutions, and recommendations from 5 years (2015–2020) of senior-level Pacific health meetings. Five main themes emerged: (i) the Healthy Islands vision has (and continues to have) a unifying influence on action for UHC; (ii) adoption of appropriate service delivery models that support integrated primary health care at the community level are needed; (iii) human resources for health are critical if efforts to achieve UHC are to be successful; (iv) access to reliable health information is core to health sector improvement; and (v) while not a panacea for all challenges, digital health offers many opportunities. Small and isolated populations, chronic workforce limitations, weak governance arrangements, ageing and inadequate health facilities, and supply chain and logistics difficulties (among other issues) interact to challenge primary health care delivery across the Pacific Islands. We found evidence that the Healthy Islands vision is a tool that garners support for UHC; however, to realize the vision, a realistic understanding of needed political, human resource, and economic investments is required. The significant disruptive effect of COVID-19 and the uncertainty it brings for implementation of the medium- to long-term health development agenda raises concern that progress may stagnate or retreat.

Canadian Public Health Laboratory Network guidelines for the use of point-of-care tests for Treponema pallidum in Canada.

Over the past few years, the increase in infectious syphilis outbreaks in major urban centres and remote or rural locations in Canada, often affecting hard-to-reach patient populations, has renewed an interest and urgency in studying the use of point-of-care tests (POCTs) that can provide test results at the time and place of primary health care delivery, obviating the repeat visit necessary with traditional syphilis serology or molecular diagnostic tests. In 2015, the Canadian Public Health Laboratory Network released its first laboratory guideline for the use of POCTs in the diagnosis of syphilis in Canada. Although Canada has no licensed POCT, two POCTs (Syphilis Health Check and the DPP® HIV Syphilis System) have received US Food and Drug Administration (FDA) approval under premarket approval applications. Most syphilis POCTs detect antibodies to treponemal antigens, so their results cannot be used to differentiate between active and past infection. The only POCT that detects antibodies to both treponemal and non-treponemal antigens does not yet have Health Canada or FDA approval. In this updated guideline, the current landscape of POCTs for syphilis, with an emphasis on data from low-prevalence countries, is described. Individual operators should consider the questions of where, when, how, and why a POCT is used before its actual implementation. Training in the operation and interpretation, quality control, proficiency program, safety, and careful documentation of the process and results are especially important for the successful implementation of POCTs.

Configuration and Delivery of Primary Care in Rural and Urban Settings

BackgroundThere are concerns about the capacity of rural primary care due to potential workforce shortages and patients with disproportionately more clinical and socioeconomic risks. Little research examines the configuration and delivery of primary care along the spectrum of rurality.ObjectiveCompare structure, capabilities, and payment reform participation of isolated, small town, micropolitan, and metropolitan physician practices, and the characteristics and utilization of their Medicare beneficiaries.DesignObservational study of practices defined using IQVIA OneKey, 2017 Medicare claims, and, for a subset, the National Survey of Healthcare Organizations and Systems (response rate=47%).ParticipantsA total of 27,716,967 beneficiaries with qualifying visits who were assigned to practices.Main MeasuresWe characterized practices’ structure, capabilities, and payment reform participation and measured beneficiary utilization by rurality.Key ResultsRural practices were smaller, more primary care dominant, and system-owned, and had more beneficiaries per practice. Beneficiaries in rural practices were more likely to be from high-poverty areas and disabled. There were few differences in patterns of outpatient utilization and practices’ care delivery capabilities. Isolated and micropolitan practices reported less engagement in quality-focused payment programs than metropolitan practices. Beneficiaries cared for in more rural settings received fewer recommended mammograms and had higher overall and condition-specific readmissions. Fewer beneficiaries with diabetes in rural practices had an eye exam. Most isolated rural beneficiaries traveled to more urban communities for care.ConclusionsWhile most isolated Medicare beneficiaries traveled to more urban practices for outpatient care, those receiving care in rural practices had similar outpatient and inpatient utilization to urban counterparts except for readmissions and quality metrics that rely on services outside of primary care. Rural practices reported similar care capabilities to urban practices, suggesting that despite differences in workforce and demographics, rural patterns of primary care delivery are comparable to urban.

COVID-19's Perceived Impact on Primary Care in New England: A Qualitative Study.

COVID-19 impacted primary care delivery, as clinicians and practices implemented changes to respond to the pandemic while safely caring for patients. This study aimed to understand clinicians' perceptions of the positive and negative impacts of COVID-19 on primary care in New England. This qualitative interview study was conducted from October through December 2020. Participants included 22 physicians and 2 nurse practitioners practicing primary care in New England. Data were thematically coded and analyzed deductively and inductively using content analysis. Through qualitative content analysis, 4 areas were identified in which clinicians perceived that COVID-19 impacted primary care: 1) bureaucracy, 2) leadership, 3) telemedicine and patient care, and 4) clinician work-life. Our findings suggest that the positive impacts of COVID-19 included changes in primary care delivery, new leadership opportunities for clinicians, flexible access to care for patients via telemedicine, and a better work-life balance for clinicians. Respondents identified negative impacts related to sustaining pandemic-inspired changes, the inability for some populations to access care via telemedicine, and the rapid implementation of telemedicine causing frustration for clinicians. Understanding clinician perspectives on how primary care transformed to respond to COVID-19 helps to identify beneficial pandemic-related changes that should be sustained and ideas for improvement that will support patient care and clinician engagement.