Primary Care Utilization Research Articles

Primary care utilization in Bulgaria: some effects of the COVID-19 pandemic

Abstract Background Disruptions to primary care provision during the pandemic set back prior advancements in screening and chronic disease management. Delays in routine vaccination added to preexisting hesitancy and sustained the downward trend in vaccination rates. The study examines the magnitude and duration of primary care disruptions in Bulgaria between 2020 and 2022. Methods The impact of the pandemic on primary care is assessed using administrative data from the National Health Insurance Fund covering the annual number of primary care services. To evaluate the effect on healthcare utilization, the average number of check-ups per person during the pandemic is compared to a pre-pandemic period (2017-2019). Results After the onset of the pandemic, all visits declined significantly on an annual basis. In 2020, overall prophylactic check-ups dropped by 6-13% and remained lower than the baseline until 2022. Initial figures for 2023 suggest some recovery, while specific services are likely to experience an ongoing decrease. During the pandemic, the average number of prophylactic examinations for children fell between 6.9 and 9.3%. In 2022, there was a modest resumption, although these services did not reach the preceding levels. Adult prophylactic visits declined by approximately 10-12% between 2020 and 2021, but following a U-shaped pattern, they rebounded in 2022. Visits associated with chronic diseases experienced a drop of 7.8% in 2020 and continued to decrease in the next two years. Child vaccination was affected for a shorter period. In 2022, the coverage for most vaccine-preventable diseases was close to the pre-pandemic levels. However, the uptake of MMR and pneumococcal vaccines failed to demonstrate a clear path to recovery. Conclusions During the pandemic, a considerable drop in primary care utilization has been recorded. Effective recovery requires sustained service delivery and a rapid post-lockdown rebound to mitigate the negative impact on health outcomes. Key messages • Primary care needs additional recovery measures to prevent long-term harmful impacts on health outcomes. • Investing in service delivery innovations can boost resilience during disruptive events.

Impact of bundled payments on healthcare use and costs for cardiovascular diseases in the Netherlands

Abstract Background Bundled payments for patients with cardiovascular diseases (CVD) aim to enhance primary care utilization in the Netherlands. This study assesses changes in healthcare utilization patterns and costs for CVD between 2015 and 2019, while investigating the potential association with bundled payment adoption. Methods We studied patients at very high risk for CVD using routinely recorded nationwide healthcare data. Multilevel logistic- and gamma regressions were conducted to assess healthcare utilizations patterns between 2015 and 2019, and the impact of bundled payments on the likelihood of receiving medical specialist care and the height of associated costs. Results The odds of medical specialist involvement declined over time for the 148,876 patients included in our study. This decline was significantly associated with practices’ use of bundled payments. Medical specialist costs did also significantly decrease between 2015 and 2019, and patients in practices with the highest level of bundled payments had significantly lower medical specialist costs. When general practice costs were included however, healthcare costs per patient stayed the same, both over time and stratified by use of bundled payments. Conclusions Our findings suggest an association between bundled payments and specialized healthcare use, potentially facilitating the transition to primary care. While we found no evidence for costs savings, our findings do support a reduction in spending growth. Key messages • We evaluated the impact of bundled payments as a means to facilitate integrated care, and found that bundled payments were associated with lower uptake of specialized medical care. • We found no cost savings were found, but findings do support reduced spending growth.

Primary care need and engagement by people with criminal legal involvement: Descriptive and associational analysis using retrospective data on the entire population ever detained in one southeastern U.S. county jail 2014-2020.

More than 7 million people are released each year from U.S. jails or prisons, many with chronic diseases that would benefit from primary care in their returning communities. The objective of this study was to provide an in-depth, payer-agnostic description and associational analysis of primary care need and utilization by all individuals ever detained in one county detention facility over a 7-year period. Detention records 2014-2020 were merged with data from an electronic health record with excellent coverage of local primary care, emergency, and hospital services. We found low primary care participation for the group as a whole, with under three quarters of those with serious chronic diseases ever seeing a primary care provider over a 7-year period and less than half ever having a year with more than one visit. Multivariable regression models estimated associations between individual characteristics (demographic, detention-related, and clinical) and ever having access to primary care (logistic) and the number of primary care visits (zero-inflated negative binomial). We found that having more jail bookings was associated with fewer primary care visits, but not one-time access, even controlling for time out of community, age, insurance, and other demographic characteristics. This finding was driven by subgroups with chronic disease such as hypertension, obstructive lung disease, and diabetes, who most need regular primary care. Being Black retained an independent effect, even controlling for bookings and other variables, and was also associated with fewer primary care visits, though not one-time access. To promote primary care utilization among individuals who have the combined challenges of repeated jail involvement and chronic disease, it is crucial to focus on engagement, as much as formal access. Access to health insurance alone will not resolve the problem; Medicaid expansion should be coupled with specialized, tailored support to promote engagement in primary care.

Early Health Impacts of a Primary Care Consultation Model for People Served by Assertive Community Treatment teams.

The cardiometabolic health outcomes and life expectancy of people living with serious mental illness (SMI) continue to significantly flag behind that of the general population. This study explores the possibility of using the evidence-based Assertive Community Treatment (ACT) model and infrastructure to increase access to primary care and improve cardiometabolic outcomes of people with SMI. Four ACT teams in a large urban area received the services of a primary care consultant who was co-located at a Federally Qualified Health Center (FQHC), met regularly with ACT team clinicians to review a cardiometabolic registry of participants, and engaged participants in primary care services. Health screening rates, primary care utilization, and cardiometabolic outcomes-body mass index, blood pressure, hemoglobin A1c, cholesterol, and tobacco smoking status-were monitored over the course of a year. The efficacy of this integrated care model was also explored through focus groups with ACT team staff and participants. Significant improvements in screening rates were found for the ACT teams that received this integrated care intervention; however, only modest improvements in cardiometabolic outcomes were found. Future longitudinal, multi-site studies are needed to fully determine the impact of integrated care models on the physical health outcomes of this vulnerable population.

Primary Care Utilization by Kidney Transplant Recipients

Primary Care Utilization by Kidney Transplant Recipients

Primary care telehealth utilization by access-challenged populations in Medicare Advantage.

Although telehealth utilization in primary care has decreased markedly since 2020, it remains higher than before the COVID-19 pandemic. There is debate about its role in a post-pandemic healthcare system, particularly for certain groups of patients that may experience greater access challenges related to in-person care. To inform this debate, we examined the use of audiovisual telehealth for primary care as a share of total primary care outpatient visits among Medicare Advantage beneficiaries with and without 3 characteristics associated with potential access challenges (low-income status, disability, and frailty). Primary care visits when the beneficiary was frail were 39.4% (OR: 1.39 [95% CI, 1.37-1.42]) more likely to be telehealth; when the beneficiary was disabled or low-income status, visits were 20.1% (OR: 1.20 [95% CI, 1.18-1.22]) and 8.3% (OR: 1.08 [95% CI, 1.05-1.12]) more likely to be telehealth, respectively. The differential use of telehealth among beneficiaries with low-income status or disability, compared with those without, was significantly larger among providers with a 2-sided risk contract compared with fee for service (low-income status: OR: 1.19 [95% CI, 1.04-1.35]; disability: OR: 1.07 [95% CI, 1.01-1.13]).

Adjusting for quality of care in primary health care utilization and benefits in Bihar, India: A Benefit Incidence Analysis

India’s public health policies prioritize the least wealthy and vulnerable. Additionally, for Primary Health Care (PHC) to achieve equitable health outcomes, all must receive high-quality care. This study determined equality of utilization and benefit incidence of PHC services across socioeconomic (SE) groups in Bihar, with and without adjusting for quality of care. It used secondary data from linked PHC facility and household surveys in Bihar that included information on PHC facility utilization, quality of care and household expenditure patterns. Lorenz curves and concentration indices were constructed to examine relative distribution of utilization and benefits from public sector PHC services by SE status, before and after adjusting for quality of care using quality weights. We found that relative distribution of public sector PHC utilization, total and net benefits was statistically no different from perfect equality. With quality weights, utilization and benefits of PHC facilities in Bihar were slightly more pro-rich but statistically no different from perfect equality. The wealthiest do not disproportionately benefit from public sector PHC facilities, but neither do the least wealthy.In conclusion, relative utilization and benefits of public sector PHC facilities were equally distributed across socioeconomic groups in Bihar. Benefits from public sector PHC facilities are not disproportionately concentrated among the least wealthy in the community. As the Ayushman-Bharat Health and Wellness Centers are strengthened to improve public sector PHC services, it would be important to target its benefits towards the least wealthy by ensuring services are accessible and amenable.

Utilization of Healthcare Services in Patients with Chronic Diseases under 18 Years Old: Differences and Contributing Factors.

Pediatric patients with chronic conditions frequently have unmet care needs, make extensive use of healthcare services, and often encounter fragmented, non-centered care. This study aimed to analyze the differences in the utilization of primary care (PC) and hospital care (HC) services by these patients according to sex, age, and complexity and to identify associated factors. A cross-sectional study was conducted in a basic health area of Madrid, including patients under 18 years. Among these patients, 15.7% had ≥1 chronic disease, 54.1% were male, the average age was 9.5 years, 3.5% had complexity, and 11.3% had multimorbidity. The mean number of contacts/year with the healthcare system was 9.1, including 8.3 contacts/year with PC (4.9 with pediatricians and 1.9 with nurses) and 0.8 contacts/year with HC (0.8 in external consultations and 0.01 hospitalizations). The factors associated with PC utilization were complexity; female sex; European origin; and diseases like asthma, epilepsy, stroke, recurrent urinary infection, attention deficit hyperactivity disorder, and anxiety, while older age was negatively associated. Thyroid disorders were significantly associated with HC utilization. These findings could help guide the design of optimized pediatric patient-centered care approaches to coordinate care across healthcare services and reduce high healthcare utilization, therefore improving the healthcare outcomes and quality of life for these patients.

Impact of family doctor system on diabetic patients with distinct service utilisation patterns: a difference-in-differences analysis based on group-based trajectory modelling

IntroductionThis study examines the impact of China’s family doctor system (FDS) on healthcare utilisation and costs among diabetic patients with distinct long-term service utilisation patterns.MethodsConducted in City A, eastern China,...

Associations Between Temperature and Primary Care Utilization in Philadelphia, Pennsylvania: A Time Series Study

Associations Between Temperature and Primary Care Utilization in Philadelphia, Pennsylvania: A Time Series Study

Real-world study of the multimorbidity and health service utilisation among individuals with non-diabetic hyperglycemia and type 2 diabetes mellitus in North West London

IntroductionThe prevalence of non-diabetic hyperglycemia (NDH) and type 2 diabetes mellitus (T2DM) is increasing. While T2DM is recognised to be associated with multimorbidity and early mortality, people with NDH are...

Emergency department visits as a potential opportunity to promote primary care attachment and modify utilization patterns – results of a pilot study in Berlin, Germany

BackgroundUtilization by low acuity patients contributes to emergency department (ED) crowding. Both knowledge deficits about adequate care levels and access barriers in primary care are important promoters of such presentations. Concurrently, not having a general practitioner (GP) increases the likelihood of low-acuity ED utilization. This pilot study thus investigated feasibility, acceptance, and potential effects of an ED-delivered intervention for low-acuity patients with no regular primary care provider, consisting of an educational leaflet on acute care options and an optional GP appointment scheduling service.MethodsLow-acuity ED consulters not attached to a GP were given an information leaflet about alternative care offers for acute health problems and offered optional personal appointment scheduling at a local GP practice. Patients were surveyed on demographics, medical characteristics, health care utilization, valuation of the intervention, and reasons for not being attached to a GP and visiting the ED. A follow-up survey was conducted after twelve months. Trends in health and health care utilization were evaluated.ResultsBetween December 2020 and April 2022, n = 160 patients were enrolled, n = 114 were followed up. The study population was characterized by young age (mean 30.6 years) and predominantly good general health. Besides good health, personal mobility was a central reason for not being attached to a GP, but general preference for specialists and bad experiences with primary care were also mentioned. Most frequently stated motives for the ED consultation were subjective distress and anxiety, a belief in the superiority of the hospital, and access problems in primary care. The interventional offers were favorably valued, 52.5% (n = 84) accepted the GP appointment scheduling service offer. At follow-up, GP utilization had significantly increased, while there were no significant changes regarding utilization of other providers, including ED. An additional practice survey showed a 63.0% take-up rate for the appointment service.ConclusionsWith this pilot study, we were able to show that a personalized appointment scheduling service seems to be a promising approach to promote GP attachment and increase primary care utilization in patients without a regular GP in a highly urbanized setting. Further larger-scale studies are needed to investigate potential quantitative effects on ED visits.Trial RegistrationGerman Clinical Trials Register (DRKS00023480); date 2020/11/27.

Data linkage studies of primary care utilisation after release from prison: a scoping review

BackgroundPrimary care plays a central role in most, if not all, health care systems including the care of vulnerable populations such as people who have been incarcerated. Studies linking incarceration records to health care data can improve understanding about health care access following release from prison. This review maps evidence from data-linkage studies about primary care use after prison release.MethodsThe framework by Arksey and O’Malley and guidance by the Joanna Briggs Institute (JBI) were used in this review. This scoping review followed methods published in a study protocol. Searches were performed (January 2012-March 2023) in MEDLINE, EMBASE and Web of Science Core Collection using key-terms relating to two areas: (i) people who have been incarcerated and (ii) primary care. Using eligibility criteria, two authors independently screened publication titles and abstracts (step 1), and subsequently, screened full text publications (step 2). Discrepancies were resolved with a third author. Two authors independently charted data from included publications. Findings were mapped by methodology, key findings and gaps in research.ResultsThe database searches generated 1,050 publications which were screened by title and abstract. Following this, publications were fully screened (n = 63 reviewer 1 and n = 87 reviewer 2), leading to the inclusion of 17 publications. Among the included studies, primary care use after prison release was variable. Early contact with primary care services after prison release (e.g. first month) was positively associated with an increased health service use, but an investigation found that a large proportion of individuals did not access primary care during the first month. The quality of care was found to be largely inadequate (measured continuity of care) for moderate multimorbidity. There were lower levels of colorectal and breast cancer screening among people released from custody. The review identified studies of enhanced primary care programmes for individuals following release from prison, with studies reporting a reduction in reincarceration and criminal justice system costs.ConclusionsThis review has suggested mixed evidence regarding primary care use after prison release and has highlighted challenges and areas of suboptimal care. Further research has been discussed in relation to the scoping review findings.

Impact of co-resident health and living alone on risk of hospital admission for people with Parkinson’s disease

BackgroundPeople with Parkinson's Disease (PwP) have a higher rate of hospitalisation compared to the general population. Little is known about the impact of having a co-resident and their health on hospitalisation rates of PwP. MethodsWe utilised Clinical Practice Research Datalink (CPRD) GOLD data (2010–2015) to identify PwP and co-residents. We classed either the fittest or youngest adult as the primary caregiver in each household. Caregiver health was classified by the Cambridge Multimorbidity Score (CMS), primary care utilisation and prescriptions. We calculated the hospitalisation (elective, emergency) incidence rate ratios (IRRs) for PwP who lived alone compared to those with a caregiver using negative binomial regression, and whether worse caregiver health predicted higher risk of admissions. ResultsWe identified 3254 PwP and 4007 family members. PwP who lived alone were less likely to have an elective admission (0.79; 95 % CI 0.69–0.91) and more likely to have an emergency admission (1.40; 95 % CI 1.70-1.54). Worse caregiver health, as measured by the CMS, was associated with an increased risk of emergency admission (IRR 1.35; 95 % CI 1.17–1.57), but this attenuated and was consistent with chance in the fully adjusted model (1.04; 95 % CI 0.95–1.13). No strong associations were seen between caregiver health and elective admissions. ConclusionPwP who live alone are at increased risk of emergency and less likely to have elective hospital admissions. It is important that health care providers support such people and ensure they receive equitable access to the potential benefits of elective procedures.

Primary Care Telehealth Initiation and Engagement Among Veterans at High Risk, 2019-2022

During the COVID-19 pandemic, the Veterans Health Administration (VHA) expanded telehealth infrastructure. Understanding telehealth initiation and sustained engagement could inform future resource allocation for high-need populations. To describe and examine primary care use, including initiation, use, and engagement factors, of telehealth modalities (telephone, video visits, and secure messaging) from 2020 to 2022. This cohort study was conducted among 1 383 070 patients in the 75th or higher percentile for 90-day risk of hospitalization or mortality (using previously validated Care Assessment Need scores) engaged in VHA primary care from March 11, 2019, to March 10, 2022. Patient sociodemographic characteristics (age, sex, race and ethnicity, and marital and housing status), health characteristics (chronic condition count, military service disability, serious mental illness, or substance use disorder diagnoses), geographic characteristics (driving distance to clinic and rural or urban location), and Federal Communications Commission-reported broadband speed among subgroups of patients at high risk categorized by telehealth use from 2020 to 2022. Primary care utilization by modality. A total of 1 383 070 patients at high risk were engaged in VHA primary care in March 2020 (median age, 73.0 years [IQR, 65-80 years]; 92.4% male; 77.7% regular telehealth users in 2019). With the onset of the COVID-19 pandemic from March 2020 to March 2021, 92.7% of patients at high risk (1 158 804 of 1 250 438 retained in care) became regular telehealth users. The following year, most patients continued as telehealth users (83.4% [942 151 of 1 129 683 retained]), including 38.2% retention of users at high risk newly engaged in 2020. Between 2019 and 2022 among those living and engaged in VHA primary care, adjusted exploratory multinomial logit models estimated that new telehealth users in 2020 (both sustained or only transiently engaged) were more often Black non-Hispanic individuals with greater comorbidity burdens than those who never engaged in telehealth use (Black non-Hispanic with new persistent telehealth use: adjusted relative risk ratio [ARR], 1.18 [95% CI, 1.16-1.20]; Black non-Hispanic with transient telehealth use: ARR, 1.11 [95% CI, 1.08-1.13]; ≥5 chronic conditions with new persistent telehealth use: ARR, 1.92 [95% CI, 1.88-1.96]; ≥5 chronic conditions with transient telehealth use: ARR, 1.43 [95% CI, 1.40-1.46]). This cohort study suggests that primary care telehealth initiation, use and sustained engagement differed among subgroups of patients at high risk throughout the COVID-19 pandemic. Those never or only transiently engaged with telehealth had lower illness burdens and were less likely to identify as members of racial or ethnic minority groups. Variation in telehealth use among subgroups of patients at high risk during this period could inform future resource allocation.

Integrated primary and community mental health care for young adults with serious mental illness: A program evaluation.

Young adults with serious mental illness (SMI) have poor physical health and high Emergency Department (ED) and hospital utilization. Integrating primary care into community mental health care may be an important form of early intervention. Adjusted multivariable regressions assessed changes in self-reported annual primary care, ED and hospital utilization for 83 young adults with SMI enrolled in integrated care. Participants' mean annual per person utilization changed significantly as follows: primary care visits, from 1.8 to 3.6, p < .001; medical ED visits, from 1.0 to 0.6, p < .01; psychiatric ED visits from 0.6 to 0.2, p < .001; medical inpatient days, from 1.2 to 0.1, p < .001 and psychiatric inpatient days, from 6.3 to 2.6, p < .001. Young adults with SMI receiving integrated care increased primary care and reduced ED and inpatient utilization. Future controlled research is warranted to further assess integrated care for young adults with SMI.

Investigating primary healthcare resource utilization, triage system awareness, and time expectations among patients presenting at emergency departments in Jordan: a cross-sectional study

This study aims to investigate patients' knowledge of the triage system, utilization of primary healthcare resources, and expectations for waiting times in Jordanian Emergency Departments (EDs). A descriptive, cross-sectional design was employed in the EDs in the largest public hospitals in Jordan. Convenient sampling resulted in 726 participants. A self-reported questionnaire included socio-demographic information and instruments assessing primary healthcare use, triage system awareness, and expected waiting times. Most participants (61.3%) lacked awareness of the triage system. The use of primary healthcare was influenced by age, education, marital status, current job, nationality, and location. Having a primary healthcare provider was associated with higher patient satisfaction. Significant variations in expected waiting times for diagnostic test results were noted based on gender, place of residence, education, current job, and marital status. Addressing patient awareness of the triage system is crucial for optimizing healthcare accessibility and quality in Jordanian EDs. Improving patient education, communication, and primary care utilization can enhance patient outcomes, reduce ED burden, and contribute to a more efficient healthcare system.

Enhancing point-of-care ultrasound (POCUS) utilization in primary care: A thyroid POCUS training course for internal medicine residents.

POCUS is valuable in primary care, yet outpatient-specific point-of-care ultrasound (POCUS) curriculum integration into internal medicine (IM) residency is limited. We addressed this gap by developing a thyroid POCUS workshop for IM residents. Develop and implement an educational curriculum to integrate thyroid POCUS into an IM residency program and evaluate the impact on resident knowledge, perceived skills, and attitudes. The study was conducted in a resident primary care clinic at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Residency Program in Internal Medicine at North Shore University Hospital and Long Island Jewish Medical Center. All 108 IM residents (PGY1-3) in one program participated in the study during their ambulatory clinic block. Residents participated in a 1-hour workshop involving a didactic session and two breakout groups: one for hands-on practice and another for case-based discussions with image review. Residents completed pre- and post-session surveys assessing knowledge, perceived skills, and attitudes toward thyroid POCUS. These data showed statistically significant increases in all assessed areas. Integrating thyroid POCUS into an IM residency curriculum significantly improved resident knowledge, attitudes, and perceived skills related to these exams. Residents valued this learning experience and expressed intentions to incorporate it into their future practice.

People-centered primary care measures in health equity: a perspective of urban-rural comparison in Beijing, China.

Person-centered primary care measures (PCPCM) facilitate high-quality and culturally appropriate primary care. Access to PCPCM remains unequal between rural and urban areas, and the available evidence on rural PCPCM is still lacking. A cross-sectional survey was conducted with stratified sampling by regions, and four districts (Xicheng, Fengtai, Huairou, and Daxing) in Beijing were selected to test the performance of PCPCM in both urban and rural areas. Descriptive statistical methods were used to compare the urban-rural differences in the demographic characteristics of PCPCM. Correlation and regression analyses were performed to determine the associations between PCPCM in demographics and utilization of primary care. The PCPCM showed good reliability and validity in both urban and rural areas (P< .001), slightly lower in rural areas, but scores of rural PCPCM (R-PCPCM) in all items were lower than urban PCPCM (U-PCPCM). Patients in either the preferred urban or rural health centers all showed the highest PCPCM scores, with U-PCPCM= 3.31 for CHCs and R-PCPCM= 3.10 for RHCs, respectively. Patients in urban areas were more likely to receive higher-quality primary care than in rural areas (P < .001). Patients who preferred hospitals (β = 2.61, P < .001) or CHCs (β = 0.71, P = .003) as providers was a significant positive predictor of U-PCPCM but it was the preference for hospitals (β = 2.95, P < .001) for R-PCPCM. Urban-rural differences existed in the performance of PCPCM, with rural areas typically more difficult to access better PCPCM. To promote health equity in rural areas, healthcare providers should strive to minimize urban-rural differences in the quality and utilization of primary care services as much as feasible.

Migration-related determinants of health-care service utilization among persons with a direct migration background in Germany: an exploratory study based on the German Socio-Economic Panel (SOEP).

It is known that the health-care service utilization in primary care of persons with a direct migration background is lower compared to non-migrants. However, potential migration-related determinants of health-care service utilization are not known. Therefore, this study aimed to analyze the associations between health-care service utilization and migration-related characteristics of persons with a direct migration background in Germany. The migration samples (M1 and M2) of the German Socio-Economic Panel (SOEP) were used as the sample for this study. Associations between the number of visits to primary care physicians in the previous three months and migration-related characteristics were examined using generalized linear models. Associations between the hospitalization within one year and migration-related characteristics were examined using logit models. The mean number of visits to primary care physicians was about 2, and 8% of persons were hospitalized. Being born in a country other than Russia was associated with a higher number of visits to primary care physicians (+ 26% to + 34%). Both, a very strong connectedness with the country of birth and very good oral German language skills were associated with higher number of visits to primary care physicians (both + 13%) compared to no connectedness and fairly bad oral German language skills. Only the country of birth, connectedness with the country of birth and oral German language skills may be migration-related determinants of health-care service utilization with regard to the number of visits to primary care physicians by persons with a direct migration background in Germany. With regard to hospitalization, no potential migration-related determinants of health-care service utilization could be identified.