Table of Contents
COVID-19 and Primary Care: Taking Stock
Trisha Greenhalgh
Background Trisha Greenhalgh, MD, professor of primary health care sciences and co-director of
Interdisciplinary Research In Health Sciences at the University of Oxford, writes
the editorial in this edition of Annals of Family Medicine. She argues that although primary care clinicians and staff stepped forward and did
their best to treat individuals with COVID; administer vaccinations; manage post-COVID
symptoms; and provide essential services, this effort was largely reactive rather
than proactive. She added that it failed to fully compensate for dramatic reductions
in care-seeking behavior and socioeconomic inequities.
What This Study Found Greenhalgh mentions the numerous papers in this edition of Annals of Family Medicine which explicate the ways in which primary care members in various countries surveilled the virus; bridged information gaps; managed patient care and clinical practices; and in general affected health outcomes in those affected by the COVID pandemic. They also studied how people affected by COVID managed long-term symptoms on their own. Those studies come from an international group of authors from countries such as Japan (Aoki et al), China (Holroyd et al), Germany (Klocke et al), Canada (Leslie et al), and the United States (Ramley et al; Solberg et al; Tong et al).
Implications
- Greenhalgh writes that primary care contributes to health system resilience. She challenges primary care clinicians to continue fighting for the resources they need to restore the existing workforce, incentivize the next generation or primary care professionals, and defend the core values that underpin the field's critical work with individuals, families, and communities.
Myles Leslie and colleagues
Background In Alberta, Canada, 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. Academic and public health stakeholders in Alberta built a data bridge between primary care and public health to improve the province's community-based response to the pandemic. The research team that studied this process conducted 57 semistructured qualitative interviews with a range of primary care and public health stakeholders working inside the Calgary Health Zone to evaluate implementation of the data bridge. They also used interpretive descriptions to analyze the interviews.
What This Study Found Stakeholders from both central public health and independent primary care practices were able to leverage a policy commitment to the Patient Medical Home (PMH) care model, a range of existing organizational structures, and governance arrangements to create the data bridge. Similar policy commitments, working relationships, and governance arrangements in other jurisdictions may facilitate the emergence of information-sharing champions, the evolution of trust, and the acceptance of improvisational activity.
Implications
- The findings highlight the importance of governance structures showing how, without a functional and well-established interface between independent PC and the central health system, both pandemic responses and everyday PC integration efforts are likely to suffer.
Daniel J. Parente and colleagues
Background Urinary tract infections are commonly diagnosed and treated in primary care. The gold
standard for diagnosing a UTI is a urine culture. However, waiting for culture results
delays treatment, so doctors often prescribe antibiotics while awaiting results. Members
of the Department of Family Medicine and Community Health at the University of Kansas
Medical Center modified a UTI detection algorithm to be usable in a primary care setting.
The algorithm had been developed and validated in an emergency room population. The
main modification was removing the requirements for microscopy since results are often
not available in primary care.
Researchers retrospectively validated the modified algorithm (NoMicro) in the emergency
department and in primary care patients, using data from 80,387 ED patients and 472
primary care adults. The primary outcome was pathogenic urine culture growing =100,000
colony forming units. Predictor variables included age; gender; dipstick urinalysis
nitrites, leukocytes, clarity, glucose, protein, and blood; dysuria; abdominal pain;
and history of UTI.
What This Study Found The researchers found that removal of microscopy features did not severely compromise
performance of the UTI detection algorithm in emergency department patients: NoMicro/XGBoost
ROC-AUC 0.862 (95% CI: 0.856-0.869) vs. NeedMicro 0.877 (95% CI: 0.871-0.884). The
algorithm also performed well in the primary care sample: NoMicro/RF ROC-AUC 0.850
(95% CI: 0.808-0.889). Retrospective simulation suggests NoMicro/RF could be used
to safely withhold antibiotics in low-risk patients, thereby reducing antibiotic overuse.
Implications
- The NoMicro algorithm appears appropriate for primary care. The authors recommend prospective trials to determine the balance of benefits and harms of using the NoMicro algorithm.
Chantel Sloan-Aagard and colleagues
Background Researchers examined whether primary care physicians's use of a secure community health information exchange (HIE) to access data about patient care transitions reduced the likelihood of hospital readmission. They identified a retrospective cohort of 8,216 hospital inpatients over 18 years old, discharged between January 1, 2021 and November 30, 2021 using the Paso del Norte Health Information Exchange. All patients had a primary care visit within 30 days after hospital discharge, and they identified which were looked up in the HIE close to that visit. Of these, 2,627 patients were rehospitalized and 3,809 patients visited an ED during the follow-up window.
What This Study Found Lookup in the HIE was associated with an increased median time to use of the ED after inpatient discharge from 99 to 238 patient-days. The likelihood of a visit to the ED decreased by 53% and rehospitalization decreased by 61%. Ethnicity, insurance, gender, and age were also significant predictors of hospital reuse.
Implications
- Increased utilization of community HIEs by PCPs on behalf of their recently
discharged patients dramatically decreased the risk of inpatient readmissions or ED visits.
Takuya Aoki and colleagues
Background Researchers from Japan examined the association between the characteristics of primary care practices and total hospitalizations during the COVID-19 pandemic. The team conducted a nationwide prospective cohort study during the pandemic using a representative sample of the Japanese adult population aged 40–75 years. They assessed the quality of primary care attributes (first contact between a patient and a primary care clinician, longitudinality of care, care coordination, comprehensiveness, and community orientation of the clinic) using the Japanese version of the Primary Care Assessment Tool (JPCAT). The primary outcome measure was any hospitalization during a 12-month period between May 2021 and April 2022 as determined by primary care characteristics. They analyzed data from 1,161 participants (follow-up rate, 92.0%).
What This Study Found Each primary care attribute – such as accessibility, continuity, coordination, and comprehensiveness – is associated with a reduction in hospitalizations. The provision of high-quality primary care was associated with decreased total hospitalizations, even during a pandemic when there are many barriers to providing usual medical care.
Implications
- The authors argue that these findings support policies intended to strengthen primary care systems during and after the COVID-19 pandemic. Especially during a pandemic, the integration of public health practice with the delivery of primary care services may be a more important process, according to the authors.
Eleanor Holroyd and colleagues
Background Researchers from mainland China, Hong Kong, and New Zealand conducted qualitative interviews examining how digital detection surveillance for COVID-19 and other infectious diseases was perceived and experienced by primary care physicians (PCPs) and patients in China. They did so to highlight ethical considerations for promoting patients' autonomy and health care rights. The authors conducted in-depth interviews with a group of 16 PCPs and 24 of their patients, reflective of a range of ages, educational backgrounds, and clinical experiences from urban areas in northern and southern China. The ethical approval was granted by the Institutional Review Board of the University of Hong Kong-Shenzhen Hospital in China. Interviews were audio recorded (with all audio recordings stored with access restricted only to the study team), transcribed, and translated. Two researchers coded data and organized it into themes. A third researcher reviewed 15% of the data and discussed findings with the other researchers to assure accuracy.
What This Study Found The team identified five frequently mentioned concerns raised by primary care physicians and patients they interviewed: ambiguity around the need for informed consent about the usage of digital detection surveillance data; the importance of autonomous decision making; the potential for discrimination with digital detection surveillance of people who have an infectious disease; the risk of social inequity and divided care outcomes; and authoritarian institutions' responsibility for maintaining health data security. The adoption of digital detection surveillance meant some patients would be reluctant to go to a hospital for fear of either being discriminated against or forcibly quarantined. Certain groups such as older people and children were thought to be vulnerable to digital detection surveillance data misuse.
Implications
- The authors argue that in establishing national and international ethical frameworks for digital detection surveillance, systems should protect patients while also allowing for coordinated management during pandemics. Guidelines should include protections against social inequity.
COVID-19 Impacts on Primary Care Clinic Care Management Processes
Leif I. Solberg and colleagues
Background Researchers from HealthPartners Institute and the University of Minnesota conducted a longitudinal cohort design study with repeated survey-based measures of care management processes (CMPs) from 2017, 2019, and 2021 in 269 primary care clinics. This data was used to learn whether the pandemic's disruptions compromised health care for people with chronic conditions. The primary outcome was the overall CMP score, defined as the percentage of CMPs present in the clinics.
What This Study Found Overall care management process scores rose by similar amounts (1.6% and 2.1%) from 2017-2019 and from 2019-2021. However, the score for two domains decreased in 2021 – Performance measurement and Management of High-Risk Patients and Hospitalizations. Clinics affiliated with larger organizations had higher care management process scores, in comparison to clinics in smaller organizations. Scores were lower in rural areas compared to urban area clinics. Improvement in CMP clinic scores occurred despite reports from 55% of clinic leaders that the pandemic had been extremely or very disruptive.
Implications
- Although disrupted by the pandemic, care management processes for chronic disease care in primary care clinics generally increased from 2019 to 2021. The pandemic experience has been very stressful for patients and health care professionals alike, but the health care system in Minnesota appears to be resilient. The continued introduction of more highly organized care management may be an important step in recovering from any losses in quality.
Primary Care Patients' and Staff's Perceptions of Self-Rooming as Alternative to Waiting Rooms
Edmond Ramly and colleagues
Background Researchers conducted a study to determine patient and staff perceptions after they implemented a process that allowed patients, after check-in, to find their own rooms upon visiting the primary care clinic, as an alternative to being escorted from a waiting room. In October-December 2020, the team surveyed patients and staff in 25 primary care clinics after the University of Wisconsin Health system expanded self-rooming from four specially built clinics during the COVID-19 pandemic. Semi-structured surveys that were answered by 241 clinic staff and 1,561 patients asked about the rooming process they preferred and perceptions of self-rooming compared to escorted rooming.
What This Study Found Most of the 1,561 patients preferred self-rooming (86%), especially among patients
aged <65 years and in family medicine clinics. Few patients felt less welcomed (10.6%),
less cared about (6.8%), more isolated (15.6%), more lost/confused (7.6%), or more
frustrated (3.2%) with self-rooming compared to escorted rooming. After adjusting
to the new process, early adopter clinics that had implemented self-rooming before
2017 had even lower rates of patients feeling more isolated, lost/confused, or frustrated
with self-rooming compared to escorted rooming.
Over half of the 241 staff (180 clinical, 61 non-clinical) preferred self-rooming
(59%) and thought most patients liked self-rooming (65.8%). Few staff reported worse
waiting times for patients (12.4%), medical assistants (15.9%), and clinicians (16.4%)
or worse crowding in waiting areas (1.7%) and hallways (10.1%). Most staff thought
self-rooming led to more patient confusion (63.8%), except in early adopter clinics
(44.4%), but actual patient-reported confusion was low (7.6%).
Implications
- Self-rooming is a patient-centered innovation that is also acceptable to staff. Researchers demonstrated that pragmatic implementation is feasible across primary care without expensive technology or specially designed buildings.
Recruiting Indigenous Patients Into Clinical Trials: A Circle of Trust
Arch G. Mainous III and colleagues
Background Indigenous populations, including people of American Indian and Alaska Native origin, are underrepresented in clinical trials. Researchers collaborated to modify the “trust triangle” model used in clinical trial recruitment and expanded it to a new model called, “The Trust Circle.” This new model takes into account the various entities that are part of the recruitment process and the trust that must be developed within that community of people and organizations in order to promote recruitment of AI/AN populations to clinical trials. This includes trial participants, researchers, and other individuals who can inspire trust, including physicians, ministers, and community leaders.
What This Study Found This new model for AI/AN populations was developed by reconceptualizing the Trust
Triangle through discussions with AI/AN investigators who conduct research in the
AI/AN community. This circle allows for the community perspective, involvement, and
sharing to facilitate recruitment and retention in a manner that considers cultural
safety and cultural humility. The four quadrants in the Circle of Trust – trusted
entities, investigators, participants, and community – are interdependent and balanced
with reciprocity.
Implications
- The authors assert that the Circle of Trust can help investigators and the AI/AN community work together to promote inclusion of AI/AN populations in clinical trials to improve health outcomes for these populations.
Pierre-Yves Meunier and colleagues
Background Researchers from France conducted a systematic review to identify and quantify the barriers and facilitators primary care professionals (PCPs) experience when using clinical decision support systems (CDSSs) – software designed to facilitate clinical decision making. They used a mixed-methods systematic review, searching PubMed/MEDLINE, PsycInfo, Embase, CINAHL, and the Cochrane library to find studies that evaluated CDSSs intended for use during a consultation and providing recommendations to PCPs. The authors performed a mixed-methods synthesis with the HOT-fit framework (Human, Organizational, Technology, Net Benefits) to evaluate the impact of the HOT-fit categories on CDSS use.
What This Study Found The team identified a total of 48 studies evaluating 45 CDSSs which articulated 186
main barriers or facilitators. Qualitatively, barriers and facilitators were classified
as human (e.g. perceived usefulness), organizational (e.g. disruption of usual workflow),
and technological (e.g. CDSS user-friendliness), with explanatory elements. The net
benefit dimension of the HOT-fit framework highlighted CDSSs’ potential to improve
quality of care, particularly for preventive care; conversely, the greatest barrier
to using CDSSs was an increased workload. Quantitatively, the human and organizational
factors had negative impacts on CDSS use, whereas the technological factor had a neutral
impact, and the benefits dimension had a positive impact.
Implications
- Although PCPs find benefit from and support the potential effectiveness of CDSS in
improving the quality and safety of care, they also highlight its lack of efficiency
due to increased workload. The authors concluded that CDSS developers need to better
address human and organizational issues, in addition to technological challenges.
They also proposed a list of 11 features of CDSSs expected to improve their usability
in primary care.
A Survey Snapshot Measuring Insulin Underuse in a Primary Care Clinic</b>
Rick Hess and colleagues
Background Researchers conducted a study to determine the prevalence of cost-related insulin underuse in a primary care environment. They administered surveys to adult participants diagnosed with diabetes who were taking insulin. The study ran from July 2019 to April 2020 and was then resumed from November 2020 to December 2021. The primary outcome was the frequency of cost-related underuse of insulin within the last year. Ninety respondents completed the survey.
What This Study Found Among the 90 patients who completed the survey, 44% experienced cost-related suboptimal therapy. Participants who reported underuse were approximately nine times more likely to have difficulty purchasing diabetes supplies (odds ratio = 9.4; 95% CI 2.6–34.1). However, the majority of respondents experiencing cost-related issues (76%) reported discussing it with their prescribers, which significantly increased the likelihood of their doctor changing their insulin (odds ratio = 4.8; 95% CI 1.6–15.0). Participants suffering poor control of diabetes were not more likely to report underuse (odds ratio 2.9; 95% CI 0.8–11.0).
Implications
- The authors recommend that primary care physicians use empathy to ask about cost barriers
as some patients may be reluctant to speak up about their challenges in obtaining
insulin.
Carina Klocke and colleagues
Background A research team from Germany gathered information via crowdsourcing research about patient-initiated therapies in response to post-COVID symptoms and the patients' needs.Almost 500 participants reached via advocacy group platforms, social media, and the homepage of the University Hospital in Tübingen, completed an online survey concerning symptoms and individual experiences with therapeutic strategies.
What This Study Found The most commonly experienced symptoms included fatigue, physical exhaustion, difficulty
concentrating, and loss of taste and smell. The researchers also identified various
approaches reported by patients to have had positive effects in alleviating the lingering
symptoms, including mind-body medicine, the use of nutritional supplements, sports
activities/exercise, and olfactory training in the case of loss of smell. When asked
about specific patients’ needs, only 13% (n = 51) of patients indicated no additional
needs; 35% (n = 232) desired more understanding and recognition regarding their situation;
and 33% (n = 223) indicated the need for specific post-COVID health care services
and better information.
Implications
- Patients are experiencing a variety of long COVID-19 symptoms; are relying on their own methods to allay those symptoms; and are in need of additional therapies from their medical care team. Additionally, doctors should consider paying more attention to patients’ needs for empathy and understanding.
Sebastian T. Tong and colleagues
Background Investigators affiliated with the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality wrote a special report about AHRQ's learning community, which operated from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. It provided a forum for participants to share learning and peer support, to better understand the stressors and challenges confronting practices, to ascertain needs, and to identify promising solutions in response to the COVID-19 pandemic.
What This Study Found The learning community identified challenges, responses, and innovations that emerged
through learning community engagement, information sharing, and dialogue. The authors
categorized these across five domains that reflect core areas integral to primary
care delivery: patient-centeredness, clinician and practice, systems and infrastructure,
and community and public health; health equity was crosscutting across all domains.
Implications
- The engagement of the community to identify real-time response and
innovation amid the global pandemic provided valuable insights that can inform future research and policy; improvements to primary care delivery; and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.
On Abortion and Autonomy: A Letter to My Unborn Daughter
Laura Krinsky
Background While pregnant with her first child, a family medicine doctor writes a letter to her daughter about the experience of providing abortions in Massachusetts (a state that has protected abortion access) and Tennessee (a state that has restricted abortion access).
What This Study Found Nineteen weeks pregnant when the US Supreme Court overturned the constitutional right to abortion, Laura Krinsky, MD, reflects on the breadth and depth of her Tennessee patients’ experiences, and wonders where those patients will go for care as abortion becomes inaccessible in the state. She also examines her role as a well-intentioned, White physician who notes that it would be easy to slip into a pattern of coercing people of color and poor people regarding their contraceptive choices in this political setting. While her baby is fortunate, by virtue of her race, financial resources, and residence in a state that allows abortion and easy access to birth control, Krinsky acknowledges that not everyone has the same privileges. She predicts that health disparities will only grow starker following the overturning of Roe vs Wade.
Implications
- She concludes her letter with the hope to raise her daughter to be compassionate and humble, care about people, and respect their bodies and their decisions. She also wants her daughter to pay attention to systems of oppression and work on dismantling them.
Ed Bujold
Background Ed Bujold, MD, a family medicine doctor with his own solo practice, writes about his practice being attacked by ransomware. Patient data, including EHRs and the practice management system, was being held "ransom" and an encryption key would be given to the practice’s cloud provider once $5.1 million was delivered in bitcoin to the hacking entity.
What This Study Found While the practice's cloud-based service had an action plan in place the next day,
staff had no idea when the system would be back online. The practice’s first action
item was to reestablish cash flow and was then forced to go back to a completely paper-based
system. The author notes that ironically, during this time frame he spent more time
with patients, less time documenting medical records and, on average, left the office
one hour earlier. After three months of negotiations, the cloud provider paid the
Russian syndicate $500,000 and they produced the encryption key providing access to
the practice’s EHR and PM systems.
Implications
- Based on his experience, Bujold recommends having a trusted computer analyst take
care of hardware and do an annual cyber security check, as well as limiting the number
of devices connected to the internet. He also recommends having a "very frank" discussion
with staff about cyber security risks and vulnerabilities.