Practice Characteristics and COVID-19: Important but not Sufficient to Explain Primary Care Successes and Failures

Context: Primary care practices experienced varying levels of success adapting care delivery and office functioning during the pandemic.

Objective: To examine clinician self-report of clinic strong or weak functioning during the pandemic and determine which clinic and clinician characteristics were associated with ability to function, and why.

Dataset/Population: Convenience sampling; one-hour interviews conducted among 76 U.S. primary care clinicians. Participants previously participated in at least one survey of their pandemic care delivery experience and responded to a request for a one-time anonymous interview.

Study Design: Each participant reported on 8 common practice characteristics (e.g. rurality, size, ownership, payment model) and were then asked how these affected care delivery. Responses were identified as “positive”, “negative”, or “mixed” for each mentioned, assessed using simple template-based coding, and analyzed for themes within each category.

Results: Clinicians in small (<3 clinicians) and self-owned clinics were three times more likely to say these characteristics were a disadvantage. However, a majority of these same clinicians also identified benefits these characteristics offered. For example, some in small clinics were able to implement changes rapidly without committee proceedings. Yet some in large clinics said being large helped them divide responsibilities and cover one another during quarantines. Some health system-based clinicians felt alienated when disagreeable decisions were made by leadership. But independent practitioners also felt a lack of agency in the struggle for funding and resources in a system built around larger institutions. Positive or negative reported effects were not consistently attributed to certain practice characteristics, and yet clinicians emphasized several qualities which were present across clinic settings. The most impactful qualities we identified were 1) a clinic’s capacity to enact change, 2) suitability of pre-pandemic workflows to pandemic-era care delivery, and 3) a clinician’s sense of agency to make a positive impact.

Conclusions: While not predictive of success or failure during the pandemic, practice characteristics played a major role in how clinicians perceived their ability to deliver care throughout. Having a diversity of models for healthcare delivery, management, and payment may result in greater resilience during future crises.