Search

Key Points Question Is there a quantifiable association between the coronavirus disease 2019 (COVID-19) pandemic and the volume, type, and content of primary care encounters in the US? Findings In this cross-sectional analysis of the US National Disease and Therapeutic Index audit of more than 125.8 million primary care visits in the 10 calendar quarters between quarter 1 of 2018 and quarter 2 of 2020, primary care visits decreased by 21.4% during the second quarter of 2020 compared with the average quarterly visit volume of the second quarters of 2018 and 2019. Evaluations of blood pressure and cholesterol levels decreased owing to fewer total visits and less frequent assessment during telemedicine encounters. Meaning The COVID-19 pandemic was associated with changes in the structure of primary care delivery during the second quarter of 2020, with the content of telemedicine visits differing from that of office-based encounters., Importance Little is known about the association between the coronavirus disease 2019 (COVID-19) pandemic and the level and content of primary care delivery in the US. Objective To quantify national changes in the volume, type, and content of primary care delivered during the COVID-19 pandemic, especially with regard to office-based vs telemedicine encounters. Design, Setting, and Participants Analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index, a 2-stage, stratified nationally representative audit of outpatient care in the US from the first calendar quarter (Q1) of 2018 to the second calendar quarter (Q2) of 2020. Main Outcomes and Measures Visit type (office-based or telemedicine), overall and stratified by patient population and geographic region; assessment of blood pressure or cholesterol measurement; and initiation or continuation of prescription medications. Results In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million (95% CI, 117.3-127.5 million) and 130.3 million (95% CI, 124.7-135.9 million) quarterly primary care visits occurred in the US (mean, 125.8 million; 95% CI, 121.7-129.9 million), most of which were office-based (92.9%). In 2020, the total number of encounters decreased to 117.9 million (95% CI, 112.6-123.2 million) in Q1 and 99.3 million (95% CI, 94.9-103.8 million) in Q2, a decrease of 21.4% (27.0 million visits) from the average of Q2 levels during 2018 and 2019. Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits). Decreases occurred in blood pressure level assessment (50.1% decrease, 44.4 million visits) and cholesterol level assessment (36.9% decrease, 10.2 million visits) in Q2 of 2020 compared with Q2 2018-2019 levels, and assessment was less common during telemedicine than during office-based visits (9.6% vs 69.7% for blood pressure; P, This cross-sectional study uses data from the National Disease and Therapeutic Index to quantify changes in volume and type of primary care visits and changes in visit content associated with the COVID-19 pandemic in the US.

Background Following a 2010-2011 pilot intervention in which a limited sample of primary care doctors offered their patients secure Web-based portal access to their office visit notes, the participating sites expanded OpenNotes to nearly all clinicians in primary care, medical, and surgical specialty practices. Objective The aim of this study was to examine the ongoing experiences and perceptions of patients who read ambulatory visit notes written by a broad range of doctors, nurses, and other clinicians. Methods A total of 3 large US health systems in Boston, Seattle, and rural Pennsylvania conducted a Web-based survey of adult patients who used portal accounts and had at least 1 visit note available in a recent 12-month period. The main outcome measures included patient-reported behaviors and their perceptions concerning benefits versus risks. Results Among 136,815 patients who received invitations, 21.68% (29,656/136,815) responded. Of the 28,782 patient respondents, 62.82% (18,081/28,782) were female, 72.90% (20,982/28,782) were aged 45 years or older, 76.94% (22,146/28,782) were white, and 14.30% (4115/28,782) reported fair or poor health. Among the 22,947 who reported reading 1 or more notes, 3 out of 4 reported reading them for 1 year or longer, half reported reading at least 4 notes, and 37.74% (8588/22,753) shared a note with someone else. Patients rated note reading as very important for helping take care of their health (16,354/22,520, 72.62%), feeling in control of their care (15,726/22,515, 69.85%), and remembering the plan of care (14,821/22,516, 65.82%). Few were very confused (737/22,304, 3.3%) or more worried (1078/22,303, 4.83%) after reading notes. About a third reported being encouraged by their clinicians to read notes and a third told their clinicians they had read them. Less educated, nonwhite, older, and Hispanic patients, and individuals who usually did not speak English at home, were those most likely to report major benefits from note reading. Nearly all respondents (22,593/22,947, 98.46%) thought Web-based access to visit notes a good idea, and 62.38% (13,427/21,525) rated this practice as very important for choosing a future provider. Conclusions In this first large-scale survey of patient experiences with a broad range of clinicians working in practices in which shared notes are well established, patients find note reading very important for their health management and share their notes frequently with others. Patients are rarely troubled by what they read, and those traditionally underserved in the United States report particular benefit. However, fewer than half of clinicians and patients actively address their shared notes during visits. As the practice continues to spread rapidly in the United States and internationally, our findings indicate that OpenNotes brings benefits to patients that largely outweigh the risks.

Women 65 years and older are commonly screened for breast cancer with mammography. Models estimate that screening 1,000 women biannually for 10 years after the age of 69 would result in two fewer cancer deaths, 200 false positive mammograms, and 13 cases of over-diagnosis (breast cancer that would not have been clinically evident otherwise).1 The study by Schonberg et al. evaluates the effects of benign breast biopsies upon older women, using validated scales of psychological and physical consequences measured at the time of biopsy and after 6 months, and uses qualitative data to develop a conceptual model of undergoing a benign breast biopsy.2 At the time of biopsy, 76 % of women reported negative psychological consequences, which persisted at 6 months for 39 %. After 6 months, one in five women felt that worry interfered with their daily activities, and there was a trend for women with ≤ 9 years life expectancy to have higher negative psychological consequences compared to healthier women. Women also noted competing health issues in the qualitative data, all of which support the need for personalized decision making to balance risks and benefits of breast cancer screening in this age group. Opportunities identified for optimizing the experience of breast biopsies for women include positive interactions with radiology staff and physicians and systematic processes that minimize the wait time for test results. Women want information that explains biopsy procedures and diagnosis-specific information post-biopsy. Patient education materials would need to reflect current recommendations,3 particularly for diagnoses that are associated with higher risk for breast cancer, such as atypia, and to acknowledge the paucity of evidence supporting mortality benefit from such follow-up. Delivering this information via the primary care provider, with whom women wanted to communicate, would improve on-going shared decision making about future breast cancer screening. Decision aids that personalize screening recommendations based upon women’s competing medical issues and life expectancy4,5 would ideally be easily accessible in the primary care setting within an electronic medical record. These supports are needed to decrease the harms of breast cancer screening among women 65 years and older.

Rationale and Objectives Mammography quality assurance programs have been in place for more than a decade. We studied radiologists’ self-reported performance goals for accuracy in screening mammography and compared them to published recommendations. Materials and Methods A mailed survey of radiologists at mammography registries in seven states within the Breast Cancer Surveillance Consortium (BCSC) assessed radiologists’ performance goals for interpreting screening mammograms. Self-reported goals were compared to published American College of Radiology (ACR) recommended desirable ranges for recall rate, false-positive rate, positive predictive value of biopsy recommendation (PPV2), and cancer detection rate. Radiologists’ goals for interpretive accuracy within desirable range were evaluated for associations with their demographic characteristics, clinical experience, and receipt of audit reports. Results The survey response rate was 71% (257 of 364 radiologists). The percentage of radiologists reporting goals within desirable ranges was 79% for recall rate, 22% for false-positive rate, 39% for PPV2, and 61% for cancer detection rate. The range of reported goals was 0%–100% for false-positive rate and PPV2. Primary academic affiliation, receiving more hours of breast imaging continuing medical education, and receiving audit reports at least annually were associated with desirable PPV2 goals. Radiologists reporting desirable cancer detection rate goals were more likely to have interpreted mammograms for 10 or more years, and >1000 mammograms per year. Conclusion Many radiologists report goals for their accuracy when interpreting screening mammograms that fall outside of published desirable benchmarks, particularly for false-positive rate and PPV2, indicating an opportunity for education.