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PURPOSE The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected. METHODS We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation. RESULTS Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%). CONCLUSIONS Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions. Key words: COVID-19; access to primary care; telemedicine; primary health care https://doi.org/10.1370/afm.3134, INTRODUCTION Primary care is the largest platform for health care delivery in the United States, (1) and an adequate supply of primary care physicians is associated with positive and more [...]

PURPOSE COVID-19 is a condition that can lead to other chronic conditions. These conditions are frequently diagnosed in the primary care setting. We used a novel primary care registry to quantify the burden of post-COVID conditions among adult patients with a COVID-19 diagnosis across the United States. METHODS We used the American Family Cohort, a national primary care registry, to identify study patients. After propensity score matching, we assessed the prevalence of 17 condition categories individually and cumulatively, comparing patients having COVID-19 in 2020-2021 with (1) historical control patients having influenza-like illness in 2018 and (2) contemporaneous control patients seen for wellness or preventive visits in 2020- 2021. RESULTS We identified 28,215 patients with a COVID-19 diagnosis and 235,953 historical control patients with influenza-like illness. The COVID-19 group had higher prevalences of breathing difficulties (4.2% vs 1.9%), type 2 diabetes (12.0% vs 10.2%), fatigue (3.9% vs 2.2%), and sleep disturbances (3.5% vs 2.4%). There were no differences, however, in the postdiagnosis monthly trend in cumulative morbidity between the COVID-19 patients (trend = 0.026; 95% CI, 0.025-0.027) and the patients with influenza- like illness (trend = 0.026; 95% CI, 0.023-0.027). Relative to contemporaneous wellness control patients, COVID-19 patients had higher prevalences of breathing difficulties and type 2 diabetes. CONCLUSIONS Our findings show a moderate burden of post-COVID conditions in primary care, including breathing difficulties, fatigue, and sleep disturbances. Based on clinical registry data, the prevalence of post-COVID conditions in primary care practices is lower than that reported in subspecialty and hospital settings. Key words: long COVID; post-COVID conditions; post-infectious disorders; primary health care; family practice; chronic illness; morbidity https://doi.org/10.1370/afm.3131, INTRODUCTION The direct and immediate impact of COVID-19 on the health of the US population has been of generational significance, and the secondary wave of persistent symptoms and new conditions [...]

PURPOSE Care continuity is foundational to the clinician/patient relationship; however, little has been done to operationalize continuity of care (CoC) as a clinical quality measure. The American Board of Family Medicine developed the Primary Care CoC clinical quality measure as part of the Measures That Matter to Primary Care initiative. METHODS Using 12-month Optum Clinformatics Data Mart claims data, we calculated the Bice-Boxerman Continuity of Care Index for each patient, which we rolled up to create an aggregate, physician-level CoC score. The physician quality score is the percent of patients with a Bice-Boxerman Index [greater than or equal to] 0.7 (70%). We tested validity in 2 ways. First, we explored the validity of using 0.7 as a threshold for patient CoC within the Optum claims database to validate its use for reflecting patient-level continuity. Second, we explored the validity of the physician CoC measure by examining its association with patient outcomes. We assessed reliability using signal-to-noise methodology. RESULTS Mean performance on the measure was 27.6%; performance ranged from 0% to 100% (n = 555,213 primary care physicians). Higher levels of CoC were associated with lower levels of care utilization. The measure indicated acceptable levels of validity and reliability. CONCLUSIONS Continuity is associated with desirable health and cost outcomes as well as patient preference. The CoC clinical quality measure meets validity and reliability requirements for implementation in primary care payment and accountability. Care continuity is important and complementary to access to care, and prioritizing this measure could help shift physician and health system behavior to support continuity. https://doi.org/10.1370/afm.2880, INTRODUCTION Continuity of care (CoC) is a central tenet of primary care and is associated with fewer hospitalizations and emergency department (ED) visits, better patterns of care utilization, lower costs [...]

PURPOSE Physicians' use of self-assessment to guide quality improvement or board certification activities often does not correlate with more objective measures, and they may spend valuable time on activities that support their strengths instead of addressing gaps. Our objective was to study whether viewing quality measures, with peer comparisons, would affect the selection of certification activities. METHODS We conducted a cluster-randomized controlled trial--the Trial of Data Exchange for Maintenance of certification and Raising Quality (TRADEMaRQ)--with 4 partner organizations during 2015-2017. Physicians were presented their quality data within their online certification portfolios before (intervention) vs after (control) they chose board certification activities. The primary outcome was whether the selected activity addressed a quality gap (a quality area in which the physician scored below the mean for the study population). RESULTS Of 2,570 invited physicians, 254 physicians completed the study: 130 in the intervention group and 124 in the control group. Nearly one-fifth of participating physicians did not complete any certification activities during the study. A sizable minority of those in the intervention group, 18.4%, never reviewed their quality dashboard. Overall, just 27.2% of completed certification activities addressed a quality gap, and there was no significant difference in this outcome in the intervention group vs the control group in either bivariate or adjusted analyses (odds ratio = 1.28; 95% CI, 0.90-1.82). CONCLUSIONS Physicians did not use quality performance data in choosing certification activities. Certification boards are being pressed to make their programs relevant to practice, less burdensome, and supportive of quality improvement in alignment with value-based payment models. Using practice data to drive certification choices would meet these goals. Ann Fam Med 2022;20:110-114. https://doi.org/10.1370/afm.2770, INTRODUCTION The Crossing the Quality Chasm landmark report of the Institute of Medicine (now National Academy of Medicine) detailed the uneven quality of the US health care system nearly 20 [...]

Objective To identify impacts of different survey methodologies assessing primary care physicians' (PCPs') experiences with electronic health records (EHRs), we compared three surveys: the 2022 Continuous Certification Questionnaire (CCQ) from the American Board of Family Medicine, the 2022 University of California San Francisco (UCSF) Physician Health IT Survey, and the 2021 National Electronic Health Records Survey (NEHRS). Materials and Methods We evaluated differences between survey pairs using Rao-Scott corrected chi-square tests, which account for weighting. Results CCQ received 3991 responses from PCPs (100% response rate), UCSF received 1375 (3.6% response rate), and NEHRS received 858 (18.2% response rate). Substantial, statistically significant differences in demographics were detected across the surveys. CCQ respondents were younger and more likely to work in a health system; NEHRS respondents were more likely to work in private practice; and UCSF respondents disproportionately practiced in larger academic settings. Many EHR experience indicators were similar between CCQ and NEHRS, but CCQ respondents reported higher documentation burden. Discussion The UCSF approach is unlikely to supply reliable data. Significant demographic differences between CCQ and NEHRS raise response bias concerns, and while there were similarities in some reported EHR experiences, there were important, significant differences. Conclusion Federal EHR policy monitoring and maintenance require reliable data. This test of existing and alternative sources suggest that diversified data sources are necessary to understand physicians' experiences with EHRs and interoperability. Comprehensive surveys administered by specialty boards have the potential to contribute to these efforts, since they are likely to be free of response bias. [ABSTRACT FROM AUTHOR]

PURPOSE The Trial of Aggregate Data Exchange for Maintenance of Certification and Raising Quality was a randomized controlled trial which first had to test whether quality reporting could be a by-product of clinical care. We report on the initial descriptive study of the capacity for and quality of exchange of whole-panel, standardized quality measures from health systems. METHODS Family physicians were recruited from 4 health systems with mature quality measurement programs and agreed to submit standardized, physician-level quality measures for consenting physicians. Identified measure or transfer errors were captured and evaluated for root-cause problems. RESULTS The health systems varied considerably by patient demographics and payer mix. From the 4 systems, 256 family physicians elected to participate. Of 19 measures negotiated for use, 5 were used by all systems. There were more than 15 types of identified errors including breaks in data delivery, changes in measures, and nonsensical measure results. Only 1 system had no identified errors. CONCLUSIONS The secure transfer of standardized, physician-level quality measures from 4 health systems with mature measure processes proved difficult. There were many errors that required human intervention and manual repair, precluding full automation. This study reconfirms an important problem, namely, that despite widespread health information technology adoption and federal meaningful use policies, we remain far from goals to make clinical quality reporting a reliable by-product of care. Key words: health information technology; quality measures; family physicians; quality indicators; health care; certification, INTRODUCTION Family physicians provide nearly 20% of all clinical outpatient visits, nearly 200 million visits in the United States annually. (1) Frontline clinicians continue to report failures of certified electronic [...]

Earlier this year, the National Academies of Sciences, Engineering, and Medicine (NASEM) published the first formal consensus study of primary care in 25 years. The consensus committee's report, 'Implementing High-Quality [...]

Still early in a long game of delivery system transformation, the United States is already experiencing some of the negative consequences of pursuing quality and value measurement on professionalism in [...]

Key words: practice transformation; organizational change; innovation; quality improvement; professional practice; health extension; outreach; practice facilitation; primary care; burnout; health information technology; practice-based research, This supplement to the Annals of Family Medicine brings together early learning from multiple examples of health extension and practice transformation support, with the goal of informing future efforts to [...]

PURPOSE To identify and prioritize the needs for new research evidence for primary health care (PHC) in low- and middle-income countries (LMICs) about organization, models of care, and financing of PHC. METHODS Three-round expert panel consultation of LMIC PHC practitioners and academics sampled from global networks, via web-based surveys. Iterative literature review conducted in parallel. Round 1 (pre--Delphi survey) elicited possible research questions to address knowledge gaps about organization and models of care and about financing. Round 2 invited panelists to rate the importance of each question, and in round 3 panelists provided priority ranking. RESULTS One hundred forty-one practitioners and academics from 50 LMICs from all global regions participated and identified 744 knowledge gaps critical to improving PHC organization and 479 for financing. Four priority areas emerged: effective transition of primary and secondary services, horizontal integration within a multidisciplinary team and intersectoral referral, integration of private and public sectors, and ways to support successfully functioning PHC professionals. Financial evidence priorities were mechanisms to drive investment into PHC, redress inequities, increase service quality, and determine the minimum necessary budget for good PHC. CONCLUSIONS This novel approach toward PHC needs in LMICs, informed by local academics and professionals, created an expansive and prioritized list of critical knowledge gaps in PHC organization and financing. It resulted in research questions, offering valuable guidance to global supporters of primary care evaluation and implementation. Its source and context specificity, informed by LMIC practitioners and academics, should increase the likelihood of local relevance and eventual success in implementing research findings. Key words: primary health care; developing countries; economics; organization and administration; knowledge; research gaps, INTRODUCTION The 1978 Declaration of Alma-Ata called for strengthening of family medicine and primary health care (PHC) globally, particularly in developing countries. (1) As the specialty of family medicine has [...]

The Affordable Care Act authorized, but did not fund, the Primary Care Extension Program (PCEP). Much like the Cooperative Extension Program of the US Department of Agriculture sped the modernization of farming a century ago, the PCEP could speed the transformation of primary care. It could also help achieve other goals such as integrating primary care with public health and translating research into practice. The urgency of these goals and their importance to achieving the Triple Aim for health care should increase interest in rapidly building the PCEP, much as the need to feed the country did a century ago.

COVID-19 altered the way the American public lived their lives,- the way they worked, ate, socialized, traveled, and ultimately received their health care. Family Medicine largely closed its doors to [...]

The American Board of Family Medicine routinely surveys its Diplomates in each national graduating cohort 3 years out of training. These data were used to characterize early career family physicians whose services include management of pregnancy and prescribing buprenorphine. A total of 261 (5.1%) respondents both provide maternity care and prescribe buprenorphine. Family physicians who care for pregnant women and also prescribe buprenorphine represented 50.4% of all buprenorphine prescribers. The family physicians in this group were trained in a small number of residency programs, with only 15 programs producing at least 25% of graduates who do this work. Key words: family medicine; addiction medicine; buprenorphine; maternity care; opioids, INTRODUCTION Morbidity and mortality associated with opioid use disorder (OUD) has steadily increased in the United States in recent years, with deaths related to opioid overdose increasing from 8,050 in [...]

In May 2021, the National Academies of Sciences, Engineering, and Medicine (NASEM) released Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. (1) Linking coordination of primary care to [...]