Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use

Post-Telemedicine Acute Care for Undifferentiated High-Acuity Conditions: Is a Picture Worth a Thousand Words?

Objectives: Telemedicine use increased substantially with the COVID-19 pandemic. Understanding of the impact of telemedicine modality (video vs. phone) on post-telemedicine acute care for higher risk conditions is limited. Methods: We conducted a retrospective study of telemedicine visits, comparing video with telephone, for selected diagnoses with potentially higher illness acuity, evaluating post-telemedicine emergency department (ED) and hospitalization rates. In a large, multicenter cohort of adult patient-initiated primary care telemedicine visits from March 1, 2020, to July 31, 2021, we evaluated 7-day ED and hospitalization rates for higher acuity diagnostic categories (cardiac, gastrointestinal, and respiratory) by telemedicine modality, provider familiarity, and patient sociodemographic and clinical characteristics. Results: Among 431,705 telemedicine encounters, 128,129 (29.7%) were video visits and 303,576 (70.3%) were telephone visits. Adjusting for patient and appointment factors, telephone encounters for cardiac conditions were associated with significantly higher 7-day ED visit rates than video encounters (5.5% vs. 4.9%, respectively) but similar hospitalization rates (0.7% vs. 0.8%, respectively); for gastrointestinal conditions, post-telemedicine adjusted ED and hospitalization rates were comparable between telemedicine modalities (4.0% for ED and 1.2% vs. 1.3% for hospitalization, respectively); among respiratory conditions, video encounters were associated with higher ED and hospitalization rates than telephone encounters (ED: 5.9% after video vs. 5.2% after phone; hospitalization: 1.9% after video vs. 1.5% after phone). Telemedicine encounters with patients' own primary care provider (PCP) were associated with lower adjusted rates of ED use across all conditions and modalities. Conclusions: Short-term ED and hospitalization rates following primary care video or telephone visits for selected acute, high-risk conditions varied by condition and PCP familiarity. Nuanced use of video visits may confer benefits triaging to downstream acute care.

Association Between Vacation Characteristics and Career Intentions of US Physicians-A Cross-Sectional Analysis

OBJECTIVE

To assess the association between physicians' vacation characteristics and career intentions.

PARTICIPANTS AND METHODS

This is a cross-sectional survey of a sample of US physicians between November 2022 and September 2023. Vacation days in the last year, inbox coverage, performance of patient-related work on vacation (WOV), intent to reduce clinical hours in the next 12 months, and intent to leave current practice in the next 24 months were assessed.

RESULTS

Of 5059 respondents, 2163 of 4537 (47.7%) reported fewer than 15 days of vacation in the last year, with 443 of 4537 (9.8%) taking 5 or fewer days. Nearly half (48.6%) reported not having full electronic health record inbox coverage on vacation. Most (72.0%) reported WOV, with 33.6% performing more than 30 minutes per day. On multivariable analyses adjusting for personal and professional characteristics, taking 15 or fewer days of vacation per year (odds ratio [OR], 1.37 [95% CI, 1.14 to 1.64]), absence of full inbox coverage (OR, 1.36 [95% CI, 1.13 to 1.63]), and more than 30 minutes per day of WOV (OR, 1.50 [95% CI, 1.24 to 1.81]) were each associated with higher odds of intent to reduce clinical hours. Similarly, taking 15 or fewer days of vacation per year (OR, 1.19 [95% CI, 1.00 to 1.41]), not having full inbox coverage (OR, 1.33 [95% CI, 1.12 to 1.57]), and more than 30 minutes per day of WOV (OR, 1.44 [95% CI, 1.21 to 1.72]) were each associated with higher odds of intent to leave current practice.

CONCLUSION

In this large, cross-sectional study, the number of vacation days taken, inbox coverage, and time spent on patient-related work while on vacation were each independently associated with career intentions. Organizational efforts to optimize these vacation characteristics may foster retention of physicians.

Ambulatory Medication Safety Events in High-risk Patients With Diabetes Before and After a COVID-19 Clinic Slowdown

OBJECTIVES

We aimed to assess possible changes in medication safety over a mandatory pre-/post- COVID-19 clinic slowdown in a high-risk population of patients with diabetes seen at a safety net clinic.

METHODS

Retrospective chart review of all patient encounters 1 year before and after the slowdown. The study cohort were all patients with poorly controlled diabetes established pre-COVID-19 who were prescribed 4+ chronic medications. Each clinic note was abstracted for reports of any medication-related problems. The primary outcomes were measures of health care system utilization and potential adverse drug events (ADEs).

RESULTS

Out of 762 patients with diabetes, 59 were poorly controlled and formed the high-risk study cohort: age 53.0±11 years, 69% female, 17% White, 29% Hispanic, and 43% African American. There were similar numbers of patient encounters pre-/post-slowdown (7.68 clinic visits vs. 4.2 clinic visits plus 3.19 telehealth visits), cancellations (2.54 vs. 2.97), and no-shows (2.17 vs. 1.98). There was no change in the number of prescribed medications pre-/post-slowdown (12.1 vs. 11.7), but more potential adverse medication events (6/380 (1.6%) vs. 17/429 (4.0%), P=0.04). Of all abstracted medication-related problems, the majority were in diabetic medications 57/78 (73.1%), and of those, most involved insulin 43/57 (75.4%). Eleven preventable ADEs over the 2-year period were observed, all involved insulin, and were often affected by patient work system challenges such as self-administration and timing.

CONCLUSIONS

There was a small increase in potential adverse medication events among a cohort of high-risk patients during the COVID-19 pandemic. The most common ADE was hypoglycemia associated with insulin.

A Home-Visiting Clinic Decreased the Emergency Transportation in Rural Japan: A Quasi-Experimental Approach

This study examined whether a home-visiting clinic decreased emergency transportations in the region, using a quasi-experimental approach derived from private practice. This study employed a retrospective observational design and was conducted in suburban Tome City, Miyagi Prefecture, with a population of approximately 80,000 and an aging population rate of 35.5% in 2020. Information on ambulance services and the age distribution in Tome City was obtained as confidential data from Tome City. Data on ambulance services and age distribution across Japan was obtained from a publicly accessible dataset. We calculated the standardized emergency transportations due to sudden illness ratio (SER), based on the standardized mortality ratio. This ratio represents the relative incidence of emergency transportations due to sudden illnesses in Tome City compared to all of Japan (with 100 for Japan), adjusted for the age distribution in Tome City through an indirect method. The SER increased to 88.2% in 2011, remained high at 89.6% in 2012, and declined from 85.6% in 2013, the year the home-visit clinic was established, to 86.7%, 83.0%, 80.5%, and 78.1%. The findings suggest that home medical care is an effective means of providing medical assistance to homebound patients and may reduce the necessity for hospitalization and ambulance services.

Integration as innovation in healthcare systems

Healthcare systems in Canada are under pressure and require change-the status quo is no longer fit for purpose, if it ever was. Innovation is often held up as a cure for what ails us, but shiny new things or novel technologies alone have not been enough. This article will explore the concepts of differentiation and integration as being important drivers in the evolution of living organisms, ecosystems, and complex human organizations. The implications of this deep pattern of systems change are essential to understanding the roles of specialization in medicine, and optionality in primary care. Specifically, overspecialization without attention to the principles of healthcare integration can lead to fragmentation of care and worse patient outcomes. Finally, this article will describe some practical examples of system integration as innovation in the form of better public health and care delivery connections, health homes, and community care coordination centres.

Telehealth in Family Medicine Clerkships After Return of In-Person Care: A CERA Study

Introduction

The COVID-19 pandemic encouraged widespread implementation of telemedicine. With the increased normalization of telemedicine in clinical practice, the authors sought to characterize telemedicine training during family medicine clerkships after the return to in-person care.

Methods

Data were collected as part of the 2023 Council of Academic Family Medicine's Educational Research Alliance (CERA) survey of family medicine clerkship directors (CDs). Along with baseline demographics about the clerkship and themselves, CDs answered which Association of American Medical Colleges (AAMC) telehealth competencies were taught during family medicine clerkships and indicated challenges related to involving medical students in telemedicine visits.

Results

More than half of the responding family medicine clerkships (57.3%) did not teach any of the AAMC telehealth core competencies and only 4.3% taught all six competencies. The three most commonly taught competencies during the clerkship included communication via telehealth (32.2%), patient safety and appropriate use of telehealth (27.1%), and technology for telehealth (17.7%). Most family medicine clerkships (68.0%) identified at least one challenge of the three possible perceived challenges with "limited site resources" as the most reported barrier. There was no significant difference in telemedicine training from CD based on type of medical school (P=.73), gender (P=.82), being a CD for 5 years or less (P=.41), or self-identification as an underrepresented minority in medicine (P=.19).

Conclusions

Of those CDs who responded, many still do not teach the AAMC telehealth core competencies within their family medicine clerkship. The majority reported limited site resources as a barrier to telehealth education.

Health Care Utilization After a Visit to a Within-Group Family Physician vs a Walk-In Clinic Physician

PURPOSE

Primary care access is a key health system metric, but little research has compared models to provide primary care access when one's regular physician is not available. We compared health system use after a visit with a patient's own family physician group (ie, within-group physician who was not the patient's primary physician) vs a visit with a walk-in clinic physician who was not part of the patient's family physician group.

METHODS

We conducted a population-based, retrospective cohort study using administrative data from Ontario, Canada, including all individuals formally enrolled with a family physician, from April 1, 2019 to March 31, 2020. We compared those visiting within-group physicians to those visiting walk-in clinic physicians using propensity score matching to account for differences in patient characteristics. The primary outcome was any emergency department visit within 7 days of the initial visit.

RESULTS

Matched patients who visited a within-group physician (N = 506,033) were 10% less likely to visit an emergency department in the 7 days after the initial visit compared to patients who saw a walk-in clinic physician (N = 506,033; 20,117 [4.0%] vs 22,320 [4.4%]; risk difference [RD] 0.4%; 95% CI 0.4-0.5; relative risk [RR] 0.90; 95% CI, 0.89-0.92). Restricting to visits occurring on weekends, the observed association was stronger (7,964 [3.7%] vs 10,055 [4.7%]; RD 1.0%; 95% CI 0.9-1.1; RR 0.79; 95% CI, 0.77-0.82). Those accessing after-hours within-group physician visits were more likely to have ≥1 additional virtual or in-person within-group physician visit within 7 days (virtual RR 1.86, in-person RR 1.87).

CONCLUSIONS

Compared to visiting a walk-in clinic physician, seeing a within-group physician after hours might decrease downstream emergency department visits. This finding could be explained by better continuity of care and can inform primary care service models and the policies that support them.

Virtual Versus In-Person Follow-up After a Psychiatric Emergency Visit: A Population-Based Cohort Study: Suivi virtuel opposé à en personne après une visite à l'urgence psychiatrique : une étude de cohorte dans la population

OBJECTIVE

With increased utilization of virtual care in mental health, examining its appropriateness in various clinical scenarios is warranted. This study aimed to compare the risk of adverse psychiatric outcomes following virtual versus in-person mental health follow-up care after a psychiatric emergency department (ED) visit.

METHODS

Using population-based health administrative data in Ontario (2021), we identified 28,232 adults discharged from a psychiatric ED visit who had a follow-up mental health visit within 14 days postdischarge. We compared those whose first follow-up visit was virtual (telephone or video) versus in-person on their risk for experiencing either a repeat psychiatric ED visit, psychiatric hospitalization, intentional self-injury, or suicide in the 15-90 days post-ED visit. Cox proportional hazard models generated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs), adjusted for age, income quintile, psychiatric hospitalization, and intentional self-injury in the 2 years prior to ED visit. We stratified by sex and diagnosis at index ED visits based on the International Classification of Diseases and Related Health Problems, 10th Revision, Canada (ICD-10-CA) coding.

RESULTS

About 65% (n = 18,354) of first follow-up visits were virtual, while 35% (n = 9,878) were in-person. About 13.9% and 14.6% of the virtual and in-person groups, respectively, experienced the composite outcome, corresponding to incidence rates of 60.9 versus 74.2 per 1000 person-years (aHR 0.95, 95% CI 0.89 to 1.01). Results were similar for individual elements of the composite outcome, when stratifying by sex and index psychiatric diagnosis, when varying exposure (7 days) and outcome periods (60 and 30 days), and comparing "only" virtual versus "any" in-person follow-up during the 14-day follow-up.

CONCLUSIONS AND RELEVANCE

These results support virtual care as a modality to increase access to follow-up after an acute care psychiatric encounter across a wide range of diagnoses. Prospective trials to discern whether this is due to the comparable efficacy of virtual and in-person care, or due solely to appropriate patient selection may be warranted.

Primary Care Telemedicine and Care Continuity: Implications for Timeliness and Short-term Follow-up Healthcare

BACKGROUND

The effectiveness of telemedicine by a patient's own primary care provider (PCP) versus another available PCP is understudied.

OBJECTIVE

Examine the association between primary care visit modality with timeliness and follow-up in-person healthcare, including variation by visits with the patient's own PCP versus another PCP.

DESIGN AND PARTICIPANTS

Cohort study including primary care visits in a large, integrated delivery system in 2022.

MEASURES

Outcomes included timeliness (visit completed within 7 days of scheduling) and in-person follow-up (PCP visits, emergency department (ED) visits, hospitalizations) within 7 days of the index PCP visit. Logistic regression measured the association between visit modality (in-person, video, and audio-only telemedicine) with the patient's own PCP or another PCP and outcomes, adjusting for characteristics.

KEY RESULTS

Among 4,817,317 primary care visits, 59% were in-person, 27% audio-only, and 14% video telemedicine. Most (71.3%) were with the patient's own PCP. Telemedicine visits were timelier, with modality having a larger association for visits with patient's own PCP versus another PCP (P < 0.001). For visits with patient's own PCPs, return office visit rates were 1.2% for in-person, 5.3% for video, and 6.1% for audio-only. For another PCP, rates were 2.2% for in-person, 7.3% for video, and 8.1% for audio. Follow-up ED visits ranged from 1.4% (in-person) to 1.6% (audio-only) with own PCP, compared to 1.9% (in-person) to 2.3% (audio-only) with another PCP. Differences in return office and ED visits between in-person and telemedicine were larger for visits with another PCP compared to their own PCP (P < 0.001). Follow-up hospitalizations were rare, ranging from 0.19% (in-person with own PCP) to 0.32% (video with another PCP).

CONCLUSION

Differences in return office and ED visits between in-person and telemedicine were larger when patients saw a less familiar PCP compared to their own PCP, reinforcing the importance of care continuity.

Characteristics of walk-in clinic physicians and patients in Ontario: Cross-sectional study

OBJECTIVE

To describe family physicians who primarily practise in a walk-in clinic setting and compare them with family physicians who provide longitudinal care.

DESIGN

A cross-sectional study that linked results from a 2019 physician survey to provincial administrative health care data in Ontario. The characteristics, practice patterns, and patients of physicians primarily working in a walk-in clinic setting were compared with those of family physicians providing longitudinal care.

SETTING

Ontario.

PARTICIPANTS

Physicians who primarily worked in a walk-in clinic setting in 2019, as indicated by an annual physician survey.

MAIN OUTCOME MEASURES

Physician demographic and practice characteristics, as well as their patients' demographic and health care utilization characteristics, were reported according to whether the physician was a walk-in clinic physician or a family physician who provided longitudinal care.

RESULTS

Compared with the 9137 family physicians providing longitudinal care, the 597 physicians who self-identified as practising primarily in walk-in clinics were more frequently male (67% vs 49%) and more likely to speak a language other than English or French (43% vs 32%). Walk-in clinic physicians tended to have more encounters with patients who were younger (mean 37 vs 47 years), who had lower levels of prior health care utilization (15% vs 19% in highest band), who resided in large urban areas (87% vs 77%), and who lived in highly ethnically diverse neighbourhoods (45% vs 35%). Walk-in clinic physicians tended to have more encounters with unattached patients (33% vs 17%) and with patients attached to another physician outside their group (54% vs 18%).

CONCLUSION

Physicians who primarily work in walk-in clinics saw many patients from historically underserved groups and many patients who were attached to another family physician.

Downstream Emergency Department and Hospital Utilization Comparably Low Following In-Person Versus Telemedicine Primary Care for High-Risk Conditions

BACKGROUND

Telemedicine use expanded greatly during the COVID-19 pandemic. More data is needed to understand how this shift may impact other venues of acute care delivery.

OBJECTIVE

We evaluate the association of visit modality (telephone, video, or office) and downstream emergency department (ED) and hospital visits among primary care visits for acute, time-sensitive conditions.

DESIGN

Observational study of patient-scheduled primary care telemedicine and office visits for acute conditions (cardiac, gastrointestinal, neurologic, musculoskeletal, and head and neck) in a large, integrated healthcare delivery system.

PARTICIPANTS

Adults with a new self-booked primary care appointment for an eligible acute condition from January 1, 2022, to December 31, 2022 (with no primary care, ED, or hospital visits in prior 30 days).

INTERVENTIONS

Visit modality, including office, video, or telephone.

MAIN MEASURES

Seven-day ED and hospital utilization, adjusted for patient and visit characteristics.

KEY RESULTS

Among 258,958 primary care visits by 239,240 adult patients, 57.7% were telemedicine visits; of these, 72.4% were telephone and 27.6% were video. Telephone visits were the timeliest, with over 70% of visits scheduled within 1 day of booking. Rates of 7-day ED utilization were low, and varied by condition group, with cardiac visits having the highest rates (4.8%) and musculoskeletal visits having the lowest (0.8%). There was less than a 1% absolute difference in ED use by visit modality for all condition types; however, telephone visits were associated with slightly higher rates than video visits. The 7-day hospitalization rate was less than 1% and observed between visit type differences varied by clinical condition.

CONCLUSIONS

Among office, telephone, and video visits in primary care for potentially high-risk, time-sensitive conditions, downstream ED and hospital use were uncommon. ED utilization was lower for video visits than telephone visits, although telephone visits were timelier and may offer a safe and accessible option for acute care.

Physician-Led Synchronous Telemedicine Compared to Face-To-Face Care in Primary Care: A Systematic Review

The COVID-19 crisis rapidly introduced telemedicine as the predominate modality to deliver healthcare however this change has not received attention in primary care settings and the health-related impacts are unknown. The study's objective was to explore the effects of physician-led synchronous telemedicine compared to face-to-face care delivered in the primary care setting on healthcare system use and attributes of primary care as reported in recent studies. We performed a comprehensive literature search in five databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycInfo) and critical appraisal using the Joanna Briggs Institute tools. Of 6,247 studies identified, 157 studies underwent full text review, and 19 studies were included. Most studies were conducted in the U.S. (78.9%) and used video and telephone telemedicine (57.9%). An outcome-based qualitative description and narrative synthesis showed similar or fewer emergency department visits, hospital visits, and prescribing, and fewer diagnostic tests and imaging for telemedicine visits compared to face-to-face care. Our systematic review fills a gap in the literature on telemedicine in primary care settings however our results need to be interpreted cautiously given studies' susceptibility to selection bias, confounding, and limited applicability to other health systems and time periods.

Primary Care in the United States: Past, Present and Future

Even though a well-functioning primary care system is widely acknowledged as critical to population health, the number of primary care physicians (PCPs) practicing in the United States has steadily declined, and PCPs are in short supply. The reasons are multiple and include inadequate income relative to other specialties, excessive administrative demands on PCPs and the lack of respect given to primary care specialties during medical school and residency. Advanced practice nurses can augment the services of primary care physicians but cannot substitute for them. To change this situation, we need action on several fronts. Medical schools should give preference to students who are more likely to enter the primary care specialties. The income gap between primary care and other specialties should be narrowed. The administrative load placed on PCPs, including cumbersome electronic medical records, must be lessened. Insurers, including Medicare and Medicaid, must provide the resources to allow primary care physicians to act as leaders of multidisciplinary teams.