Impact of COVID-19 on Primary Care Practice Sites and Their Vulnerable Patients

Purpose: While COVID-19 has upended lives, it has also catalyzed innovation with potential to advance health delivery. Yet, we know little about how the delivery system, and primary care in particular, has responded and how this has impacted vulnerable patients. We aimed to understand the impact of COVID-19 on primary care practice sites and their vulnerable patients and to identify explanations for variation. Approach: We developed and administered a survey to practice managers and physician leaders from 173 primary care practice sites, October-November 2020. We report and graphically depict results from univariate analysis and examine potential explanations for variation in practices' process innovations in response to COVID-19 by assessing bivariate relationships between seven dependent variables and four independent variables. Findings: Among 96 (55.5%) respondents, primary care practice sites on average took more safety (8.5 of 12) than financial (2.5 of 17) precautions in response to COVID-19. Practice sites varied in their efforts to protect patients with vulnerabilities, providing care initially postponed, and experience with virtual visits. Financial risk, practice size, practitioner age, and emergency preparedness explained variation in primary care practices' process innovations. Many practice sites plan to sustain virtual visits, dependent mostly on patient and provider preference and continued reimbursement. Value: While findings indicate rapid and substantial innovation, conditions must enable primary care practice sites to build on and sustain innovations, to support care for vulnerable populations, including those with multiple chronic conditions and socio-economic barriers to health, and to prepare primary care for future emergencies.

Association Between HEDIS Performance and Primary Care Physician Age, Group Affiliation, Training, and Participation in ACA Exchanges

BACKGROUND

There are a limited number of studies investigating the relationship between primary care physician (PCP) characteristics and the quality of care they deliver.

OBJECTIVE

To examine the association between PCP performance and physician age, solo versus group affiliation, training, and participation in California's Affordable Care Act (ACA) exchange.

DESIGN

Observational study of 2013-2014 data from Healthcare Effectiveness Data and Information Set (HEDIS) measures and select physician characteristics.

PARTICIPANTS

PCPs in California HMO and PPO practices (n = 5053) with part of their patient panel covered by a large commercial health insurance company.

MAIN MEASURES

Hemoglobin A1c testing; medical attention nephropathy; appropriate treatment hypertension (ACE/ARB); breast cancer screening; proportion days covered by statins; monitoring ACE/ARBs; monitoring diuretics. A composite performance measure also was constructed.

KEY RESULTS

For the average 35- versus 75-year-old PCP, regression-adjusted mean composite relative performance scores were at the 60th versus 47th percentile (89% vs. 86% composite absolute HEDIS scores; p < .001). For group versus solo PCPs, scores were at the 55th versus 50th percentiles (88% vs. 87% composite absolute HEDIS scores; p < .001). The effect of age on performance was greater for group versus solo PCPs. There was no association between scores and participation in ACA exchanges.

CONCLUSIONS

The associations between population-based care performance measures and PCP age, solo versus group affiliation, training, and participation in ACA exchanges, while statistically significant in some cases, were small. Understanding how to help older PCPs excel equally well in group practice compared with younger PCPs may be a fruitful avenue of future research.

Patient Activation Changes as a Potential Signal for Changes in Health Care Costs: Cohort Study of US High-Cost Patients

BACKGROUND

Programs to improve quality of care and lower costs for the highest utilizers of health services are proliferating, yet such programs have difficulty demonstrating cost savings.

OBJECTIVE

In this study, we explore the degree to which changes in Patient Activation Measure (PAM) levels predict health care costs among high-risk patients.

PARTICIPANTS

De-identified claims, demographic data, and serial PAM scores were analyzed on 2155 patients from multiple medical groups engaged in an existing Center for Medicare and Medicaid Innovation-funded intervention over 3 years designed to activate and improve care coordination for high-risk patients.

DESIGN

In this prospective cohort study, four levels of PAM (from low to high) were used as the main predictor variable. We fit mixed linear models for log₁₀ of allowed charges in follow-up periods in relation to change in PAM, controlling for baseline PAM, baseline costs, age, sex, income, and baseline risk score.

MAIN MEASURES

Total allowed charges were derived from claims data for the cohort. PAM scores were from a separate database managed by the local practices.

KEY RESULTS

A single PAM level increase was associated with 8.3% lower follow-up costs (95% confidence interval 2.5-13.2%).

CONCLUSIONS

These findings contribute to a growing evidence base that the change in PAM score could serve as an early signal indicating the impact of interventions designed for high-cost, high-needs patients.

Do adverse childhood experiences affect surgical weight loss outcomes?

Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p < 0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.