Clinical Outcomes of a Newly Instituted Hospital at Home Program During the COVID19 Pandemic.

Context: The COVID19 pandemic stressed U.S. health systems beyond their capacity and created worsening clinical outcomes. Hospital a Home (HaH) programs were utilized infrequently prior to pandemic. The Acute Care at Home Waiver was introduced in 2020 to facilitate the creation of HaH programs with a goal of promoting treatment in the home setting. A potential alternative approach to creating rapid inpatient level health system capacity is providing hospital-level care at home to substitute for inpatient hospitalization. The overall impact on clinical outcomes of a HaH program in patients with COVID19 is not well understood. Objective: To compare clinical outcomes of a HaH program versus usual hospital care for patients admitted for COVID19. Study Design: Matched case-control retrospective chart review. Setting or Dataset: Academic medical center. Population studied: Patients admitted with COVID19 and subsequently enrolled into the HaH program from February 1, 2021 to January 31, 2022. Patients aged <18 were excluded from consideration for enrollment. A case-control sample was matched on age, gender, and severity of illness. A total of 200 patients (100 HaH and 100 control) were included for analysis. Outcome Measures: Primary outcome: 30-day readmissions, Secondary outcomes: Inpatient length of stay (iLOS) defined as length of stay in the physical hospital, total length of stay (tLOS) (sum of iLOS and HaH program days), time to readmission, and 30-day emergency department visits. Results: Analysis included 200 patents. The mean age was 50.4. The sample was 55% female. 48.5% were black, 43.5% were white, and 8% were other races. Compared with usual care patients, HaH patients had no difference in 30-day readmissions (11% vs. 14%, p=0.648), mean days to readmission (9.0 vs. 11.8, p=0.201), or return ED visits (17% vs. 20%, p=0.701). Inpatient LOS (5.7 vs. 9.4 days, p=0.005) was shorter in the HaH group. Total LOS (13.0 vs. 9.4 days, p<0. 001) was longer in the HaH group. Conclusions: The HaH program was associated with no difference in readmissions, time to readmission, or return ED visits compared to usual hospital care. HaH programs were associated with shorter inpatient length of stays, but longer total length of stays. In surge times, HaH programs could potentially reduce iLOS and increase bed capacity. Future studies should look to evaluate the economic impact of HaH programs and investigate the drivers of the increased tLOS.

Clinically Useful Family Medicine Research.

What is next for family medicine? After the long, rough road since the beginning of the COVID-19 pandemic, other topics are again receiving renewed attention. Family medicine researchers continue to consider issues important to our patients and practices. There is a collection of clinical research on children's health care. One article outlines practical actions to move medical academia past racism. The need for physician trust in patients is also often overlooked. Other articles address how to improve the practice of family medicine and a framework for thinking about legal and ethical issues in sports medicine. Three in-depth clinical reviews cover lumps and bumps of wrists and hands, spondylosis/spondylolistheses, and vitamin D association with specific disease entities.

Family Physicians Can/Should Do: What? Where? And How?

This issue's teasers: A broad scope of care by family physicians could be incentivized and has positive outcomes. Family physicians could do more dermoscopy-a mixed specialty group of experts provide information on diagnosis with associated features and proficiency standards for primary care clinicians. Clinicians could trust more, and do less, such as adult measles-mumps-rubella boosters. Family physicians differ from pediatricians on how to deliver vitamin D to newborns. Practice scope varies by location. Is monetary incentive a key to incentivize COVID vaccination? A new, useful, easy functional status questionnaire. This issue also includes articles on both adult and pediatric obesity, a systematic review of social determinants of health and documentation thereof, plus more.

Trust Takes Two .

Research throughout the COVID-19 pandemic, including investigations of resulting pandemic response strategies, evolving public health recommendations, and vaccine development, has highlighted the role of trust between physicians and patients. The focus, however, has largely been on patient trust in physicians. Although the importance of patient trust in physicians has long been recognized, physician trust in patients remains underappreciated. Physician trust in patients is an important factor in the physician-patient relationship. When physicians trust patients, patients can communicate freely, their experiences are validated, and trust may be engendered through reciprocal trust. Thus, a bidirectional approach to trust is necessary that acknowledges the role of physician trust in patients. We posit that shared trust is the dyadic factor that influences positive patient outcomes and is the foundation of shared decision making. Recognizing shared trust as an important outcome of the physician-patient relationship is a necessary step in evaluating how our practice, research, and education can influence or sow distrust of patients. In this commentary, we discuss the importance of attending to shared trust and physician trust in patients, particularly in family medicine.

A Comparison of Family Medicine Resident Documentation Following Implementation of an Asynchronous vs Synchronous Telemedicine Curriculum.

Introduction: Prior to the start of the 2020 COVID pandemic, the use of telemedicine among family physicians was limited; telemedicine curriculum in undergraduate and graduate medical education (GME) was even more scarce. In response to the need for training, we developed synchronous and asynchronous versions of a telemedicine curriculum focused on documentation, communication, and virtual physical exam. As the evaluation of the curriculum, this study compares the documentation behaviors of the clinicians participating in the curriculum. Methods: We compared the documentation practice of asynchronous learners to those participating in synchronous learning over 1 month. We reviewed each clinical note for five practice behaviors: (1) consent for delivery of care via telemedicine, (2) time on the phone, (3) physical examination, (4) procedure code, and (5) billing code. Results: We reviewed notes from 11 interns (synchronous) and 22 senior residents (asynchronous). Notes written by an intern were significantly more likely to include documentation of consent and a focused exam. Notes written by senior resident were significantly more likely to include documentation of length of the encounter. We detected no significant differences for documenting the billing or procedure code. Conclusion: Our analysis determined that correct documentation behaviors can be taught through asynchronous mediums. Components requiring effective communication (consent for care and a virtual physical exam) are more effectively taught when there is deliberate practice and immediate feedback on the skills.

Mental Health of Patients and Clinicians Before and During the COVID-19 Pandemic.

The mental health of patients and clinicians before and during the pandemic are investigated and reported by multiple investigators. Improving health through practice change is challenging but possible. Telehealth increased dramatically since the beginning of the pandemic; what is its future?

Family Medicine Researchers Explore the Social Determinants of Health, COVID-19 Issues, and Cancer Survivor Care.

As usual, this issue of the JABFM contains research as broad as the specialty of family medicine itself. The social determinants of health are again a prominent topic. COVID-19 topics in this issue include over-the-counter supplements as adjunct treatments and the influence of public health safety measures on influenza rates during the pandemic. Two separate reports look at the way cancer survivors interact with primary care and the difficulties encountered. A CERA study describes how departments of family medicine are tackling the challenge of training tomorrow's family physicians in point-of care-ultrasound. Physician workforce studies examine pay inequities and burnout. An impressive number other commonly encountered issues in family medicine are addressed using a wide variety of methods and data sources.

The "Telehealth Divide"-Who Are the Underserved, and What Care Is Improved?

After years of slow progress, the COVID-19 pandemic forced a rapid adoption of telehealth and telemedicine. The transition was not uniform across demographic groups, reflecting social determinants of health. This special issue of JABFM highlights many lessons learned and reviews insights gained by patients, clinicians, and health care administrators about telehealth and telemedicine during the pandemic. The focus on research on the COVID-19 pandemic is turning increasingly toward the long-term impact of the pandemic. Reports on Medicare wellness visits, drug safety, medical abortion, and the differences in scope and location of practice by race and ethnicity of family physicians can also be found in this issue.

This Issue's Emphasis: Inequity and COVID-19, Intertwined.

This issue continues our tradition of advancing family medicine by publishing articles on issues that affect patients and the practice of family medicine, specifically with an emphasis on inequity and the COVID pandemic, which are often intertwined. We have articles on topical issues such as appropriate transgender care, newer diabetes medications, transportation as a social risk, and a thought-provoking commentary on ableism. A clinical review on olfactory loss takes on new meaning. Oregon Medicaid coverage policy supported family physicians assisting their patients by decreasing their opioid use, and a article suggests that buprenorphine should be decriminalized. Strengthening the desire to enter family medicine before starting medical school can help meet future patient needs.

The dynamics of trust and communication in COVID-19 vaccine decision making: A qualitative inquiry.

In response to the COVID-19 pandemic, scientists coordinated a complex immunization effort that developed and distributed vaccines by December 2020. This study aimed to explain COVID-19 vaccination decision-making process to inform vaccine communication with patients and the public. Building on quantitative research on COVID-19 vaccine hesitancy, we conducted a grounded theory study, collecting 30 qualitative interviews with employees at a U.S. university that provided vaccine eligibility in December 2020. Analysis followed the Sort and Sift, Think and Shift method. Participants who had chosen to receive the vaccine and those who had not both described five factors that impacted their decision-making: emotional response, understanding, personal values, culture, and social norms. Across these factors, we identified three cross-cutting themes: time, trust, and communication tactics. In a time of emerging science and changing answers, the constant introduction of new information created information overload for participants. COVID-19 vaccine development was a "grand experiment globally," which required trust, not only knowledge, to overcome hesitancy. The complex information environment surrounding COVID-19 vaccination requires multi-level intervention that cannot rely on knowledge translation alone. We need to help patients build trusting relationships with experts that can create scaffolding for future information processing.

Research on the Issues Family Physicians Face Today: Controlled Substances, COVID-19, Hypertension, and "Slow Medicine," Among Many More Topics.

This issue of the JABFM features research on a broad array of clinical topics. The topics of 5 articles involve controlled substances, including a sobering article on the risks of amphetamines in older adults. An excellent quick reference guide for managing common COVID-19 symptoms is presented. Two other articles consider hypertension treatment in primary care, demonstrating that treating blood pressure is anything but straightforward. Several additional clinical topics include mononucleosis, influenza, and the impact of home life on childhood weight and eating habits. A study from Virginia underscores that primary care, as a system, is distressed. A review of the existing literature on "slow medicine" comes to important conclusions. Some health systems are partnering with local resources to practically address such social determinants as food insecurity. Not surprisingly, family physicians are filling gaps in emergency care around the country.

Practical Clinical Topics, Digging Deeper into COVID-19, Social Determinants of Health, and Equity.

As a discipline, we continue to learn lessons from Coronavirus disease 2019 (COVID-19)-lessons for practice, systems, and patient care. This issue also includes articles focused on 2 other topics that attract increasing attention by family physicians. First, articles describe how the social determinants of health impact health and how family physicians can overcome those obstacles with their patients. Patients want assistance from health systems for 1 specific need related to social determinants of their health. Second, we see increasing evidence about opioid prescriptions in primary care. Multiple clinical articles are pertinent to family medicine, such as different implications of an elevated sedimentation rate compared with C-reactive protein, practice facilitation, adolescent vaccination, family physician accuracy with potentially malignant skin lesions, and more.

Who's Guarding the Gate? The Reach of Prereviewed Emerging Science and Implications for Family Medicine Education.

BACKGROUND AND OBJECTIVES: Online publication of prereviewed manuscripts disseminates research simultaneously to scientists, clinicians, and patients, enabling the media and public to act as scientific reviewers for studies that are not yet endorsed by the scientific and clinical community. This study describes the reach of prereview literature and frames it within the pursuit to teach evidence-based medicine. METHODS: In this deductive content analysis, the primary unit of analysis was the individual preprint manuscript submitted to the medRxiv preprint server during the emergence of the COVID-19 pandemic. The coding scheme included study design, negative or positive findings, dissemination status (whether it was withdrawn from the server or eventually published), and three levels of reach: user engagement, news media coverage, and social media engagement. RESULTS: Prereviewed manuscripts describe a variety of study methods. Dissemination status was significantly related to abstract views, manuscript views, news coverage, and social media exposure. Studies with negative findings had higher counts of abstract views, manuscript views, and news coverage, but no significant relationships were detected. CONCLUSIONS: Results demonstrate that not only are scientists publishing negative findings, but that those studies reach a wide audience. Notably, eventually-withdrawn manuscripts, potentially containing incomplete or uncertain science, is reaching the public domain. Increasingly, family physicians will need to critically appraise emerging literature before it is peer reviewed, whether they encounter it in their own searches or when a patient presents information they found before an appointment.

Correlates of COVID-19 Vaccine Hesitancy among a Community Sample of African Americans Living in the Southern United States.

In the United States, African Americans (AAs) have been disproportionately affected by COVID-19 mortality. However, AAs are more likely to be hesitant in receiving COVID-19 vaccinations when compared to non-Hispanic Whites. We examined factors associated with vaccine hesitancy among a predominant AA community sample. We performed a cross-sectional analysis on data collected from a convenience sample of 257 community-dwelling participants in the Central Savannah River Area from 5 December 2020, through 17 April 2021. Vaccine hesitancy was categorized as resistant, hesitant, and acceptant. We estimated relative odds of vaccine resistance and vaccine hesitancy using polytomous logistic regression models. Nearly one-third of the participants were either hesitant (n = 40, 15.6%) or resistant (n = 42, 16.3%) to receiving a COVID-19 vaccination. Vaccine-resistant participants were more likely to be younger and were more likely to have experienced housing insecurity due to COVID-19 when compared to both acceptant and hesitant participants, respectively. Age accounted for nearly 25% of the variation in vaccine resistance, with 21-fold increased odds (OR: 21.93, 95% CI: 8.97-5.26-91.43) of vaccine resistance in participants aged 18 to 29 compared to 50 and older adults. Housing insecurity accounted for 8% of the variation in vaccine resistance and was associated with 7-fold increased odds of vaccine resistance (AOR: 7.35, 95% CI: 1.99-27.10). In this sample, AAs under the age of 30 and those experiencing housing insecurity because of the COVID-19 pandemic were more likely to be resistant to receiving a free COVID-19 vaccination.

COVID-19 Pandemic Practices, Payment Models, and Publication Successes: Family Medicine Studies a Variety of Primary Care Questions.

This issue provides inspiring reports of family medicine during the Coronavirus disease 2019 (COVID-19) pandemic and the provision of just-in-time COVID-19 information for clinicians. Conversely, burnout - yes or no? The issue includes information that suggests the negative effects of social determinants are related to America's system of paying for medical care. The announcement of the availability of an on-line archive of the official first journal of family medicine gives us the chance to acclaim Dr. Geyman, who started the Journal of Family Practice and was the first editor of this journal. And, as usual, there is more!

A Stepwise Transition to Telemedicine in Response to COVID-19.

INTRODUCTION: With the emergence of COVID-19, many primary care offices closed their physical space to limit exposure. Despite decades of telemedicine in clinical practice, it is rare to find it used in small-metro and academic settings. Following the decision to limit face-to-face care, we tracked our practice's transition to telemedicine. METHODS: This was a prospective quality improvement project following Plan-Do-Study-Act (PDSA) cycles to optimize the use of telemedicine (both telephone and video in this practice) encounters. Central to the PDSA cycles was the use of a post-encounter questionnaire to track patient, appointment, and physician factors. Throughout the cycles, inferential statistics were used to inform process improvement. RESULTS: In Cycle 2, a logistic regression model showed length of encounter, need for physical examination, and physician satisfaction correctly predicted a physician's preferred medium (χ2(3) = 40.56, P < .001). In Cycle 3, a χ2 test showed the reason for visit predicted the preferred medium (χ2(4) = 47.30, P < .001). In cycle 4, week of telemedicine, need for physical examination, length of encounter and physician satisfaction predicted the preferred medium (χ2(9) = 172.52, P < .001). DISCUSSION: Using the variables that predicted preference for telemedicine, we were able to adjust our processes through PDSA cycles. CONCLUSION: Early use of the PDSA cycle allows for informed quality improvement at the local level. Our findings highlight factors to consider when implementing telemedicine such as need for physical examination and type or length of encounter. In addition, physician satisfaction can encourage use of telemedicine, and tools for learning and practicing telemedicine should be available.