A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Hospital-based Health Information Technology Infrastructure: Evidence of Reduced Medicare Payments and Racial Disparities Among Patients With ADRD.

BACKGROUND: Alzheimer disease and related dementia (ADRD) is one of the most expensive health conditions in the United States. Understanding the potential cost-savings or cost-enhancements of Health Information Technology (HIT) can help policymakers understand the capacity of HIT investment to promote population health and health equity for patients with ADRD. OBJECTIVES: This study examined access to hospital-based HIT infrastructure and its association with racial and ethnic disparities in Medicare payments for patients with ADRD. RESEARCH DESIGN: We used the 2017 Medicare Beneficiary Summary File, inpatient claims, and the American Hospital Association Annual Survey. Our study focused on community-dwelling Medicare fee-for-service beneficiaries who were diagnosed with ADRD. Our study focused on hospital-based telehealth-postdischarge (eg, remote patient monitoring) and telehealth-treatment (eg, psychiatric and addiction treatment) services. RESULTS: Results showed that hospital-based telehealth postdischarge services were associated with significantly higher total Medicare payment and acute inpatient Medicare payment per person per year among patients with ADRD on average. The associations between hospital-based telehealth-treatment services and payments were not significant. However, the association varied by patient's race and ethnicity. The reductions of the payments associated with telehealth postdischarge and treatment services were more pronounced among Black patients with ADRD. Telehealth-treatment services were associated with significant payment reductions among Hispanic patients with ADRD. CONCLUSION: Results showed that having hospital-based telehealth services might be cost-enhancing at the population level but cost-saving for Black and Hispanic patients with ADRD. Results suggested that personalized HIT services might be necessary to reduce the cost associated with ADRD treatment for racial and ethnic minority groups.

Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities.

The COVID-19 pandemic has underscored the urgency to focus on the essential value of public health systems (PHSs) in fostering health equity across the US health care delivery system. PHS integration and care coordination can be successfully achieved through health information technology systems. The objective of the study was to examine the association between PHS partnerships (PHSPs), telehealth postdischarge, and racial and ethnic disparities in health care. The analysis used 2017 Centers for Medicare and Medicaid Services Medicare 100% inpatient claims data, the Medicare Beneficiary Summary File, the American Hospital Association Annual Survey, and the American Community Survey. Results showed that compared with those treated in hospitals with neither PHSP nor telehealth postdischarge services, beneficiaries treated in hospitals with PHSP encountered significantly lower Medicare payment and inpatient and readmission rates. Black patients experienced significantly lower cost, inpatient visits, and readmission rates when treated in hospitals with PHSP and telehealth postdischarge services (coefficient = -0.051, P < 0.001; incidence rate ratio [IRR] = 0.982, P = 0.007; IRR = 0.891, P = 0.003). The results of the study demonstrated the importance of combining PHSP and telehealth postdischarge services to improve the efficiency of the health care delivery system and health equity. It is urgent to ensure that PHSs have adequate funding and telehealth infrastructure to support population health.

Rural and urban disparities in potentially preventable hospitalizations among US patients with Alzheimer's Disease and Related Dementias: Evidence of hospital-based telehealth and enabling services.

We examined urban and rural disparities in potentially preventable hospitalizations (PPHs) among US patients with Alzheimer's Disease and Related Dementias (ADRD) and the use of telehealth post-discharge and enabling services as mediators. We merged 2017 100% Medicare Fee-For-Service (FFS) claims with the Medicare Beneficiary Summary File, along with population and hospital-based characteristics. Logistic regression models were employed to examine differences in PPHs by telehealth and enabling services. The rates of PPHs related to acute and chronic conditions for patients with ADRD living in rural and micropolitan areas were significantly higher compared to patients with ADRD in urban areas. Telehealth post-discharge combined with enabling services significantly decreased the odds of PPHs associated with acute (OR: 0.93, 95% CI: 0.89-0.98, P-value <0.01) and chronic conditions (OR: 0.96, 95% CI: 0.92-1.00, P-value = 0.07). In addition, telehealth post-discharge combined with enabling services significantly decreased the odds of PPHs in patients with ADRD in rural (acute PPHs OR: 0.56, 95% CI: 0.41-0.77, P-value <0.01; chronic PPHs OR: 0.73, 95% CI: 0.55-0.97, P-value = 0.03) and micropolitan (acute PPHs OR: 0.65, 95% CI: 0.57-0.73, P-value <0.01; chronic PPHs OR: 0.83, 95% CI: 0.74-0.93, P-value <0.01) areas. Our results suggest that the combinations of telehealth post-discharge and enabling services are important interventions in helping to reduce preventable hospitalizations among patients with ADRD living in rural and micropolitan areas.

An HIT-Supported Care Coordination Framework for Reducing Structural Racism and Discrimination for Patients With ADRD.

Black and Latinx Americans are disproportionately at greater risk for having Alzheimer's disease and related dementias (ADRD) than White Americans. Such differences in risk for ADRD are arguably explained through health disparities, social inequities, and historical policies. Structural racism and discrimination (SRD), defined as "macro-level conditions that limit opportunities, resources, and well-being of less privileged groups," have been linked with common comorbidities of ADRD, including hypertension, obesity, diabetes, depression. Given the historical impact of SRD-including discriminatory housing policies resulting in racial residential segregation that has been shown to limit access to education, employment, and healthcare-Black and Latinx populations with ADRD are directly or indirectly negatively affected by SRD in terms of access, quality and cost for healthcare. Emerging studies have brought to light the value of structural-level hospital and public health collaboration on care coordination for improving healthcare quality and access, and thus could serve as a macro-level mechanism for addressing disparities for minoritized racial and ethnic populations with ADRD. This paper presents a conceptual framework delineating how care coordination can successfully be achieved through health information technology (HIT) systems and ultimately address SRD. To address health inequities, it is therefore critical that policy initiatives invest in HIT capacities and infrastructures to promote care coordination, identify patient needs and preferences, and promote engagement of patients with ADRD and their caregivers.

Predictors of intubation in COVID-19 patients undergoing awake proning in the emergency department.

BACKGROUND: Awake prone positioning (PP) has been used to avoid intubations in hypoxic COVID-19 patients, but there is limited evidence regarding its efficacy. Moreover, clinicians have little information to identify patients at high risk of intubation despite awake PP. We sought to assess the intubation rate among patients treated with awake PP in our Emergency Department (ED) and identify predictors of need for intubation. METHODS: We conducted a multicenter retrospective cohort study of adult patients admitted for known or suspected COVID-19 who were treated with awake PP in the ED. We excluded patients intubated in the ED. Our primary outcome was prevalence of intubation during initial hospitalization. Other outcomes were intubation within 48 h of admission and mortality. We performed classification and regression tree analysis to identify the variables most likely to predict the need for intubation. RESULTS: We included 97 patients; 44% required intubation and 21% were intubated within 48 h of admission. Respiratory oxygenation (ROX) index and P/F (partial pressure of oxygen / fraction of inspired oxygen) ratio measured 24 h after admission were the variables most likely to predict need for intubation (area under the receiver operating characteristic curve = 0.82). CONCLUSIONS: Among COVID-19 patients treated with awake PP in the ED prior to admission, ROX index and P/F ratio, particularly 24 h after admission, may be useful tools in identifying patients at high risk of intubation.

Overcoming the Dual Stigma of Mental Illness and Aging: Preparing New Nurses to Care for the Mental Health Needs of Older Adults.

OBJECTIVE: Registered nurses are uniquely positioned to fill shortages in the geropsychiatric healthcare workforce. With training, nurses can coordinate both mental and physical healthcare and deliver mental health interventions. Our objective was to determine how nursing educators are preparing students to care for the mental health needs of older adults and to explore the challenges they face in this effort. METHODS: This was a qualitative study using semi-structured, in-depth interviews. Participants were undergraduate psychiatric nursing instructors recruited from schools of nursing in the Northeastern United States. Semistructured interviews focused on challenges and strategies related to preparing nursing students to meet the mental health needs of older patients. RESULTS: Fourteen interviews were conducted. An overarching theme of bias against geropsychiatric care was identified as a challenge for educators. Educators reported that nursing students carry biases against patients with mental illness and older patients. Nursing students indicated negative perceptions of the psychiatric and geriatric nursing specialties. Most nursing students plan to work in nonpsychiatric settings and do not consider mental health a priority for their patients. To overcome these challenges, educators suggested increased exposure and integration. To prepare new nurses to care for the mental health needs of older patients, nursing schools should expose nursing students to older adults in a variety of settings and integrate mental health topics and training throughout the undergraduate nursing curriculum. CONCLUSION: Nursing schools should evaluate their curricula to ensure that mental health content is prioritized and sufficiently integrated with physical health topics. An increased focus on geropsychiatric and integrated mental health content should be supported by nursing programs and state boards of nursing.

Risky Behaviors of Youth Living in the Slums of Kampala: A Closer Examination of Youth Participating in Vocational Training Programs.

Obtaining formal education is associated with a decreased risk of HIV transmission among youth in sub-Saharan Africa. However, little is known about the role vocational skills training programs may have on risk behaviors linked to HIV transmission among vulnerable youth in sub-Saharan Africa. This study examined the characteristics and risk behaviors among vulnerable youth who receive vocational skills training by a community-based organization. Empirical analyses were conducted using a cross-sectional survey administered in 2014 to youth (ages 12 to 18 years) in the slums of Kampala (N=1134). Five multivariable logistic regression models were computed to determine the association between participating in a vocational training program and self-reported risk behaviors pertaining to alcohol use, lack of condom use, sex with multiple partners, and transactional sex. In our study, 29.6% of youth attended a vocational training program. Our findings show that youth who participated in vocational training were more likely to report often feeling hopeful (AOR: 1.7; 95% CI: 1.1, 3.0) and less likely to report alcohol use (AOR: 0.4; 95% CI: 0.2, 0.7) than those not attending vocational training programs, in multivariable analyses. Overall, findings varied for males and females. These findings, while preliminary, indicate that self-reported behaviors associated with risk for HIV transmission vary in some respects for youth participating in vocational training versus those who do not. However, additional research is needed, as are evaluations of the benefits and potential impact of vocational training in both the short and long-term for vulnerable youth in resource-poor settings and with limited access to formal education.