You Cannot Function in "Overwhelm": Helping Primary Care Navigate the Slow End of the Pandemic.

GOAL: This study was developed to explicate underlying organizational factors contributing to the deterioration of primary care clinicians' mental health during the COVID-19 pandemic. METHODS: Using data from the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good's national survey of primary care clinicians from March 2020 to March 2022, a multidisciplinary team analyzed more than 11,150 open-ended comments. Phase 1 of the analysis happened in real-time as surveys were returned, using deductive and inductive coding. Phase 2 used grounded theory to identify emergent themes. Qualitative findings were triangulated with the survey's quantitative data. PRINCIPAL FINDINGS: The clinicians shifted from feelings of anxiety and uncertainty at the start of the pandemic to isolation, lack of fulfillment, moral injury, and plans to leave the profession. The frequency with which they spoke of depression, burnout, and moral injury was striking. The contributors to this distress included crushing workloads, worsening staff shortages, and insufficient reimbursement. Consequences, both felt and anticipated, included fatigue and demoralization from the inability to manage escalating workloads. Survey findings identified responses that could alleviate the mental health crisis, namely: (1) measuring and customizing workloads based on work capacity; (2) quantifying resources needed to return to sufficient staffing levels; (3) promoting state and federal support for sustainable practice infrastructures with less administrative burden; and (4) creating patient visits of different lengths to rebuild relationships and trust and facilitate more accurate diagnoses. PRACTICAL APPLICATIONS: Attention to clinicians' mental health should be rapidly directed to on-demand, confidential mental health support so they can receive the care they need and not worry about any stigma or loss of license for accepting that help. Interventions that address work-life balance, workload, and resources can improve care, support retention of the critically important primary care workforce, and attract more trainees to primary care careers.

Is primary care ready for a potential new public health emergency in the wake of the COVID-19 pandemic, now subsided?

INTRODUCTION: The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity. METHODS: From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions. RESULTS: An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had. CONCLUSION: These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs.

Telemedicine in Primary Care: Lessons Learned About Implementing Health Care Innovations During the COVID-19 Pandemic.

PURPOSE: During the COVID-19 pandemic, telemedicine emerged as an important tool in primary care. Technology and policy-related challenges, however, revealed barriers to adoption and implementation. This report describes the findings from weekly and monthly surveys of primary care clinicians regarding telemedicine during the first 2 years of the pandemic. METHODS: From March 2020 to March 2022, we conducted electronic surveys using convenience samples obtained through social networking and crowdsourcing. Unique tokens were used to confidentially track respondents over time. A multidisciplinary team conducted quantitative and qualitative analyses to identify key concepts and trends. RESULTS: A total of 36 surveys resulted in an average of 937 respondents per survey, representing clinicians from all 50 states and multiple specialties. Initial responses indicated general difficulties in implementing telemedicine due to poor infrastructure and reimbursement mechanisms. Over time, attitudes toward telemedicine improved and respondents considered video and telephone-based care important tools for their practice, though not a replacement for in-person care. CONCLUSIONS: The implementation of telemedicine during COVID-19 identified barriers and opportunities for technology adoption and highlighted steps that could support primary care clinics' ability to learn, adapt, and implement technology.

Measuring Primary Care Across 35 OECD Countries.

PURPOSE: To examine the psychometric properties and scores of the Person-Centered Primary Care Measure (PCPCM) in 28 languages and 35 Organisation for Economic Co-operation and Development (OECD) countries. METHODS: Using a paid online sampling service, we requested age- and sex-representative samples of 360 adults in each country. We administered the Person-Centered Primary Care Measure-a previously validated 11-item, patient-reported measure that was developed using what patients and clinicians said is most important about primary care. We also assessed construct validity through associations with demographics, the Patient-Enablement Instrument, number of years the person had been with their primary care physician and practice, whether the patient thought the doctor knowing the results would improve their care, and whether it was hard to complete the survey. We assessed the psychometric properties of the PCPCM in each country and report the summative and item-specific PCPCM scores for each country. RESULTS: The PCPCM exhibited solid psychometric properties across all languages and countries, with Cronbach's alphas ranging from 0.88 to 0.95, and corrected item-total correlations ranging from 0.47 to 0.81, with the vast majority of countries ranging from the low 0.50s to the high 0.70s. Multiple analyses showed strong evidence of concurrent validity. With a potential range from a low of 1 to a high of 4, the overall mean score was 2.74, with a standard deviation of 0.19. Mean PCPCM scores ranged from the lowest in Sweden (2.28) to the highest in Turkey (3.08), with Germany ranking second (3.01), and the United States third (2.99). CONCLUSION: The internal consistency and concurrent validity of the PCPCM across multiple countries provides strong evidence of the coherence of the breadth of primary care functions that patients and clinicians say are important. The diversity of total and item-specific scores across countries provokes interesting hypotheses about the influence of each different country's policies, practices, demographics, and culture on primary care, and provides a strong impetus for further ecological and individual data analyses using the Person-Centered Primary Care Measure. Annals "Online First" article.

Low-Intensity Intervention Supports Diabetes Registry Implementation: A Cluster-Randomized Trial in the Ambulatory Care Outcomes Research Network (ACORN).

BACKGROUND: Previous research demonstrated that registries are effective for improving clinical guideline adherence for the care of patients with type 2 diabetes. However, registry implementation has typically relied on intensive support (such as practice facilitators) for practice change and care improvement. OBJECTIVE: To determine whether a remotely delivered, low-intensity organizational change intervention supports implementation and use of diabetes registries in primary care. DESIGN: Cluster-randomized controlled effectiveness trial of providing limited external support leveraging internal practice resources and problem-solving capacities for driving diabetes registry implementation in 32 practices in Virginia. INTERVENTION: All practices identified local implementation champions who participated in an in-person education session on the value and use of diabetes registries, while intervention practices were also paired with peer mentors and had access to a physician informaticist, who worked remotely to assist practices with implementation. MAIN MEASURES: Practice champions reported progress on registry implementation milestone achievement, and reported practice-level organizational capacity by using a modified version of the Assessment of Chronic Illness Care (ACIC). KEY RESULTS: Intervention practices were significantly more likely to have implemented a registry (44% vs 6%, P = .04) and to have achieved more implementation milestones (5.5 vs 2.6, P < .0001) than control practices. Baseline ACIC scores indicated room for organizational improvement with regard to chronic illness care (overall median, 6.4; range, 3.8 to 10.8) and clinical information systems use (median, 6.0; range, 0 to 11) with no significant differences between intervention and control practices. CONCLUSIONS: Remotely provided guidance paired with limited in-person assistance can support rapid implementation of diabetes registries in typical primary care practices.

Coyote (Canis latrans) in South America: potential routes of colonization.

During the last century, the coyote (Canis latrans) has increased its distribution in Central America. Before the 1980s, it had not been recorded in Panama. New records show that coyotes have crossed the Panama Canal, indicating that continues to expand; therefore, there is a possibility that it will reach northern South America. Our objectives were to identify potential coyote colonization routes to South America, and the variables that favor its expansion. We hypothesized that habitat fragmentation benefits coyote expansion. We applied 7 algorithms to model the potential distribution of the coyote, using 196 presence records and 12 variables. The models with better performance were used to generate a consensus model. Using our consensus model and the areas with highest probability of presence, a potential colonization route was generated between Central America and northern South America. This route lies through southern Costa Rica, along the Pacific coast of Panama to the south, to the Andean mountains in northern Colombia. The variables that explained potential coyote distribution were human population density, altitude, and percentage of crops with positive influence, and tropical broadleaf forests with negative influence. These results indicate that human activities and deforestation are related to coyote distribution expansion. Actions can be implemented within the identified route to improve environmental management, in order to avoid the presence of the coyote in the ecosystems of northern South America.

What Is the Impact on Rural Area Residents When the Local Physician Leaves?

BACKGROUND AND OBJECTIVES: Scarce evidence exists in the medical literature describing the attitudes of rural community residents about the impact of losing their local physician. This pilot study explores aspects of access to care, both within and outside of primary care settings, that result from loss of a rural family physician. METHODS: We selected study participants through convenience and snowball sampling, and we conducted in-person interviews of up to 60 minutes. We audio recorded and transcribed the interviews (May to August, 2018), then analyzed transcripts using immersion crystallization and managed within Atlas.ti 7.0 software (Berlin, Germany). RESULTS: We interviewed 18 participants, some of whom interviewed as pairs. Our analysis revealed three significant themes: rurally-specific access to care concerns, relationships valued for being both community and care based, and loss felt specific to the integrated community leadership roles occupied by family physicians. In addition, participants identified social challenges they associated with losing their "country doctor," such as withering community cohesion. CONCLUSIONS: Our findings suggest that rural physicians offer tremendous value to their communities, both inside and beyond their clinic walls. Issues of social cohesion and local health leadership affected by physician loss should be addressed by policy makers and educators charged with designing patient-centered solutions to improve health outcomes in rural communities. Current health and medical education reforms would benefit from greater focused attention on these issues.

A New Comprehensive Measure of High-Value Aspects of Primary Care.

PURPOSE: To develop and evaluate a concise measure of primary care that is grounded in the experience of patients, clinicians, and health care payers. METHODS: We asked crowd-sourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts in a 2½ day international conference to provide additional insights. A multidisciplinary team conducted a qualitative analysis of the combined data to develop a parsimonious set of patient-reported items. We evaluated items using factor analysis, Rasch modeling, and association analyses among 2 online samples and 4 clinical samples from diverse patient populations. RESULTS: The resulting person-centered primary care measure parsimoniously represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, advocacy, community context, comprehensiveness, continuity, coordination, family context, goal-oriented care, health promotion, integration, and relationship. Principal axes factor analysis identified a single factor. Factor loadings and corrected item-total correlations were >0.6 in online samples (n = 2,229) and >0.5 in clinical samples (n = 323). Factor scores were fairly normally distributed in online patient samples, and skewed toward higher ratings in point-of-care patient samples. Rasch models showed a broad spread of person and item scores, acceptable item-fit statistics, and little item redundancy. Preliminary concurrent validity analyses supported hypothesized associations. CONCLUSIONS: The person-centered primary care measure reliably, comprehensively, and parsimoniously assesses the aspects of care thought to represent high-value primary care by patients, clinicians, and payers. The measure is ready for further validation and outcome analyses, and for use in focusing attention on what matters about primary care, while reducing measurement burden.

Genetic diversity and structure of Crotalus triseriatus, a rattlesnake of central Mexico.

The isolated and fragmented populations are highly susceptible to stochastic events, increasing the extinction risk because of the decline in putative adaptive potential and individual fitness. The population has high heterozygosity values and a moderate allelic diversity, the heterozygosity values are higher than in most other Crotalus species and snake studies. Possibly these high levels of genetic diversity can be related to a large founder size, high effective population size, multiple paternity and overlapping generations. We did not find the genetic structuring but the effective number of alleles (Ne) was 138.1. We found evidence of bottlenecks and the majority of rattlesnakeswere unrelated, despite the small sample size, endemic status, the isolated and fragmented habitat. The genetic information provided in this study can be useful as a first approach to try to make informed conservation efforts for this species and also, important to preserve the habitat of this species; the endangered Abies-Pinus forest of the Nevado the Toluca Volcano.

Less AND More Are Needed to Assess Primary Care.

Significant federal investment is now being directed toward lessening the burden of clinical quality measurement; at the same time, there is growing recognition that current measures are inadequate to capture the domains of primary care that result in improved person and population health at sustainable cost. Our study reveals a significant gap between the universe of what is measured and those elements most critical to good quality primary care, indicating that the important efforts to reduce measurement burden must be accompanied by efforts to increase the relevance of measures to domains of care that affect patient-centered and community health outcomes.

Genetic variability and structure of an isolated population of Ambystoma altamirani, a mole salamander that lives in the mountains of one of the largest urban areas in the world.

Amphibians are globally threatened by habitat loss and fragmentation; species within the order Ambystoma are not the exception, as there are 18 species of mole salamanders in México, of which 16 are endemic and all species are under some national or international status of protection. The mole salamander, Ambystoma altamirani is a microendemic species, which is distributed in central México, within the trans-Mexican volcanic belt, and is one of the most threatened species due to habitat destruction and the introduction of exotic species. Nine microsatellite markers were used to determine the genetic structure, genetic variability, effective population size, presence of bottlenecks and inbreeding coefficient of one population of A. altamirani to generate information which might help to protect and conserve this threatened species. We found two genetic subpopulations with significant level of genetic structure (FST = 0.005) and high levels of genetic variability (Ho = 0.883; He = 0.621); we also found a small population size (Ne = 8.8), the presence of historical (M = 0.486) and recent bottlenecks under IAM and TPM models, with a low, but significant coefficient of inbreeding (FIS = -0.451). This information will help us to raise conservation strategies of this microendemic mole salamander species.

Genetic structure and diversity in an isolated population of an endemic mole salamander (Ambystoma rivulare Taylor, 1940) of central Mexico.

Human activities are affecting the distribution of species worldwide by causing fragmentation and isolation of populations. Isolation and fragmentation lead to populations with lower genetic variability and an increased chance of inbreeding and genetic drift, which results in a loss of biological fitness over time. Studies of the genetic structure of small and isolated populations are critically important for management and conservation decisions. Ambystoma rivulare is a micro-endemic Mexican mole salamander from central Mexico. It is found in the most ecologically disturbed region in Mexico, the Trans-Mexican Volcanic Belt. The goal of this study of the population genetics of the micro-endemic mole salamander was to provide information to be used as a basis for future research and conservation planning of this species and other species of the Ambystoma genus in Mexico. The structural analysis found two subpopulations, one for each river sampled, with no signs of admixture and very high levels of genetic differentiation. Medium to high levels of heterozygosity and few alleles and genotypes were observed. Evidence of an ancestral genetic bottleneck, low values of effective population size, small inbreeding coefficients, and low gene flow were also found.

Genetic diversity and genetic structure of an endemic Mexican Dusky Rattlesnake (Crotalus triseriatus) in a highly modified agricultural landscape: implications for conservation.

It is necessary to determine genetic diversity of fragmented populations in highly modified landscapes to understand how populations respond to land-use change. This information will help guide future conservation and management strategies. We conducted a population genetic study on an endemic Mexican Dusky Rattlesnake (Crotalus triseriatus) in a highly modified landscape near the Toluca metropolitan area, in order to provide crucial information for the conservation of this species. There was medium levels of genetic diversity, with a few alleles and genotypes. We identified three genetically differentiated clusters, likely as a result of different habitat cover type. We also found evidence of an ancestral genetic bottleneck and medium values of effective population size. Inbreeding coefficients were low and there was a moderate gene flow. Our results can be used as a basis for future research and C. triseriatus conservation efforts, particularly considering that the Trans-Mexican Volcanic Belt is heavily impacted by destructive land-use practices.

Practice-based innovations: More relevant and transportable than NIH-funded studies.

In 2003, the National Institutes of Health (NIH) created a translational science funding stream to foster widespread, practice-based dissemination of scientific evidence. A decade later, our study of a national cohort of innovative practices suggests that effective dissemination continues to be prevented by the limited biomedical focus of funded research, conventional research strategies, and failure to report contextual factors.

Microhabitat types promote the genetic structure of a micro-endemic and critically endangered mole salamander (Ambystoma leorae) of Central Mexico.

The reduced immigration and emigration rates resulting from the lack of landscape connectivity of patches and the hospitality of the intervening matrix could favor the loss of alleles through genetic drift and an increased chance of inbreeding. In order for isolated populations to maintain sufficient levels of genetic diversity and adapt to environmental changes, one important conservation goal must be to preserve or reestablish connectivity among patches in a fragmented landscape. We studied the last known population of Ambystoma leorae, an endemic and critically threatened species. The aims of this study were: (1) to assess the demographic parameters of A. leorae and to distinguish and characterize the microhabitats in the river, (2) to determine the number of existing genetic groups or demes of A. leorae and to describe possible relationships between microhabitats types and demes, (3) to determine gene flow between demes, and (4) to search for geographic locations of genetic discontinuities that limit gene flow between demes. We found three types of microhabitats and three genetically differentiated subpopulations with a significant level of genetic structure. In addition, we found slight genetic barriers. Our results suggest that mole salamander's species are very sensitive to microhabitat features and relatively narrow obstacles in their path. The estimates of bidirectional gene flow are consistent with the pattern of a stepping stone model between demes, where migration occurs between adjacent demes, but there is low gene flow between distant demes. We can also conclude that there is a positive correlation between microhabitats and genetic structure in this population.

National Committee for Quality Assurance (NCQA) patient-centered medical home (PCMH) recognition is suboptimal even among innovative primary care practices.

The National Committee for Quality Assurance (NCQA) has promoted patient-centered medical home (PCMH) recognition among primary care practices since 2008 as a standard indicator of which practices have transformed into medical homes. A 40% PCMH adoption rate among a large national cohort of identified practices with innovative staffing (n = 131) calls into question whether the NCQA recognition process is truly transformative and patient-centered or simply another certificate to hang on the wall.

[Mammals' camera-trapping in Sierra Nanchititla, Mexico: relative abundance and activity patterns]. / Fototrampeo de mamíferos en la Sierra Nanchititla, México: abundancia relativa y patrón de actividad.

Species conservation and their management depend on the availability of their population behavior and changes in time. This way, population studies include aspects such as species abundance and activity pattern, among others, with the advantage that nowadays new technologies can be applied, in addition to common methods. In this study, we used camera-traps to obtain the index of relative abundance and to establish activity pattern of medium and large mammals in Sierra Nanchititla, Mexico. The study was conducted from December 2003 to May 2006, with a total sampling effort of 4 305 trap-days. We obtained 897 photographs of 19 different species. Nasua narica, Sylvilagus floridanus and Urocyon cinereoargenteus were the most abundant, in agreement with the relative abundance index (RAI, number of independent records/100 trap-days), and according to previous studies with indirect methods in the area. The activity patterns of the species showed that 67% of them are nocturnal, except Odocoileus virginianus, Nasua narica and others. Some species showed differences with previously reported patterns, which are related with seasonality, resources availability, organism sex, principally. The applied method contributed with reliable data about relative abundance and activity patterns.

Fototrampeo de mamíferos en la Sierra Nanchititla, México: abundancia relativa y patrón de actividad

Mammals’ camera-trapping in Sierra Nanchititla, Mexico: relative abundance and activity patterns. Species conservation and their management depend on the availability of their population behavior and changes in time. This way, population studies include aspects such as species abundance and activity pattern, among others, with the advantage that nowadays new technologies can be applied, in addition to common methods. In this study, we used camera-traps to obtain the index of relative abundance and to establish activity pattern of medium and large mammals in Sierra Nanchititla, Mexico. The study was conducted from December 2003 to May 2006, with a total sampling effort of 4 305 trap-days. We obtained 897 photographs of 19 different species. Nasua narica, Sylvilagus floridanus and Urocyon cinereoargenteus were the most abundant, in agreement with the relative abundance index (RAI, number of independent records/100 trap-days), and according to previous studies with indirect methods in the area. The activity patterns of the species showed that 67% of them are nocturnal, except Odocoileus virginianus, Nasua narica and others. Some species showed differences with previously reported patterns, which are related with seasonality, resources availability, organism sex, principally. The applied method contributed with reliable data about relative abundance and activity patterns. Rev. Biol. Trop. 59 (1): 373-383. Epub 2011 March 01.

La conservación de las especies y su manejo adecuado dependen de la disponibilidad de información sobre sus poblaciones, por ello es importante estudiar aspectos como la abundancia y el patrón de actividad. En esta investigación se utilizaron trampas-cámara para obtener índices de abundancia relativa y establecer el patrón de actividad de los mamíferos medianos y grandes de la Sierra Nanchititla, México. El trabajo se llevó a cabo durante el periodo de diciembre de 2003 a mayo de 2006, con un esfuerzo total de 4 305 días-trampa. Se obtuvieron 897 fotografías de 19 especies, las más abundantes fueron: Nasua narica, Sylvilagus floridanus y Urocyon cinereoargenteus, de acuerdo con el índice de abundancia relativa (IAR, número de registros independientes/100 días trampa), coincidiendo con estudios basados en métodos indirectos. El patrón de actividad de las especies registradas mostraron que el 67% son de hábitos nocturnos. Algunas especies mostraron diferencias con los patrones mencionados por otros autores, las cuales se relacionan principalmente con la estacionalidad, la disponibilidad de recursos y el sexo de los individuos.