Capacity of Primary Care to Deliver Telehealth in the United States.

BACKGROUND: Because of the Coronavirus disease 2019 (COVID 19) pandemic, many primary care practices have transitioned to telehealth visits to keep patients at home and decrease the transmission of the disease. Yet, little is known about the nationwide capacity for delivering primary care services via telehealth. METHODS: Using the 2016 National Ambulatory Medical Survey we estimated the number and proportion of reported visits and services that could be provided via telehealth. We also performed cross-tabulations to calculate the number and proportion of physicians providing telephone visits and e-mail/internet encounters. RESULTS: Of the total visits (nearly 400 million) to primary care physicians, 42% were amenable to telehealth and 73% of the total services rendered could be delivered through telehealth modalities. Of the primary care physicians, 44% provided telephone consults and 19% provided e-consults. DISCUSSION: This study underscores how and where primary care services could be delivered. It provides the first estimates of the capacity of primary care to provide telehealth services for COVID-19 related illness, and for several other acute and chronic medical conditions. It also highlights the fact that, as of 2016, most outpatient telehealth visits were done via telephone. CONCLUSIONS: This study provides an estimate of the primary care capacity to deliver telehealth and can guide practices and payers as care delivery models change in a post-COVID 19 environment.

New Allopathic Medical Schools Train Fewer Family Physicians Than Older Ones.

The first significant expansion of allopathic medical schools since the 1970s was anticipated to produce more physicians capable of addressing the nation's current and projected primary care shortages. However, our analysis of the early outputs of new allopathic medical schools suggests that these students were nearly 40% less likely to specialize in family medicine than existing schools.

Characteristics of Young Family Physician Hospitalists.

Based on a 2016 survey of family physicians who were then three years out of residency training, we found that almost 9 percent self-identified as hospitalists. These family physician hospitalists were significantly more likely than their non-hospitalist peers to be male, work longer hours, be better paid, and be more satisfied with their work. These attributes may attract more family physicians to hospital medicine, with negative implications for the supply of primary care physicians. (J Am Board Fam Med 2018;31:680-681.).

New "Core Quality Measures": Only a Beginning.

A plethora of quality measures are used in health care for quality improvement, accountability (including reimbursement), and research. The Core Quality Measures Collaborative, with input from the American Association of Family Physicians, recently released several groups of reduced core measure sets, including one for primary care. The proposed measures are less helpful for the increasing proportion patients with multiple morbidities or advancing illness. Going forward, the development of quality measures that assess multidimensional patient experiences and how closely the health care patients receive matches their goals in the face of multiple morbidities and advancing illness should be the focus.

Improving the implementation of diabetes self-management: findings from the Alliance to Reduce Disparities in Diabetes.

To enhance the health and well-being of patients managing type 2 diabetes, the five grantees comprising the Alliance to Reduce Disparities in Diabetes implemented evidence-based approaches to patient self-management education as part of their programs. This article describes strategies implemented by the grantees that may help explain program success, defined as improvement in clinical values and patient-reported outcomes. A process evaluation of grantee programs included interviews and document review at the beginning, midpoint, and end of the Alliance initiative. A total of 97 interviews were conducted over time with 65 program representatives. The Alliance programs served 2,328 people from diverse racial and ethnic backgrounds and provided 36,826 diabetes self-management sessions across the intervention sites. Framework analysis of the interviews identified four key themes that emerged across time and program sites that may help account for program success: empowerment, increasing access and support, addressing local needs and barriers, and care coordination. The overall evaluation findings may help other diabetes self-management programs seeking to translate and implement evidence-based approaches to reduce disparities and enhance patient well-being.

Cross-site evaluation of the Alliance to Reduce Disparities in Diabetes: clinical and patient-reported outcomes.

Alliance programs implemented multilevel, multicomponent programs inspired by the chronic care model and aimed at reducing health and health care disparities for program participants. A unique characteristic of the Alliance programs is that they did not use a fixed implementation strategy common to programs using the chronic care model but instead focused on strategies that met local community needs. Using data provided by the five programs involved in the Alliance, this evaluation shows that of the 1,827 participants for which baseline and follow-up data were available, the program participants experienced significant decreases in hemoglobin A1c and blood pressure compared with a comparison group. A significant time by study group interaction was observed for hemoglobin A1c as well. Over time, more program participants met quality indicators for hemoglobin A1c and blood pressure. Those participants who attended self-management classes and experienced more resources and support for self-management attained more benefit. In addition, program participants experienced more diabetes competence, increased quality of life, and improvements in diabetes self-care behaviors. The cost-effectiveness of programs ranged from $23,161 to $61,011 per quality-adjusted life year. In sum, the Alliance programs reduced disparities and health care disparities for program participants.

Comparison between US Preventive Services Task Force recommendations and Medicare coverage.

PURPOSE: The US Preventive Services Task Force (USPSTF) is authorized by the US government to review and disseminate the scientific evidence for clinical preventive services. The purpose of this study was to evaluate the alignment of Medicare preventive services coverage with the recommendations of the USPSTF before implementation of health reform. METHODS: We recorded all Medicare coverage for preventive services as listed in the Medicare preventive services guide of 2007 (including the 2009 update) for all recommended (A-or B-rated) USPSTF and not recommended (D-rated) guidelines for preventive screening and counseling in adults aged 65 years and older. We analyzed 2 components of preventive care: preventive coordination (risk assessment, patient motivation, and arranging of preventive service) and the preventive service itself. The main outcome measure was the percentage of agreement between USPSTF recommendations and Medicare coverage. RESULTS: The USPSTF recommended 15 preventive interventions for adults aged 65 years and older. Although Medicare partially reimbursed 93% of recommended services, full reimbursement for the preventive coordination, as well as the service, was available for only 7% of these services. This partial coverage is available mostly as part of the Welcome to Medicare Visit. Further, the USPSTF recommended against 16 preventive services; Medicare reimbursed clinicians for 44% of these services. CONCLUSIONS: Medicare coverage for preventive services needs to be reassessed, with special focus on preventive coordination. Continuing previous practices will likely promote both inadequate and excessive delivery of preventive services. The new health care reform law has the potential to improve the provision of preventive services to Medicare beneficiaries.

Development and validation of an instrument to measure resources and support for chronic illness self-management: a model using diabetes.

PURPOSE: Few comprehensive and practical instruments exist to measure the receipt of self-management support for chronic illness. An instrument was developed to measure resources and support for self-management (RSSM) for the survey component of the evaluation of the Robert Wood Johnson Foundation's Diabetes Initiative. It includes items to measure an ecological range of RSSM. This article describes the development and validation of the instrument, focusing on individuals' reported access to RSSM from providers and from nonclinical, social, and community sources. METHODS: Cross-sectional analyses of the second wave of a survey of participants in the Diabetes Initiative (68% response rate, n = 957) were used. RESULTS: Confirmatory factor analyses supported grouping the 17 items into 5 subscales, measuring key aspects of RSSM: individualized assessment, collaborative goal setting, enhancing skills, ongoing follow-up and support, and community resources (comparative fit index = 0.97, Tucker-Lewis fit index = 0.99, and root means square error of approximation = 0.06). The overall scale and 5 subscales were internally consistent (Cronbach alpha >or= .70) and were significantly, positively related to diabetes self-management behaviors, supporting their construct validity. CONCLUSIONS: This instrument shows promise for measuring RSSM. Although it was developed for diabetes programs, its ecological orientation and link to the broad framework of chronic care suggest broader application.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

Changing perceptions of the childhood obesity epidemic.

OBJECTIVES: To examine changes in public attitudes about childhood obesity and support for prevention. METHODS: RTI surveyed US households (N = 1047 and N = 1139) about perceived severity, causes, and support for specific obesity interventions. Logistic regressions examined differences in obesity attitudes and support for prevention. RESULTS: Perceived health threat of childhood obesity increased between the 2 surveys. Support increased for interventions such as regulation of restaurant portions and fast food advertising. Logistic regressions revealed differences among sociodemographic groups. CONCLUSIONS: Public support for childhood obesity prevention is increasing. Policy makers can use these findings to develop appropriate prevention strategies.

Public perceptions of childhood obesity.

BACKGROUND: Obesity has been identified as an epidemic by the Centers for Disease Control and Prevention. Rates of unhealthy body weight among children and adolescents have tripled since the 1980s to 15%. Media coverage of obesity has also increased, and the public is now highly aware of obesity-related health threats facing adults and children. METHODS: RTI International sponsored a representative survey of U.S. households (n =1047) that included detailed questions about perceptions of the severity, causes, and public support for specific intervention strategies to combat childhood obesity. Logistic regressions were calculated to examine differences in support by sociodemographic characteristics. RESULTS: Respondents considered childhood obesity to be as serious as other major childhood health threats, such as tobacco use and violence, but not as serious as drug abuse. They supported most school-, community-, and media-based strategies that involved offering health information, limiting unhealthy food promotion, and increasing healthy nutrition and physical activity choices, but were generally opposed to regulatory and tax- or cost-based interventions. Logistic regressions revealed significantly greater support for some interventions among highly educated individuals and women, and lower support among parents with children at home. CONCLUSIONS: This study demonstrates that there is strong public support for interventions aimed at reducing overweight and obesity among children and adolescents. It also shows specific school, community, and media interventions that the public supports and opposes, and what consequences the public will accept in combating childhood obesity. These findings can help policymakers and public health professionals design and implement appropriate interventions.