Identifying Patterns of Primary Care In-Person and Telemedicine Use in the Veterans Health Administration: A Latent Class Analysis.

BACKGROUND: The Veterans Health Administration increased synchronous telemedicine (video and telephone visits) in primary care in response to the COVID-19 pandemic. OBJECTIVE: Our objective was to determine veteran use patterns of in-person and telemedicine primary care when all modalities were available. DESIGN: A retrospective cohort analysis. We performed a latent class analysis of primary care visits over a 1-year period to identify veteran subgroup (i.e., class) membership based on amount of primary care use and modality used. Then, we used multinomial logistic regression with a categorical outcome to identify patient characteristics associated with class identification. PARTICIPANTS: A random national sample consisting of 564,580 primary care empaneled veterans in June 2021. MAIN MEASURES: Latent class membership. KEY RESULTS: We identified three latent classes: those with few primary care visits that were predominantly telephone-based (45%), intermediate number of visits of all modalities (50%), and many visits of all modalities (5%). In an adjusted model, characteristics associated with the "few" visits class, compared to the intermediate class, were older age, male sex, White race, further driving distance to primary care, higher Gagne, optimal internet speed, and unmarried status (OR 1.002, 1.52, 1.13, 1.004, 1.04, 1.05, 1.06, respectively; p < .05). Characteristics associated with membership in the "many" visits class, compared to the intermediate class, were Hispanic race, higher JEN Frailty Index and Gagne (OR 1.12, 1.11, 1.02, respectively; p < .05), and higher comorbidity by Care Assessment Need score quartile (Q2 1.73, Q3 2.80, Q4 4.12; p < 0.05). CONCLUSIONS: Veterans accessing primary care in-person or via telemedicine do so primarily in three ways: (1) few visits, predominantly telephone; (2) intermediate visits, all modalities, (3) many visits, all modalities. We found no groups of veterans receiving a majority of primary care through video.

National and State-Level Trends in Mental Health and Substance Use Disorder Services at Federally Qualified Health Centers, 2012-2019.

INTRODUCTION: A disproportionate share of Federally Qualified Health Center (FQHC) users have a behavioral health condition, but there exists limited research examining changes in behavioral health provision in FQHCs. The objectives of this study were to describe how the provision of behavioral health services by FQHCs to the population of people with behavioral health conditions has changed over time in the US, how these trends varied across states, and whether the proportion of total delivered services that are behavioral health services has changed within FQHCs over time. METHODS: Descriptive analysis using the Uniform Data System and Global Burden of Disease Datasets from years 2012 to 2019. RESULTS: From 2012 to 2019, FQHC behavioral health visits per 1,000 population with any behavioral health condition grew 103%, with a 26-fold difference in average rates across states during the study period. Annual behavioral health visits per patient increased from 3.2 to 2012 to 3.4 in 2019. From 2012 to 2019, the number of behavioral health visits per 1,000 FQHC patients grew by 51%, whereas the rate of asthma visits declined by 14%, heart disease visits declined by 4%, and hypertension and diabetes related visits remained stable (changing < 1% for both). DISCUSSION/CONCLUSION: Behavioral health visit growth at FQHCs outpaced national prevalence of behavioral health conditions. This growth was driven by FQHCs serving an increasing number of patients with behavioral health conditions, without sacrificing the frequency of visits for individual patients with behavioral health conditions.

Use of New Audio-Only Telemedicine Claim Modifiers.

Importance: Policymakers at both the state and federal levels face decisions about coverage of audio-only telemedicine amid a dearth of reliable data due to changes and variation in billing practices. Objective: To describe early trends in the use of new audio-only telemedicine claims modifiers 93 and FQ in Washington State, which were introduced to improve the designation and identification of audio-only telemedicine claims. Design, Setting, and Participants: This retrospective cohort study analyzed claims data from the Washington All-Payer Claims Database from January to November 2022. Participants included 4.3 million children and adults insured for at least 6 months in 2021 through public or private insurance plans. Exposures: Use of audio-only telemedicine was compared by age, race, ethnicity, insurance type, rurality, and Social Vulnerability Index. Main Outcomes and Measures: Audio-only telemedicine services were identified by claims appended by Current Procedural Terminology (CPT) code modifiers 93 or FQ or that included telephone-only CPT codes. Modifiers 93 and FQ denote audio-only telemedicine services for any reason and for behavioral health concerns, respectively. Results: In 2022, there were a total of 917 589 audio-only telemedicine services, of which 345 941 (38%) were appended with modifier FQ and 55 352 (6%) with modifier 93. Audio-only telemedicine services with these modifiers were most frequent for behavioral health diagnoses or routine prenatal and postpartum care. Individuals who used telemedicine exclusively via audio-only modality were more likely to be older (mean [SD] age, 46.0 [22.5] vs 42.0 [21.4] years) and insured by Medicare (41 758 of 196 225 [21%] vs 95 962 of 707 626 [14%]) than those who used at least 1 audiovisual service. Conclusions and Relevance: In this cohort study of a statewide all-payer claims database, modifiers 93 and FQ offered the important capability to identify audio-only telemedicine services beyond telephone-only CPT codes, but their uptake remained low. Audio-only telemedicine appears to offer an important means for access to behavioral health and perinatal care access, but further work is needed to study outcomes and quality of care.

Reflections From Family Medicine Residents on Training During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Given their broad scope of training, family medicine residents were uniquely situated to care for the American public throughout the COVID-19 pandemic, yet little has been written about their experiences. The objective of this report is to capture the diversity of experiences and contributions of family medicine residents across the United States to the care of the American public during the COVID-19 pandemic. METHODS: Investigators recruited resident interviewees from four residencies throughout the United States via convenience sample. These residencies represented a diversity of geography, rurality, and structure (hospital based vs community based). Investigators conducted 30 to 60-minute, semistructured interviews with family medicine residents. Interviews were recorded and examined for themes. RESULTS: Three major themes emerged through the interview process. First, family medicine residents were a critical component of the inpatient response to COVID-19 in a variety of geographies from urban centers to rural towns to Native American reservations. Second, family medicine residents continued to provide expanded outpatient care to include telehealth, immunization clinics, and public health campaigns to meet the needs of the community. Finally, not only did these residents have an immense impact in the response to COVID-19, but the pandemic also had an immense impact on them, both personally and professionally. CONCLUSIONS: The story of family medicine contributions to the care of the public during COVID-19 reflects the history of COVID-19 in the United States, and the critical role trainees and family medicine physicians have in the US health care system.

Knowledge, Attitudes, and Confidence in Accountable Care Organization-Based Payment Models Among RI Physicians.

Study Objective or Background: To assess Rhode Island (RI) physician knowledge, attitudes, and confidence to succeed in Accountable Care Organizations (ACOs). Study Design and Methods: We surveyed RI physicians' attitudes and beliefs about ACOs, including scales measuring Physician Knowledge (7 Multiple Choice and True/False items), Attitudes (8 Likert scale items), and Confidence (7 Likert Scale Items), and examined how physician characteristics related to these measures. Primary Results: The response rate was 6 percent (72/1183). Means (100-point scale) and standard deviations were calculated for Knowledge 65.3 (22), Attitudes for ACO participants 56.3 (13.2) and ACO non-participants 42.7 (14.3), and Confidence 32.4 (25.9). Primary care physicians had higher Attitudes compared with specialists among ACO participants (60.2 vs. 51.8, p=.047) and ACO non-participants (48.2 vs. 34.4, p=.030). Principal Conclusions: RI Physicians have low scores in Knowledge, Attitudes, and Confidence scales in ACOs. Primary care physicians have more positive Attitudes about ACOs than specialists. This study is limited by its low response rate. [Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Subtotal Parathyroidectomy vs Total Parathyroidectomy with Autotransplantation for Secondary Hyperparathyroidism in Dialysis Patients: Short- and Long-Term Outcomes.

BACKGROUND: Two operations are performed for management of secondary hyperparathyroidism, subtotal parathyroidectomy (SPTX) and total parathyroidectomy with autotransplantation (TPTX-AT). There is no consensus among endocrine surgeons about which operation is the preferred treatment. This study compares the short- and long-term outcomes of SPTX and TPTX-AT for dialysis patients with secondary hyperparathyroidism. STUDY DESIGN: This is a retrospective review of 46 dialysis patients undergoing PTX from 2006 to 2017 at a 719-bed tertiary care hospital. RESULTS: Calcium on postoperative day 1 was 7.7 ± 0.8 mg/dL for SPTX and 7.9 ± 1.3 mg/dL for TPTX-AT (p = 0.49). Parathyroid hormone values on postoperative day 1 were 32.6 ± 26.0 pg/mL for SPTX and 9.5 ± 4.2 pg/mL for TPTX-AT (p ≤ 0.05). Hospital length of stay was 3.7 ± 1.9 days for SPTX and 4.4 ± 3.5 days for TPTX-AT (p = 0.46). The required doses of calcium and calcitriol at discharge did not differ significantly. Reoperation for recurrence or persistence of disease was required in 6 SPTX patients and 2 TPTX-AT patients (p = 0.12). Parathyroid hormone values <15 pg/mL at long-term follow-up occurred in 5.6% of SPTX patients and 26.7% of TPTX-AT patients (p = 0.09). Parathyroid hormone values >200 pg/mL at long-term follow-up occurred in 38.9% of SPTX patients vs 6.7% of the TPTX-AT patients (p ≤ 0.05). Calcium supplementation at more than 6 months was required for 36.8% of SPTX and 71.4% of TPTX-AT patients (p < 0.05). CONCLUSIONS: The long-term control of parathyroid hormone elevation and avoidance of recurrent disease is improved with TPTX-AT, but carries a higher risk of long-term hypocalcemia.