Telehealth as a Bright Spot of the COVID-19 Pandemic: Recommendations From the Virtual Frontlines ("Frontweb").

The coronavirus disease (COVID-19) pandemic has accelerated the telehealth tipping point in the practice of family medicine and primary care in the United States, making telehealth not just a novel approach to care but also a necessary one for public health safety. Social distancing requirements and stay-at-home orders have shifted patient care from face-to-face consultations in primary care offices to virtual care from clinicians' homes or offices, moving to a new frontline, which we call the "frontweb." Our telehealth workgroup employed the Clinical Transformation in Technology implementation framework to accelerate telehealth expansion and to develop a consensus document for clinician recommendations in providing remote virtual care during the pandemic. In a few weeks, telehealth went from under 5% of patient visits to almost 93%, while maintaining high levels of patient satisfaction. In this paper, we share clinician recommendations and guidance gleaned from this transition to the frontweb and offer a systematic approach for ensuring "webside" success.

Lack of private health insurance is associated with higher mortality from cancer and other chronic diseases, poor diet quality, and inflammatory biomarkers in the United States.

OBJECTIVE: The lack of health insurance reduces access to care and often results in poorer health outcomes. The present study simultaneously assessed the effects of health insurance on cancer and chronic disease mortality, as well as the inter-relationships with diet, obesity, smoking, and inflammatory biomarkers. We hypothesized that public/no insurance versus private insurance would result in increased cancer/chronic disease mortality due to the increased prevalence of inflammation-related lifestyle factors in the underinsured population. METHODS: Data from the Third National Health and Nutrition Examination Survey participants (NHANES III;1988-1994) were prospectively examined to assess the effects of public/no insurance versus private insurance and inflammation-related lifestyle factors on mortality risk from cancer, all causes, cardiovascular disease (CVD) and diabetes. Cox proportional hazards regression was performed to assess these relationships. RESULTS: Multivariate regression analyses revealed substantially greater risks of mortality ranging from 35% to 245% for public/no insurance versus private insurance for cancer (HR=1.35; 95% CI=1.09,1.66), all causes (HR=1.54; 95% CI=1.39,1.70), CVD (HR=1.62; 95% CI=1.38,1.90) and diabetes (HR=2.45; 95% CI=1.45,4.14). Elevated CRP, smoking, reduced diet quality and higher BMI were more prevalent in those with public insurance, and were also associated with increased risks of cancer/chronic disease mortality. DISCUSSION: Insurance status was strongly associated with cancer/chronic disease mortality after adjusting for lifestyle factors. The results suggest that inadequate health insurance coverage results in a substantially greater need for preventive strategies that focus on tobacco control, obesity, and improved dietary quality. These efforts should be incorporated into comprehensive insurance coverage programs for all Americans.

Primary care access barriers as reported by nonurgent emergency department users: implications for the US primary care infrastructure.

The objective was to explore variation by insurance status in patient-reported barriers to accessing primary care. The authors fielded a brief, anonymous, voluntary survey of nonurgent emergency department (ED) visits at a large academic medical center and conducted descriptive analysis and thematic coding of 349 open-ended survey responses. The privately insured predominantly reported primary care infrastructure barriers-wait time in clinic and for an appointment, constraints related to conventional business hours, and difficulty finding a primary care provider (because of geography or lack of new patient openings). Half of those insured by Medicaid and/or Medicare also reported these infrastructure barriers. In contrast, the uninsured predominantly reported insurance, income, and transportation barriers. Given that insured nonurgent ED users frequently report infrastructure barriers, these should be the focus of patient-level interventions to reduce nonurgent ED use and of health system-level policies to enhance the capacity of the US primary care infrastructure.

Health care reform: possibilities & opportunities for primary care.

Amid the swirl of change in today's US health care system, there are opportunities for new care delivery models to slow rising costs and improve outcomes in family medicine. This review summarizes the possibilities.

Terminology matters: patient understanding of "opioids" and "narcotics".

BACKGROUND: The terms "opioid" and "narcotic" are often used interchangeably by healthcare providers. The purpose of this study was to compare understanding "narcotics" vs. "opioids." METHODS: A convenience sample of English-speaking women (n = 188), aged 21-45 years, seeking care at a primary care clinic were asked (1) "What is an opioid/narcotic?" (2) "Give an example of an opioid/narcotic?" (3) "Why does someone take an opioid/narcotic?" and (4) "What happens when someone takes an opioid/narcotic for a long time?" Responses were recorded verbatim by a research assistant and then coded independently by two investigators. RESULTS: More than half of respondents (55.9%) responded "don't know" to all 4 opioid questions, while just 3.2% responded "don't know" to all 4 narcotic questions (P < 0.01). Most women were unfamiliar with the term opioid (76.3%) and did not know why someone would take an opioid (68.8%). About two-thirds of respondents were able to give an example of a narcotic (64.2%) and knew the consequences of long-term narcotic use (63.2%). CONCLUSIONS: While more women were more familiar with narcotic, many identified negative connotations with this term. Future research should explore how to improve patient understanding and attitudes regarding both the terms opioids and narcotics.

The impact of patient and physician computer mediated communication skill training on reported communication and patient satisfaction.

OBJECTIVE: The objective was to evaluate parallel patient and physician computer-mediated communication skill training on participants' report of skill use and patient satisfaction. METHODS: Separate patient and clinician web-tools comprised of over 500, 10-s video clips demonstrating patient-centered skills in various ways. Four clinician members of the American Academy of Family Physicians National Research Network participated by enrolling 194 patients into a randomized patient trial and 29 physicians into a non-randomized clinician trial of respective interventions. All participants completed baseline and follow-up self-report measures of visit communication and satisfaction. RESULTS: Intervention patients reported using more skills than controls in five of six skill areas, including identification of problems/concerns, information exchange, treatment adherence, shared decision-making and interpersonal rapport (all p<.05); post intervention, physicians reported using more skills in the same 5 areas (all p<.01). Intervention group patients reported higher levels of satisfaction than controls in five of six domains (all p<.05). CONCLUSION: Communication skill training delivered in a computer mediated format had a positive and parallel impact on both patient and clinician reported use of patient-centered communication and in patient satisfaction. PRACTICE IMPLICATIONS: Computer-mediated interventions are cost and time effective thereby increasing patient and clinician willingness to undertake training.

Heart rate control with adrenergic blockade: clinical outcomes in cardiovascular medicine.

The sympathetic nervous system is involved in regulating various cardiovascular parameters including heart rate (HR) and HR variability. Aberrant sympathetic nervous system expression may result in elevated HR or decreased HR variability, and both are independent risk factors for development of cardiovascular disease, including heart failure, myocardial infarction, and hypertension. Epidemiologic studies have established that impaired HR control is linked to increased cardiovascular morbidity and mortality. One successful way of decreasing HR and cardiovascular mortality has been by utilizing beta-blockers, because their ability to alter cell signaling at the receptor level has been shown to mitigate the pathogenic effects of sympathetic nervous system hyperactivation. Numerous clinical studies have demonstrated that beta-blocker-mediated HR control improvements are associated with decreased mortality in postinfarct and heart failure patients. Although improved HR control benefits have yet to be established in hypertension, both traditional and vasodilating beta-blockers exert positive HR control effects in this patient population. However, differences exist between traditional and vasodilating beta-blockers; the latter reduce peripheral vascular resistance and exert neutral or positive effects on important metabolic parameters. Clinical evidence suggests that attainment of HR control is an important treatment objective for patients with cardiovascular conditions, and vasodilating beta-blocker efficacy may aid in accomplishing improved outcomes.

Ambulatory blood pressure monitoring in primary care.

The accurate assessment and appropriate management of blood pressure (BP) is critical for primary care physicians. Traditional office-based BP measurement has limitations that can be addressed, in part, through the use of ambulatory BP monitoring (ABPM). Because BP readings are provided at specific time intervals throughout a 24-hour period, ABPM represents a better picture of the normal fluctuations in BP levels associated with daily activities, including sleep. Blood pressure values obtained by 24-hour ABPM are a better predictor of cardiovascular risk than office-based BP measurements, and the technique can be used to discern white-coat hypertension and to evaluate masked, resistant, and pseudoresistant hypertension. It can also be helpful in the assessment of autonomic dysfunction and monitoring of a patient's response to antihypertensive therapy. Ambulatory BP monitoring is also being increasingly used in clinical trials that assess the antihypertensive effects of medications.

Racial differences in barriers to blood pressure control in a family practice setting.

OBJECTIVE: Hypertension prevalence in the African American community is greater than in all other ethnic groups. Cultural perceptions of health and disease introduce barriers to providing effective care. The purpose of this study was to identify racial differences in the perceived causes of hypertension, current behaviors performed to control blood pressure, and perceived barriers to preventing or treating hypertension. METHODS: A self-administered survey of patients seen for medical care in a primary care network was conducted. The survey was developed to measure perceptions of hypertension etiology and treatments. Data from African American (n = 69) and Caucasian (n = 218) respondents were used to assess racial differences in perceptions of blood pressure control. RESULTS: About half of respondents knew their current blood pressures. African American patients were significantly less likely to believe that hypertension was caused by a lack of exercise and obesity. Significantly more Caucasians were less likely to report cutting down on table salt and taking prescription medications for blood pressure control. Both African Americans and Caucasians believed that sodium reduction was the most easily changed behavior to control their blood pressure, while both groups identified weight loss as being the most difficult. CONCLUSION: Racial differences exist in the perceived causes and treatments of high blood pressure, indicating a need for further patient education. When treating and counseling patients, physicians and support staff members must be sensitive to racial diversity and strive to offer culturally relevant solutions, especially for behaviors perceived as most difficult to change.

When your patient's blood pressure won't come down.

Is your patient's persistent hypertension really resistant to treatment, or are other factors at work? Consider these 2 cases and let this algorithm help you decide.

Sociology meets genetics: sociogenetic implications for future management of hypertension and heart failure.

Hypertension and heart failure contribute significantly to morbidity and mortality in the United States. Suboptimal control of these disease processes is multifactorial and involves poorly understood mechanisms affected by the environment (socioeconomic factors) and genetics (cell biology). Dietary sodium is an illustrative case. Although physicians intuitively accept that sodium affects renal and cardiovascular physiology, the complex overlay of genetics, environment, and culture is not practically addressed to make a meaningful difference in patient care. Optimal control of hypertension and heart failure will require a personalized care plan for each patient that includes lifestyle changes and carefully selected pharmacotherapy and also accounts for sociogenetic factors that affect each patient's life and thus his or her disease process. Physicians' cultural biases and perceptions also must be factored into this complex patient care equation.

Barriers to blood pressure control as reported by African American patients.

PURPOSE: To understand African American patients' opinions as to barriers to hypertension treatment. METHODS: Focus groups (n=3) were led by a trained African American moderator of African American patients with hypertension (n=26) who receive their care from a large primary care network. Discussions were transcribed verbatim. Information was displayed in a data matrix and analyzed for emerging themes. Descriptive statistics were used to enhance the content validity of lifestyle modification efforts planned as part of this ongoing research. RESULTS: Most participants were female (n=20), and the mean age was 49 years. All participants were at least high school graduates. Four major levels of influence emerged from data analysis: (1) the health care system, (2) the community, (3) the family, and (4) the individual. The most prevalent concerns about hypertension centered on sodium, diet, neighborhoods, mistrust, and denial. Of great concern was lack of provider trust and a fatalistic, hopeless mindset. To improve trust, our participants suggested developing a hypertension education program and providing patients with culturally specific materials. CONCLUSIONS: Culturally sensitive materials need to be designed and tested to improve blood pressure control. Community input regarding cultural issues is essential for designing effective and successful programs for reducing health disparities.

Physician reported perception in the treatment of high blood pressure does not correspond to practice.

BACKGROUND: High blood pressure is a significant health problem world-wide. Physician factors play a significant role in the suboptimal control of hypertension in the United States. We sought to better understand primary care physician's opinions regarding use of hypertension guidelines, patient and physician related barriers to treatment and physician treatment decision making in the management of hypertension as part of a first step in developing research tools and interventions designed to address these issues. METHODS: An IRB approved survey pertaining to physician opinion regarding the treatment of hypertension. Items consisted of questions regarding: 1) knowledge of hypertension treatment guidelines; 2) barriers to hypertension control (physician vs. patient); and 3) self-estimation of physician treatment of hypertension. Descriptive Statistics were used to describe results. RESULTS: All physicians were board certified in family or general internal medicine (n = 28). Practices were located in urban (n = 12), suburban (n = 14) and inner city locations (n = 1). All physicians felt they did a good job of treating hypertension. Most physicians felt the biggest barrier to hypertension control was patient non-compliance. Half of physicians would fail to intensify treatment for hypertension when blood pressure was above recommended levels for all disease states studied (essential hypertension, heart disease, diabetes, and renal disease). CONCLUSION: Physician ability to assess personal performance in the treatment of hypertension and physician opinion that patient noncompliance is the greatest barrier to optimal hypertension control is contradictory to reported practice behavior. Optimal blood pressure control requires increased physician understanding on the evaluation and management of blood pressure. These data provide crucial formative data to enhance the content validity of physician education efforts currently underway to improve the treatment of blood pressure in the primary care setting.