The Impact of the COVID-19 Pandemic on Patient Disparities in Long-Term Opioid Therapy.

BACKGROUND: The COVID-19 pandemic disrupted how primary care patients with chronic pain received care. Our study sought to understand how long-term opioid therapy (LtOT) for chronic pain changed over the course of the pandemic overall and for different demographic subgroups. METHODS: We used data from electronic health records of 64 primary care clinics across Washington state and Idaho to identify patients who had a chronic pain diagnosis and were receiving long-term opioid therapy. We defined 10-month periods in 2019 to 2021 as prepandemic, early pandemic and late pandemic and used generalized estimating equations analysis to compare across these time periods and demographic characteristics. RESULTS: We found a proportional decrease in LtOT for chronic pain in the early months of the pandemic (OR = 0.94, P = .007) followed by an increase late pandemic (OR = 1.08, P = .002). Comparing late pandemic to prepandemic, identifying as Asian or Black, having fewer comorbidities, or living in an urban area were associated with higher likelihood of being prescribed LtOT. DISCUSSION: The use of LtOT for chronic pain in primary care has increased from before to after the COVID-19 pandemic with racial/ethnic and geographic disparities. Future research is needed to understand these disparities in LtOT and their effect on patient outcomes.

The Role of Primary Care in the Social Isolation and Loneliness Epidemic.

The United States is facing a social isolation and loneliness crisis. In response, the US Surgeon General issued an advisory in May 2023 recommending actions that health care, community programs, and social services can take to collaboratively improve social connection. Primary care has a critical role to play in implementing the Surgeon General's recommendations. We present social isolation and loneliness as medical issues and highlight next steps for the primary care sector to combat this epidemic.Annals Early Access article.

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.

Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia.

Introduction: There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality. Methods: Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses. Results: Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (ß=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (ß=0.01, p=0.002) or with mental health disorders (ß= -0.12, p<0.001), despite higher fatal opioid overdoses. Conclusions: There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.

Maternity Access in Rural America: The Role of Family Physicians in Providing Access to Cesarean Sections.

INTRODUCTION: As an increasing number of rural hospitals close their maternity care units, many of the approximately 28 million reproductive-age women living in rural America do not have local access to obstetric services. We sought to describe the characteristics and distribution of cesarean section-providing family physicians who may provide critical services in maintaining obstetric access in rural hospitals. METHODS: Using a cross-sectional study design, we linked data from the 2017 to 2022 American Board of Family Medicine's Continuting Certification Questionnaire on provision of cesarean sections as primary surgeon and practice characteristics to geographic data. Logistic regression determined associations with provision of cesarean sections. RESULTS: Of 28,526 family physicians, 589 (2.1%) provided cesarean sections as primary surgeon. Those who provided cesarean sections were more likely to be male (odds ratio (OR) = 1.573, 95% confidence limits (CL) 1.246-1.986), and work in rural health clinics (OR = 2.157, CL 1.397-3.330), small rural counties (OR = 4.038, CL 1.887-8.642), and in counties without obstetrician/gynecologists (OR = 2.163, CL 1.440-3.250). DISCUSSION: Although few in number, family physicians who provide cesarean sections as primary surgeon disproportionately serve rural communities and counties without obstetrician/gynecologists, suggesting that they provide access to obstetric services in these communities. Policies that support family physician training in cesarean sections and facilitate credentialing of trained family physicians could reverse the trend of closing obstetric units in rural communities and reduce disparities in maternal and infant health outcomes.

Racial/Ethnic Minority Identifying Family Physicians Are More Likely to Work in Solo Practices.

While the overall proportion of family physicians who work in solo practices has been steadily declining, Black, Hispanic/Latino, and Asian family physicians are more likely to work in these settings. Given their association with high levels of continuity and improved health outcomes, and given patient preference for racial concordance with their physicians, policy makers and payors should consider how to support family physicians in solo practice in the interest of promoting access to and quality of care for ethnic/racial minorities.

Characteristics of Family Physicians Practicing Collaboratively With Behavioral Health Professionals.

Integrating behavioral health into primary care can improve access to behavioral health and patient health outcomes. We used 2017-2021 American Board of Family Medicine continuing certificate examination registration questionnaire responses to determine the characteristics of family physicians who work collaboratively with behavioral health professionals. With a 100% response rate, 38.8% of 25,222 family physicians reported working collaboratively with behavioral health professionals, with those working in independently owned practices and in the South having substantially lower rates. Future research exploring these differences could help develop strategies to support family physicians implement integrated behavioral health to improve care for patients in these communities.

Primary Care's Challenges and Responses in the Face of the COVID-19 Pandemic: Insights From AHRQ's Learning Community.

The COVID-19 pandemic dramatically disrupted health care systems and delivery in the United States. Despite emotional, psychological, logistical, and financial stress, primary care clinicians responded to the challenges that COVID-19 presented and continued to provide essential health services to their communities. As the lead federal agency for primary care research, the Agency for Healthcare Research and Quality (AHRQ) identified a need to engage and support primary care in responding to COVID-19. AHRQ initiated a learning community from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. The learning community provided a forum for participants to share learning and peer support, better understand the stressors and challenges confronting practices, ascertain needs, and identify promising solutions in response to the pandemic. We identified challenges, responses, and innovations that emerged through learning community engagement, information sharing, and dialog. We categorized these across 5 domains that reflect core areas integral to primary care delivery: patient-centeredness, clinician and practice, systems and infrastructure, and community and public health; health equity was crosscutting across all domains. The engagement of the community to identify real-time response and innovation in the context of a global pandemic has provided valuable insights to inform future research and policy, improve primary care delivery, and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.

Emergence of Gun Violence as a Patient Priority.

PURPOSE: Gun violence is a growing public health epidemic that disproportionately affects underserved and minority communities. Our study sought to document patient experiences of community gun violence as a theme that emerged in the context of interviews exploring community-level factors influencing patients' engagement in primary care within the context of a larger study on cardiovascular health. METHODS: We completed semistructured qualitative interviews of individuals with uncontrolled hypertension recruited from primary care practices serving underserved communities in metro Richmond, Virginia that were participating in a larger study on improving cardiovascular health. RESULTS: Of 19 individuals interviewed, 11 discussed without prompting the negative effects of gun violence in their community. Themes that emerged included both the acute and chronic traumatic experience, the physiologic and cognitive effects of gun violence and the negative effects on ability to manage heart health. CONCLUSIONS: The effects of gun violence on not only cardiovascular health but also all aspects of health emerged unprompted in qualitative interviews about community level factors influencing management of cardiovascular health. Given the widespread negative effects of experiencing gun violence on health, family physicians could play an important role in identifying and managing the effects of gun violence. Future studies on how primary care clinicians can address gun violence in the caring for their patients comprehensively are needed.

Realizing the Dream: The Future of Primary Care Research.

Primary care research is central to the successful transformation of care delivery, providing the crucial evidence to overcome the longstanding and widespread threats and challenges to the realization of primary care's full potential. The Agency for Healthcare Research and Quality (AHRQ), as the federal agency specifically charged with conducting and supporting primary care research, plays a pivotal role in supporting the research and generating the evidence needed to advance primary care. Drawing upon decades of AHRQ-supported research studies, extensive stakeholder consultation, and a Primary Care Research Summit held in fall 2020, we discuss the primary care research central to successful primary care transformation and for realizing the vision of a high-performing US health system to effectively serve all Americans and their communities while advancing health equity.Realizing the potential of primary care will require wise investments in primary care research. Newly generated evidence needs to be rapidly incorporated into the design of the delivery system, clinical care, and community interventions. Investments in evidence-informed primary care redesign can catalyze progress to achieving the quintuple aim-improved health outcomes, increased value, better patient and clinician experience, and health equity. Primary care research can provide the evidence to help stem the twin epidemics of clinician burnout and lack of trust in the health system. Actualizing this vision will require a concerted and coordinated effort by policy makers, researchers, clinicians, and community members and a commitment to ensuring people and communities have ready access to primary care.Appeared as Annals "Online First" article.

Practice Patterns of Family Physicians With and Without Addiction Medicine Board Certification.

BACKGROUND: The American Board of Medical Specialties recognized addiction medicine (ADM) as a subspecialty in 2016, which was timely given the recent rise in substance use disorder (SUD). The impact of this dual board opportunity on Family Medicine has not been described. Our study enumerates and characterizes physicians dually certified in Family Medicine and ADM. METHODS: We linked American Board of Medical Specialties data from March 2020 on physicians dually boarded in Family Medicine and ADM to responses on demographic and scope of practice questions in the American Board of Family Medicine (ABFM) National Graduate Survey and Family Medicine Certification Examination Registration Questionnaire. RESULTS: Of current ABFM Diplomates, 0.53% (492/93,269) are also boarded in ADM. Based on survey responses from a subset of dually certified physicians, those who are dually certified are more likely to practice in federally qualified health centers and to hold a faculty position. Dually certified physicians are more likely to provide HIV/AIDS and hepatitis C management and are as likely as non-dually certified physicians to provide newborn care, obstetric deliveries, inpatient adult medicine care, and intensive care. DISCUSSION: While only a small proportion of family physicians carry dual ADM board certification, those that do disproportionately serve vulnerable populations while retaining broad scope of care. Further work is needed to examine whether SUD treatment access could be addressed by implementing models that support dually certified physicians in consultative and educational efforts that would amplify their impact across the primary care workforce.

Understanding the Value of the Wellness Visit: A Descriptive Study.

INTRODUCTION: Clinical preventive services can reduce mortality and morbidity, but Americans receive only half of the recommended care. Although wellness visits protect time for clinicians to review needs and discuss care with patients, studies have not shown that having a wellness visit improves health outcomes. This study seeks to understand the types of discussions and volume of care delivered during wellness visits. METHODS: Using a sample of 1,008 patients scheduled for a wellness visit from 22 primary care clinicians across 3 states from 2018 to 2019, electronic health records were reviewed, and a subset of visits was audio recorded. The discussion and delivery of clinical preventive services, as recommended by the U.S. Preventive Services Task Force, were measured, and new diagnoses were identified from the clinical preventive services. Analyses were completed in 2020. RESULTS: Even though patients were up to date with 80% of the recommended clinical preventive services 3 months after the visit, only 0.5% of patients were up to date with all the recommended clinical preventive services. On average, 6.9 clinical preventive service discussions occurred during each wellness visit on the basis of electronic health records review, and 7.7 clinical preventive services discussions occurred on the basis of audio recordings. An average of 0.4 new diagnoses was identified, including cancer diagnoses, cardiovascular risks, and infections. CONCLUSIONS: Wellness visits are an important time for patients and clinicians to discuss prevention strategies and to deliver recommended clinical preventive services, leading to the identification of previously unrecognized diagnoses. This will improve patients' health. Policies and incentives that promote wellness visits are important, and efforts are needed to deliver them to those most in need.

The Essential Role of Family Physicians in Providing Cesarean Sections in Rural Communities.

Of family physicians who perform cesarean sections, more than half do so in rural communities and 38.6% provide cesarean sections in counties without any obstetrician/gynecologists. As policymakers in the United States struggle with a widening landscape of 'obstetrical deserts,' efforts to adequately train a family physician workforce prepared to provide cesarean sections could help maintain access to local obstetric services in rural communities and reduce perinatal morbidity and mortality.

Uptake of Statin Guidelines to Prevent and Treat Cardiovascular Disease.

INTRODUCTION: In December 2013, cholesterol treatment guidelines changed the approach to statin therapy by recommending fixed doses of low-, medium-, or high-intensity statins based on cardiovascular risk. We sought to evaluate the guideline's adoption in a diverse group of practices. METHODS: Using a mixed-methods approach, we analyzed electronic health record data the year before and 2 years following guideline publication in 45 practices across 8 states. We examined associations based on patient, clinician, and practice characteristics and interviewed 24 clinicians and practice leaders to inform findings. RESULTS: The proportion of patients adherent with all recommendations 2 years after the guideline only increased from 18.5% to 20.3% (P < .01). There were clinically insignificant increases in statin use across risk strata (1.7% to 3.5%) and small increases in high-intensity statin use (2.6% to 4.6%). Only half of patients with cardiovascular disease (52.9%) were on any statin, not much different from patients at moderate (49.6% to 50.9%) or low (41.6% to 48.7%) risk. Multiple patient (risk, use of health care), clinician (age), and practice (type, rurality) factors were associated with statin use. Clinicians reported patient resistance to statins but liked having a risk calculator to guide discussions. CONCLUSION: Despite general agreement with statin benefit, the guideline was poorly implemented. Marginal differences in statin use between the highest and lower risk strata of patients is concerning. Rather than intensifying statin potency and recommending more patients take statins, guidelines may want to focus on ensuring that those who will benefit most get treatment.

Practice, clinician, and patient factors associated with the adoption of lung cancer screening.

OBJECTIVES: Lung cancer remains the leading cause of cancer-related deaths in the United States. In 2013, the US Preventive Services Task Force recommended annual screening for lung cancer with low-dose computed tomography in adults meeting certain criteria. This study seeks to assess lung cancer screening uptake in three health systems. SETTING: This study was part of a randomized controlled trial to engage underserved populations in preventive care and includes 45 primary care practices in eight states. METHODS: Practice and clinician characteristics were manually collected. Lung cancer was measured from electronic health record data. A generalized linear mixed model was used to assess characteristics associated with screening. RESULTS: Patient records between 2012 and 2016 were examined. Lung cancer screening uptake overall increased only slightly after the guideline change (2.8-5.6%, p < 0.01). One health system did not show an increase in uptake (0.2-0.1%, p = 0.32), another had a clinically insignificant increase (1.5-2.9%, p < 0.01), and the third nearly doubled its higher baseline screening rate (10.4-19.1%, p < 0.01). Within the third health system, patients more likely to be screened were older, male, had more comorbid conditions, visited the office more frequently, were seen in practices closer to the screening clinic, or were uninsured or covered by Medicare or Medicaid. CONCLUSIONS: Certain patients appeared more likely to be screened. The only health system with increased lung cancer screening explicitly promoted screening rather than relying on clinicians to implement the new guideline. Systems approaches may help increase the low uptake of lung cancer screening.

Factors Influencing Uptake of Changes to Clinical Preventive Guidelines.

BACKGROUND: Despite widespread recognition that adherence to clinical preventive guidelines improves patient outcomes, clinicians struggle to implement guideline changes in a timely manner. Multiple factors influence guideline adoption and effective implementation. However, few studies evaluate their collective and inter-related effects. This qualitative study provides a comprehensive picture of the interplay between multiple factors on uptake of new or changed preventive guidelines. METHODS: Semistructured interviews conducted in 2018 with a diverse sample of clinicians and practice leaders sought to understand patient, clinician, practice, health system, environment, and guideline factors of influence. An immersion-crystallization approach was used to identify emergent themes. RESULTS: Interviewees expressed motivation to adhere to guidelines but also valued sharing decisions with patients. Personal biases and fears affected both clinician and patient guideline adoption. Practices facilitated implementation through workflow optimization and encouraging a culture of evidence-based practice while a key health system function was to maintain electronic health record alerts. More traditional environmental factors, such as insurance coverage or transportation, were less of a barrier to guideline adoption and implementation than the influence of media and specialists. Various specific guideline characteristics also affected ease of adoption and implementation. Different settings expressed greater health system, practice, or clinician-centric approaches to guideline implementation. CONCLUSIONS: Guideline uptake is influenced by a complex interplay of multiple levels of factors including the patient, clinician, practice, health system, environment, and guideline levels. Comprehensively understanding all levels of influence for each specific clinical setting may help to determine the optimal intervention(s) for improving uptake of evidence-based guidelines.

A state-level study of opioid use disorder treatment access and neonatal abstinence syndrome.

BACKGROUND: Adult opioid use and neonatal abstinence syndrome (NAS) are growing public health problems in the United States (U.S.). Our objective was to determine how opioid use disorder treatment access impacts the relationship between adult opioid use and NAS. METHODS: We conducted a cross-sectional state-level ecologic study using 36 states with available Healthcare Cost and Utilization Project State Inpatient Databases in 2014. Opioid use disorder treatment access was determined by the: 1) proportion of people needing but not receiving substance use treatment, 2) density of buprenorphine-waivered physicians, and 3) proportion of individuals in outpatient treatment programs (OTPs). The incidence of NAS was defined as ICD-9 code 779.5 (drug withdrawal syndrome in newborn) from any discharge diagnosis field per 1000 live births in that state. RESULTS: Unmet need for substance use disorder treatment correlated with NAS (r = 0.54, 95% CI: 0.26-0.73). The correlation between adult illicit drug use/dependence and NAS was higher in states with a lower density of buprenorphine-waivered physicians and individuals in OTPs. CONCLUSIONS: Measures of opioid use disorder treatment access dampened the correlation between illicit drug use/dependence and NAS. Future studies using community- or individual-level data may be better poised to answer the question of whether or not opioid use disorder treatment access improves NAS relative to adult opioid use.

Chronic Opioid Prescribing in Primary Care: Factors and Perspectives.

BACKGROUND: Primary care clinicians write 45% of all opioid prescriptions in the United States, but little is known about the characteristics of patients who receive them and the clinicians who prescribe opioids in primary care settings. Our study aimed to describe the patient and clinician characteristics and clinicians' perspectives of chronic opioid prescribing in primary care. METHODS: Using a mixed methods approach, we completed an analysis of 2016 electronic health records from 21 primary care practices to identify patients who had received chronic opioids, which we defined as in receipt of an opioid prescription for at least 3 consecutive months. We compared those receiving chronic opioids with those not in terms of their demographics, prescribing clinician characteristics, and risk factors for opioid-related harms, as identified by the Centers for Disease Control and Prevention Guideline on Opioid Prescribing for Chronic Pain. We then interviewed 16 primary care clinicians about their perspectives on chronic opioid prescribing. RESULTS: Of 84,029 patients, 1.1% (902/84,929) received chronic opioid prescriptions. Characteristics associated with being prescribed chronic opioids include being female, being of black or African American race, and having risks for opioid-related harms, such as mental health diagnoses, substance use disorder, and concurrent benzodiazepine use. Clinicians report multiple difficulties in weaning patients from chronic opioids, including medical contraindications of nonopioid alternatives and difficulty justifying weaning by stable long-term patients. CONCLUSION: Although patients prescribed opioids in primary care have higher risks of opioid-related harms, clinicians report multiple barriers in deprescribing chronic opioids. Future studies should examine strategies to mitigate these harms and engage patients in shared decision making about their chronic opioid use.