Ongoing Decline in Continuity With GPs in English General Practices: A Longitudinal Study Across the COVID-19 Pandemic.

PURPOSE: Relationship continuity of care has declined across English primary health care, with cross-sectional and longitudinal variations between general practices predicted by population and service factors. We aimed to describe cross-sectional and longitudinal variations across the COVID-19 pandemic and determine whether practice factors predicted the variations. METHODS: We conducted a longitudinal, ecological study of English general practices during 2018-2022 with continuity data, excluding practices with fewer than 750 patients or National Health Service (NHS) payments exceeding £500 per patient. Variables were derived from published data. The continuity measure was the product of weighted responses to 2 General Practice Patient Survey questions. In a multilevel mixed-effects model, the fixed effects were 11 variables' interactions with time: baseline continuity, NHS region, deprivation, location, percentage White ethnicity, list size, general practitioner and nurse numbers, contract type, NHS payments per patient, and percentage of patients seen on the same day as booking. The random effects were practices. RESULTS: Main analyses were based on 6,010 practices (out of 7,190 active practices). During 2018-2022, mean continuity in these practices declined (from 29.3% to 19.0%) and the coefficient of variation across practices increased (from 48.1% to 63.6%). Both slopes were steepest between 2021 and 2022. Practices having more general practitioners and higher percentages of patients seen the same day had slower declines. Practices having higher baseline continuity, located in certain non-London regions, and having higher percentages of White patients had faster declines. The remaining variables were not predictors. CONCLUSIONS: Variables potentially associated with greater appointment availability predicted slower declines in continuity, with worsening declines and relative variability immediately after the COVID-19 lockdown, possibly reflecting surges in demand. To achieve better levels of continuity for those seeking it, practices can increase appointment availability within appointment systems that prioritize continuity.

The Impact of Primary Care Clinic and Family Physician Continuity on Patient Health Outcomes: A Retrospective Analysis From Alberta, Canada.

PURPOSE: Continuity of care is broadly associated with better patient health outcomes. The relative contributions of continuity with an individual physician and with a practice, however, have not generally been distinguished. This retrospective observational study examined the impact of continuity of care for patients seen at their main clinic but by different family physicians. METHODS: We analyzed linked health administrative data from 2015-2018 from Alberta, Canada to explore the association of physician and clinic continuity with rates of emergency department (ED) visits and hospitalizations across varying levels of patient complexity. Physician continuity was calculated using the known provider of care index and clinic continuity with an analogous measure. We developed zero-inflated negative binomial models to assess the association of each with all-cause ED visits and hospitalizations. RESULTS: High physician continuity was associated with lower ED use across all levels of patient complexity and with fewer hospitalizations for highly complex patients. Broadly, no (0%) clinic continuity was associated with increased use and complete (100%) clinic continuity with decreased use, with the largest effect seen for the most complex patients. Levels of clinic continuity between 1% and 50% were generally associated with slightly higher use, and levels of 51% to 99% with slightly lower use. CONCLUSIONS: The best health care outcomes (measured by ED visits and hospitalizations) are associated with consistently seeing one's own primary family physician or seeing a clinic partner when that physician is unavailable. The effect of partial clinic continuity appears complex and requires additional research. These results provide some reassurance for part-time and shared practices, and guidance for primary care workforce policy makers.

Association between self-perceived consultation time and understanding of the prescribed treatment: An analysis of a national survey in Peru.

OBJECTIVE: To assess the relationship between the self-perceived consultation time and the knowledge of the proposed treatment. METHODS: Secondary data from a 2015 national survey of health services in Peru were analyzed. The self-perceived consultation time was calculated by asking how long it took from when you entered the consultation until you departed. It was then categorized as low, medium, and high. Five self-reported questions were used to construct a knowledge of the prescribed treatment. Adjusted regression models from the Poisson family models were used to evaluate the relationship. We report adjusted prevalence ratios (aPR) with their 95% confidence intervals (95%CI). RESULTS: A total of 9939 outpatients were analyzed, with 58% women; the average age was 44 years; and 45.4% had higher education. Using low self-perceived consultation time as references, medium and high consultation times were associated with understanding the prescribed treatment (aPR=1.17; 95%CI, 1.04-1.33 and aPR=1.30; 95%CI, 1.20-1.40, respectively). CONCLUSION: Patients who reported a medium and high self-perceived consultation time better understood the prescribed treatment. IMPLICATIONS FOR PRACTICE: Healthcare professionals should strive to maximize consultation time to ensure effective communication and improve patient knowledge of treatments, improving overall patient satisfaction and health outcomes.

Management of Pediatric Psoriasis: A U.S. Survey Based on Visits from the National Ambulatory Medical Care Survey (NAMCS).

INTRODUCTION: Approximately one-third of psoriasis cases present in the first two decades of life. Many psoriasis treatments are approved by the U.S. Food and Drug Administration (FDA) for adults, including topical agents, systemic non-biologic agents, and systemic biologic agents. Only a handful of psoriasis treatments are FDA approved for children. Given the constantly evolving landscape of pediatric psoriasis management, our aim is to characterize how children with psoriasis are treated in the U.S. METHODS: Data from the 2003-2016 and 2018 National Ambulatory Medical Care Survey (NAMCS) were used to evaluate patient demographics and treatment patterns for visits of children with psoriasis. Visits were stratified by those with a diagnosis of psoriasis and those for children with a diagnosis of psoriasis. Separate analyses for visits of children with a diagnosis of psoriasis were performed, including for sex, race, ethnicity, age, specialty of provider seen, and medications prescribed. RESULTS: Pediatric psoriasis visits accounted for 3.3% of visits with psoriasis from 2003 to 2016 and in 2018; about one-third of those visits were to primary care providers. Children with psoriasis were prescribed a variety of topical and systemic medications, of which the most frequently prescribed treatments were topical tacrolimus, followed by topical clobetasol and topical betamethasone dipropionate or betamethasone valerate. Etanercept was the only biologic prescribed to children. At least 59% of the visits for children with a diagnosis of psoriasis included a topical prescription while at least 5.3% of the visits included a systemic prescription. CONCLUSION: Use of off-label treatments was common for pediatric psoriasis. Most children with psoriasis were treated with topicals, of which tacrolimus, an unapproved treatment, was the most common. The frequent use of tacrolimus could indicate an avoidance of corticosteroids in children.

The Evolution of Primary Care Telehealth Disparities During COVID-19: Retrospective Cohort Study.

BACKGROUND: Telehealth has become widely used as a novel way to provide outpatient care during the COVID-19 pandemic, but data about telehealth use in primary care remain limited. Studies in other specialties raise concerns that telehealth may be widening existing health care disparities, requiring further scrutiny of trends in telehealth use. OBJECTIVE: Our study aims to further characterize sociodemographic differences in primary care via telehealth compared to in-person office visits before and during the COVID-19 pandemic and determine if these disparities changed throughout 2020. METHODS: We conducted a retrospective cohort study in a large US academic center with 46 primary care practices from April-December 2019 to April-December 2020. Data were subdivided into calendar quarters and compared to determine evolving disparities throughout the year. We queried and compared billed outpatient encounters in General Internal Medicine and Family Medicine via binary logic mixed effects regression model and estimated odds ratios (ORs) with 95% CIs. We used sex, race, and ethnicity of the patient attending each encounter as fixed effects. We analyzed socioeconomic status of patients in the institution's primary county based on the patient's residence zip code. RESULTS: A total of 81,822 encounters in the pre-COVID-19 time frame and 47,994 encounters in the intra-COVID-19 time frame were analyzed; in the intra-COVID-19 time frame, a total of 5322 (11.1%) of encounters were telehealth encounters. Patients living in zip code areas with high utilization rate of supplemental nutrition assistance were less likely to use primary care in the intra-COVID-19 time frame (OR 0.94, 95% CI 0.90-0.98; P=.006). Encounters with the following patients were less likely to be via telehealth compared to in-person office visits: patients who self-identified as Asian (OR 0.74, 95% CI 0.63-0.86) and Nepali (OR 0.37, 95% CI 0.19-0.72), patients insured by Medicare (OR 0.77, 95% CI 0.68-0.88), and patients living in zip code areas with high utilization rate of supplemental nutrition assistance (OR 0.84, 95% CI 0.71-0.99). Many of these disparities persisted throughout the year. Although there was no statistically significant difference in telehealth use for patients insured by Medicaid throughout the whole year, subanalysis of quarter 4 found encounters with patients insured by Medicaid were less likely to be via telehealth (OR 0.73, 95% CI 0.55-0.97; P=.03). CONCLUSIONS: Telehealth was not used equally by all patients within primary care throughout the first year of the COVID-19 pandemic, specifically by patients who self-identified as Asian and Nepali, insured by Medicare, and living in zip code areas with low socioeconomic status. As the COVID-19 pandemic and telehealth infrastructure change, it is critical we continue to reassess the use of telehealth. Institutions should continue to monitor disparities in telehealth access and advocate for policy changes that may improve equity.

Changes in Billing and Reimbursement for Urology Office Visits Before and After Medicare Payment Reforms.

INTRODUCTION: The impact of Medicare reimbursement changes on urology office visit reimbursements has not been fully examined. This study aims to analyze the impact of urology office visit Medicare reimbursements from 2010 to 2021, with a focus on 2021 Medicare payment reforms. METHODS: The Centers for Medicare and Medicaid Services Physician/Procedure Summary data from 2010-2021 were utilized to examine office visit CPT (Current Procedural Terminology) new patient visit codes 99201-99205 and established patient visit codes 99211-99215 by urologists. Mean office visit reimbursements (2021 USD), CPT specific reimbursements, and proportion of level of service were compared. RESULTS: The 2021 mean visit reimbursement was $110.95, up from $99.42 in 2020 and $94.44 in 2010 (both P < .001). From 2010 to 2020, all CPT codes, except for 99211, had a decrease in mean reimbursement. From 2020 to 2021, there was an increase in mean reimbursement for CPT codes 99205, 99212-99215 and decreases in 99202, 99204 and 99211 (P < .001). New and established patient urology office visits had significant migration of billing codes from 2010 to 2021 (P < .001). New patient visits were most commonly as 99204, which increased from 47% in 2010 to 65% in 2021 (P < .001). The most commonly billed established patient urology visit was 99213 until 2021 when 99214 became the most common at 46% (P < .001). CONCLUSIONS: Urologists have seen increases in mean reimbursements for office visits both before and after the 2021 Medicare payment reform. Contributing factors consist of increased established patient visit reimbursements despite decreased new patient visit reimbursements, and changes in level of CPT code billings.

Predictors of Timely and Delayed Urological Evaluation Following Referral for Elevated Prostate-specific Antigen in a Diverse, Urban, High-risk Population.

INTRODUCTION: This study aimed to evaluate predictors of timely urological evaluation among men referred for initial elevated PSA in a diverse, high-risk, urban community. METHODS: We conducted a retrospective cohort study of all men aged 50+ referred to urology within our healthcare network between January 2018 and December 2021 for initial elevated PSA. Time to initial urological evaluation was categorized as timely (within 4 months of referral), late (after 4 months), or absent (no urology evaluation). Demographic and clinical variables were abstracted. A multivariable multinomial logistic regression model was conducted to identify predictors of timely vs late vs absent urological evaluation controlling for age, referral year, household income, distance to care, and PSA at referral. RESULTS: A total of 1,335 men met inclusion criteria; 589 (44.1%), 210 (15.7%), and 536 (40.1%) had timely, late, and absent urological evaluation, respectively. The majority were non-Hispanic Black (46.7%), English-speaking (84.0%), and married (54.6%). Median time to initial urological evaluation differed significantly between timely and late groups (16 vs 210 days, P < .001). Multivariable logistic regression revealed the following to be significant predictors of timely urological evaluation: non-Hispanic Black (OR=1.59, P = .03), Hispanic (OR=2.07, P = .001), Spanish-speaking (OR=1.44, P = .03), or former-smokers (OR=1.31, P = .04). CONCLUSIONS: In our diverse community, men who are non-Hispanic White or English-speaking have a decreased odds of timely urological evaluation after a referral for elevated PSA in our diverse patient population. Our study underscores cohorts that may benefit from implementation of institutional safeguards such as patient navigation systems to facilitate and ensure appropriate follow-up upon referral for elevated PSA.

Innovative Remote Management Solutions for the Control of Hypertension.

We stand at a critical juncture in the delivery of health care for hypertension. Blood pressure control rates have stagnated, and traditional health care is failing. Fortunately, hypertension is exceptionally well-suited to remote management, and innovative digital solutions are proliferating. Early strategies arose with the spread of digital medicine, long before the COVID-19 pandemic forced lasting changes to the way medicine is practiced. Highlighting one contemporary example, this review explores salient features of remote management hypertensive programs, including: an automated algorithm to guide clinical decisions, home (as opposed to office) blood pressure measurements, an interdisciplinary care team, and robust information technology and analytics. Dozens of emerging hypertension management solutions are contributing to a highly fragmented and competitive landscape. Beyond viability, profit and scalability are critical. We explore the challenges impeding large-scale acceptance of these programs and conclude with a hopeful look to the future when remote hypertension care will have dramatic impact on global cardiovascular health.

The Impact of an Electronic Portal on Patient Encounters in Primary Care: Interrupted Time-Series Analysis.

BACKGROUND: Electronic patient portals are online applications that allow patients access to their own health information, a form of asynchronous virtual care. The long-term impact of portals on the use of traditional primary care services is unclear, but it is an important question at this juncture, when portals are being incorporated into many primary care practices. OBJECTIVE: We sought to investigate how an electronic patient portal affected the use of traditional, synchronous primary care services over a much longer time period than any existing studies and to assess the impact of portal messaging on clinicians' workload. METHODS: We conducted a propensity-score-matched, open-cohort, interrupted time-series evaluation of a primary care portal from its implementation in 2010. We extracted information from the electronic medical record regarding age, sex, education, income, family health team enrollment, diagnoses at index date, and number of medications prescribed in the previous year. We also extracted the annual number of encounters for up to 8 years before and after the index date and provider time spent on secure messaging through the portal. RESULTS: A total of 7247 eligible portal patients and 7647 eligible potential controls were identified, with 3696 patients matched one to one. We found that portal registration was associated with an increase in the number of certain traditional encounters over the time period surrounding portal registration. Following the index year, there was a significant jump in annual number of visits to physicians in the portal arm (0.42 more visits/year vs control, P<.001) but not for visits to nurse practitioners and physician assistants. The annual number of calls to the practice triage nurses also showed a greater increase in the portal arm compared to the control arm after the index year (an additional 0.10 calls, P=.006). The average provider time spent on portal-related work was 5.7 minutes per patient per year. CONCLUSIONS: We found that portal registration was associated with a subsequent increase in the number of some traditional encounters and an increase in clerical workload for providers. Portals have enormous potential to truly engage patients as partners in their own health care, but their impact on use of traditional health care services and clerical burden must also be considered when they are incorporated into primary care.

Proportion of subsequent clinic visits among persons without regular clinic visits who were screened as having hyperglycemia: A retrospective cohort study.

AIMS/INTRODUCTION: We aimed to examine the proportion of subsequent clinic visits for persons screened as having hyperglycemia based on glycated hemoglobin (HbA1c) levels at screening and the presence/absence of hyperglycemia at health checkups before 1 year of the screening among those without previous diabetes-related medical care and attending regular clinic visits. MATERIALS AND METHODS: This retrospective cohort study used the 2016-2020 data of Japanese health checkups and claims. The study analyzed 8,834 adult beneficiaries aged 20-59 years without regular clinic visits who had never received diabetes-related medical care and whose recent health checkups showed hyperglycemia. The rates of 6-month subsequent clinic visits after health checkups were evaluated according to HbA1c levels and the presence/absence of hyperglycemia at checkups a year before. RESULTS: The overall clinic visit rate was 21.0%. The HbA1c-specific rates were 17.0, 26.7, 25.4 and 28.4% for <7.0, 7.0-7.4, 7.5-7.9 and ≥8.0% (64 mmol/mol), respectively. Persons with hyperglycemia at a previous screening had lower clinic visit rates than those without hyperglycemia, particularly in the HbA1c category of <7.0% (14.4% vs 18.5%; P < 0.001) and 7.0-7.4% (23.6% vs 35.1%; P < 0.001). CONCLUSIONS: The overall rate of subsequent clinic visits among those without previous regular clinic visits was <30%, including for participants with HbA1c ≥8.0%. Persons with previously detected hyperglycemia had lower clinic visit rates, despite requiring more health counseling. Our findings might be useful for designing a tailored approach to encourage high-risk individuals to seek diabetes care through clinic visits.

Improving breastfeeding care & support in a large, urban, pediatric primary care practice.

BACKGROUND AND SPECIFIC AIMS: Human milk/breastfeeding is the gold standard for infant nutrition. Interventions in pediatric primary care could improve breastfeeding exclusivity and duration. Our specific aims were two-fold: 1) Accurately measure breastfeeding indicators and 2) Implement AAP Breastfeeding-Friendly Pediatric Office Practice Recommendations. MATERIALS AND METHODS: In 2018, a single, urban, large primary care pediatric practice initiated a Quality Improvement project to improve breastfeeding outcomes. Stakeholders met to discuss metrics of interest, develop documentation templates, review data capture, and plan interventions to support breastfeeding. Practice based interventions to improve measurement included: piloting documentation templates, incorporation of default templates office-wide, and developing tracking tools for both use of templates and breastfeeding outcomes. Interventions to support breastfeeding occurred simultaneously and included workflow redesign to increase nurse-provided breastfeeding education, partnering with community-based lactation consultants for outpatient support, staff education, and National Breastfeeding Month activities. RESULTS: Since initiation of the data analytic tool, breastfeeding data has been analyzed from over 30,000 visits (86% Medicaid-insured, 82% Black race). Currently, 80% of providers use default templates that allow standardized data capture. At first newborn visit, 74% of infants were breastfed. At six months, 36% of infants were breastfed; 23% exclusively. Standardized documentation of infant feeding status improved and has remained consistent. Breastfeeding duration did not significantly improve despite practice interventions. CONCLUSIONS: Pediatric primary care measurement tools are feasible and critical to understand breastfeeding continuation. Increased resources and interventions to support breastfeeding in Primary Care are necessary to improve outcomes.

Changes in dental and medical visits before and during the COVID-19 pandemic among U.S. children aged 1-17 years.

OBJECTIVES: The COVID-19 pandemic has tremendously impacted the U.S. healthcare system, but no study has examined the impact of the pandemic on utilization of dental care among U.S. children. Changes in past-year dental versus medical visits and perceived unmet health needs between 2019 and 2020 among U.S. children aged 1-17 years were examined. METHODS: National and state representative, cross-sectional data from the National Survey of Children's Health conducted during June 2019-January 2020 (i.e. pre-pandemic, n = 28 500) and July 2020-January 2021 (i.e. intra-pandemic, n = 41 380) were analysed. Any past-year visit and perceived unmet needs (i.e. delay or inability to receive needed care) were reported by the parent proxy. Weighted prevalence estimates were compared using two-tailed chi-squared tests at p < .05. Poisson regression analyses were used to explore the relationship between having dental and/or medical unmet needs during the pandemic and indicators of poor health and social wellbeing. RESULTS: Between 2019 and 2020, a significantly reduced prevalence of past-year medical (87.2%-81.3%) and dental visits (82.6%-78.2%) among U.S. children aged 1-17 years (all p < .05) were observed. Correspondingly, perceived unmet needs increased by half for dental care (from 2.9% in 2019 to 4.4% in 2020) and almost one-third for medical care (from 3.2% to 4.2% in 2020). Subgroups with the highest prevalence of unmet dental need included those with low socio-economic status, living with their grandparents, uninsured and living with a smoker. CONCLUSIONS: Unmet health needs increased in general but increased more for dental than for medical care among U.S. children aged 1-17 years. Enhanced and sustained efforts will be needed to deliver targeted services towards disadvantaged segments of the population to narrow existing disparities.

Female LUTS adaptations to COVID era: Lessons learned from the ICS TURNOVER (Transition of fUnctional uRology to New COVID ERa).

Introduction: The COVID-19 pandemic has dramatically affected the Female and Functional Urology (FFU) practice, leading to massive waiting lists, while patients' quality of life remains severely impaired. The aim of the present study is to develop consensual recommendations to guide clinicians on the management of FFU patients. The present paper focuses on female LUTS. Methods: The authors used the Delphi methodology to develop a robust survey questionnaire, covering the principal topics in FFU, based on literature review and expert opinions. Regarding female LUTS, a 98-question survey was distributed among FFU specialists to obtain optimized recommendations, under the auspicious of the International Continence Society (TURNOVER, ICS project). A quantitative analysis of the data was performed, categorizing the mean value from 0-10. Consensus achievement was defined as attaining ≥ 70% agreement. Results: 98 ICS members completed the F-LUTS survey. Recommendations for the diagnosis and management of female LUTS are summarized. Video-consultation should be used for initial assessment, sending questionnaires and bladder diaries in advance to the patient to be filled out before the consultation. However, face-to-face visits are mandatory if POP or continuous incontinence are suspected, and prior to any surgical procedure, regardless of the health alert. Moreover, prescribing medications such as anticholinergics or ß 3 agonists in a telemedicine setting is not considered a safe practice. Follow-up teleconsultations can be used to assess the efficacy and treatment-related adverse events.Urodynamic testing should be only performed if consequences on F-LUTS treatment are expected. The study should be postponed until the pandemic local behaviour flattens.Invasive procedures should be postponed during a high alert. In case surgery is scheduled, outpatient clinics and local anaesthesia should be prioritized. Every patient should be screened for SARS-CoV-2 infection before invasive tests or procedures, following local authorities' guidance. Conclusions: During a pandemic, telemedicine offers a novel way of communication, maintaining medical care while preventing viral transmission. Non-urgent procedures should be postponed until the pandemic curve flattens. Ambulatory procedures under regional or local anaesthesia should be prioritized, aiming to reduce bed occupancy and risk of transmission.

Physicians' and Patients' Interruptions in Clinical Practice: A Quantitative Analysis.

PURPOSE: Physicians' interruptions have long been considered intrusive, masculine actions that inhibit patient participation, but a systematic analysis of interruptions in clinical interaction is lacking. This study aimed to examine when and how primary care physicians and patients interrupt each other during consultations. METHODS: We coded and quantitatively analyzed interruption type (cooperative vs intrusive) in 84 natural interactions between 17 primary care physicians and 84 patients with common somatic symptoms. Data were analyzed using a mixed-effects logistic regression model, with role, gender, and consultation phase as predictors. RESULTS: Of the 2,405 interruptions observed, 82.9% were cooperative. Among physicians, men were more likely to make an intrusive interruption than women (ß = 0.43; SE, 0.21; odds ratio [OR] = 1.54; 95% CI, 1.03-2.31), whereas among patients, men were less likely to make an intrusive interruption than women (ß = -0.35; SE, 0.17; OR = 0.70; 95% CI, 0.50-0.98). Patients' interruptions were more likely to be intrusive than physicians' interruptions in the phase of problem presentation (ß = 0.71; SE, 0.23; OR = 2.03; 95% CI, 1.30-3.20), but not in the phase of diagnosis and/or treatment plan discussion (ß = -0.17; SE, 0.15; OR = 0.85; 95% CI, 0.63-1.15). CONCLUSIONS: Most interruptions in clinical interaction are cooperative and may enhance the interaction. The nature of physicians' and patients' interruptions is the result of an interplay between role, gender, and consultation phase.

Reasons behind high rate of non-compliance to scheduled office visits in hypertensive patients: results from the Egyptian registry of specialized hypertension clinics.

BACKGROUND: Hypertensive patients' compliance to the clinic's follow-up visits is associated with a better blood pressure control. The aim of this study was to detect the reasons of non-compliance to office visits in Egyptian hypertensive patients. RESULTS: This is an observational, prospective, cross-sectional research study where patients were enrolled from the registry of the specialized hypertension clinics of 9 university hospitals. Those who attended less than 3 office visits, throughout the registry period, were considered non-compliant and were contacted through the phone. A simple questionnaire was prepared, which included questions about the reasons of non-compliance to follow up. There were 3014 patients eligible for inclusion in this study but only 649 patients (21.5%) completed the questionnaire. Patients claimed that the reasons of non-compliance to the follow up visits in the specialized hypertension clinics were as follows: 444 patients (68.4%) preferred to follow up elsewhere mostly in pharmacies, 53 patients (8.2%) claimed that the healthcare service was unsatisfactory, 94 patients (14.5%) were asymptomatic, and 110 patients (16.9%) said that the clinic was far from their homes. Despite non-compliance to office visits, 366 patients (59.2%) were compliant to their antihypertensive medications and 312 (48.1%) patients were compliant to salt restriction. About 34% of patients used herbs, mainly hibiscus, as adjuvant to their antihypertensive medications. CONCLUSIONS: Reasons for non-compliance to office visits in hypertensive patients were either patient-related, or healthcare-related. To improve patients' compliance, physicians need to educate their patients about hypertension, patients need to follow their doctors' instructions as regard medications, salt restriction and scheduled office visits, and governments need to provide better and cheaper healthcare services.

Effects of early preventive dental visits and its associations with dental caries experience: a cross-sectional study.

OBJECTIVES: Limited information is known about preventive dental visits (PDVs) before seven years of age among children in China. This study aimed to examine the early PDV rate, identify the impact of PDV on dental caries and untreated dental caries, and explore the factors related to PDV among Chinese sampled children under seven years old. METHODS: A cross-sectional survey was conducted in five selected primary health care facilities in Chengdu, China, from May to August 2021. Parent-child dyads during regular systematic medical management were recruited to participate. Children's dental caries were identified through dental examinations and documented as decayed, missing and filled teeth index (dmft) by trained primary care physicians. Dental-related information was collected through a questionnaire. Zero-inflated negative binomial (ZINB) regression was used to test the effect of early PDV on the dmft value, and logistic regression was used to analyse impact factors on the early PDV. RESULTS: A total of 2028 out of 2377 parent-child dyads were qualified for analysis. Half of the children (50.4%) were male, with a mean age of 4.8 years. Among all the children, 12.1% had their first dental visit for preventive purposes, 34.4% had their first dental visit for symptomatic purposes, and more than half had never visited a dentist. The results showed that a lower dmft value (adjusted OR: 0.69, 95% CI: 0.48-0.84), a higher rate of caries-free (aOR: 6.5, 95% CI: 3.93-10.58), and a lower rate of untreated dental caries (aOR: 0.40, 95% CI: 0.21-0.76) were associated with early PDV utilization. Children who had a higher rate of PDV were positively associated with living in a family with better parental behaviours (aOR: 2.30, 95% CI: 1.71-3.08), better parental oral health perception (aOR: 1.23, 95% CI: 1.06-1.32), fathers who had no untreated caries (aOR: 0.68, 95% CI: 0.47-0.97), families with higher socioeconomic status (aOR: 1.09, 95% CI: 1.04-1.16), and dental health advice received from well-child care physicians (aOR: 1.47, 95% CI: 1.08-2.00). CONCLUSIONS: Early PDV was associated with a lower rate of dental caries prevalence and untreated dental caries among sampled children younger than seven in Western China. Underutilization and social inequities existed in PDV utilization. Public health strategies should be developed to increase preventive dental visits and eliminate social disparities that prevent dental care utilization.

Virtual and in-person visits by Ontario physicians in the COVID-19 era.

INTRODUCTION: We examined the coronavirus disease 2019 (COVID-19) pandemic impact on weekly trends in the billing of virtual and in-person physician visits in Ontario, Canada. METHODS: In this retrospective cohort study, physician billing records from Ontario were aggregated on a weekly basis for in-person and virtual visits from 3 January 2016 to 27 March 2021. For each type of visit, a segmented negative binomial regression analysis was performed to estimate the weekly pre-pandemic trend in billing volume per thousand adults (3 January 2016 to 14 March 2020), the immediate change in mean volume at the start of the pandemic, and additional change in weekly volume in the pandemic era (15 March 2020 to 27 March 2021). RESULTS: Before the start of the pandemic, the weekly volume of virtual visits per thousand adults was low with a 0.5% increase per week (rate ratio [RR]: 1.0053, 95% confidence interval [CI]: 1.0050-1.0056). A dramatic 65% reduction in in-person visits (RR: 0.35, 95% CI: 0.32-0.39) occurred at the start of the pandemic while virtual visits grew by 21-fold (RR: 21.3, 95% CI: 19.6-23.0). In the pandemic era, in-person visits rose by 1.4% per week (RR: 1.014, 95% CI: 1.011-1.017) but no change was observed for virtual visits (p-value = 0.31). Overall, we noted a 57.6% increase in total weekly physician visits volume after the start of the pandemic. DISCUSSION: These results are meaningful for virtual care reimbursement models. Future study needs to assess the quality of care and whether the increase in virtual care volume is cost-effective to society.

Association between the reduction of face-to-face appointments and the control of patients with type 2 diabetes mellitus during the Covid-19 pandemic in Catalonia.

AIM: To analyse the relation between face-to-face appointments and management of patients with type 2 diabetes mellitus (T2DM) visited in primary care practices (PCP). METHODS: Retrospective study in 287 primary care practices (PCPs) attending>300,000 patients with T2DM. We analysed the results of 9 diabetes-related indicators of the Healthcare quality standard, comprising foot and retinopathy screening, blood pressure (BP) and glycemic control; and the incidence of T2DM. We calculated each indicator's percentage of change in 2020 with respect to the results of 2019. RESULTS: Indicators' results were reduced in 2020 compared to 2019, highlighting the indicators of foot and retinopathy screening (-51.6% and -25.7%, respectively); the glycemic control indicator (-21.2%); the BP control indicator (-33.7%) and the incidence of T2DM (-25.6%). Conversely, the percentage of type 2 diabetes patients with HbA1c > 10% increased by 34%. PCPs with<11 weekly face-to-face appointments offered per professional had greater reductions than those PCPs with more than 40. For instance, a reduction of -60.7% vs -38.2% (p-value < 0.001) in the foot screening's indicator; -27.5% vs -12.5% (p-value < 0.001) in glycemic control and -40.2 vs -24.3% (p-value < 0.001) in BP control. CONCLUSIONS: Reducing face-to-face visits offered may impact T2DM patients' follow-up and thus worsen their control.

Clinician Response to Patient Emotion: Impact on Subsequent Communication and Visit Length.

PURPOSE: It is widely cited-based on limited evidence-that attending to a patient's emotions results in shorter visits because patients are less likely to repeat themselves if they feel understood. We evaluated the association of clinician responses to patient emotions with subsequent communication and visit length. METHODS: We audio-recorded 41 clinicians with 342 unique patients and used the Verona Coding Definitions of Emotional Sequences (VR-CoDES) to time stamp patient emotional expressions and categorize clinician responses. We used random-intercept multilevel-regression models to evaluate the associations of clinician responses with timing of the expressed emotion, patient repetition, and subsequent length of visit. RESULTS: The mean visit length was 30.4 minutes, with 1,028 emotional expressions total. The majority of clinician responses provided space for the patient to elaborate on the emotion (81%) and were nonexplicit (56%). As each minute passed, clinicians had lower odds of providing space (odds ratio [OR] = 0.96; 95% CI, 0.95-0.98) and higher odds of being explicit (OR = 1.02; 95% CI, 1.00-1.03). Emotions were more likely to be repeated when clinicians provided space (OR = 2.33; 95% CI, 1.66-3.27), and less likely to be repeated when clinicians were explicit (OR = 0.61; 95% CI, 0.47-0.80). Visits were shorter (ß = -0.98 minutes; 95% CI, -2.19 to 0.23) when clinicians' responses explicitly focused on patient affect. CONCLUSION: If saving time is a goal, clinicians should consider responses that explicitly address a patient's emotion. Arguments for providing space for patients to discuss emotional issues should focus on other benefits, including patients' well-being.