Telemedicine in Primary Care: Lessons Learned About Implementing Health Care Innovations During the COVID-19 Pandemic

Understanding Long-Stay Gabapentin Use Increases: A National Nursing Home Clinician Survey on Prescribing Intent

OBJECTIVES

Explore the indications for long-stay gabapentin use and elucidate the factors spurring the rapid increase in gabapentin prescribing in nursing homes (NHs).

METHODS

National cross-sectional survey of NH prescribers distributed anonymously using SurveyMonkey. Sampling for convenience was obtained through crowdsourcing, leveraging collaborations with NH clinician organizations. Developed by a multidisciplinary team, pilot data/existing literature informed survey content.

RESULTS

A total of 131 surveys completed. Participants: 71% white, 52% female, 71% physicians. Off-label gabapentin prescribing was ubiquitous. Nearly every clinician used gabapentin for neuropathic pain, most for any form of pain. Many clinicians also prescribe gabapentin to moderate psychiatric symptoms and behaviors. Clinicians' prescribing was influenced by opioid, antipsychotic, and anxiolytic reduction policies because gabapentin was perceived as an unmonitored and safer alternative.

CONCLUSIONS

Off-label gabapentin increases are closely linked to opioid reduction efforts as more NH clinicians utilize gabapentin as an unmonitored opioid alternative. Our results highlight, however, the less recognized significance of long-stay prescribing for psychiatric symptoms and the similar contribution of psychotropic reduction initiatives, a phenomenon warranting further scrutiny.

CLINICAL IMPLICATIONS

Clinicians perceive gabapentin as safer than the drugs it is replacing. Whether this is true remains unclear; the individual- and population-level risks of increased gabapentin use are largely unknown.

Effect of telemedicine use on medical spending and health care utilization among patients with gastrointestinal cancer

BACKGROUND

We sought to assess the impact of telemedicine on healthcare utilization and medical expenditures among patients with a diagnosis of gastrointestinal (GI) cancer.

METHODS

Patients with newly diagnosed GI cancer from 2013 to 2020 were identified from the IBM MarketScan database (IBM Watson Health) . Healthcare utilization, total medical outpatient insurance payments within 1 year post-diagnosis, and out-of-pocket (OOP) expenses among telemedicine users and non-users were assessed after propensity score matching (PSM).

RESULTS

Among the 32,677 patients with GI cancer (esophageal, n = 1862, 5.7%; gastric, n = 2009, 6.1%; liver, n = 2929, 9.0%; bile duct, n = 597, 1.8%; pancreas, n = 3083, 9.4%; colorectal, n = 22,197, 67.9%), a total of 3063 (9.7%) utilized telemedicine. After PSM (telemedicine users, n = 3064; non-users, n = 3064), telemedicine users demonstrated a higher frequency of clinic visits (median: 5.0 days, IQR 4.0-7.0 vs non-users: 2.0 days, IQR 2.0-3.0, P < .001) and fewer potential days missed from daily activities (median: 7.5 days, IQR 4.5-12.5 vs non-users: 8.5 days, IQR 5.5-13.5, P < .001). Total medical spending per month and utilization of emergency room (ER) visits for telemedicine users were higher vs non-users (median: $10,658, IQR $5112-$18,528 vs non-users: $10,103, IQR $4628-$16,750; 46.8% vs 42.6%, both P < .01), whereas monthly OOP costs were comparable (median: $273, IQR $137-$449 for telemedicine users vs non-users: $268, IQR $142-$434, P = .625).

CONCLUSION

Telemedicine utilization was associated with increased outpatient clinic visits yet reduced potential days missed from daily activities among patients with GI cancer. Telemedicine users tended to have more ER visits and total medical spending per month, although monthly OOP costs were comparable with non-users.

Management of Rheumatoid Arthritis in Primary Care: A Scoping Review

Rheumatoid arthritis (RA) can lead to severe joint impairment and chronic disability. Primary care (PC), provided by general practitioners (GPs), is the first level of contact for the population with the healthcare system. The aim of this scoping review was to analyze the approach to RA in the PC setting. PubMed, Scopus, and Web of Science were searched using the MESH terms "rheumatoid arthritis" and "primary care" from 2013 to 2023. The search strategy followed the PRISMA-ScR guidelines. The 61 articles selected were analyzed qualitatively in a table and discussed in two sections, namely criticisms and strategies for the management of RA in PC. The main critical issues in the management of RA in PC are the following: difficulty and delay in diagnosis, in accessing rheumatological care, and in using DMARDs by GPs; ineffective communication between GPs and specialists; poor patient education; lack of cardiovascular prevention; and increase in healthcare costs. To overcome these criticisms, several management strategies have been identified, namely early diagnosis of RA, quick access to rheumatology care, effective communication between GPs and specialists, active patient involvement, screening for risk factors and comorbidities, clinical audit, interdisciplinary patient management, digital health, and cost analysis. PC appears to be the ideal healthcare setting to reduce the morbidity and mortality of chronic disease, including RA, if a widespread change in GPs' approach to the disease and patients is mandatory.

You Cannot Function in "Overwhelm": Helping Primary Care Navigate the Slow End of the Pandemic

GOAL

This study was developed to explicate underlying organizational factors contributing to the deterioration of primary care clinicians' mental health during the COVID-19 pandemic.

METHODS

Using data from the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good's national survey of primary care clinicians from March 2020 to March 2022, a multidisciplinary team analyzed more than 11,150 open-ended comments. Phase 1 of the analysis happened in real-time as surveys were returned, using deductive and inductive coding. Phase 2 used grounded theory to identify emergent themes. Qualitative findings were triangulated with the survey's quantitative data.

PRINCIPAL FINDINGS

The clinicians shifted from feelings of anxiety and uncertainty at the start of the pandemic to isolation, lack of fulfillment, moral injury, and plans to leave the profession. The frequency with which they spoke of depression, burnout, and moral injury was striking. The contributors to this distress included crushing workloads, worsening staff shortages, and insufficient reimbursement. Consequences, both felt and anticipated, included fatigue and demoralization from the inability to manage escalating workloads. Survey findings identified responses that could alleviate the mental health crisis, namely: (1) measuring and customizing workloads based on work capacity; (2) quantifying resources needed to return to sufficient staffing levels; (3) promoting state and federal support for sustainable practice infrastructures with less administrative burden; and (4) creating patient visits of different lengths to rebuild relationships and trust and facilitate more accurate diagnoses.

PRACTICAL APPLICATIONS

Attention to clinicians' mental health should be rapidly directed to on-demand, confidential mental health support so they can receive the care they need and not worry about any stigma or loss of license for accepting that help. Interventions that address work-life balance, workload, and resources can improve care, support retention of the critically important primary care workforce, and attract more trainees to primary care careers.

Family Physicians' Perspectives on the Pros, Cons, and Application Areas of Telemedicine: A Qualitative Study

Background: There is evidence that telemedicine can be used safely, easily, and cost-effectively in primary health care services. This study aims to determine family physicians' opinions regarding the potential advantages, disadvantages, and usage areas of telemedicine in primary health care services. Methods: This study was designed with a qualitative case study. The Standards for Reporting Qualitative Research (SRQR) checklist was followed throughout the research process. Interviews were conducted with family physicians working in a provincial center using snowball sampling in the study. MaxQDA 20 software was used for analysis process, and themes and subthemes were identified through a deductive-reflective thematic analysis method. The family physicians who participated in the study are between 29 and 56. In addition, family medicine specialists, general practitioners, and academic department heads were included in the study. Family physicians are evenly distributed in terms of gender and professional experience. Results: All interviewed family physicians stated that they had not received professional or technical training in delivering telemedicine. It was observed that family physicians had different perspectives on telemedicine in primary care. The data obtained in the study were analyzed under the main themes of the advantages, disadvantages, and services that can be provided in primary telemedicine. Physicians have different views on telemedicine, including negative, undecided, and positive opinions. Conclusion: It is understood that many services could be delivered remotely if the scope, procedures, and processes of the services to be provided are determined with guidelines. It is recommended that family physicians receive professional and technical training in telemedicine.

Is primary care ready for a potential new public health emergency in the wake of the COVID-19 pandemic, now subsided?

INTRODUCTION

The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity.

METHODS

From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions.

RESULTS

An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had.

CONCLUSION

These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs.