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Britz JB, Huffstetler AN, Brooks EM, Richards A, Sabo RT, Webel BK, McCray N, Krist AH. Increased Organizational Stress in Primary Care: Understanding the Impact of the COVID-19 Pandemic, Medicaid Expansion, and Practice Ownership. J Am Board Fam Med 2024; 36:892-904. [PMID: 38092433 PMCID: PMC10860742 DOI: 10.3122/jabfm.2023.230145r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 06/26/2023] [Accepted: 07/24/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Primary care is the foundation of health care, resulting in longer lives and improved equity. Primary care was the frontline of the COVID-19 pandemic public response and essential for access to care. Yet primary care faces substantial structural and systemic challenges. As part of a longitudinal analysis to track the capacity and health of primary care, we surveyed every primary care practice in Virginia in 2018 and again in 2022. METHODS Surveys were emailed or mailed up to 6 times and nonresponders received a phone call. Questions assessed organizational characteristics, scope of care, capacity, and organizational stress in the prior year. From respondents, 39 clinicians, nurses, staff, administrators, and practice managers were interviewed. RESULTS 526 out of 2296 primary care practices (23% response rate) completed the survey, with broad representation across geography, ownership, and payer mix. Compared with 2018, in 2022 there were increases in practices owned by health systems (25% vs 43%, P < .0001) and average percent of patients with Medicaid per practice (12% vs 22%, P < .0001). The percent of practices reporting any major stressor increased from 34% to 53% (P < .0001). The main increased stress was losing a clinician, with 13% of practices in 2018 versus 42% in 2022 reporting losing a clinician (P < .0001). CONCLUSIONS Primary care practices are resilient and continue to serve their communities, including a broad scope of services and care for underserved people. However, the COVID-19 pandemic caused significant stress. With an increase in clinicians leaving clinical practice, we anticipate worsening access to primary care.
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Affiliation(s)
- Jacqueline B Britz
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC). )
| | - Alison N Huffstetler
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
| | - E Marshall Brooks
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
| | - Alicia Richards
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
| | - Roy T Sabo
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
| | - Ben K Webel
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
| | - Neil McCray
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
| | - Alex H Krist
- From the Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA (JBB, ANH, EMB, AR, RTS, BKW, AHK), Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC (ANH), Virginia Department of Medical Assistance Services, Richmond, VA (NMC)
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Krist AH, Huffstetler AN, Villalobos G, Rockwell MS, Richards A, Funk A, Sabo RT, Bortz B, Webel B, Lee JH, Russel K, Kuzel A, Britz JB, Moeller FG. Use of population health data to promote equitable recruitment for a primary care practice implementation trial addressing unhealthy alcohol use. J Clin Transl Sci 2023; 7:e110. [PMID: 37250994 PMCID: PMC10225269 DOI: 10.1017/cts.2023.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/25/2023] [Accepted: 04/05/2023] [Indexed: 05/31/2023] Open
Abstract
Background Recruiting underrepresented people and communities in research is essential for generalizable findings. Ensuring representative participants can be particularly challenging for practice-level dissemination and implementation trials. Novel use of real-world data about practices and the communities they serve could promote more equitable and inclusive recruitment. Methods We used a comprehensive primary care clinician and practice database, the Virginia All-Payers Claims Database, and the HealthLandscape Virginia mapping tool with community-level socio-ecological information to prospectively inform practice recruitment for a study to help primary care better screen and counsel for unhealthy alcohol use. Throughout recruitment, we measured how similar study practices were to primary care on average, mapped where practices' patients lived, and iteratively adapted our recruitment strategies. Results In response to practice and community data, we adapted our recruitment strategy three times; first leveraging relationships with residency graduates, then a health system and professional organization approach, followed by a community-targeted approach, and a concluding approach using all three approaches. We enrolled 76 practices whose patients live in 97.3% (1844 of 1907) of Virginia's census tracts. Our overall patient sample had similar demographics to the state for race (21.7% vs 20.0% Black), ethnicity (9.5% vs 10.2% Hispanic), insurance status (6.4% vs 8.0% uninsured), and education (26.0% vs 32.5% high school graduate or less). Each practice recruitment approach uniquely included different communities and patients. Discussion Data about primary care practices and the communities they serve can prospectively inform research recruitment of practices to yield more representative and inclusive patient cohorts for participation.
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Affiliation(s)
- Alex H. Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
- Inova Health System, Fairfax, VA, USA
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, USA
| | - Alison N. Huffstetler
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
- Inova Health System, Fairfax, VA, USA
| | - Gabriela Villalobos
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Michelle S. Rockwell
- Department of Family & Community Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Alicia Richards
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Adam Funk
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Roy T. Sabo
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, USA
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Beth Bortz
- Virginia Center for Health Innovation, Richmond, VA, USA
| | - Ben Webel
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Jong Hyung Lee
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Kyle Russel
- Virginia Health Information, Richmond, VA, USA
| | - Anton Kuzel
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - Jaqueline B. Britz
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, VA, USA
| | - F. Gerard Moeller
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, USA
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