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Policy PointsTelehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode.Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities.To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. Context: The COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic. Methods: The study analyzed data about small primary care practices' telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene's Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city's efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State's stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents' telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only. Findings: While all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas. Conclusions: Between April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. [ABSTRACT FROM AUTHOR]

An estimated 3 to 5 million Americans are chronically infected with hepatitis C virus (HCV), and approximately 75% of those persons were born between 1945 and 1965 (the so-called baby boomer generation). Because of the largely asymptomatic nature of HCV, up to 50% of those infected are unaware of their disease. Risk-based testing has been largely ineffective. Based on prevalence data, the Centers for Disease Control and Prevention and other organizations recommend a onetime HCV antibody test for all baby boomers. However, uptake of this recommendation requires significant changes in clinical practice for already busy primary care clinicians. We studied the effectiveness of a quality improvement initiative based on continuous audit and feedback combined with education for improving testing in alignment with guidelines; the control group was a cohort of clinicians whose only reminder was an institution-wide electronic health record prompt. Our data show improved testing rates among all clinician groups, but more significant improvement occurred among providers who received continuous feedback about their clinical performance coupled with education. [ABSTRACT FROM AUTHOR]

Purpose: We wanted to describe small, independent primary care practices' performance in meeting the Million Hearts ABCSs (aspirin use, blood pressure control, cholesterol management, and smoking screening and counseling), as well as on a composite measure that captured the extent to which multiple clinical targets are achieved for patients with a history of arteriosclerotic cardiovascular disease (ASCVD). We also explored relationships between practice characteristics and ABCS measures.Methods: We conducted a cross-sectional, bivariate analysis using baseline data from 134 practices in New York City. ABCS data were extracted from practices' electronic health records and aggregated to the site level. Practice characteristics were obtained from surveys of clinicians and staff at each practice.Results: The proportion of at-risk patients meeting clinical goals for each of the ABCS measures was 73.0% for aspirin use, 69.6% for blood pressure, 66.7% for cholesterol management, and 74.2% screened for smoking and counseled. For patients with a history of ASCVD, only 49% were meeting all ABC (aspirin use, blood pressure control, cholesterol management) targets (ie, composite measure). Solo practices were more likely to meet clinical guidelines for aspirin (risk ratio [RR] =1.17, P =.007) and composite (RR=1.29, P = .011) than practices with multiple clinicians.Conclusion: Achieving targets for ABCS measures varied considerably across practices; however, small practices were meeting or exceeding Million Hearts goals (ie, 70% or greater). Practices were less likely to meet consistently clinical targets that apply to patients with a history of ASCVD risk factors. Greater emphasis is needed on providing support for small practices to address the complexity of managing patients with multiple risk factors for primary and secondary ASCVD. [ABSTRACT FROM AUTHOR]

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation. [ABSTRACT FROM AUTHOR]

The article discusses research which examines the challenges facing small urban practices serving low-income patients when they attempt to become recognized by the U.S. National Committee for Quality Assurance (NCQA) as patient-centered medical homes (PCMH). It analyzes the dimensions of the PCMH model that exist in practices participating in the Primary Care Information Project (PCIP). It reveals that many of such practices achieved the spirit of the law in terms of PCMH' key dimensions.

Examines the efficacy of child development services provided by Medicaid managed care organizations in the U.S. Importance of good nutrition and during the first three years of life for optimal growth and development; Details on child development programs for low income families; Family education on developmental progress of children.

Background: Unmet social risks such as housing, food insecurity and safety concerns are associated with adverse health outcomes in adults and children. Experimentation with social needs screening in primary care is currently underway throughout the United States. Pediatric primary care practices are well-positioned to amplify the effects of social needs screening and referral programs because all members of the household have the potential to benefit from connection to needed social services; however, more research is needed to determine effective implementation strategies., Methods: To describe common implementation barriers and facilitators, we conducted 48 in-depth qualitative interviews with leadership, providers and staff between November 2018 and June 2019 as part of a multiple case study of social needs screening and referral programs based out of four pediatric ambulatory care clinics in New York City. Interviews were recorded, transcribed and coded using a protocol-driven, template-based rapid analysis approach designed for pragmatic health services research. In addition to analyzing content for our study, we delivered timely findings to each site individually in order to facilitate quality improvement changes in close-to-real time., Results: Effective implementation strategies included tailoring screening tools to meet the needs of families seen at the clinic and reflect the resources available in the community, hiring dedicated staff to manage the program, building strong and lasting partnerships with community-based organizations, establishing shared communication methods between partners, and utilizing technology for efficient tracking of screening data. Respondents were enthusiastic about the value of their programs and the impact on families, but remained concerned about long-term sustainability after the grant period., Conclusion: Implementation of social needs screening and referral interventions is dependent on contextual factors including the nature of family needs and the availability of intraorganizational and community resources to address those needs. Additional research is needed to prospectively test promising implementation strategies that were found to be effective across sites in this study. Sustainability of programs is challenging, and future research should also explore measurable outcomes and payment structures to support such interventions in pediatric settings, as well as aim to better understand caregiver perspectives to improve engagement., (© 2022. The Author(s).)

Background: Primary care practices have remained on the frontline of health care service delivery throughout the COVID-19 pandemic. The purpose of our study was to understand the early pandemic experience of primary care practices, how they adapted care processes for chronic disease management and preventive care, and the future potential of these practices' service delivery adaptations., Methods: We interviewed 44 providers and staff at 22 high-performing primary care practices located throughout the United States between March and May 2020. Interviews were transcribed and coded using a modified rapid assessment process due to the time-sensitive nature of the study., Results: Practices reported employing a variety of adaptations to care during the COVID-19 pandemic including maintaining safe and socially distanced access through increased use of telehealth visits, using disease registries to identify and proactively outreach to patients, providing remote patient education, and incorporating more home-based monitoring into care. Routine screening and testing slowed considerably, resulting in concerns about delayed detection. Patients with fewer resources, lower health literacy, and older adults were the most difficult to reach and manage during this time., Conclusion: Our findings indicate that primary care structures and processes developed for remote chronic disease management and preventive care are evolving rapidly. Emerging adapted care processes, most notably remote provision of care, are promising and may endure beyond the pandemic, but issues of equity must be addressed (e.g., through payment reform) to ensure vulnerable populations receive the same benefit., (© 2021. The Author(s).)

Objective: The Endocrinology ECHO intervention utilized a tele-mentoring model that connects primary care providers (PCPs) and community health workers (CHWs) with specialists for training in diabetes care. We evaluated the impact of the Endo ECHO intervention on healthcare utilization and care for Medicaid patients with diabetes in New Mexico., Methods: Between January 2015 and April 2017, patients with complex diabetes from 10 health centers in NM were recruited to receive diabetes care from a PCP and CHW upskilled through Endo ECHO. We matched intervention patients in the NM Medicaid claims database to comparison Medicaid beneficiaries using 5:1 propensity matching. We used a difference-in-difference (DID) approach to compare utilization and processes of care between intervention and comparison patients., Results: Of 541 Medicaid patients enrolled in Endo ECHO, 305 met inclusion criteria and were successfully matched. Outpatient visits increased with Endo ECHO for intervention patients as compared to comparison patients (rate ratio, 1.57; 95% confidence interval &lsqb;CI], 1.43 to 1.72). The intervention was associated with an increase in emergency department (ED) visits (rate ratio, 1.30; 95% CI, 1.04 to 1.63) but no change in hospitalizations (rate ratio, 1.47; 95% CI, 0.95 to 2.23). Among intervention patients, utilization of metformin increased from 57.1% to 60.7%, with a DID between groups of 8.8% (95% CI, 4.0% to 13.6%). We found similar increases in use of statins (DID, 8.5%; 95% CI, 3.2% to 13.8%), angiotensin-converting enzyme inhibitors (DID, 9.5%; 95% CI, 3.5% to 15.4%), or antidepressant therapies (DID, 9.4%; 95% CI, 1.1% to 18.1%)., Conclusion: Patient enrollment in Endo ECHO was associated with increased outpatient and ED utilization and increased uptake of prescription-related quality measures. No impact was observed on hospitalization., (© 2020 American Association of Clinical Endocrinologists. Published by Elsevier, Inc. All rights reserved.)

Clinicians are aware of the importance of thromboprophylaxis, and that the application of measures to prevent venous thromboembolism (VTE) occurrence in hospitalized patients must be improved. To enhance clinician execution of appropriate steps to reduce the risk of inpatient VTE, a performance improvement (PI) continuing medical education (CME) initiative consisting of 3 independent tracks for hospitalized patients-patients who are medically ill, patients receiving oncology treatment, and patients undergoing major orthopedic surgery-was designed and implemented. After a baseline chart review of select evidenced-based performance measures for VTE risk stratification and prevention, participants identified ≥ 1 area of personal improvement. Participants then engaged in a period of self-improvement and reassessed their performance with a second chart review. After participating in the PI CME activity, clinician participants in the medically ill track increased their documentation of VTE risk assessments upon patient admission from baseline (56% vs 93%, n = 250; P < 0.001) and their prescription of low-molecular-weight heparin, low-dose unfractionated heparin, or fondaparinux (72% vs 88%, n = 250; P < 0.001). Orthopedic-track participants were significantly more likely to prescribe 15 to 35 days of VTE prophylaxis after total hip arthroplasty or hip fracture surgery upon patient discharge compared with baseline (51%, n = 123 vs 61%, n = 107; P < 0.001). Oncology-track participants demonstrated a nonsignificant trend for assessing and documenting bleeding risk after participation in the PI CME activity (56% vs 68%, n = 80; P = 0.143). Improvements in evidence-based strategies to reduce the risk of inpatient VTE were associated with PI CME participation. Although areas for improvement remain, increased participant identification and use of prophylactic measures can reduce the risk of VTE in hospitalized patients.

Purpose: In the United States, colorectal cancer (CRC) is the third leading cause of cancer after breast and prostate cancer. Numerous improvement programs have been implemented to increase CRC screening rates, but few have focused on improving the care and management of patients with a diagnosis of this malignancy. As national medical organizations focus on quality of care, efforts are necessary to provide clinicians the opportunity for self-assessment and methods for practice improvement. With this goal in mind, a national continuing medical education-certified performance improvement initiative was conceived., Methods: THE INITIATIVE CONSISTED OF THREE STAGES: First, participants self-assessed their performance of predetermined topic measures through a review of patient charts. The topic areas included patient safety and supportive care, evidence-based surveillance, and evidenced-based treatment and were derived from current guidelines and other successful quality-improvement initiatives. Second, an actionable plan for practice improvement was developed in at least one of the three topic areas. Third, after a period of self-improvement, participants reassessed their performance of the same topic measures to determine tangible changes in patient care., Results: A total of 540 patient charts were reviewed by 27 clinicians. Notable results showed large gains in areas of supportive care, such as quantitative pain assessments and emotional well-being evaluations, which traditionally have been a minor focus of other quality-improvement initiatives. Participants also showed tangible improvements in the performance of leading measures of quality care., Conclusion: These findings support the need for continued efforts toward performance improvement in both established and emerging areas of CRC patient care.

Despite the existence and wide acceptance of guidelines for the treatment of patients with acute coronary syndromes, gaps in patient care still remain. To improve clinical processes of acute coronary syndromes care, a performance improvement (PI) continuing medical education (CME) program, a CME format approved by the American Medical Association, was developed. Clinician participants underwent a 3-stage process: (1) an initial patient chart review for self-assessment purposes, (2) the development and implementation of a personalized PI plan focusing on strategies to enhance processes of care, and (3) a second patient chart review to assess the changes in practice. Although participants provided a high baseline level of guideline-recommended care, there was an improvement in the documentation of the use of risk scores and a trend towards improved treatment times including many participants reaching a door-to-needle time of within 30 minutes. Participants were also more likely to measure cardiac biomarkers and document electrocardiogram performance times. These results demonstrate that PI is a valid and effective means of CME that has the potential to positively affect patient outcomes.

The American College of Cardiology and the American Heart Association guidelines are the nationally accepted standards for the treatment of patients with acute coronary syndromes. Despite this recognition, adherence to guideline recommendations remains suboptimal with 25% of opportunities to provide guideline appropriate care missed. To address performance gaps related to acute coronary syndrome care and improve patient outcomes, a performance improvement (PI) initiative was designed for cardiologists and emergency department physicians. As an American Medical Association-approved, standardized continuing medical education initiative, participating physicians can earn up to 20 American Medical Association-PRA Category 1 Credits by completing 2 phases of self-assessment in addition to developing and implementing a PI plan to address self-identified areas where improvement in patient care is needed. As the second in a series of 3 articles, this article describes the initial data submitted by 101 participating physicians and how their treatment practices compared with American College of Cardiology/American Heart Association guidelines as well as with current national standards. Overall, participating physicians meet guideline expectations with performance and documentation of a 12-lead electrocardiography, measurement of cardiac biomarkers, and administration of aspirin. Identified areas of improvement were the standardization of treatment protocols, use of risk assessment scores, appropriate dosing of anticoagulants, and improvement in patient treatment times. A noted challenge of this PI initiative is the low rate of physician participation, with fewer than 10% of registered physicians actively submitting patient data. This fact may reflect several barriers to PI, such as: (1) lack of time to collect and submit data, (2) the belief that current practices do not need to be improved, and (3) the need for system-based improvements.

Arterial and venous thrombosis are serious health threats. Patients with atrial fibrillation (AF), acute coronary syndromes (ACS), and venous thromboembolism (VTE) can reduce their risk of thrombosis through proper anticoagulation. Multiple evidence-based guidelines exist regarding the proper use of antithrombotic therapy, yet previous studies have shown the prevalence of inconsistent practices with respect to guideline recommendations. Here, we describe a survey of 647 practicing physicians and their current beliefs, behaviors, and knowledge surrounding the use of antithrombotic therapies in the treatment of their patients with AF, ACS, and VTE. Results show that while most physicians are confident in their abilities to treat patients with these conditions, specific knowledge of guideline recommendations for the optimal use of antithrombotic agents use is low. In addition, physician concerns over bleeding risks and complicated monitoring procedures associated with antithrombotic use were reported as barriers to their use in patients. Survey results also demonstrated that physicians have little knowledge of investigational antithrombotic agents, but would like education about them. These data suggest a need for education on guideline recommendations regarding the appropriate use of current antithrombotic therapies, as well as a need for information on the potential benefits and limitations of investigational drugs that may be used in the future to manage thrombosis in patients with AF, ACS, and VTE.

Objectives: We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma., Methods: Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance., Results: Caregivers' level of acculturation was associated with children's diagnosed asthma (P = .025) and total asthma (P = .078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR] = 1.12, P= .005) and children's insurance, both public (OR = 4.71, P= .009) and private (OR = 2.87, P= .071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P= .001)., Conclusions: The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk.