Comparing Primary Health-Care Service Delivery Disruptions Across Disasters

Objective: The aim of this study was to compare primary care appointment disruptions around Hurricanes Ike (2008) and Harvey (2017) and identify patterns that indicate differing continuity of primary care or care systems across events. Methods: Primary care appointment records covering 5 wk before and after each storm were identified for Veterans Health Affairs (VA) facilities in the greater Houston and surrounding areas and a comparison group of VA facilities located elsewhere. Appointment disposition percentages were compared within and across storm events to assess care disruptions. Results: For Hurricane Harvey, 14% of primary care appointments were completed during the week of landfall (vs 33% for Hurricane Ike and 69% in comparison clinics), and 49% were completed the following week (vs 58% for Hurricane Ike and 71% for comparison clinics). By the second week after Hurricane Ike and third week after Harvey, the scheduled appointment completion percentage returned to prestorm levels of approximately 60%. Conclusions: There were greater and more persistent care disruptions for Hurricane Harvey relative to Hurricane Ike. As catastrophic emergencies including major natural disasters and infectious disease pandemics become a more recognized threat to primary and preventive care delivery, health-care systems should consider implementing strategies to monitor and ensure primary care appointment continuity.

Maternal health around pregnancy and autism risk: a diagnosis-wide, population-based study

Background Many studies have reported an increased risk of autism spectrum disorder (ASD) associated with some maternal diagnoses in pregnancy. However, such associations have not been studied systematically, accounting for comorbidity between maternal disorders. Therefore our aim was to comprehensively test the associations between maternal diagnoses around pregnancy and ASD risk in offspring. Methods This exploratory case–cohort study included children born in Israel from 1997 to 2008, and followed up until 2015. We used information on all ICD-9 codes received by their mothers during pregnancy and the preceding year. ASD risk associated with each of those conditions was calculated using Cox proportional hazards regression, adjusted for the confounders (birth year, maternal age, socioeconomic status and number of ICD-9 diagnoses during the exposure period). Results The analytic sample consisted of 80 187 individuals (1132 cases, 79 055 controls), with 822 unique ICD-9 codes recorded in their mothers. After extensive quality control, 22 maternal diagnoses were nominally significantly associated with offspring ASD, with 16 of those surviving subsequent filtering steps (permutation testing, multiple testing correction, multiple regression). Among those, we recorded an increased risk of ASD associated with metabolic [e.g. hypertension; HR = 2.74 (1.92–3.90), p = 2.43 × 10−8], genitourinary [e.g. non-inflammatory disorders of cervix; HR = 1.88 (1.38–2.57), p = 7.06 × 10−5] and psychiatric [depressive disorder; HR = 2.11 (1.32–3.35), p = 1.70 × 10−3] diagnoses. Meanwhile, mothers of children with ASD were less likely to attend prenatal care appointment [HR = 0.62 (0.54–0.71), p = 1.80 × 10−11]. Conclusions Sixteen maternal diagnoses were associated with ASD in the offspring, after rigorous filtering of potential false-positive associations. Replication in other cohorts and further research to understand the mechanisms underlying the observed associations with ASD are warranted.

Improving Advance Care Planning Documentation Using Reminders to Patients and Physicians: A Longitudinal Study in Primary Care

Objective: Documenting advance care planning (ACP) in primary care requires multiple triggers. New Medicare codes make it easier for providers to bill for these encounters. This study examines the use of patient and provider reminders to trigger advance care planning discussions in a primary care practice. Secondary outcome was billing of new ACP billing codes. Methods: Patients 75 years and older scheduled for a primary care appointment were screened for recent ACP documentation in their chart. If none was found, an electronic or mail message was sent to the patient, and an electronic message to their provider, about the need to have discussion at the upcoming visit. Chart review was performed 3 months after the visit to determine if new ACP discussion was documented in the chart. Results: In the 3 months after the reminder had been sent to patients and providers, new ACP documentation or billing was found in 28.8% of the patients. Most new documentation was health care decision maker (75.6% of new documentation) with new DNR orders placed for 32.3% of these patients. The new Medicare billing code was filled 10 times (7.8%). Conclusion: Reminders sent to both patients and providers can increase documentation of ACP during primary care visits, but rarely triggers a full ACP conversation.

Holistic approach to improved patient satisfaction in family medicine clinic: Findings from a tertiary facility-based survey in Calabar, Nigeria

Objectives: Patient satisfaction remains a critical tool for assessing quality of care in the emerging context of patient-centered care. The objective of this study was to assess patient satisfaction with services received at a tertiary family medicine clinic in Calabar, Nigeria. Material and Methods: This was a cross-sectional descriptive study with data collected from 208 adults by systematic random sampling using a validated self-administered patient satisfaction questionnaire-46. Data were analyzed using SPSS version 18. Results: Most respondents (188, 90.4%) were generally satisfied with overall services. Highest prevalence of satisfaction was with doctors (95.7%), while least prevalence of satisfaction was with facility (27.9%). Satisfaction with nurses and appointment each had prevalence rate of 69.2%, while 65.9% were satisfied with access to care. Proportionally, subjects who were satisfied with each of the five domains access, doctors and nurses care, appointment, and facility were also satisfied generally and vice versa (P < 0.05). Conclusion: In conclusion, a significant proportion of patients were satisfied with services received at the family medicine clinic. The level of patient satisfaction was dependent on the entire chain of service delivery. Patient satisfaction could be further improved by improving the five domains assessed, especially the condition of care environment at the clinic. Findings of this study may contribute significantly to improved patient care, add to existing local literature and further studies.

Characterization and Comparison of Primary Care Appointment Utilization Patterns Among Military Health System Beneficiaries

Introduction The role of primary care in the United States is vitally important to improving health outcomes, minimizing waste, and controlling cost. The Military Health System is tasked with both caring for its beneficiaries and ensuring the medical readiness of active duty service members, who often have needs unique to those in the civilian population. Balancing the number of individuals assigned to a primary care clinician with the clinician’s capacity to meet their medical needs and anticipated appointment demand is a fundamental cornerstone of effective primary care clinic management in any setting. Materials and methods Using the Military Health System Data Repository, this cross-sectional study utilized descriptive statistics and Poisson regression to describe crude and adjusted primary care appointment utilization trends among Military Health System beneficiaries during fiscal year 2016. Results The primary care appointment utilization rate of the study population was 3.3 visits per person-year. The youngest and oldest age groups, women, active duty, and those enrolled to Army clinics had the highest utilization rates within each of the respective covariates. Active duty women had the highest utilization of any group in the data set, with a crude rate of 4.7 visits per person-year. Conclusions Primary care utilization trends are different among different demographic subgroups within the Military Health System (MHS). Unmet demand, patient acuity, clinician continuity, robustness of team support, and other important factors that influence appointment utilization were not incorporated in this study. Superficially, these data suggest that the MHS enrollment target of 1,100–1,300 patients per full-time primary care clinician is roughly appropriate, though this should be interpreted with caution given the limitations.

Reduced health-care utilization among people with chronic medical conditions during coronavirus disease 2019

The coronavirus disease 2019 (COVID-19) outbreak may impact the health-care-seeking behaviour of people with pre-existing chronic medical conditions. We aimed to assess the extent, reasons and correlates of reduced health-care utilization among people with chronic medical conditions in Singapore during the COVID-19 pandemic. We administered a web-survey to a panel of residents between 31 March and 14 April 2020. We assessed the proportion of participants with self-reported chronic conditions that missed their health-care appointment during the outbreak either voluntarily (demand driven) or because it was cancelled by their provider (supply driven). We performed a logistic regression to examine the association of voluntarily missing the health-care appointment with participants’ age and risk perceptions. Of the 1017 surveyed participants, 349 reported at least one chronic medical condition. Of these, 40% reported missing their health-care appointment during the COVID-19 outbreak. Of these, 72% did so voluntarily, and 39% reported that it was cancelled by their provider. Younger participants, those with a greater worry of contracting COVID-19 and those with a higher perceived risk of dying due to COVID-19 were more likely to miss their health-care appointments voluntarily. These results highlight the need to ensure continuity of care for people with chronic medical conditions in order to avoid the long-term impact on their health and mortality.