COVID-19 Ahead-of-Print Subject Collection

The following ahead-of-print manuscripts are available for download below. All manuscripts listed are under copyright by the American Board of Family Medicine and will be published in a special copy-edited February 2021 (v34/s1) issue. The final published version of each manuscript will be indexed in PubMed. Please note ahead-of-print manuscripts are not copy edited and information could change during the publishing process. 

POLICY BRIEF

COMMENTARIES

ORIGINAL RESEARCH

EVIDENCE-BASED CLINICAL MEDICINE

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

SPECIAL COMMUNICATIONS

BRIEF REPORTS

RESEARCH LETTERS

REFLECTIONS IN FAMILY MEDICINE

POLICY BRIEF

COVID Timeline: CMS Changes and Primary Care Support Were Not Enough to Prevent Practice Losses

Christian Gausvik, MD; Yalda Jabbarpour, MD

Corresponding Author: Christian Gausvik, MD; The Robert Graham Center for Policy Studies in Primary Care. Email: christian.gausvik@gmail.com       

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COMMENTARY

Family Physicians’ Role in Simplifying Medication Abortion During the COVID-19 Pandemic and Beyond

Payal Patel, MD; Sumathi Narayana, MD, MS; Zoey Thill, MD, MPP, MPH; Marji Gold, MD; Zoey Thill, MD, MPP, MPH; Allison Paul, MD, MPH

Corresponding Author: Marji Gold, MD; Albert Einstein College of Medicine. Email: marji.gold@einsteinmed.org

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Introduction: Despite first trimester abortion being common and safe, there are numerous restrictions that lead to barriers to seeking abortion care. The COVID-19 pandemic has only exacerbated these barriers, as many state legislators push to limit abortion access even further. During this pandemic, family physicians across the country have incorporated telemedicine into their practices to continue to meet patient needs. Medication abortion can be offered to patients by telemedicine in most states, and multiple studies have shown that labs, imaging, and physical exam are not medically necessary for the majority of cases. Furthermore, several studies have highlighted that medication abortion is safe and effective when offered in the family medicine setting. Methods: Data from the 2018-2019 Family Medicine National Graduate Survey were analyzed to determine the proportion of respondents who indicated they were trained to provide pregnancy termination and were providing pregnancy termination upon graduation. Results: Of the family medicine graduates three years out of residency, 3.7% of respondents reported providing pregnancy termination. However, 13.3% of respondents reported feeling prepared to provide pregnancy termination based on training during residency. Conclusion: Family physicians are well-poised to incorporate medication abortion into their practices using approaches that limit the spread of the coronavirus, ultimately increasing access to abortion in these unprecedented times.

COMMENTARY

Respiratory Illness and Site of Care – Implications for COVID-19 Like Illness

John M Westfall; Anuradha Jetty; Stephen Petterson; Yalda Jabbarpour

Corresponding Author: John M Westfall; Robert Graham Center. Email: jack.westfall@ucdenver.edu

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COVID-19 is primarily a respiratory illness. Historically, upper and lower respiratory illness has been cared for at home or in the ambulatory primary care setting. It is likely that patients experiencing COVID-19 like symptoms may first contact their primary care provider.The Medical Expenditure Panel Survey (MEPS) is a representative sample of patients from the United States that regularly assesses their use of medical care services. We analyzed 2017 MEPS data to determine the number and proportion of patients who were seen in primary care or family medicine ambulatory settings or hospitalized for upper or lower respiratory illness or pneumonia.  In a given year, 19.5 million patients are seen by primary care for a upper respiratory illness, 10.7 million patients for bronchitis, and 9 million for pneumonia. In contrast, 890,000 patients are hospitalized with pneumonia . Given that a primary etiology for respiratory illness in early 2020 was SARS CoV-2 (COVID-19) primary care practices likely were the site of first contact for most patients with COVID-19 illness. Unfortunately, there has been inadequate support for in-person and telehealth visits. Primary care clinicians reported serious shortages of personal protective equipment (PPE) and testing capacity. Inadequate reimbursement for telehealth visits coupled with decreased in-person visits put primary care practices at risk of layoffs and closure. Policies related to primary care payment, federal relief efforts, PPE access, testing and follow-up capacity, and telehealth technical support are essential so primary care can provide first contact and continuity for their patients and communities throughout the COVID-19 pandemic response and recovery.

COMMENTARY

Advance Care Planning During the COVID-19 Pandemic

Melissa A. Bender, MD, FAAHPM; Kuang-Ning Huang, MD; Jaqueline Raetz, MD

Corresponding Author: Melissa A. Bender, MD, FAAHPM; University of Washington School of Medicine. Email: benderma@uw.edu

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Background: Advance care planning (ACP) is especially important during the COVID-19 pandemic. Previously identified barriers to ACP include lack of time during patient visits, billing, clinician and patient discomfort and lack of resources, and difficulties with documenting and accessing ACP documents. Purpose: Here we describe new challenges and new opportunities for ACP that have arisen from the COVID-19 pandemic, both due to the complexities of the illness and expedited changes in some of the stagnancies in the healthcare system. Discussion: The shared risk for COVID-19 that all people face brings urgency to ACP conversations that include eliciting patient preferences regarding care in the context of becoming critically ill with COVID-19. The pandemic has expedited changes that may facilitate ACP completion, including improved access and ability to bill for telehealth and telephone visits, and institutional policy changes to ACP form completion. However, research should assess acceptability and effectiveness of these strategies.

COMMENTARY

Achieving Equity in Telehealth: "Centering at the Margins" in Access, Provision, and Reimbursement

Andrea Westby, MD, FAAFP; Tanner Nissly, DO; Rebecca Gieseker, MD, PGY-1; Kaleigh Timmins, MD, PGY-1; Kathryn Justesen, MD

Corresponding Author: Andrea Westby, MD, FAAFP; University of Minnesota Medical School. Email: westby@umn.edu

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The SARS-CoV2 epidemic has led to rapid transformation of healthcare delivery and access with increased provision of telehealth services despite previously identified barriers and limitations to this care. While telehealth was initially envisioned to increase equitable access to care for under-resourced populations, the way in which telehealth provision is designed and implemented may result in worsening disparities if not thoughtfully done. This commentary seeks to demonstrate the opportunities for telehealth equity based on past research, recent developments, and a recent patient experience case example highlighting benefits of telehealth care in underserved patient populations. Recommendations to improve equity in telehealth provision include improved virtual visit technology with a focus on patient ease of use, strategies to increase access to video visit equipment, universal broadband wireless, and inclusion of telephone visits in CMS reimbursement criteria for telehealth.

COMMENTARY

What Can Your Pharmacist Do For You? The Time is Now to Embrace the Pharmacist as Part of the Primary Care Team

Cynthia Moreau, PharmD, BCACP

Corresponding Author: Cynthia Moreau, PharmD, BCACP; Nova Southeastern University College of Pharmacy. Email: Cm1524@nova.edu

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Pharmacists’ roles and training have evolved to prepare pharmacists to provide clinical patient care services as part of interdisciplinary teams in primary care settings. Especially now, amidst a global health crisis such as COVID-19, patients may become more aware of their health status and be exposed to increased medical information in the media. Additionally, some patients may have delayed routine care, which may result in exacerbations of chronic disease states. Pharmacists can help alleviate the burden on primary care providers by serving as a drug information resource for patients and staff while providing patient education on management of chronic disease states.

COMMENTARY

The CMS COVID-19 Brief: Unsettling Racial and Ethnic Health Disparities

Eli Y. Adashi, MD, MS; Philip A. Gruppuso, MD

Corresponding Author: Eli Y. Adashi, MD, MS; Brown University. Email: eli_adashi@brown.edu

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On June 22, 2020, the Centers for Medicare & Medicaid Services (CMS) unveiled an aggregate data set on the impact of the coronavirus disease 2019 (COVID-19) on its beneficiaries. The CMS brief is especially noteworthy for offering COVID-19-related racial and ethnic health disparity data on a national scale thereby extending reports heretofore limited to states, cities, or health systems. The CMS COVID-19 brief exposes distressing racial and ethnic health disparities.  It is the objective of this commentary to trace the origins of the CMS COVID-19 brief, discuss its salient findings, and consider its implications.

ORIGINAL RESEARCH

A National Study of Community Health Centers’ Readiness to Address COVID-19

April Joy Damian, PhD,MSc; Melanie Gonzalez, MA; May Oo, MPH; Daren Anderson, MD

Corresponding Author: April Joy Damian, PhD, MSc; Johns Hopkins Bloomberg School of Public Health. Email: adamian2@jhu.edu

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Background: The coronavirus disease 2019 (COVID-19) outbreak, a public health emergency of international concern, poses a serious health risk, particularly for older adults and persons with underlying chronic medical conditions. Community health centers (CHCs) serve as the patient medical home for populations that are disproportionately more susceptible to COVID-19; yet, there is a lack of understanding of the current efforts in place by CHCs working to prepare for and respond to the current pandemic. Methods: We conducted a sequential explanatory mixed methods approach, using a comprehensive cross-sectional survey and focus groups with physicians, nurses, medical support staff, and administrative leaders to understand the needs and current efforts in place by CHCs across the U.S. working to prepare for and respond to COVID-19. We applied the transcript-based analysis approach to the focus group data and derived themes using the constant comparative method. Results: Survey respondents (n=234; 19% response rate) identified guidance regarding COVID-19 infection prevention and control (76%), safety precautions (72%), and screening, diagnostic testing, and management of patients (66%) as their major educational needs. Findings from the focus groups (n=39) highlighted five key themes relevant to foundational aspects of readiness: leadership, resources, workforce capacity, communication, and formal policies and procedures. Discussion and Conclusion: The COVID-19 pandemic has exacerbated longstanding capacity issues that CHCs have faced, making it challenging for these safety-net practices to adequately respond to the current disease outbreak. Policies that promote greater investment in CHCs may strengthen these systems to better meet the needs of the most vulnerable members of society, and thereby, help flatten the curve.

ORIGINAL RESEARCH

Capacity of Primary Care to Deliver Telehealth in the United States

Anuradha Jetty, MPH; Yalda Jabbarpour, MD; Matthew Westfall, BA; Douglas B Kamerow, MD, MPH; Stephen Petterson, PhD; John Westfall, MD MPH

Corresponding Author: Anuradha Jetty, MPH; The Robert Graham Center for Policy Studies in Primary Care. Email: ajetty@aafp.org

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Background: Because of the COVID 19 pandemic, many primary care practices have transitioned to telehealth visits to keep patients at home and decrease the transmission of the disease. Yet, little is known about the nationwide capacity for delivering primary care services via telehealth. Methods: Using the 2016 National Ambulatory Medical Survey we estimated the number and proportion of reported visits and services that could be provided via telehealth. We also performed cross-tabulations to calculate the number and proportion of physicians providing telephone visits and email/internet encounters. Results: Of the total visits (nearly 400 million) to primary care physicians, 42% were amenable to telehealth and 73% of the total services rendered could be delivered through telehealth modalities. Of the primary care physicians, 44% provided telephone consults and 19% provided e-consults. Discussion: This study underscores how and where primary care services could be delivered. It provides the first estimates of the capacity of primary care to provide telehealth services for COVID-19 related illness, and for several other acute and chronic medical conditions. It also highlights the fact that, as of 2016, most outpatient telehealth visits were done via telephone. Conclusions: This study provides an estimate of the primary care capacity to deliver telehealth and can guide practices and payers as care delivery models change in a post-COVID 19 environment.

ORIGINAL RESEARCH

Demographic Characteristics Associated with Utilization of Noninvasive Treatments for Chronic Low Back Pain and Related Clinical Outcomes During the COVID-19 Pandemic in the United States

John C. Licciardone, DO, MS, MBA

Corresponding Author: John C. Licciardone, DO, MS, MBA; University of North Texas Health Science Center. Email: john.licciardone@unthsc.edu

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Introduction: This study was conducted to determine if limited access to health care during the COVID-19 pandemic impacted utilization of recommended non-pharmacological treatments, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids by persons with chronic low back pain and affected clinical outcomes relating to pain intensity and disability. Methods: Participants within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation were eligible if they provided encounter data in the three months immediately before and after the national emergency proclamation date (NEPD). Results: The mean age of the 528 study participants was 53.9 yr and 74.1% were women. Utilization of exercise therapy, massage therapy, and spinal manipulation decreased during the pandemic. Increasing age was associated with decreased utilization of all non-pharmacological treatments except exercise therapy, and with increased opioid use during the pandemic. African-American participants reported decreased utilization of yoga and spinal manipulation during the pandemic. Overall, mean change scores for pain intensity and disability before and after the NEPD were not significant. However, African-American participants consistently reported worse pain intensity and disability outcomes during the pandemic. Marginally worse outcomes were observed less consistently for pain intensity with increasing age and for disability among women. Discussion: Social distancing during the pandemic impacted the uptake of recommended non-pharmacological treatments for chronic low back pain that require visiting community-based facilities or interacting closely with providers. Conclusions: The pandemic threatens to exacerbate the impact of chronic low back pain, particularly among African-American patients and the older population, by impeding access to guideline-informed noninvasive treatments.

ORIGINAL RESEARCH

Key Factors Promoting Rapid Implementation of Virtual Screening Modalities for the COVID-19 Pandemic Response

Beth Careyva, MD; Grant Greenberg, MD, MHSA, MA; Robert Kruklitis, MD, PhD; Kyle Shaak, MPH; John Stoekle, MD; Jennifer Stephens, DO, FACP

Corresponding Author: Beth Careyva, MD; Lehigh Valley Health Network. Email: beth_a.careyva@lvhn.org

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Background: The COVID-19 (C-19) pandemic required swift response from healthcare organizations to mitigate spread and impact. A large integrated health network rapidly deployed and operationalized multiple access channels to the community, allowing assessment and triage to occur virtually. These channels were characterized by swift implementation of virtual models including asynchronous e-visits, and video visits for C-19 screening. Purpose: 1) Evaluate implementation characteristics of C-19 screening e-visits and video visits. 2) Identify volume of C-19 screening and other care provided via e-visits and video visits 3) Discuss future implications of expanded virtual access models. Methods: Retrospective analysis of implementation data for C-19 screening e-visits and video visits in a large health network including operational characteristics and visit / screening volumes conducted. Results: Virtual channels were implemented and rapidly expanded within this organization during the first week C-19 testing was made available. Over the study period, primary care clinicians conducted 10,673 e-visits and 31,226 video visits with 9,126 and 26,009 patients, respectively. Within these two virtual modalities, 4,267 C-19 tests were ordered (10% of visits). 448 clinicians participated in supporting 24/7 access to these virtual modalities. Discussion: Implementation of C-19 screening virtual visits required I/S infrastructure creation, stakeholder engagement, development and modification of EHR templates and an available workforce. Rapid deployment of these methods provided timely access to effective C-19 community screening. Given ongoing patient interest and opportunity, virtual healthcare services will continue to be available for an expanded number of symptoms and diagnoses.

ORIGINAL RESEARCH

On the Front (Phone) Lines: Results of a COVID-19 Hotline in Northeast Ohio

David Margolius, MD; Mary Hennekes, BS; Jimmy Yao, BA; Douglas Einstadter, MD, MPH; Douglas Gunzler, PhD; Nabil Chehade, MD; Ashwini R. Sehgal, MD; Yasir Tarabichi, MD; Adam T. Perzynski, PhD

Corresponding Author: Adam T. Perzynski, PhD; Case Western Reserve University. Email: Adam.Perzynski@case.edu

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Background: Severe acute respiratory syndrome coronavirus (SARS-CoV-2) and the associated coronavirus disease of 2019 (COVID-19) have presented immense challenges for health care systems. Many regions have struggled to adapt to disruptions to health care practice and employ systems that effectively manage the demand for services. Methods: This was a cohort study using electronic health records at a health care system in Northeast Ohio that examined the effectiveness of the first five weeks of a 24/7 physician-staffed COVID-19 hotline including social care referrals for patients required to self-isolate. We describe clinical diagnosis, patient characteristics (age, sex race/ethnicity, smoking status, insurance status), and visit disposition. We use logistic regression to evaluate associations between patient characteristics, visit disposition and subsequent emergency department use, hospitalization, and SARS-Cov-2 PCR testing. Participants: In 5 weeks, 10,112 patients called the hotline (callers). Of these, 4,213 (42%) were referred for a physician telehealth visit (telehealth patients). Mean age of callers was 42 years; 67% were female, 51% white, and 46% were on Medicaid/uninsured. Results: Common caller concerns included cough, fever, and shortness of breath. Most telehealth patients (79%) were advised to self-isolate at home, 14% were determined to be unlikely to have COVID-19, 3% were advised to seek emergency care, and 4% had miscellaneous other dispositions. A total of 287 (7%) patients had a subsequent ED visit, and 44 (1%) were hospitalized with a COVID-19 diagnosis. Of the callers, 482 (5%) had a COVID-19 test reported with 69 (14%) testing positive. Among patients advised to stay at home, 83% had no further face-to-face visits. In multivariable results, only a physician recommendation to seek emergency care was associated with emergency room use (OR=4.73, 95%CI 1.37-16.39, p=.014). Only older age was associated with having a positive test result. Patients with social needs and interest in receiving help were offered services to meet their needs including food deliveries (N=92), behavioral health telephone visits (N=49), and faith-based comfort calls from pastoral care personnel (N=37). Conclusions and Relevance: Robust, physician-directed telehealth services can meet a wide range of clinical and social needs during the acute phase of a pandemic, conserving scarce resources such as personal protective equipment and testing supplies and preventing the spread of infections to patients and health care workers.

ORIGINAL RESEARCH

Development and Validation of the COVID-NoLab and COVID-SimpleLab Risk Scores for Prognosis in 6 US Health Systems

Mark H. Ebell, MD, MS; Xinyan Cai, MPH; Robert Lennon, MD; Derjung M. Tarn, MD, PhD; Arch G. Mainous III, PhD; Aleksandra E. Zgierska, MD, PhD; Bruce Barrett, MD, PhD; Wen-Jan Tuan, DHA, MS, MPH; Kevin Maloy, MD; Munish Goyal, MD; Alex Krist MD, MPH, PhD

Corresponding Author: Mark H. Ebell, MD, MS; UGA Health Sciences Campus. Email: ebell@uga.edu 

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Purpose: To develop and validate simple risk scores based on initial clinical data and no or minimal laboratory testing to predict mortality in hospitalized adults with COVID-19. Methods: We identified consecutive inpatients with COVID-19 who had either died or been discharged alive at six US health centers and gathered clinical and initial laboratory variables n admission. Data were divided into derivation and validation groups. Logistic regression was used to develop two predictive models, one using no laboratory values (COVID-NoLab) and one adding tests available in many outpatient settings (COVID-SimpleLab). The regression models were converted to point scores and their accuracy evaluated in the validation group. Results: We identified 1340 adult inpatients who had complete data for non-laboratory parameters and 741 who had complete data for white blood cell count (WBC), differential, creactive protein (CRP), and serum creatinine. The COVID-NoLab risk score includes age, respiratory rate, and oxygen saturation and identified risk groups with 0.8%, 11.4% and 40.4% mortality in the validation group (AUROCC=0.803). The COVID-SimpleLab risk score includes age, respiratory rate, oxygen saturation, WBC, CRP, serum creatinine and comorbid asthma, and identified risk groups with 1.0%, 9.1%, and 29.3% mortality in the validation group (AUROCC=0.833). Calibration of both models was good. Conclusions: We developed and internally validated two simple risk scores for hospitalized patients that require either no or minimal laboratory testing. Due to their limited data requirements these risk scores have potential applicability in the outpatient setting, but require prospective validation in that setting before being used.

EVIDENCE-BASED CLINICAL MEDICINE

Interpreting COVID-19 Test Results in Clinical Settings: It Depends!

Rachael Piltch-Loeb, PhD; Kyeong Yun Jeong; Kenneth W. Lin, MD, MPH; John D. Kraemer, JD, MPH; Michael A. Stoto, PhD

Corresponding Author: Kenneth W. Lin, MD, MPH; Georgetown University Medical Center. Email: Kenneth.Lin@georgetown.edu

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Tests for COVID-19 are intended for a disparate and shifting range of purposes including: (1) diagnosing patients who present with symptoms to inform individual treatment decisions; (2) organizational uses such as “cohorting” potentially infected patients and staff to protect others; and (3) contact tracing, surveillance, and other public health purposes. Often lost when testing is encouraged is that testing does not by itself confer health benefits. Rather, testing is useful to the extent it forms a critical link to subsequent medical or public health interventions. Such interventions might be individual-level, like better diagnosis, treatment, isolation, or quarantine of contacts. They might aid surveillance to understand levels and trends of disease within a defined population that enables informed decisions to implement or relax social distancing measures. In this paper, we describe the range of available COVID-19 tests; their accuracy and timing considerations; and the specific clinical, organizational, and public health considerations that warrant different testing strategies. Three representative clinical scenarios illustrate the importance of appropriate test use and interpretation. The reason a patient seeks testing is often a strong indicator of the pre-test probability of infection, and thus how to interpret test results. In addition, the level of population spread of the virus and the timing of testing play critical roles in the positive or negative predictive value of the test. We conclude with practical recommendations regarding the need for testing in various contexts, appropriate tests and testing methods, and the interpretation of test results. 

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Family Medicine with Refugee Newcomers During the COVID-19 Crisis

Jackson Andrew Smith, MA; Jean de Dieu Basabose, PhD; Margaret Brockett, EdD, BSR (OT); Dillon Thomas Browne, Ph.D., CPsych; Sandy Shamon, MD, CCFP (PC); Michael Stephenson, MD

Corresponding Author: Dillon Thomas Browne, PhD, CPsych; University of Waterloo. Email: dillon.browne@uwaterloo.ca

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Certain members of society are disproportionately affected by the COVID-19 crisis and the added strain being placed on already overextended healthcare systems. In this article, we focus on refugee newcomers. We outline vulnerabilities refugee newcomers face in the context of COVID-19, including barriers to accessing healthcare services, disproportionate rates of mental health concerns, financial constraints, racism, and higher likelihoods of living in relatively higher density and multigenerational dwellings. Additionally, we describe the response to COVID-19 by a community-based refugee primary health centre in Ontario, Canada. This includes how the clinic has initially responded to the crisis as well as recommendations for providing services to refugee newcomers as the COVID-19 crisis evolves. Recommendations include: (1) considering social determinants of health in the new context of COVID-19; (2) providing services through a trauma-informed lens; (3) increasing focus on continuity of health and mental health care; and (4) mobilization of International Medical Graduates for triaging patients based on COVID-19 symptoms; and (5) diversifying communication efforts to educate refugees about COVID-19.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Bracing for Impact: One Family Medicine Residency Program’s Response to an Impending COVID-19 Surge

Jessica Devitt, MD; Naomi Malam, MD; Linda Montgomery, MD, FAAFP

Corresponding Author: Jessica Devitt, MD; University of Colorado School of Medicine. Email: jessica.devitt@cuanschutz.edu

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The University of Colorado Family Medicine Residency watched as the first cases of COVID-19 were being reported in the United States along with the rest of the nation in March 2020. Concern grew as epidemiological models began to predict alarming hospital bed shortages for the state. Massive scheduling adjustments were needed as faculty and residents found themselves in groups at high risk for severe COVID-19 and residents found themselves dismissed from non-essential learning experiences in an effort to conserve PPE and limit exposures. A dedicated Surge Team was formed to tackle these issues while continuing to support our goals of maximizing patient safety, resident education, and physician wellness. The Surge Team created a plan that was implemented in 2 main phases. Phase 1 assumed business as usual with increased layers of backup for both residents and faculty. Phase 2 redistributed unassigned residents and inpatient faculty to increase capacity for adult medicine and COVID-19 patients on our essential services. Lessons learned from these surge efforts may help inform similar decisions being made by other residency programs presently and in the future.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Rapid Transition to Telehealth During COVID-19: Lessons Learned That Can Move Primary Care Forward

Kyle Knierim, MD; Brian S. Bacak, MD; Shandra M. Brown Levey, PhD; Heather Holmstrom, MD; Jodi Summers Holtrop, PhD, MCHES; Erik Seth Kramer, DO, MPH; Christina Palmer, MD; Rachel S. Rodriguez, MD; Alison Shmerling, MD, MPH; Peter Smith, MD; Elizabeth W. Staton, MSTC

Corresponding Author: Kyle Knierim, MD; University of Colorado School of Medicine. Email: Kyle.Knierim@cuanschutz.edu

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Introduction: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic. We describe practical guidance for successful, rapid transition to telehealth in primary care. Initial Work: Initial implementation of telehealth began in 2017. Provider reluctance and inadequate reimbursement prevented widespread adoption at the time. The COVID-19 served as the catalyst to accelerate telehealth efforts. Implementation: COVID-19 resulted in the need for patient care with “social distancing.” Also due to the pandemic, the Centers for Medicare and Medicaid Services began expanded reimbursement for telehealth. Practice-based virtual visit champions rapidly developed strategies and training resources to transition to all providers to telehealth. More than 2000 providers received virtual health training in less than two weeks. These efforts contributed to a ready system environment for rapid adoption and upscaling of primary care telehealth. As a result, in March 2020, we provided 2376 virtual visits, and in April 5293, which was over 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October, 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual. Lessons Learned: Several key lessons are important for future efforts regarding clinical implementation: 1) prepare for innovation, 2) cultivate an innovation mindset, 3) standardize (but not too much), 4) technological innovation is necessary but not sufficient, and 4) communicate widely and often.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond

John M. Westfall, Winston Liaw, Kim Griswold, Kurt Stange, Larry A. Green, Robert Phillips, Andrew Bazemore, Carlos Roberto Jaén, Lauren S. Hughes, Jen DeVoe, Heidi Gullett, James C. Puffer, Robin S. Gotler

Corresponding Author: John M. Westfall; 1Robert Graham Center for Policy Studies in Primary Care. Email: jwestfall@aafp.org

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The COVID-19 pandemic has laid bare the dis-integrated healthcare system in the United States. Decades of inattention and dwindling support for public health, coupled with declining access to primary care medical services have left many vulnerable communities without adequate COVID19 response and recovery capacity. Health is a Community Affair is a 1966 effort to build and deploy local communities of solution that align public health, primary care, and community organizations to identify healthcare problem sheds, and activate local asset sheds. After decades of independent effort, the COVID-19 pandemic offers an opportunity to reunite and align the shared goals of public health and primary care. The ideas and concepts laid out in Health is a Community Affair offer a COVID-19 response and recovery approach. By bringing public health and primary care together in community now, a future that includes a shared vision and combined effort may emerge.

SPECIAL COMMUNICATION

Alexa: “Can You Be My Family Medicine Doctor?” The Future of Family Medicine in the Coming Techno-World

Allen F. Shaughnessy, PharmD, MMedEd; David C. Slawson, MD; Ashley P. Duggan, PhD

Corresponding Author: Allen F. Shaughnessy, PharmD, MMedEd; Tufts University School of Medicine. Email: Allen.Shaughnessy@tufts.edu

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Even before social distancing disrupted normative expectations and prompted an immediate shift to remote doctor/patient interactions, technology companies – Amazon, Apple, and Google – were preparing to disrupt medical care through the innovative use of technology. This article presents a possible scenario for how technology, in the near future, will completely up-end primary care practice. What does face-to-face interaction accomplish that cannot be done remotely? What do family physicians offer that can’t be accomplished by technology? More than just relationship, family medicine brings the therapeutic use of the self to engage with people, an ability to advocate for patients, and the ability to step back and reflect on the power of relationships. In addition, family physicians bring wisdom, making decisions in the liminal state between patient and physician, the resulting product of the human connection but also the ability to manage complexity using the best evidence. The ability to do both gives family medicine physician the skills to leverage but also control the coming big data.

SPECIAL COMMUNICATION

A New, More Equitable Normal in Health Care

Cynthia J. Sieck, PhD, MPH; Mark Rastetter, MD; Ann Scheck McAlearney, ScD, MS

Corresponding Author: Cynthia J. Sieck, PhD, MPH; Ohio State University College of Medicine. Email: Cynthia.sieck@osumc.edu

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In response to the COVID-19 pandemic, many physicians and healthcare systems have shifted to providing care via telehealth as much as possible. While necessary to control spread of the virus and preserve personal protective equipment, this shift highlights existing disparities in access and care. Patients without the skills and tools to access telehealth services may increase their risk of exposure by seeking care in-person or may delay care entirely. We know that patients need internet access, devices capable of visual communication, and the skills to use these devices to experience the full benefits of telehealth, yet we also know that disparities are present in each of these areas. Currently, Federal programs have given physicians greater flexibility in providing care remotely and have expanded internet access for vulnerable patients to promote telehealth services. However, these changes are temporary and it is uncertain which will remain when the pandemic is over. Family medicine physicians have an important role to play in identifying and addressing these disparities and facilitating more equitable care moving forward.

SPECIAL COMMUNICATION

Building Bridges Between Community Health Centers and Academic Medical Centers in a Pandemic

Nicholas Kenji Taylor, MD, MSc; Noha Aboelata, MD; Megan Mahoney, MD; Timothy Seay-Morrison, EdD, LCSW; Baldeep Singh, MD; Sang-ick Chang, MD, MPH; Steven M. Asch, MD, MPH; Jonathan G. Shaw, MD, MS

Corresponding Author: Nicholas Kenji Taylor, MD, MSc; Stanford University. Email: kenji.taylor@gmail.com     

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The threat to the public health of the United States from the COVID-19 pandemic is causing rapid, unprecedented shifts in the health care landscape. Community health centers serve the patient populations most vulnerable to the disease, yet often have inadequate resources to combat it. Academic medical centers do not always have the community connections needed for the most effective population health approaches. We describe how a bridge between a community health center partner (Roots Community Health Center) and a large academic medical center (Stanford Medicine) brought complementary strengths together to address the regional public health crisis. The two institutions began the crisis with an overlapping clinical and research faculty member (NKT). Building on that foundation, we worked in three areas. First, we partnered to reach underserved populations with the academic center’s newly developed COVID test. Second, we developed and distributed evidence-based resources to these same communities via a large community health navigator team. Third, as telemedicine became the norm for medical consultation, the two institutions began to research how reducing the digital divide could help improve access to care. We continue to think about how best to create enduring partnerships forged through ongoing deeper relationships beyond the pandemic.

BRIEF REPORT

Localized Scarlatiniform Rash of the Ears and Antecubital Fossa in COVID-19

Timothy Truong Phamduy, DO; Douglas Morris Young, DO; Paras Batuk Ramolia, MD

Corresponding Author: Timothy Truong Phamduy, DO; US Air Force. Email: timothy.phamduy@gmail.com

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The worldwide spread of the novel Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to a global pandemic since its identification in Wuhan, China in December 2019.1 Few cases of COVID-19-associated dermatologic manifestations have been reported in the literature to date. This report describes the clinical features of a localized pruritic scarlatiniform rash of the ears and antecubital fossa upon defervescence in a 29-year-old patient with COVID-19. Our case stands to further illuminate the dermatologic manifestations of this novel disease.

BRIEF REPORT

Launching a Statewide COVID-19 Primary Care Hotline and Telemedicine Service for Oregon

Anthony Cheng, MD; Heather Angier, PhD, MPH; Nathalie Huguet, PhD; Kellen Strickland, BSN; Emily Barclay, MS; Eric Herman, MD; Craig McDougall, MD; Frances E Biagioli, MD; Kam Pierce, MPA; Carliana Straub; Bennett Straub; Deborah J. Cohen, PhD; Jennifer DeVoe, MD, DPhil

Corresponding Author: Anthony Cheng, MD; Oregon Health & Science University. Email: chengan@ohsu.edu

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Introduction: To respond to the COVID19 pandemic and recover from its aftermath, primary care teams will face waves of overwhelming demand for information and the need to significantly transform care delivery. Innovation: Oregon Health & Science University’s primary care team envisioned and implemented the COVID-19 Connected Care Center, a statewide telephone “hotline” service to offer technical assistance to Oregon primary care practices and to integrate within existing care services and augment care for all Oregonians. This paper describes the implementation of the COVID-19 Connected Care Center. Results: The hotline has taken over 5,825 calls from patients in 33 of Oregon’s 36 counties in less than 3 months. In preliminary survey data, 86% of patients said their questions were answered during the call, 90% would recommend this service to a friend or family member and 70% reported a reduction in stress levels about coronavirus. In qualitative interviews, patients reported their questions were answered, they are not asked to wait on hold for long periods of time, nurses spend as much time as they needed and appropriate follow up was arranged. Conclusion: Academic health centers, like OHSU, may have the capacity to leverage their extensive research, clinical and educational resources to rapidly launch a multi-phased pandemic response that meets peoples’ need for information and access to primary care, while minimizing risk of infection and emergency department utilization, and rapidly supporting primary care teams to make the necessary operational changes to do the same in their communities. Such efforts require external funding in a fee for service payment model. 

BRIEF REPORT

A PBRN Research Roadmap for Evaluating COVID-19 in Community Health Centers

Jennifer E. DeVoe, MD, DPhil; Sonja Likumahuwa-Ackman, MID, MPH; Heather Angier, PhD, MPH; Nathalie Huguet, PhD; Deborah J. Cohen, PhD; Susan A. Flocke, PhD; Miguel Marino, PhD; Rachel Gold, PhD, MPH

Corresponding Author: Sonja Likumahuwa-Ackman, MID, MPH; Oregon Health & Science University. Email: likumahu@ohsu.edu

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Background: Primary care Practice-based Research Networks (PBRNs) are critical laboratories for generating evidence from real-world settings, including studying natural experiments. Primary care’s response to the novel coronavirus-19 (COVID-19) pandemic is arguably the most impactful natural experiment in our lifetime. The OCHIN PBRN and the BRIDGE-C2 Center: Evaluating the Impact of COVID-19. We briefly describe the OCHIN PBRN of community health centers (CHCs), its partnership with implementation scientists, and how we are leveraging this infrastructure and expertise to create a rapid research response evaluating how CHCs across the country responded to the COVID-19 pandemic. COVID-19 Research Roadmap: Our research agenda focuses on asking: How has care delivery in CHCs changed due to COVID-19? What impact has COVID-19 had on the delivery of preventive services in CHCs? What PBRN services (e.g., data surveillance, training, evidence synthesis) are most impactful to real-world practices? What decision-making strategies were used in the PBRN and its practices to make real-time changes in response to the pandemic? What critical factors in successfully and sustainably transforming primary care are illuminated by pandemic-driven changes? Discussion & Conclusions: PBRNs enable real-world evaluation of practice change and natural experiments, and thus are ideal laboratories for implementation science research. We present a realtime example of how a PBRN ‘Implementation Laboratory’ activated a response to study an historic natural experiment, to help other PBRNs charting a course through this pandemic.

BRIEF REPORT

A Case Report of COVID-19 Pneumonia with Severely Elevated Inflammatory Markers: A Narrative Review of Clinical Laboratory Predictors of Severe Disease

Edward Kwon, MD; Nathan Whitlow, MD; Alexander Reed, MD

Corresponding Author: Edward Kwon, MD; Fort Belvoir Community Hospital. Email: eddiekwon6@yahoo.com

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Introduction: In late December 2019, the coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China. It quickly spread and emerged as a global pandemic with far-reaching impacts on society. As clinical research on this novel virus emerges, there is a limited amount of data that review clinical and laboratory predictors of severe disease. We present a case of a patient with severely elevated inflammatory markers who remained clinically stable during his hospital course. Case discussion: A 53-year-old male presented to the emergency room with 11 days of persistent fevers and new-onset anterior chest tightness. He was admitted to the hospital due to a reported oxygen desaturation at home to 87% (taken by his spouse, a healthcare professional) and ambulatory oxygen desaturation down to 87%. He was noted to have severely elevated inflammatory markers, lymphopenia, and computed tomography pulmonary angiography findings consistent with COVID-19. He remained on room air and clinically stable throughout his 3 day hospital course. While his C-reactive protein levels improved, his ferritin and erythrocyte sedimentation rate continued to elevate. He was discharged home and was symptom-free within 4 days of hospital discharge. Discussion: COVID-19 has proven to be a viral disease with a high transmission rate, that has caused over 100,000 deaths in the United States, thus far. The decision to admit a patient must balance the risks of transmission with the benefit of being readily available to provide urgent supportive care should the patient develop complications. Thus, there is a significant benefit to being able to predict poor outcomes. We performed a targeted review of the literature, focusing on clinical and laboratory predictors of poor outcomes in COVID-19. Our case report and narrative review outlines these findings within the context of our case.

 

BRIEF REPORT

Using Virtual Visits to Care for Primary Care Patients with COVID-19 Symptoms

Derjung Mimi Tarn, MD, PhD; Courtney Hintz, MD; Eluar Mendez-Hernandez, MD; Sabrina P. Sawlani, DO; Michelle A. Bholat, MD, MPH

Corresponding Author: Derjung Mimi Tarn, MD, PhD; David Geffen School of Medicine at UCLA. Email: dtarn@mednet.ucla.edu

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Purpose: Examine utilization of office resources by primary care patients who were initially evaluated through telehealth, telephone, or in-person encounters. Methods: Retrospective electronic health record review on 202 patients seen from March 3-31, 2020 in a large California academic family medicine practice for evaluation of potential COVID-19 symptoms, to assess the total number of interactions (electronic messaging, telehealth, telephone, and in-person office encounters) with physicians and office staff. Results: Of 202 patients, 89 (44%) had initial telehealth, 55 (27%) telephone, and 52 (25%) inperson encounters. Patients initially evaluated through telehealth, telephone and in-person encounters had a mean of 6.1 (SD=3.7), 5.2 (SD=3.6), 4.5 (SD=3.0) total interactions with the office, respectively (p=0.03), and 9%, 12.7%, and 19.2%, respectively, had a subsequent inperson or emergency department visit (p=0.22). Five patients who tested positive for COVID-19 were all initially evaluated via telehealth; one required subsequent hospitalization. Of all patients presenting for care, 78% reported having a cough. Multivariable analysis showed no differences in number of office interactions based on visit type; older patients (95% CI=0.00-0.07) and those with subjective fevers (95% CI=1.01-3.01) or shortness of breath (95% CI=0.23-2.28) had more interactions with the office. Conclusion: Primary care providers utilized virtual visits to care for most patients presenting with potential COVID-19 symptoms, with many patients choosing telephone over telehealth visits. Virtual visits can successfully limit patient exposure to other people, and consideration could be given to increasing its use for patients with potential symptoms of COVID-19.

BRIEF REPORT

Not Telehealth: What Primary Care Visits Need In-Person Care?

Yalda Jabbarpour, MD; Anuradha Jetty, MPH; Matthew Westfall; John Westfall, MD MPH

Corresponding Author: Yalda Jabbarpour, MD; The Robert Graham Center for Policy Studies in Primary Care. Email: yjabbarpour@aafp.org

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The COVID 19 pandemic has resulted in a rapid shift to telehealth and many services that need in-person care have been avoided. Yet, as practices and payment policies return to a new normal, there will be many questions about what proportion of visits should be done in-person vs telehealth. Using the 2016 National Ambulatory Medical Survey we estimated what proportion of visits were amenable to telehealth prior to COVID-19 as a guide. We divided services into those that needed in-person care and those that could be done via telehealth. Any visit that included at least one service where in-person care was needed was counted as an in-person only visit. We then calculated what proportion of reported visits and services in 2016 could have been provided via telehealth, as well as what proportion of in-person only services were done by primary care. We found that 66% of all primary care visits reported in NAMCS in 2016 required an in-person service. 90% of all wellness visits and immunizations were done in primary care offices, as were a quarter of all pap smears. As practices reopen, patient will need to catch up on many of the in-person only visits that were postponed such as pap smears and wellness visits. At the same time, patients and clinicians now accustomed to telehealth, may have reservations about returning to in-person only visits. Our estimates may provide a guide to practices as they navigate how to deliver care in a post COVID-19 environment.

BRIEF REPORT

Designing and Evaluating COVID Protocols for an Office-Based Opioid Treatment Program in an Urban Underserved Setting

David T. O’Gurek, MD, FAAFP

Corresponding Author: David T. O’Gurek, MD, FAAFP; Lewis Katz School of Medicine at Temple University. Email: david.ogurek@temple.edu

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Background: Despite changing federal regulations for providing telehealth services and provision of controlled substances during the COVID-19 pandemic, there is little guidance available for office-based opioid treatment (OBOT) programs integrated in primary care settings. Purpose: 1) Develop disaster-preparedness protocols specific to the COVID-19 pandemic for an urban OBOT program, and 2) evaluate the impacts of the protocol and telehealth on care. Methods: Disaster-preparedness protocols specific to the COVID-19 pandemic were developed for an urban OBOT program, implemented on March 16, 2020. Retrospective chart review compared patients from January 1, 2020-March 13, 2020, to patients from March 16, 2020-April 30,2020, abstracting patient demographics and comparing show and no show rates between studied groups. Results: The disaster-preparedness protocol was developed under a deliberative process to address social issues of the urban underserved population. Of 852 visits conducted between Jan 1, 2020 and April 30, 2020, an 91.7% show rate (n=166/181) was documented for telemedicine visits after protocol implementation compared to a 74.1% show rate (n=497/671) for routine inperson care (p=0.06) without significant differences between the study populations. The no show rate was significantly lower after protocol implementation (8.3% vs 25.9%; p<0.05). Conclusions: OBOTs require organized workflows to continue to provide services during the COVID-19 pandemic. Telemedicine, in the face of relaxed federal regulations, has the  opportunity to enhance addiction care, creating a more convenient as well as an equally effective mechanism for OBOTs to deliver care that should inform future policy.

BRIEF REPORT

Buprenorphine Microdose Induction for the Management of Prescription Opioid Dependence: A Case Series in Primary Care

Jonathan L. Robbins, MD, MS; Honora Englander, MD; Jessica Gregg, MD, PhD

Corresponding Author: Jonathan Robbins, MD, MS; Oregon Health & Science University. Email: robbijon@ohsu.edu

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Prescription opioid dependence remains a major source of morbidity and mortality in the US. Patients previously on high dose opioids may poorly tolerate opioid tapers. Current guidelines support the use of buprenorphine therapy in opioid tapering protocols, even among patients without a diagnosis of opioid use disorder. Buprenorphine microinduction protocols can be used to transition patients to buprenorphine therapy without opioid withdrawal. From November 2019 – April 2020 we transitioned 8 patients on high dose prescribed opioids for pain to sublingual buprenorphine-naloxone using a microdose protocol without any evidence of precipitated withdrawal. Six of these patients remain on buprenorphine-naloxone and report improved analgesia. Due to its simplicity, the buprenorphine microinduction protocol can be easily adapted for telemedicine and may help to prevent unnecessary clinic visits and opioid-related admissions in the setting of social distancing regulations during the Coronavirus 2019 pandemic.

BRIEF REPORT

A Stepwise Transition to Telemedicine in Response to COVID-19

Sabrina L. Silver, DO, CAQSM; Meghan N. Lewis, MD; Christy J.W. Ledford, PhD​

Corresponding Author: Sabrina L Silver, DO, CAQSM; Uniformed Services University of the Health Sciences. Email: silvesab@gmail.com

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Introduction: With the emergence of COVID-19, many primary care offices closed their physical space to limit exposure.  Despite decades of telemedicine in clinical practice, it is rare to find it used in small-metro and academic settings.  Following the decision to limit face-to-face care, we tracked our practice’s transition to telemedicine.  Methods: This was a prospective quality improvement project following Plan-Do-Study-Act (PDSA) cycles to optimize the use of telemedicine encounters.  Central to the PDSA cycles was the use of a post encounter questionnaire to track patient, appointment, and physician factors.  Throughout the cycles, inferential statistics were used to inform process improvement.   Results: In cycle 2, a logistic regression model showed length of encounter, need for physical exam, and physician satisfaction correctly predicted a physician’s preferred medium. In cycle 3 a chi-square test showed the reason for visit predicted the preferred medium.  In cycle 4, week of telemedicine, need for physical exam, length of encounter, and physician satisfaction predicted the preferred medium. Discussion: Using the variables that predicted preference for telephone modality, we were able to adjust our processes through PDSA cycles.  Conclusion: Early use of the PDSA cycle allows for informed quality improvement at the local level.  Our findings highlight factors to consider when implementing telemedicine such as need for physical exam and type or length of encounter. Additionally, physician satisfaction can encourage use of telemedicine and tools for learning and practicing telemedicine should be available.

 

BRIEF REPORT

Quantifying Worsened Glycemic Control During the COVID-19 Pandemic

Ledford CJW, Roberts C, Whisenant E, Walters C, Akamiro K, Butler J, Ali A, Seehusen DA

 

Corresponding Author: Dean A. Seehusen, MD, MPH; Medical College of Georgia. Email: dseehusen@msn.com

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Aims: We hypothesized that glycemic control in outpatients, measured by HbA1c, was worse during the early months of the COVID-19 pandemic than the prior year. We sought to quantify how much worse mean glycemic control was in 2020 compared to 2019. We also sought to determine if social determinants of health were associated with these differences. Materials and Methods: Data were extracted from the electronic medical records of two cohorts of patients seen in the family medicine clinic of a Southeastern academic health center. A total of 300 patients with baseline HbA1c results, as well as HbA1c results in May 2019 or May 2020, were evaluated. Results: The groups had similar mean baseline HbA1c (7.65, SD = 1.50 for 2019; 7.61, SD =1.71 for 2020; p = 0.85). Mean May HbA1c decreased from baseline in 2019 (7.19, SD = 1.45) but rose in 2020 (7.63, SD = 1.73), a statistically significant difference (p < 0.01). Controlling for age, gender, race, and insurance status, HbA1c in May 2020 (meanadj= 7.73) was significantly higher than in May 2019 (meanadj= 7.16). No demographic variables were associated with HbA1c levels. Conclusions: During the early months of the COVID-19 pandemic, glycemic control in our patient population was significantly worse than during the same period in 2019 (mean HbA1c difference = 0.57). Contrary to our expectations, we did not find associations between patient demographic variables and glycemic control, including race.

BRIEF REPORT

Influenza Vaccination and Hospitalizations Among COVID-19 Infected Adults

Ming-Jim Yang, MD, MS; Benjamin J. Rooks, MS; Thanh-Tam Thi Le, MD; Inocente O. Santiago III, MD; Jeffrey Diamond, BS; Nicholas L. Dorsey, MD; Arch G. Mainous III, PhD

Corresponding Author: Ming-Jim Yang, MD; University of Florida. Email: mjyang527@ufl.edu

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Introduction: To date, there are no effective treatments for decreasing hospitalizations in COVID-19 infections. It has been suggested that the influenza vaccine might attenuate the severity of COVID-19. Methods: This is a retrospective single-centered cohort review of a de-identified database of 2,005 patients over the age of 18 within the University of Florida health care system who tested positive for COVID-19. Comorbidities and influenza vaccination status were examined. Primary outcome was severity of disease as reflected by hospitalization and ICU admission. A logistic regression was performed to examine the relationship between influenza status and hospitalization. Results: Covid-19 positive patients who had not received the influenza vaccination within the last year had a 2.44 (1.68, 3.61) greater odds of hospitalization and a 3.29 (1.18, 13.77) greater odds of ICU admission when compared to those who were vaccinated. These results were controlled to account for age, race, gender, hypertension, diabetes, COPD, obesity, coronary artery disease, and congestive heart failure.  Discussion: Our analysis suggests that the influenza vaccination is potentially protective from moderate and severe cases of COVID-19 infection. This protective effect holds regardless of comorbidity. The literature points to a potential mechanism via natural killer cell activation. Though our data potentially is limited by its generalizability and our vaccination rate is low, it holds significant relevance given the upcoming influenza season. Not only could simply encouraging influenza vaccination decrease morbidity and mortality from the flu, but it might help flatten the curve in regards to the COVID-19 epidemic as well. We encourage further studies into this finding.

 

RESEARCH LETTER

The Demography of Deaths in Health Care Workers: An Overview of 1,004 Reported
COVID-19 Deaths

Divakara Gouda, BS; Preet Mohinder Singh, MD; Prabhakara Gouda; Basavana Goudra, MD, FRCA, FCARCSI

Corresponding Author: Basavana Goudra, MD, FRCA, FCARCSI; Hospital of the University of Pennsylvania. Email: goudrab@uphs.upenn.edu

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Objectives: As of May 13, 2020, 1004 healthcare worker (HCW) deaths due to coronavirus disease 2019 (COVID-19) have been reported globally. This study seeks to organize these deaths by demographic group, including age, gender, country and occupation. Methods: Medscape publishes a crowdsourced list of global HCW COVID-19 deaths. We collected data from this list, including age, gender, country, occupation and for physicians, specialty. Results: As of May 13, 2020, of 1004 HCW deaths, 550 were physicians. The average age of physician death is 62.49 and skewed right and non-physician death is 52.62 and approximately symmetrical. The majority of United States HCW deaths are male (64.1%). General practitioners, family medicine and primary care physicians account for 26.9% of physician deaths while anesthesiologists, emergency medicine and critical care physicians account for 7.4%. The United States has the highest number of HCW deaths but a similar number as a fraction of national cases and deaths compared to other developed countries. Conclusions: Among HCWs globally, there have been more reported deaths of physicians (vs. non-physicians), primary care physicians (vs. physicians of other specialties), males in the United States (vs. females in the United States), and HCWs living in the United States (vs. HCWs of other countries). Further research is needed to understand relative risks of death due to COVID-19 in each of these demographic groups.

RESEARCH LETTER

Teachings After COVID-19 Outbreak From a Survey on Family Practitioners

Marco Toselli, MD; Ignazio Palazzi, MD; Martina Lambertini, MD; Andrea Maurizzi, MD; Alberto Cereda, MD; Arif Khokhar, BM, BCh; Stefano Landi, MD; Fabrizio Toscano, MD; Giovanni Marasco, MD

Corresponding Author: Marco Toselli, MD; Maria Cecilia Hospital. Email: marco.toselli2@gmail.com

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Background: since December 2019, the dramatic escalation in Corona virus (COVID-19) cases worldwide has had a significant impact upon healthcare systems. Family practitioners (FPs) played a critical role in the coordination of healthcare between patients and hospitals or new COVID-19 units. Materials and methods: we performed an online prospective survey to assess the impact of the pandemic on FPs practice. It was supported and delivered by the Local Association of Physicians of Forli-Cesena and Rimini, Emilia Romagna, Italy from the 16th-30th of April 2020. Results: A total of 300 FPs were included, mean age was 53.6±13.5 years. 60.2% reported >75/week outpatient visits before the pandemic which reduced down to an average of <20/week for 79.8% of FPs. 24.2% of FPs discontinued home visits, whilst for 94.7% of FPs there was a >50% increase in the number of telephone consultations. Concern related to the risk of contagion was elevated (≥3/5 in 74.6%) and even higher to the risk of infecting relatives and patients (≥3/5 in 93.3%). The majority of FPs (87%) supported the role of telemedicine in the near future. The satisfaction regarding the network with hospitals/COVID-19 dedicated wards received a score ≤2/5 in 46.9% of the cases. Conclusions: A collaboration is needed with well-established networks between FPs and referral centers. The COVID-19 pandemic has had a significant impact on the working practices of FPs. This necessity for change provided new insights and opportunities to inform future working practices. 

REFLECTIONS IN FAMILY MEDICINE

Exploring the Face-to-Face: Revisiting Patient-Doctor Relationships in a Time of Expanding Telemedicine

Jennifer Y. C. Edgoose, MD, MPH

Corresponding Author: Jennifer Y. C. Edgoose, MD, MPH; University of Wisconsin School of Medicine and Public Health. Email: jennifer.edgoose@fammed.wisc.edu 

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The patient-doctor relationship lies at the heart of medicine. Confronted with the challenges of COVID-19, we find ourselves unable to provide care and comfort in the same physical space as our patients. As we are forced to reckon with telemedicine visits, and contemplate continuing them in a post-pandemic future, it is important to understand the difference relationally between telemedicine and face-to-face encounters. I will argue that face-to-face visits remain essential in establishing the most fundamentally human components of relationships: responsibility and vulnerability. This established bond assures fidelity in subsequent encounters, whether by phone, video or in person.

REFLECTIONS IN FAMILY MEDICINE

Turning Life's Lemons Into Sweet Lemonade: A Positive Reflection on the Impact of Covid-19 

Karim Hanna, MD

Corresponding Author: Karim Hanna, MD; University of South Florida. Email: khanna@usf.edu   

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I have found that negativity can flood thoughts and conversations. I have been taught however, that instead of cursing the darkness, I should light a candle. There are many positives that need to be exposed in order to help us move forward amidst this global pandemic. 

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