COVID-19 Ahead-of-Print Subject Collection

Noting the dramatic impact of the COVID-19 pandemic on the primary care landscape, and the rapid transformation of primary care practices that has resulted, JABFM would like to invite COVID-19 related articles for a special peer-reviewed - ahead of print - subject collection to be published on the JABFM website immediately after acceptance. All articles that are included in the subject collection will be published in a special print issue in 2021.

The following ahead-of-print articles are available for download now. Please note these papers are not copy edited and information could change during the publishing process. All manuscripts listed below are under copyright by the American Board of Family Medicine. 

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.

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.

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.

FAMILY MEDICINE WORLD PERSPECTIVE

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.

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.

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.

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