Advancing an understanding of access as ‘human fit’: A qualitative participatory case study in general practice

Background: Good access to primary care is an important determinant of population health. Whilst the academic literature on access to care emphasises its complexity, policies aimed at improving access to general practice in the UK have tended to focus on measurable aspects, such as timeliness or number of appointments. Aim: To fill the gap between the complex understanding of primary care access in the literature and the narrow definition of access assumed in UK policies. Design and Setting: Qualitative, community-based participatory case study within the geographic footprint of a Clinical Commissioning Group in northwest England. Method: We applied Levesque et al.’s conceptual framework of patient-centred access and used multiple qualitative methods (interviews, focus groups, observation). Analysis was ongoing, iterative, inductive, and abductive with the theory. Results: The comprehensiveness of Levesque et al.’s access theory resonated with diverse participant experiences. However, while a strength of Levesque et al. was to highlight the importance of people’s abilities to access care, our data suggest equal importance of healthcare workforce abilities to make care accessible. Thus, we present a definition of access as the ‘human fit’ between the needs and abilities of people in the population and the abilities and capacity of people in the healthcare workforce, and provide a modified conceptual framework reflecting these insights. Conclusion: An understanding of access as ‘human fit’ has the potential to address longstanding problems of access within general practice, focusing attention on the need for staff training and support, and emphasising the importance of continuity of care.

Healthcare Providers’ Perceptions of Potentially Preventable Rural Hospitalisations: A Qualitative Study

Potentially preventable hospitalisations (PPHs) are common in rural communities in Australia and around the world. Healthcare providers have a perspective on PPHs that may not be accessible by analysing routine patient data. This study explores the factors that healthcare providers believe cause PPHs and seeks to identify strategies for preventing them. Physicians, nurses, paramedics, and health administrators with experience in managing rural patients with PPHs were recruited from southern Tasmania, Australia. Semi-structured telephone interviews were conducted, and reflexive thematic analysis was used to analyse the data. Participants linked health literacy, limited access to primary care, and perceptions of primary care services with PPH risk. The belief that patients did not have a good understanding of where, when, and how to manage their health was perceived to be linked to patient-specific health literacy challenges. Access to primary healthcare was impacted by appointment availability, transport, and financial constraints. In contrast, it was felt that the prompt, comprehensive, and free healthcare delivered in hospitals appealed to patients and influenced their decision to bypass rural primary healthcare services. Strategies to reduce PPHs in rural Australian communities may include promoting health literacy, optimising the delivery of existing services, and improving social support structures.

Atrial fibrillation screening: feasible approaches and implementation challenges across Europe

Background Atrial fibrillation (AF) screening has the potential to increase early detection and possibly reduce complications of AF. Guidelines recommend screening, but the most appropriate approaches are unknown. Purpose We aimed to explore the views of stakeholders across Europe about the opportunities and challenges of implementing four different AF screening scenarios. Method This qualitative study included 21 semi-structured interviews with healthcare professionals and regulators potentially involved in AF screening implementation in nine European countries. Data were analysed using thematic analysis. Results Three themes evolved. 1) Current approaches to screening: there are no national AF screening programmes, with most AF detected in symptomatic patients. Patient-led screening exists via personal devices, creating screening inequity by the reach of screening programmes being limited to those who access healthcare services. 2) Feasibility of screening approaches: single time point opportunistic screening in primary care using single lead ECG devices was considered the most feasible approach and AF screening may be possible in previously unexplored settings such as dentists and podiatrists. Software algorithms may aid identification of patients suitable for screening and telehealth services have the potential to support diagnosis. However, there is a need for advocacy to encourage the use of telehealth to aid AF diagnosis, and training for screening familiarisation and troubleshooting. 3) Implementation requirements: sufficient evidence of benefit is required. National rather than pan-European screening processes must be developed due to different payment mechanisms and health service regulations. There is concern that the rapid spread of wearable devices for heart rate monitoring may increase workload due to false positives in low risk populations for AF. Data security and inclusivity for those without access to primary care or personal devices must be addressed. Conclusions There is an overall awareness of AF screening. Opportunistic screening appears to be most feasible across Europe. Challenges that need to be addressed concern health inequalities, identification of best target groups for screening, streamlined processes, the need for evidence of benefit, and a tailored approach adapted to national realities. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): H2020 Screening Scenarios Graphical abstract

COVID-19 – An Opportunity to Improve Access to Primary Care Through Organizational Innovations?

Background COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a health care system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes, during the first year of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia.MethodsWe conducted a multiple case studies, based on 63 semi-structured interviews (n=33 in Quebec, n=30 in Nova Scotia) conducted between October 2020 and May 2021 and a review of related internal documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policymakers, decision-makers, family physicians, nurses) involved in reorganizing primary care during COVID-19 using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models.Results We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, and interim primary care clinics for unattached patients and community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, in modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations.Conclusion COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after COVID-19. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Information seeking behaviours and uncertainty around accessing primary care in the changing landscape of the COVID-19 pandemic: a qualitative study

BackgroundThe COVID-19 pandemic has and will continue to have a disproportionate effect on the most vulnerable. Public health messaging has been vital to regulate the impact of the pandemic. However, messages intended to slow the transmission of the virus may also cause harm. Understanding the areas where public health messaging could be improved may help reduce this harm.AimTo explore and understand health communication issues faced by those most likely to be impacted by the COVID-19 pandemic.Design & settingA qualitative study using online surveys. The area of focus was Fife, a local authority in Scotland, UK.MethodTwo consecutive surveys were conducted. Survey 1: N=19 support workers and Facebook group moderators, focussing on key issues faced by service users, as well as examples of good practice. Survey 2: N=34 community members, focussing on issues regarding access to and communication around access to primary care.ResultsSurvey one found broad issues around communication and access to primary care services. Survey two emphasised key issues in accessing primary care, including, (a) the lengthy process of making appointments, (b) feeling like a burden for wanting to be seen, (c) a lack of confidence in remote triaging and consultations, and (d) not knowing what to expect prior to getting an appointment.ConclusionClear issues regarding access to primary care were identified. Our new understanding of these issues will inform a co-creation process designed to develop clear, actionable and effective public health messages centred on improving access to primary care.

Changes to telehealth practices in primary care in New Brunswick (Canada): A comparative study pre and during the COVID-19 pandemic

Background During the COVID-19 pandemic, telehealth technologies were used in the primary health care setting in New Brunswick as a means to continue providing care to patients while following public health guidelines. This study aimed to measure these changes and examine if they improved timely access to primary care. A secondary goal was to identify which telehealth technologies were deemed sustainable by primary care providers. Methods This was a comparative study on the use of telehealth technology before and during the COVID-19 pandemic. Between April 2020 and November 2020, 114 active primary care providers (family physicians or nurse practitioners) responded to the online survey. Results The findings illustrated an increase in the use of telehealth technologies. The use of phone consultations increased by 122%, from 43.9% pre-pandemic to 97.6% during the pandemic (p < 0.001). The use of virtual consultation (19.3% pre-pandemic vs. 41.2% during the pandemic, p < 0.001), emails and texts also increased during the pandemic. Whereas the more structural organizational tools (electronic medical charts and reservation systems) remained stable. However, those changes did not coincide with a significant improvement to timely access to care during the pandemic. Many participants (40.1%) wanted to keep phone consultations, and 21.9% of participants wanted to keep virtual consultations as part of their long-term practice. Interpretation The observed increase in the use of telehealth technologies may be sustainable, but it has not significantly improved timely access to primary care in New Brunswick.

Referrals for physical therapy for osteoarthritis during the COVID-19 pandemic: A retrospective analysis

Background Osteoarthritis (OA) is a leading cause of musculoskeletal pain and disability among Americans. Physical therapy (PT) is recommended per the 2019 ACR /Arthritis Foundation Guideline for Treatment of OA of the Hand, Hip, and Knee. During COVID-19, access to healthcare has been altered in a variety of clinical settings, with the pandemic creating delays in healthcare, with an unknown impact on access to PT care for OA. Objectives We sought to determine whether referrals to PT for OA were reduced in 2020 during the COVID-19 pandemic compared to 2019. Methods A retrospective analysis was done of 3586 PT referrals placed by the University of California, Davis for 206 OA ICD-10 codes from January to November 2019 and from January to November 2020. The numbers of PT referrals per month of each year were compared using both descriptive statistics and Poisson Regression analysis. Results A total of 1972 PT referrals for OA were placed from January to November 2019. Only 1614 referrals for OA were placed from January to November 2020, representing a significant decrease (p = 0.001). Month-by-month analysis of 2020 compared to 2019 revealed statistically significant drops in PT referrals for OA in April (p = 0.001), May (p = 0.001), and August (p = 0.001). Conclusions These findings reveal a significant reduction in the number of referrals for PT for OA placed in 2020 during the first year of the COVID-19 pandemic. These reductions were particularly evident in the months following state-mandated actions and closures. Factors associated with this outcome may include decreased access to primary care providers, perceptions of PT availability by health care providers, decreased mobility limiting access to both clinic and PT appointments, and/or willingness to engage in PT by patients during the pandemic.

The Association of Demographic, Socioeconomic, and Geographic Factors with Potentially Preventable Emergency Department Utilization

Introduction: Prevention quality indicators (PQI) are a set of measures used to characterize healthcare utilization for conditions identified as being potentially preventable with high quality ambulatory care. These indicators have recently been adapted for emergency department (ED) patient presentations. In this study the authors sought to identify opportunities to potentially prevent emergency conditions and to strengthen systems of ambulatory care by analyzing patterns of ED utilization for PQI conditions. Methods: Using multivariable logistic regression, the authors analyzed the relationship of patient demographics and neighborhood-level socioeconomic indicators with ED utilization for PQI conditions based on ED visits at an urban, academic medical center in 2017. We also used multilevel modeling to assess the contribution of these variables to neighborhood-level variation in the likelihood of an ED visit for a PQI condition. Results: Of the included 98,522 visits, 17.5% were categorized as potentially preventable based on the ED PQI definition. On multivariate analysis, age < 18 years, Black race, and Medicare insurance had the strongest positive associations with PQI visits, with adjusted odds ratios (aOR) of 1.41 (95% confidence interval [CI], 1.29, 1.56), 1.40 (95% CI, 1.22, 1.61), and 1.40 (95% CI, 1.28, 1.54), respectively. All included neighborhood-level socioeconomic variables were significantly associated with PQI visit likelihood on univariable analysis; however; only level of education attainment and private car ownership remained significantly associated in the multivariable model, with aOR of 1.13 (95% CI, 1.10, 1.17) and 0.96 (95% CI, 0.93, 0.99) per quartile increase, respectively. This multilevel model demonstrated significant variation in PQI visit likelihood attributable to neighborhood, with interclass correlation decreasing from 5.92% (95% CI, 5.20, 6.73) in our unadjusted model to 4.12% (95% CI, 3.47, 4.87) in our fully adjusted model and median OR similarly decreasing from 1.54 to 1.43. Conclusion: Demographic and local socioeconomic factors were significantly associated with ED utilization for PQI conditions. Future public health efforts can bolster efforts to target underlying social drivers of health and support access to primary care for patients who are Black, Latino, pediatric, or Medicare-dependent to potentially prevent emergency conditions (and the need for emergency care). Further research is needed to explore other factors beyond demographics and socioeconomic characteristics driving spatial variation in ED PQI visit likelihood.

Access to primary care and cognitive impairment: results from a national community study of aging Americans

Background Despite a growing burden of Alzheimer’s Disease and related dementias (ADRD) in the US, the relationship between health care and cognitive impairment prevention is unclear. Primary care manages risk causing conditions and risk reducing behaviors for dementia, so we examine the association between individual and area-level access to primary care and cognitive impairment in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Methods REGARDS participants with a cognitive assessment and vascular measurements at their baseline visit were included in this cross-sectional analysis. Cognitive impairment was defined as a Six-Item Screener (SIS) score < 5. Primary care supply, primary care utilization and emergency department (ED) utilization were measured at the primary care service area (PCSA) level based on participant’s address. Individual access to care was self-reported. Models were adjusted for confounding by demographics, socioeconomic status and behavioral risk factors. Results Among 25,563 adults, living in a PCSA with low primary care supply was associated with 25% higher odds of cognitive impairment (OR 1.25 CI 1.07-1.45). Not having a regular source of medical care was associated with 14% higher odds of cognitive impairment (OR 1.14 CI 1.02-1.28), and living in a PCSA with high emergency department utilization was associated with 12% higher odds of cognitive impairment (OR 1.12 CI 1.02-1.23). Conclusions Our results are an important first step in understanding how health care may prevent cognitive impairment. They highlight the importance of primary care and suggest future work clarifying its role in preventing cognitive decline is imperative.