Fighting the COVID-19 pandemic from the clinic-impact of the primary care provider [Meeting Abstract]
BACKGROUND: COVID-19 has overwhelmed hospitals at various stages of the pandemic, leading to intense focus on availability of inpatient resources and less attention to primary care contributions. There is clear evidence that medical comorbidities, social determinants of health, and individual behaviors such as mask-wearing affect COVID-19 outcomes. By managing medical comorbidities and modifying social behaviors, it is plausible that primary care physicians (PCPs) improve COVID-19 outcomes. Socioeconomic status (SES) and environment likely affect the number of PCPs and their effectiveness in a community. Notwithstanding these factors, we hypothesize that PCPs contribute to healthier communities and that this will correlate with decreased COVID-19 cases and mortality.
METHOD(S): We used three surrogate measures of PCP effectiveness: PCP rate (#PCPs/population), flu vaccination rate, and number of preventable hospital stays. We merged county-level data from USA Facts, the New York Times masking survey, the Robert Wood Johnson Foundation County Health Data, and the Health Resources & Services Administration. We ran multiple linear regression models to measure the contributed variance in COVID-19 cases or deaths of the measures of PCP effectiveness after adjusting for age, race, economic, and environmental factors. A second model also measured the effect of PCP rates on mask adherence adjusted for the same confounders. Data were merged and analyzed using SPSS v.25.
RESULT(S): Data were available from 2957 of 3143 county equivalents. There were an average of 55 PCPs per 100,000 population. By December 27, 2020 there were 18,750,038 COVID-19 cases and 325,507 deaths nationally. In multiple linear regression models, PCP rate (beta=-0.07), flu vaccination rate (beta=-0.067), and preventable hospital stays (beta=0.136) were all significant (p<=0.001) contributors to the variance seen in COVID-19 cases after adjusting for confounding variables. Similarly, PCP rate (beta=-0.056, p=0.003), flu vaccination rate (beta=-0.006, p=0.001), and preventable hospital stays (beta=0.166, p<0.001) were significant contributors to the variance seen in COVID-19 deaths. PCP rate was also found to be a significant contributor to variance in mask adherence (beta=0.078, p<0.001).
CONCLUSION(S): All measures of PCP effectiveness were significantly correlated with lower COVID-19 cases and deaths and higher self-reported mask adherence even after accounting for SES and environmental factors. The pandemic has exposed an American healthcare system that is detrimentally more reactive than preventative. Our study demonstrates the modest-but significant- success of prevention efforts by PCPs. We hope it will serve to increase resource allocation and attention toward the primary care sector of the healthcare workforce. LEARNING OBJECTIVE #1: Identify how increasing resource allocation to primary care may improve systems-based practice. LEARNING OBJECTIVE #2: Recognize the role that primary care physicians may play in improving COVID-19 outcomes
Charting a Key Competency Domain: Understanding Resident Physician Interprofessional Collaboration (IPC) Skills
BACKGROUND: Interprofessional collaboration (IPC) is essential for quality care. Understanding residents' level of competence is a critical first step to designing targeted curricula and workplace learning activities. In this needs assessment, we measured residents' IPC competence using specifically designed Objective Structured Clinical Exam (OSCE) cases and surveyed residents regarding training needs. METHODS: We developed three cases to capture IPC competence in the context of physician-nurse collaboration. A trained actor played the role of the nurse (Standardized Nurse - SN). The Interprofessional Education Collaborative (IPEC) framework was used to create a ten-item behaviorally anchored IPC performance checklist (scored on a three-point scale: done, partially done, well done) measuring four generic domains: values/ethics; roles/responsibilities; interprofessional communication; and teamwork. Specific skills required for each scenario were also assessed, including teamwork communication (SBAR and CUS) and patient-care-focused tasks. In addition to evaluating IPC skills, the SN assessed communication, history-taking and physical exam skills. IPC scores were computed as percent of items rated well done in each domain (Cronbach's alpha > 0.77). Analyses include item frequencies, comparison of mean domain scores, correlation between IPC and other skills, and content analysis of SN comments and resident training needs. RESULTS: One hundred and seventy-eight residents (of 199 total) completed an IPC case and results are reported for the 162 who participated in our medical education research registry. IPC domain scores were: Roles/responsibilities mean = 37 % well done (SD 37 %); Values/ethics mean = 49 % (SD 40 %); Interprofessional communication mean = 27 % (SD 36 %); Teamwork mean = 47 % (SD 29 %). IPC was not significantly correlated with other core clinical skills. SNs' comments focused on respect and IPC as a distinct skill set. Residents described needs for greater clarification of roles and more workplace-based opportunities structured to support interprofessional education/learning. CONCLUSIONS: The IPC cases and competence checklist are a practical method for conducting needs assessments and evaluating IPC training/curriculum that provides rich and actionable data at both the individual and program levels.
Distinct or shared actions of peptide family isoforms: II. Multiple pyrokinins exert similar effects in the lobster stomatogastric nervous system
Many neuropeptides are members of peptide families, with multiple structurally similar isoforms frequently found even within a single species. This raises the question of whether the individual peptides serve common or distinct functions. In the accompanying paper, we found high isoform specificity in the responses of the lobster (Homarus americanus) cardiac neuromuscular system to members of the pyrokinin peptide family: only one of five crustacean isoforms showed any bioactivity in the cardiac system. Because previous studies in other species had found little isoform specificity in pyrokinin actions, we examined the effects of the same five crustacean pyrokinins on the lobster stomatogastric nervous system (STNS). In contrast to our findings in the cardiac system, the effects of the five pyrokinin isoforms on the STNS were indistinguishable: they all activated or enhanced the gastric mill motor pattern, but did not alter the pyloric pattern. These results, in combination with those from the cardiac ganglion, suggest that members of a peptide family in the same species can be both isoform specific and highly promiscuous in their modulatory capacity. The mechanisms that underlie these differences in specificity have not yet been elucidated; one possible explanation, which has yet to be tested, is the presence and differential distribution of multiple receptors for members of this peptide family.