BACKGROUND:With the advent of enhanced recovery after surgery pathways, older adults who undergo major elective surgery return home early in the postoperative period and rely more on care-partner support. Little has been done to assess current challenges that older patient/care-partner dyads experience after major elective surgery and to identify intervention targets to improve transitions home after surgery. METHODS:This multimethods study recruited 15 dyads of major elective surgery patients aged 65+ years from 3 surgical specialties and their care-partners (30 participants total). Demographic, quality of life, and caregiver burden surveys were completed. Each participant underwent a 1-on-1 interview exploring challenges, resources received, and communication experiences. Survey data were analyzed using descriptive statistics. Interview data were analyzed deductively, mapping themes onto the 5Ms of the Geriatrics framework. RESULTS:We enrolled 6 thoracic, 5 colorectal, and 4 orthopedic patients, along with their care-partners (n = 30). Most participants were female (67%) and educated (ie, college degree +, 57%). Zarit Burden Interview surveys suggested mild-moderate burden (9.3; standard deviation, 10.38) with thoracic care-partners reporting higher burden (14.33; standard deviation, 13.98). World Health Organization quality-of-life scores were also lower among thoracic surgery dyads. The range of when the interview occurred in relation to the surgery date was 1-5 months. Qualitative analysis revealed the need for emotional support, improved anticipatory guidance about expected recovery, and assistance with activities of daily living/independent activities of daily living and medication management. CONCLUSION:Older surgical patients and their care-partners identified specific targets to improve transitions out of the hospital during surgical recovery, including enhanced communication, education, and emotional/physical support. Surgical teams, researchers, and health care system leaders can use these findings to improve care quality and support care-partners assisting older adults.

Introduction The lingering burden of the COVID-19 pandemic on primary care clinicians and practices poses a public health emergency for the United States. This study uses clinician-reported data to examine changes in primary care demand and capacity.Methods From March 2020 to March 2022, 36 electronic surveys were fielded among primary care clinicians responding to survey invitations as posted on listservs and identified through social media and crowd sourcing. Quantitative and qualitative analyses were performed on both closed- and open-ended survey questions.Results An average of 937 respondents per survey represented family medicine, pediatrics, internal medicine, geriatrics, and other specialties. Responses reported increases in patient health burden, including worsening chronic care management and increasing volume and complexity. A higher frequency of dental- and eyesight-related issues was noted by respondents, as was a substantial increase in mental or emotional health needs. Respondents also noted increased demand, "record high" wait times, and struggles to keep up with patient needs and the higher volume of patient questions. Frequent qualitative statements highlighted the mismatch of patient needs with practice capacity. Staffing shortages and the inability to fill open clinical positions impaired clinicians' ability to meet patient needs and a substantial proportion of respondents indicated an intention to leave the profession or knew someone who had.Conclusion These data signal an urgent need to take action to support the ability of primary care to meet ongoing patient and population health care needs.

Background Engaging patients in quality improvement and innovation projects is increasingly important, yet challenges persist with involving patients who speak languages other than English. This article presents design activities our team used to engage Spanish-speaking patients and cultural brokers. Objective To develop a clinician communication tool to enhance patient trust in pregnancy care clinicians, especially among minoritized populations who face language and cultural barriers, using human-centered design (HCD). Patient involvement and innovation We centered end-user experiences, including clinicians, Spanish-speaking patients, and Spanish-speaking cultural brokers, in our design process through multiple feedback sessions and modalities. Methods We used a HCD process to understand the problem, co-design a tool, and prepare for testing of a clinician tool. Design activities included a critical literature review, user interviews, design principles, solution sketching, rapid cycle feedback with subject matter experts, and field experience with pregnancy clinicians. Results We innovated on a widely used clinical communication tool, the Four Habits Model, and developed the Five Habits for Pregnancy Care to support pregnancy care clinicians in building trust by bridging cultural and language differences. We added an equity-focused habit “Pause and Reflect” to bookend the Four Habits. We refined the tool to meet different needs across pregnancy care visits based on feedback from 7 clinicians. Discussion We applied equity principles in a HCD process to understand a problem, co-design a tool, and prepare for testing by engaging with patients and cultural brokers in Spanish. Balancing the differing approaches for designers and researchers yielded important insights for enhancing equitable processes and outcomes in healthcare improvement. Practical value Communication tools designed with and for minoritized populations are critical for improving trust in all patient-clinician dyads during pregnancy care.

In July 2023, primary health care experts from more than 20 countries, the World Health Organization (WHO), and most agencies within the US Department of Health and Human Services (HHS) met at the National Academy of Sciences in Washington, DC, to catalyze action toward revitalizing primary care in the United States align efforts to advance primary health care worldwide, and improve health and security for all.1 This meeting was informed by the NASEM's critical primary care report, which highlighted the need for federal leadership to strengthen primary care services in the United States, especially for underserved populations, and to inform primary care systems around the world. To that end, this meeting was designed to explore the challenges and opportunities of investing in primary health care as a common good and critical for health security and resilience across the globe.2 In this issue, you will find {number} special communications from this conference that highlight the need to evolve from primary care to primary health care, the importance of primary care and public health collaboration, and the necessity for ongoing external scientific expertise to inform US federal government coordination efforts. Despite the clear consensus among global stakeholders regarding the importance of Primary Health Care to health equity, behavioral health, health security, and pandemic resilience, a year later the anticipated HHS Action Plan to guide implementation of the NASEM primary care recommendations has yet to be launched. While some agencies are moving ahead with initiatives and programs within their purview, the lack of a Primary Care Action Plan remains a missed opportunity to coalesce politically powerful stakeholders around a united and much-needed vision for a US health system centered on Primary Health Care, particularly in light of our challenges in responding to COVID-19. (J Am Board Fam Med 2024;37:S21-S25.)

Primary care clinicians came under great pressure during the Covid-19 pandemic, exacerbating a long-standing crisis in U.S. primary care. In March 2020, the Larry A. Green Center for the Advancement of Primary Health Care for the Public Good launched a survey series of primary care physicians, nurse practitioners, physician assistants/associates, and other specialists. Analyzing both quantitative and open-ended responses over 2 years of the survey, which drew 32,817 responses from 8,100 respondents in every state, the authors report on clinicians' concerns and propose a sweeping package of policy reforms to strengthen U.S. primary care practice. The findings showed severe staff shortages, financial stress, difficulty providing accessible care, challenges in sustaining telehealth, and mental exhaustion due to the growing patient burdens in mental health, untreated chronic disease, and acute care delays. These data support the 2021 recommendations on primary care by the National Academies of Sciences, Engineering, and Medicine, including expansion of population-based payment models. The authors also recommend immediate establishment of a Federal Emergency Primary Care Support Fund.

A survey of the NEJM Catalyst Insights Council finds a host of interrelated challenges to primary care delivery, led by payment structure, staffing shortages, and organizational structure and management.

The graduate medical education (GME) system is heavily subsidized by the public in return for producing physicians who meet society's needs. Under the terms of this implicit social contract, decisions about how this funding is allocated are deferred to the individual training sites. Institutions receiving public funding face potential conflicts of interest, which have at times prioritized institutional purposes and needs over societal needs, highlighting that there is little public accountability for how such funding is used. The cost and institutional burden of assessing many fundamental GME outcomes, such as specialty, geographic physician distribution, training-imprinted cost behaviors, and populations served, could be mitigated as data sources and methods for assessing GME outcomes and guiding training improvement already exist. This new capacity to assess system-level outcomes could help institutions and policymakers strategically address the greatest public needs. Measurement of educational outcomes can also be used to guide training improvement at every level of the educational system (i.e., the individual trainee, individual teaching institution, and collective GME system levels). There are good examples of institutions, states, and training consortia that are already assessing and using GME outcomes in these ways. The ultimate outcome could be a GME system that better meets the needs of society and better honors what is now only an implicit social contract.

Costa Rica is a bright spot of primary healthcare (PHC) performance, providing first-contact accessibility and continuous, comprehensive, coordinated, and patient-centered care to its citizens. Previous research hypothesized that strong data collection and use for quality improvement are central to Costa Rica's success. Using qualitative data from 40 interviews with stakeholders across the Costa Rican healthcare system, this paper maps the various data streams at the PHC level and delineates how these data are used to make decisions around insuring and improving the quality of PHC delivery. We describe four main types of PHC data: individual patient data, population health data, national healthcare delivery data, and local supplementary healthcare delivery data. In particular, we find that the Healthcare Delivery Performance Index-a ranking of the nation's 106 Health Areas using 15 quality indicators-is utilized by Health Area Directors to create quality improvement initiatives, ranging from education and coaching to optimization of care delivery and coordination. By ranking Health Areas, the Index harnesses providers' intrinsic motivation to stimulate improvement without financial incentives. We detail how a strong culture of valuing data as a tool for improving population health and robust training for personnel have enabled effective data collection and use. However, we also find that the country's complex data systems create unnecessary duplication and can inhibit efficient data use. Costa Rica's experience with data collection, analysis, and use for quality improvement hold important lessons for PHC in other public sector systems.

Rapid, widespread COVID-19 vaccination is critical to pandemic mitigation and recovery. To help policymakers interested in further enhancing primary care delivery of COVID-19 vaccines, it is important to estimate the absolute number of vaccination opportunities, and identify how these opportunities may fall disproportionately among different communities given the unequal way that COVID-19 falls upon communities of color, low-income, and rural communities. To quantify the potential benefits of greater primary care engagement in vaccination efforts, we estimated the number of potential vaccination opportunities (PVOs) in primary care in the remaining calendar months of year 2021, and the possible uptake if we supplied enough vaccine to primary care practices to fulfill their opportunities. To estimate how many potential vaccination opportunities (PVOs) may occur in primary care, we used three sets of data, analyzing the latest available waves of the following: (i) the National Ambulatory Medical Care Survey (NAMCS, 2016, N = 677 providers); (ii) the National Health Interview Survey (NHIS, 2018, N = 29,839 individuals in 29,839 households); and (iii) the Medical Expenditure Panel Survey (MEPS, 2018, N = 40,025 individuals in 14,500 households). Per the NAMCS data, which provide a nationally-representative sample of ambulatory care visits, primary care physicians normally provide 40.2 million primary care visits per month. The majority of the primary care utilization is absorbed by those aged 16 to 64 years old who are not otherwise priority groups (i.e., not having chronic diseases as defined by ACIP) but the second large group of visits are those with a chronic disease (27.2% of all visits). As compared to the NAMCS data providing an estimate of care from the perspective of providers, the overall sample in NHIS provides a view of primary care access and utilization from a population perspective. Per NHIS, 34% of the civilian US population saw a generalist physician in the prior calendar year, or 109.8 million people. Overall, we would estimate that over the latter half of calendar year 2021, approximately 15 million potential vaccine opportunities would be available through US primary care practices.