Little is known about the characteristics of the workforce providing home-based medical care for traditional (fee-for-service) Medicare beneficiaries. We found that the number of participating home care providers in traditional Medicare increased from about 14,100 in 2012 to around 16,600 in 2016. Approximately 4,000 providers joined or reentered that workforce annually, and 3,000 stopped or paused participation. The number of home visits that most participants provided each year remained below 200. Only 0.7 percent of physicians in Medicare provided fifty or more home visits annually, with little change over the course of five years. In contrast, the number of home-visiting nurse practitioners almost doubled, and the average number of home visits they made increased each year. Despite generally low overall participation of traditional Medicare providers in home-based care, the workforce has seen modest but steady growth, driven primarily by increasing nurse practitioner participation. Additional stimuli may be necessary to ensure workforce adequacy and stability.

Background: Residents of nursing homes are among the most vulnerable to COVID-19. There is no standardized approach for integration with hospitals for outbreak response. Previously, we described collaboration between a hospital and regional facilities. As a component of our COVID-19 Outbreak Response, we describe the impact of virtual daily rounds as an efficient and effective tool for facility outbreak in Central Virginia. Methods: At this facility, 82 (60%) residents were infected. Our team rapidly deployed technology to support staff at the facility. Virtual daily rounds created a systematic approach for patient care. The goals of virtual daily rounds include (1) efficiently facilitating HIPAA-compliant communication between nursing and all licensed independent providers, (2) rapid identification of clinical decline, (3) facilitation of care escalation, (4) facilitating bidirectional transfers, and (5) rapid and efficient identification of patients appropriate for telemedicine pulmonary consultation. Results: The outbreak remained active 6 weeks; 82 of 136 (60%) residents were infected, and 36 (44%) COVID-19 positive residents were seen by telemedicine consultation. Fifty-seven (70%) residents remained in-facility for treatment. Twenty-one residents died (15%); 10 in facility, 11 in hospital. Of those seen in telemedicine consultation, 24 (69%) remained on the treat-in-place protocol with goal-concordant care. These hospitalization and mortality rates are significantly lower than similar outbreaks reported. Discussion and Conclusion: We have since instituted this system at seven other facilities. A model of virtual daily rounding holds promise for decreasing mortality/hospitalization in this vulnerable population through systematically identifying patients most appropriate for telemedicine and cultivating close collaboration between hospitals and nursing homes.

The COVID-19 pandemic is devastating post-acute and long-term care (PA/LTC). As geriatricians practicing in PA/LTC and a regional academic medical center, we created this program for collaboration between academic medical centers and regional PA/LTC facilities. The mission of the Geriatric Engagement and Resource Integration in Post-Acute and Long-Term Care Facilities (GERI-PaL) program is to support optimal care of residents in PA/LTC facilities during the COVID-19 pandemic. There are 5 main components of our program: (1) Project ECHO; (2) nursing liaisons; (3) infection advisory consultation; (4) telemedicine consultation; and (5) resident social contact remote connections. Implementation of this program has had positive response from our local PA/LTC facilities. A key component of our program is our interprofessional team, which includes physicians and nursing, emergency response, and public health experts. With diverse professional backgrounds, our team members have created a new model for academic medical centers to collaborate with local PA/LTC facilities.

Purpose: The vulnerability of postacute and long-term care (PA/LTC) facility residents to COVID-19 has manifested across the world with increasing facility outbreaks associated with high hospitalization and mortality rates. Systematic protocols to guide telehealth-centered interventions in response to COVID-19 outbreaks have yet to be delineated. This article is intended to inform PA/LTC facilities and neighboring health care partners how to collaboratively utilize telehealth-centered strategies to improve outcomes in facility outbreaks. Methods: The University of Virginia rapidly developed a multidisciplinary telehealth-centered COVID-19 facility outbreak strategy in response to a LTC facility outbreak in which 41 (out of 48) facility residents and 7 staff members tested positive. This strategy focused on supporting the facility team remotely using rapidly deployed technologic solutions. Goals included (1) early identification of patients who need their care escalated, (2) monitoring and treating patients deemed safe to remain in the facility, (3) care coordination to facilitate bidirectional transfers between the skilled nursing facility (SNF) and hospital, and (4) daily facility needs assessment related to technology, infection control, and staff well-being. To achieve these goals, a standardized approach centered on daily multidisciplinary virtual rounds and telemedicine consultation was provided. Results: Over a month since the outbreak began, 18 out of 48 (38%) facility residents required hospitalization and 6 (12.5%) died. Eleven facility residents have since returned back to the SNF after recovering from their hospitalization. No staff required hospitalization. Conclusions: Interventions that reduce hospitalizations and mortality are a critical need during the COVID-19 pandemic. The mortality and hospitalization rates seen in this PA/LTC facility outbreak are significantly lower than has been documented in other facility outbreaks. Our multidisciplinary approach centered on telemedicine should be considered as other PA/LTC facilities partner with neighboring health care systems in responding to COVID-19 outbreaks. We have begun replicating these services to additional PA/LTC facilities facing COVID-19 outbreaks.

A New Stranger at the Bedside:Industrial Quality Management and the Erosion of Clinical Judgment in American Medicine Justin B. Mutter (bio) INTRODUCTION: A NEW STRANGER in the autumn of 2017, a public dispute broke out among certain physician specialty societies in the United States. At issue was a new, more stringent definition of hypertension (high blood pressure), coupled with more exacting targets for control in both younger and older adults (Whelton et al. 2018). The new guidelines, from the American College of Cardiology and the American Heart Association, received widespread media attention. "Few risk factors are as important to health" as blood pressure, intoned an article in the New York Times, noting that approximately half of all adults would find themselves possible candidates for pharmacotherapy under the new recommendations (Kolata 2017). Generalist medical societies, however, which had published guidelines for older adults earlier in the year, expressed concern and declined to endorse the new standards. A representative from the American Academy of Family Physicians, for instance, claimed the scientific high ground, asserting, "With competing guidelines [End Page 931] and recommendations, family physicians have an opportunity to be a guiding light in the darkness of confusion to deliver quality care that's grounded in science and is patient-centered" (Crawford 2017). Disputes like this have long been fodder for historians, sociologists, and anthropologists studying the politics of defining disease. In many ways, this recent contest is a recapitulation of a common theme that historian Jeremy Greene identifies as "a state where the line between the normal and the pathological [is] a numerical abstraction" (2007, xi). Who gets to draw that line is, of course, a perennial question. Beyond the issue of definition, however, is a more pressing question of medical practice: How do the definitions become operational? Such public disputes are not abstract; they structure clinical judgment at the bedside, with sometimes dramatic consequences for good or for ill. Writing in a major medical journal, for instance, a physician in the Midwest describes the experience of a patient in his mid-eighties, whose fall resulting in a hip fracture spiraled into a nightmare. The author traces the patient's fall to the incorporation of hypertension and blood sugar targets in clinicians' performance expectations, a practice he characterizes as "tyranny." Such guidelines are not just suggestions; they are tools used to regulate clinician behavior and decisionmaking. As such, they powerfully condition what is and is not recommended in the provider-patient encounter. As the physician writes, "His doctor may have received a bonus for adhering to the guidelines, but [the patient] lost his home and independence" (Sarosi 2015, 562). The political economy of medical guidelines is a relatively new phenomenon. While textbooks are as old as medicine itself, guidelines as an authoritative form of "regulatory objectivity" date only to the post–World War II era, and especially the late twentieth and early twenty-first centuries (Weisz et al. 2007; Cambrosio et al. 2006). By 1990, the number of available guidelines had approximately tripled to 70; by 2012, there were over 7,500 (Upshur 2014). Clinical guidelines are one spoke in the wheel of "quality management" in US health care that has been spinning for at least three decades. Another spoke [End Page 932] is comprised of quality metrics for medical providers and organizations. Their exponential growth mirrors the proliferation of clinical guidelines. These measures, numbering in the thousands, cost each individual provider at least $40,000 annually to manage (Casalino et al. 2016). In a fairly short time, quality management has become a substantial micro-industry within health care organizations, complete with ever-expanding authority over clinical practice. This essay offers a critical account of how the quality management industry rose to prominence in health care, and examines its impact on the nature of clinical judgment. Borrowing David Roth-man's apt concept of "strangers at the bedside" (1991), I argue that quality management is best understood as an integral feature of the "atomic unit of health care," the triad of providers, patients, and "information" (Nelson et al. 2011, 3–4). What comprises the third point on the triangle—"information"—has evolved over time. In Rothman's original formulation, the initial...

Quality management in American health care is in crisis. Performance measurement in its current form is costly, redundant, and labyrinthine. Increasingly, its contribution to achieving the Quadruple Aim is under close examination, especially in the domain of primary care services, where the burden of measurement is heaviest. This article assesses the state of quality management in primary care in the United States, particularly the 2015 Medicare Access and Children's Health Insurance Program Reauthorization Act, in comparative perspective, drawing lessons from the Quality and Outcomes Framework in the United Kingdom. The health care delivery function specific to primary care is pivotal to crossing the quality chasm, yet prior efforts to improve the quality of this function have failed more often than succeeded. These failures are the result of quality programs unguided by core principles of primary care. Quality management in primary care requires a more disciplined approach, adherent to 4 foundational principles: optimizing holistic patient and population health; harnessing the Quadruple Aim as a dynamic whole; applying measurements as tools for quality, not outcomes of quality; and prioritizing therapeutic relationships. These principles serve as the foundation for a bridge to high-functioning primary care that will lead American health care closer to the Quadruple Aim.

One nonfatal myocardial infarction (MI) will be avoided for every 126 to 138 adults who take daily aspirin for 10 years (strength of recommendation [SOR]: A, systematic reviews and meta-analyses of multiple randomized controlled trials [RCTs]). Taking low-dose aspirin for primary prevention shows no clear mortality benefit. A benefit for primary prevention of stroke is less certain. Although no evidence establishes increased risk of hemorrhagic stroke from daily low-dose aspirin, one gastrointestinal hemorrhage will occur for every 72 to 357 adults who take aspirin for longer than 10 years (SOR: A, systematic reviews and meta-analyses of multiple RCTs and cohort studies).