BACKGROUND: The onset of the COVID-19 pandemic drove a rapid and widespread shift to virtual care, followed by a gradual return to in-person visits. Virtual visits may offer more convenient access to care for some, but others may experience challenges accessing care virtually, and some medical needs must be met in-person. Experiences of the shift to virtual care and benefits of in-person care may vary by immigration experience (immigration status and duration), official language level, and age. We examined use of virtual care and return to in-person visits in the Canadian province of British Columbia (BC), comparing patterns by age and across immigration groups, including length of time in Canada and language level (official languages English and French) at time of arrival.
METHODS: We used linked administrative health and immigration data to examine total primary care visits (virtual or in-person) and return to in-person visits during the COVID-19 pandemic (2019/20-2021/2) in BC. We examined the proportion of people with any primary care visits and with any in-person visits within each year as measures of access to primary care. We estimated the odds of any primary care visits and any in-person visits by immigration group and official language level assessed prior to arrival: non-immigrants, long-term immigrants, recent immigrants (< 5 years) with high assessed official language level and recent immigrants (< 5 years) with low assessed official language level (assessed prior to arrival), stratified by age.
RESULTS: In general, changes in access to primary care (odds of any visits and odds of any in-person visits) were similar across immigration groups over the study period. However, we observed substantial disparities in access to primary care by immigration group among people aged 60 + , particularly in recent immigrants with low official language level (0.42, 0.40-0.45). These disparities grew wider over the course of the pandemic.
CONCLUSIONS: Though among younger adults changes in access to primary care between 2019-2021 were similar across immigration groups, we observed significant and growing inequities among older adults, with particularly limited access among adults who immigrated recently and with low assessed official language level. Targeted interventions to ensure acceptable, accessible care for older immigrants are needed.

The average panel for family physicians dropped from about 2400 to about 1800 patients from 2013 to 2022. Likely reasons for this decline: 1) fewer people seeking primary care, and 2) fewer people receiving their care through a long-term continuity relationship with a primary care clinician.

Underinvestment in primary care and erosion of the primary care physician workforce are resulting in patients across the US experiencing growing difficulty in obtaining access to primary care. Compounding this access problem, we find that the average patient panel size among US family physicians may have decreased by 25% over the past decade (2013 to 2022). Reversing the decline in access to primary care in the face of decreasing panel sizes requires both better supporting family physicians to manage larger panels, such as by expanding primary care teams, and substantially increasing the supply of family physicians.

BACKGROUND: Evidence concerning health care use related to virtual visits is conflicting. More research has been called for regarding the effectiveness of text-based virtual visits (eVisits). Therefore, we investigated patient characteristics, diagnoses, and subsequent health care contacts after eVisits to primary care.
METHODS: We conducted a register-based cohort study of eVisits to an all-virtual public primary care unit in Sweden and subsequent health care contacts within 14 days. Data for 2021 were acquired from the regional health care databases. Diagnoses were sorted into relevant diagnostic groups, such as skin diagnoses and respiratory tract diagnoses. Multiple logistic regression was performed with subsequent health care contact as the outcome variable and diagnostic group for the eVisit as the predictor variable. Analyses were adjusted for age, sex, and socioeconomic index.
RESULTS: There were 5817 eVisits to a nurse and 4267 eVisits to a general practitioner (N = 10 084). Most patients were 20 to 39 years of age (41.8%). Skin diagnoses were most frequent (47.3%), followed by respiratory tract diagnoses (19.9%). Approximately one-fourth (25.8%) of the patients who completed an eVisit with a nurse or a general practitioner had a subsequent face-to-face visit within 14 days, mostly in primary care. Subsequent contacts were more frequent after an eVisit to a nurse than to a general practitioner. After an eVisit to a general practitioner, patients with infections (especially respiratory tract but also urinary tract) and unspecified diagnoses (especially skin-related) were more likely to require further health care contact compared to a group with various other diagnoses.
CONCLUSIONS: eVisits to an all-virtual primary care unit may be appropriate for uncomplicated medical complaints. Nonetheless, the effectiveness of eVisits in terms of substitution of physical visits, and resource utilization in relation to the more complex care needs of a primary care population, should be further studied.

OBJECTIVE: The COVID-19 pandemic not only exacerbated existing disparities in health care in general but likely worsened disparities in access to primary care. Our objective was to quantify the nationwide decrease in primary care visits and increase in telehealth utilization during the pandemic and explore whether certain groups of patients were disproportionately affected.
METHODS: We used a geographically diverse primary care electronic health record data set to examine the following 3 outcomes: (1) change in total visit volume, (2) change in in-person visit volume, and (3) the telehealth conversion ratio defined as the number of pandemic telehealth visits divided by the total number of prepandemic visits. We assessed whether these outcomes were associated with patient characteristics including age, gender, race, ethnicity, comorbidities, rurality, and area-level social deprivation.
RESULTS: Our primary sample included 1,652,871 patients from 408 practices. During the pandemic we observed decreases of 7% and 17% in total and in-person visit volume and a 10% telehealth conversion ratio. The greatest decreases in visit volume were observed among pediatric patients (-24%), Asian patients (-11%), and those with more comorbidities (-9%). Telehealth usage was greatest among Hispanic or Latino patients (17%) and those living in urban areas (12%).
CONCLUSIONS: Decreases in primary care visit volume were partially offset by increasing telehealth use for all patients during the COVID-19 pandemic, but the magnitude of these changes varied significantly across all patient characteristics. These variations have implications not only for the long-term consequences of the COVID-19 pandemic, but also for planners seeking to ready the primary care delivery system for any future systematic disruptions.

UNASSIGNED: The 2018 Veterans Affairs Maintaining Internal Systems and Strengthening Integrated Outside Networks (VA MISSION) Act was implemented to increase timely access to care by expanding veterans\' opportunities to receive Veterans Affairs (VA)-purchased care in the community (community care [CC]). Because health equity is a major VA priority, it is important to know whether Black and Hispanic veterans compared with White veterans experienced equitable access to primary care within the VA MISSION Act.
UNASSIGNED: To examine whether utilization of and wait times for primary care differed between Black and Hispanic veterans compared with White veterans in rural and urban areas after the implementation of the VA MISSION Act.
UNASSIGNED: This cross-sectional study used VA and CC outpatient and consult data from the VA\'s Corporate Data Warehouse for fiscal years 2021 to 2022 (October 1, 2020, to September 30, 2022). Separate fixed-effects multivariable models were run to predict CC utilization and wait times. Each model was run twice, once comparing Black and White veterans and then comparing Hispanic and White veterans. Adjusted risk ratios (ARRs) were calculated for Black and Hispanic veterans compared with White veterans within rurality status for both outcomes.
UNASSIGNED: VA and CC primary care utilization as measured by primary care visits (utilization cohort); VA and CC primary care access as measured by mean wait times (access cohort).
UNASSIGNED: A total of 5 046 087 veterans (994 517 [19.7%] Black, 390 870 [7.7%] Hispanic, and 3 660 700 [72.6%] White individuals) used primary care from fiscal years 2021 to 2022. Utilization increased for all 3 racial and ethnicity groups, more so in CC than VA primary care. ARRs were significantly less than 1 regardless of rurality status, indicating Black and Hispanic veterans compared with White veterans were less likely to utilize CC for primary care. There were 468 246 primary care consultations during the study period. The overall mean (SD) wait time was 33.3 (32.4) days. Despite decreases in wait times over time, primary care wait times remained longer in CC than in VA. Black veterans compared with White veterans had significantly longer wait times in CC (ARRs >1) but significantly shorter wait times in VA (ARRS <1) regardless of rurality status in VA and CC. CC wait times for Hispanic veterans compared with White veterans were longer in rural areas only and in VA rural and urban areas (ARRs >1).
UNASSIGNED: The results of this cross-sectional study suggest that additional research should explore the determinants and implications of utilization differences among Black and Hispanic veterans compared with White veterans. Efforts to promote equitable primary care access for all veterans are needed so that policy changes can be more effective in ensuring timely access to care for all veterans.

OBJECTIVE: To explore how to help make online consultation notes easier for patient audiences to understand.
BACKGROUND: Most patients in England will soon be able to access all new prospective entries (including free-text) within their online primary care health record via the NHS App or other online services.
METHODS: We conducted interviews and focus group discussions with 26 patients from underserved communities. Participants responded to vignettes about fictional patient consultation scenarios and assessed the clarity of corresponding simulated records. Participants were then asked to identify potential comprehension issues, offensive content, or anxiety triggers.
RESULTS: Most participants struggled to understand a large proportion of simulated notes, particularly medical acronyms, clinician shorthand, and non-clinical abbreviations. Participants also identified issues that may cause unintended offence or additional anxiety. Participants considered that most patients will struggle to fully understand the content of their consultation notes in their current format. They made a number of suggestions about how this service may be improved to meet the needs of patient audiences and maintain positive patient-clinician relationships.
CONCLUSIONS: Opening up online record access to include patient audiences necessitates a significant cultural shift in the way that consultation notes are written and used. To maximise NHS investment in this policy and avoid worsening health inequalities, it is essential to ensure that all patients can understand and access the benefits of online access to their notes. To do this, clinicians need to be supported to manage the challenges of writing for patient audiences, while continuing to maintain effective clinical care.

OBJECTIVE: To examine children and young people\'s (CYP), caregivers\' and healthcare professionals\' (HCPs) views or experiences of facilitators and barriers to CYP access to UK primary care services to better understand healthcare inequity. To explore differences across CYP subpopulations with greater health needs from deprived areas, identifying as ethnic minorities, with experiences of state care, special educational needs or disabilities, chronic conditions or mental health problems.
METHODS: Scoping review.
METHODS: Included studies were in English, published 2012-2022 and reported: the views/experiences of CYP (0-25 years), caregivers or HCPs about accessing UK primary care; using quantitative or qualitative empirical methods.
METHODS: PubMed, CINAHL, Web of Science, PsycINFO and Scopus.
RESULTS: We included 47 reports (46 studies). CYP/caregivers\' decision to access care was facilitated by CYP/caregivers\' or their family/friends\' ability to identify a health issue as warranting healthcare attention. Barriers to accessing care included perceived stigma (eg, being seen as a bad parent), embarrassment and discrimination experiences. CYP and caregivers believed longer opening hours could facilitate more timely access to care. Caregivers and HCPs reported that delayed or rejected referrals to secondary or adult care were a barrier to having needs met, especially for CYP with poor mental health. CYP and caregivers in numerous studies emphasised the importance of communication and trust with HCPs, including taking their concerns seriously, being knowledgeable and providing continuity of care for CYP. Common barriers reported across high-need subpopulations were caregivers needing knowledge and confidence to advocate for their child, gaps in HCP\'s knowledge and a lack of connectedness between primary and secondary care.
CONCLUSIONS: Connecting general practices and community health workers/services, improving CYP/caregivers\' understanding of common childhood conditions, addressing HCP\'s knowledge gaps in paediatric care and integrated approaches between primary and secondary care may reduce inequity in access.

OBJECTIVE: To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level.
UNASSIGNED: We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019.
METHODS: We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender.
METHODS: We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence.
RESULTS: Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination.
CONCLUSIONS: We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation.

BACKGROUND: Access to dental care may affect diagnosis of oral squamous cell carcinoma (OSCC). We tested whether the incidence rate of OSCC is higher in regions with less dental care access in the city of Chicago and state of Illinois.
METHODS: Ecological cohort.
METHODS: Population, outpatients, and inpatients.
METHODS: We extracted 5-year averages of the state-wide county-level and city-level OSCC incidence rates from 2015 to 2019 from the Illinois Department of Public Health. Dental care access information was also collected for each county for the same period, as well as the percentage of people that had ≥1 visit to a dentist in the previous year in Chicago. Multivariate Poisson regression was used to investigate the relationship between county-level access to dental care (and city-level dentist visits) and OSCC incidence rate, controlling for confounders, with additional flexible semiparametric models for confirmatory sensitivity analysis.
RESULTS: In Illinois, higher 5-year incidence rate of OSCC was significantly associated with low access to dental care by county (IRR = 0.96, 95% CI 0.91, 0.98). Southern/southwestern counties had higher incidence rates of OSCC (15.5%-28.4%) and the lowest rates of dental care access (47.5%-69.2%) compared to northern counties (10.3%-15% and 55.4%-80.6%, respectively). In Chicago, people with more dentist visits had a reduced chance of being diagnosed with OSCC (IRR = 0.97, 95% CI 0.91, 0.99), consistent with state-wide analyses.
CONCLUSIONS: OSCC incidence rate is closely associated with poor local dental healthcare access in a major state and urban city. Increasing dental access could improve cancer outcomes via improved oral health and earlier detection.