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Heintzman J, O’Malley J, Marino M, et al. SARS-CoV-2 Testing and Changes in Primary Care Services in a Multistate Network of Community Health Centers During the COVID-19 Pandemic. JAMA. Published online August 31, 2020. doi:10.1001/jama.2020.15891
The effect of the coronavirus disease 2019 (COVID-19) pandemic on the primary care community health centers (CHCs) in the US has not been well described. CHCs serve approximately 30 million people,1 including high proportions of patients susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and adverse outcomes.2,3 Surveys indicate that many primary care practices, including CHCs, lacked access to SARS-CoV-2 testing, personal protective equipment, and emergency financial resources, and that in-person visits and preventive and chronic illness care have been reduced.4 We describe SARS-CoV-2 testing, individuals with positive test results, and changes in select primary care services in a multistate network of CHCs in the first weeks of the pandemic.
We used electronic health record (EHR) data from OCHIN, a network of CHCs in 21 states that share a linked EHR.5 We included patients aged 79 years or younger with a clinic visit between January 1, 2019, and May 31, 2020. We examined patients who underwent SARS-CoV-2 testing and had results positive for SARS-CoV-2 in their EHR by patient characteristics (Table 1) from March 1, 2020, to May 31, 2020, using bivariable generalized estimating equation Poisson regression accounting for clustering of patients within health systems. Patients were considered “tested” once their first test was recorded; subsequent tests were included only in counts of positive test results. We also compared the clinic-level delivery of common primary care services indicated for varying ages/sexes (relative rates of face-to-face visits with a medical professional, well-child visits, Papanicolaou testing, hemoglobin A1c testing, and mammogram orders) in January 2019 to February 2019, March 2019 to May 2019, January 2020 to February 2020, and March 2020 to May 2020 using generalized estimating equation Poisson regression. Statistical significance was defined as a 95% CI that did not include 1.0. Analyses were performed with SAS Enterprise Guide, version 7.15. This study was considered exempt by the Advarra Institutional Review Board.
Among 1 938 736 patients seen at 431 primary care clinics in 132 CHCs, 33 266 patients (1.7%) underwent SARS-CoV-2 testing, of whom 9348 (28% of all tests) had positive results (Table 1). New patients (n = 75 053) seen between March 1, 2020, and May 31, 2020, had higher SARS-CoV-2 testing rates compared with established patients. Being Asian, speaking a language other than English or Spanish, and being publicly insured (Medicare or Medicaid/other) were associated with lower testing rates. Having a Charlson Comorbidity Index6 of at least 4 and being uninsured were associated with higher testing rates. Speaking Spanish, being Hispanic, being uninsured, and speaking a language other than English or Spanish were associated with higher rates of positive test results than reference comparators. Being female and having a Charlson Comorbidity Index of 1 to 3 or greater than or equal to 4 (vs 0) were associated with lower rates of positive test results. There were no differences in rates of positive test results across age groups.
In March 2020 to May 2020, compared with March 2019 to May 2019, rates of face-to-face visits (relative rate [RR], 0.58 [95% CI, 0.51-0.66]), well-child visits (RR, 0.47 [95% CI, 0.41-0.54]), Papanicolaou tests (RR, 0.34 [95% CI, 0.30-0.39]), hemoglobin A1c tests (RR, 0.51 [95% CI, 0.46-0.57]), and mammograms (RR, 0.44 [95% CI, 0.38-0.51]) declined. No such decline was observed comparing January to February in 2019 vs 2020 (Table 2).
Despite limited test availability,4 CHCs reported thousands of SARS-CoV-2 tests, underscoring their important role in serving vulnerable populations. The 75 053 patients seen for the first time after the pandemic started suggests that CHCs were an access point in the midst of the crisis. Small differences in testing and positive rates by race, and larger differences by ethnicity, preferred language, and insurance status, suggest ongoing need for targeted, language-concordant testing strategies.
In the pandemic’s initial weeks, delivery of common services in CHCs declined, possibly due to in-person care reductions. Although these changes may have been necessary and unavoidable, the potential consequences are concerning because reductions in preventive/chronic disease care may affect population health.
Study limitations include not having clinical presentation data of tested patients or additional clinic-level factors, such as testing capacity, geography, local disease rates, and infrastructure. CHC patients may have received tests that were not recorded in the networked EHR; therefore, the results may underestimate true population testing rates. Results may not be generalizable to all primary care clinics; however, the network has similar patient characteristics as CHCs nationwide.1,5 Further research should assess differences in clinical presentation in various demographic groups, the effect of remote (telephone/video) visits on care quality, and the potential ongoing role of CHCs in mitigating pandemic-related inequity.
Corresponding Author: John Heintzman, MD, MPH, OCHIN Inc, 1881 SW Naito Pkwy, Portland, OR 97201 (firstname.lastname@example.org).
Accepted for Publication: August 5, 2020.
Published Online: August 31, 2020. doi:10.1001/jama.2020.15891
Author Contributions: Dr Heintzman and Ms O’Malley had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: O’Malley, Marino, Stange, Gold.
Drafting of the manuscript: Heintzman, O’Malley, Marino, Stange.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: O’Malley, Marino.
Obtained funding: Marino, Gold.
Administrative, technical, or material support: Todd.
Supervision: Heintzman, Stange, Gold.
Conflict of Interest Disclosures: Dr Heintzman reported receiving grants from PCORNet during the conduct of the study and, in other similar research projects, receiving funding from the National Institutes of Health (the National Institute of Minority Health and Health Disparities and the National Institute on Aging) and the Agency for Healthcare Research and Quality. Dr O'Malley reported receiving grants from the National Cancer Institute during the conduct of the study. Dr Marino reported receiving grants from the National Cancer Institute during the conduct of the study. Dr Huguet reported receiving grants from the National Cancer Institute during the conduct of the study. Dr Gold reported receiving grants from the National Institutes of Health during the conduct of the study. No other disclosures were reported.
Funding/Support: This work was supported by the National Cancer Institute of the National Institutes of Health under award No. P50CA244289. This work was also supported by a grant from the Patient Centered Outcomes Research Network (Accelerating Data Value Across a National Community Health Center Network Clinical Research Network phase 3).
Role of the Funder/Sponsor: These funders had no role in the specific design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Additional Contributions: We acknowledge Pedro Rivera, MS; Erika Cottrell, PhD; Teresa Schmidt, PhD; Annie Larson, PhD; Rebecca Block, PhD; Matthew Jones, MS (OCHIN); and Jennifer DeVoe, MD, DPhil (Oregon Health & Science University), for reviewing the manuscript. Dr DeVoe received compensation through the National Cancer Institute award cited above. The other individuals did not receive compensation for their contributions.
Additional Information: This program was launched by the National Cancer Institute as part of the Cancer Moonshot.
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