Introduction: Our university hospital-based primary care practices transitioned a budding interest in telehealth to a largely telehealth-based approach in the face of the COVID-19 pandemic.Initial work: Implementation of telehealth began in 2017. Health system barriers, provider and patient reluctance, and inadequate reimbursement prevented widespread adoption at the time. COVID-19 served as the catalyst to accelerate telehealth efforts.Implementation: COVID-19 resulted in the need for patient care with "social distancing." In addition, due to the pandemic, the Centers for Medicare and Medicaid Services and other insurers began expanded reimbursement for telehealth. More than 2000 providers received virtual health training in less than 2 weeks. In March 2020, we provided 2376 virtual visits, and in April 5293, which was more than 75 times the number provided in February; 73% of all visits in April were virtual (up from 0.5% in October 2019). As COVID-19 cases receded in May, June, and July, patient demand for virtual visits decreased, but 28% of visits in July were still virtual.Lessons learned: Several key lessons are important for future efforts regarding clinical implementation: (1) prepare for innovation, (2) cultivate an innovation mindset, (3) standardize (but not too much), (4) technological innovation is necessary but not sufficient, and (5) communicate widely and often. ( J Am Board Fam Med 2021;34:S196-S202.

Patients with advanced fibrosis are at increased risk of severe outcomes if they develop acute infection with hepatitis A (HAV) or hepatitis B (HBV) viruses. There are no data on the efficacy of combined HAV/HBV vaccination in patients with advanced fibrosis. Our aim was to evaluate the response to the HAV and HBV vaccine alone or in combination for patients with chronic hepatitis C (HCV) and advanced fibrosis and to evaluate the impact of administering the vaccine while patients were receiving peginterferon for treatment of chronic HCV. In this prospective study of patients with advanced fibrosis (Ishak 3-6), those without serologic evidence of prior exposure were vaccinated with either Havrix HAV, Engerix( HBV, or the TWINRIX HAV/HBV combination vaccine as appropriate, and response was defined as the development of anti-HAV or anti-HBV surface antibodies. Of the 162 eligible patients, the prevalence of prior exposure to HAV and HBV was 30 and 18%, respectively. Of the 84 patients vaccinated, 38% received Havrix, 14% Engerix, and 48% TWINRIX. The response to the HAV vaccine was 75% in those receiving Havrix compared to 78% receiving TWINRIX. In contrast, the response to HBV vaccination was 42% in patients receiving Engerix compared to 60% in those vaccinated with TWINRIX (difference 18.3%; OR 0.29; 95% CI: 0.57-7.79). The presence of diabetes was the only risk factor identified for reduced HBV response (P = 0.01). Responses to both HAV and HBV vaccines when administered alone or in combination were lower than expected in patients with HCV and advanced fibrosis, especially in those with diabetes. The observation that the decline in HBV vaccine response was somewhat lower when this was administered alone as opposed to the combination A/B vaccine suggests that the administration of a combination vaccine may enhance the vaccination response to HBV.

Health literacy is a key determinant of health in refugee and migrant populations living in in high-income countries (HICs). We conducted a systematic review of randomized-controlled trials (RCTs) to characterize the scope, methodology, and outcomes of research on interventions aimed at improving health literacy among these vulnerable populations. We searched EMBASE, MEDLINE, PsycINFO, CINAHL, and Web of Science databases to identify RCTs of health literacy intervenions in our target population published between 1997 and 2018. The search yielded 23 RCTs (n = 5625 participants). Study demographics, health literacy topics, interventions, and outcome measures were heterogeneous but demonstrated overall positive results. Only two studies used a common health literacy measure. Few RCTs have been conducted to investigate interventions for improving the health literacy of refugees and migrants in HICs. The heterogeniety of health literacy outcome measures used impeded a robust comparison of intervention efficacy.

Objective: Despite the overwhelming prevalence and health implications of obesity, it is rarely addressed in a health care setting. Providers and patients alike cite innumerable barriers as to the reasons why. The current study provides a framework to systematically address and deconstruct these barriers.Methods: A pilot study was conducted to evaluate the feasibility of the PATHWEIGH weight loss intervention in primary care. The intervention consisted of staff team training, workflow system management and data capture from the electronic medical record (EPIC). Two family medicine clinics in the same health care system were compared in their approach to weight management: PATHWEIGH method vs. Standard of Care (SOC); matched for provider expertise. Statistical analyses examined patient demographics, weight-related comorbidities, baseline weight and weight loss over 18 months.Results: Patients in the PATHWEIGH group (N = 109) vs. SOC (N = 338) were younger (45 vs. 54 years old, p < 0.001), more likely to be female (89% vs. 65%, p < 0.01) and be commercially insured (93% vs. 52%, p < 0.001). The groups were comparable with respect to the numbers of weight-related comorbidities (p = 0.57). Baseline weight was not different between the groups (103.8 vs. 101.5 kg, p = 0.32), but weight lost was significantly greater in the PATHWEIGH group (7.9 kg / 7.2% body weight vs. 2.4 kg / 2.1% body weight SOC, p < 0.001 for both) despite a similar percentage of patients receiving bariatric surgery (10% for both groups, p = 0.99). Anti-obesity medication was more commonly prescribed in PATHWEIGH vs. SOC (79.8 vs. 20.7%, p < 0.001). Conclusion:These preliminary data demonstrate the feasibility and suggest superiority of using PATHWEIGH for weight loss in a primary care setting.

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