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Requests for reprints should be addressed to Robert Nathanson, MD, Division of Hospital Medicine, Department of Medicine, University of Texas Health San Antonio, 7703 Floyd Curl Dr, MC 7982, San Antonio, TX 78229.
Department of Pulmonary, Critical Care and Sleep Medicine, The George Washington University, Washington, DCPulmonary and Critical Care Medicine, Veterans Affairs Medical Center, Washington, DC
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TennDepartment of Emergency Medicine, VA Tennessee Valley Healthcare System—Nashville
Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TennDepartment of Emergency Medicine, VA Tennessee Valley Healthcare System—Nashville
Pulmonary Section, Minneapolis Veterans Affairs Health Care System, MinnDivision of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, University of Minnesota, Minneapolis
Medicine Service, VA NY Harbor Healthcare System, New York, NYDivision of Pulmonary, Critical Care, and Sleep Medicine, New York University Grossman School of Medicine, New York, NY
Emergency Medicine, VA Greater Los Angeles Healthcare System, CalifDepartment of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Calif
Medicine Service, South Texas Veterans Health Care System, San AntonioDivision of Hospital Medicine, University of Texas Health San AntonioDivision of Pulmonary Diseases & Critical Care Medicine, University of Texas Health San Antonio
More primary care providers (PCPs) have begun to embrace the use of point-of-care ultrasound (POCUS), but little is known about how PCPs are currently using POCUS and what barriers exist. In this prospective study, the largest systematic survey of POCUS use among PCPs, we assessed the current use, barriers to use, program management, and training needs for POCUS in primary care.
Methods
We conducted a prospective observational study of all VA Medical Centers (VAMCs) between June 2019 and March 2020 using a web-based survey sent to all VAMC Chiefs of Staff and Chiefs of primary care clinics (PCCs).
Results
Chiefs of PCCs at 105 VAMCs completed the survey (82% response rate). Only 13% of PCCs currently use POCUS, and the most common applications used were bladder and musculoskeletal ultrasound. Desire for POCUS training exceeded current use, but lack of trained providers (78%), ultrasound equipment (66%), and funding for training (41%) were common barriers. Program infrastructure to support POCUS use was uncommon, and only 9% of VAMCs had local policies related to POCUS. Most PCC chiefs (64%) would support POCUS training.
Conclusions
Current use of POCUS in primary care is low despite the recent growth of POCUS training in Internal Medicine residency programs. Investment in POCUS training and program infrastructure is needed to expand POCUS use in primary care and ensure adequate supervision of trainees.
Few primary care clinics currently use point-of-care ultrasound (POCUS), based on a national survey conducted among Veterans Affairs Medical Centers.
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The most common barriers to POCUS use in primary care were lack of trained providers, ultrasound equipment, and funding for training.
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Investment in POCUS training and program infrastructure is needed to expand POCUS use in primary care and ensure adequate supervision of trainees.
Introduction
Point-of-care ultrasound (POCUS) is defined as the use of ultrasound at the point of patient care to answer a specific diagnostic question or guide the performance of an invasive procedure.
Prevalence and scope of point-of-care ultrasound education in internal medicine, pediatric, and medicine-pediatric residency programs in the United States.
little is known about the current use of POCUS by PCPs.
To better understand POCUS use in primary care clinics (PCCs), we conducted a national survey to assess current use, training, barriers, and program management in PCCs in the Veterans Affairs (VA) Healthcare System. Our study's findings can guide implementation of POCUS in primary care, along with the development of POCUS training curricula and program infrastructure.
Methods
We performed a prospective observational study of all VA Medical Centers (VAMCs) between June 2019 and March 2020. A multidisciplinary POCUS Technical Advisory Group of emergency medicine, hospital medicine, and critical care physicians collaborated with the VA's Healthcare Analysis and Information Group to develop and disseminate a web-based survey systemwide. The survey included questions on current use, barriers, institutional support, equipment, and training needs of POCUS. The University of Texas Health San Antonio Investigational Review Board deemed this study to be nonresearch (Protocol Number: HSC20210630NRR). Chiefs of Staff (n = 130) of all VAMCs initially completed 10 questions about facility-level POCUS use, training, competency, and policies. Next, section chiefs of PCCs associated with 128 VAMCs were identified and received 18 questions on POCUS use, training needs, workflows, and equipment availability in PCCs.
Results
A total of 105 of 128 surveys were completed (82% response rate), and characteristics of the PCCs are summarized in Table 1. Currently, 13% of PCCs had at least one provider using POCUS and 29% had providers who desired POCUS training. Few PCPs received prior training through residency/fellowship or continuing medical education courses. The most common POCUS applications used were bladder, urinary retention, and joint injections. Desire for training in bladder and musculoskeletal POCUS applications exceeded current use (Figure and Appendix).
Table 1Characteristics, Current Use, and POCUS Training Received in Primary Care Clinics at VA Medical Centers (n = 105 Facilities)
High-complexity facilities have high levels of patient volume, patient risk, specialists, teaching, and research. Low-complexity facilities have medium to low levels of patient volume and patient risk, and some to little teaching or research.
High
76 (72%)
Low
29 (28%)
Region
Northeast
25 (23%)
Midwest
30 (29%)
South
29 (28%)
West
21 (20%)
Location
Urban
90 (86%)
Current use
At least one primary care provider uses POCUS
14 (13%)
Providers have desire for POCUS Training
30 (29%)
Service Chief knows of ≥1 facility-wide policy for POCUS
Data presented from the primary care clinics that reported use of POCUS (n = 14).
Via CME
None
7%
Few (1%-25%)
29%
Some (26%-50%)
14%
Most (>50%)
0%
Unknown/unclear
50%
Via residency/fellowship
None
14%
Few (1%-25%)
43%
Some (26%-50%)
0%
Most (>50%)
0%
Unknown/unclear
43%
CME = Continuing Medical Education; POCUS = point-of-care ultrasound; VA = Veterans Affairs; VHA = Veterans Health Administration.
High-complexity facilities have high levels of patient volume, patient risk, specialists, teaching, and research. Low-complexity facilities have medium to low levels of patient volume and patient risk, and some to little teaching or research.
† Data presented from the primary care clinics that reported use of POCUS (n = 14).
Only 1 in 5 facilities had a process for providers to obtain POCUS training. Two-thirds of chiefs would support participation of their physicians in an on-site or regional POCUS course. Program infrastructure to support POCUS use was uncommon. Few chiefs (9%) reported having local policies related to POCUS use, such as credentialing, machine maintenance, and documentation.
Barriers to POCUS use were common among PCCs (Table 2). The most common barriers reported were lack of trained providers (78%), available ultrasound equipment (66%), funding for training (41%), perceived benefit (40%), and clinician champion (39%). In open-ended survey questions, some chiefs stated that ultrasound techniques would be difficult to implement in PCCs, and POCUS use was either not needed or needed only on a limited basis.
Table 2Barriers to POCUS Use in Primary Care Clinics at VA Medical Centers (n = 105 Facilities)
We have conducted the largest systematic survey of POCUS use by PCPs, and our findings can further guide POCUS implementation in primary care. In contrast to hospital medicine and emergency medicine,
relatively few PCPs currently use POCUS. Our results are consistent with a recent national survey, which showed that only 17% of Internal Medicine residency programs provided POCUS training in outpatient settings.
Most PCC chiefs recognize the benefits of POCUS and key barriers, such as lack of training, that must be addressed to foster widespread adoption of POCUS in PCCs.
Current use of POCUS in primary care is low despite the recent growth of POCUS training in Internal Medicine residency programs.
Lack of training, equipment, and program infrastructure were identified as significant barriers to POCUS use. The training gap between residents and their supervising physicians continues to widen, with residents becoming more proficient.
Substantive investment in POCUS training of attending physicians nationwide is needed to ensure adequate supervision of trainees.
Most PCCs lacked available ultrasound equipment, and chiefs felt that improved access to ultrasound machines would promote training of PCPs and residents. Chiefs frequently reported that lack of program infrastructure at their VAMC would prevent PCPs from receiving POCUS credentials. Image archiving, documentation, and quality improvement and quality assurance programs are critical for assessment of POCUS competency.
Although POCUS use in other specialties has been shown to improve diagnostic accuracy, procedural success rates, complication rates, costs, and patient satisfaction,
chiefs reported lack of studies in primary care settings as a barrier to adoption. High-quality POCUS research on effective implementation and clinical outcomes in primary care may promote increased utilization.
Strengths of our study include high response rates and broad representation of VAMCs nationwide. However, our data are limited to PCCs located at VAMCs and freestanding community-based outpatient clinics were not included in our survey. Few respondents were from rural PCCs. Although PCPs in rural settings were more likely to use POCUS in a 2018 study, no rural PCCs in our survey used POCUS.
Further, our findings may not be generalizable to non-VA health care systems, although VAMCs are often staffed by physicians who practice at affiliated medical schools and non-VA facilities.
There is potential for improved outcomes, patient satisfaction, and lower total costs with POCUS use in primary care.
Development of national guidelines for POCUS use in primary care, along with support for faculty training, equipment, and program infrastructure are needed to expand POCUS adoption in primary care.
Disclaimer
The contents of this publication do not represent the views of the US Department of Veterans Affairs or the United States Government.
Appendix POCUS Applications Used and Training Desired within Primary Care (N = 105)
Tabled
1
Application
Used
Training Desired
Abdominal
Bladder
6 (6%)
12 (11%)
Urinary retention
5 (5%)
17 (16%)
Abdominal aortic aneurysm (AAA)
2 (2%)
9 (9%)
Hydronephrosis
1 (1%)
7 (7%)
Peritoneal fluid
1 (1%)
7 (7%)
Nephrolithiasis
1 (1%)
5 (5%)
Biliary
1 (1%)
5 (5%)
Hernia
1 (1%)
5 (5%)
Appendicitis
1 (1%)
4 (4%)
Small bowel obstruction
1 (1%)
2 (2%)
Prostate
1 (1%)
2 (2%)
Pneumoperitoneum
1 (1%)
1 (1%)
Uterus
0 (0%)
6 (6%)
Ovaries
0 (0%)
6 (6%)
Intrauterine pregnancy
0 (0%)
4 (4%)
Focused assessment with sonography for trauma (FAST)
0 (0%)
1 (1%)
Procedures
Joint injection
4 (4%)
18 (17%)
Tendon injection
2 (2%)
13 (12%)
Bursa injection
1 (1%)
16 (15%)
Abscess drainage
1 (1%)
13 (12%)
Paracentesis
1 (1%)
3 (3%)
Peripheral IV access
1 (1%)
3 (3%)
Central line placement
1 (1%)
1 (1%)
Arterial line placement
1 (1%)
0 (0%)
Arthrocentesis
0 (0%)
12 (11%)
Foreign body removal
0 (0%)
6 (6%)
Intrauterine device insertion
0 (0%)
6 (6%)
Nephrostomy tube
0 (0%)
6 (6%)
Suprapubic catheter
0 (0%)
2 (2%)
Chest tube
0 (0%)
1 (1%)
Peripheral nerve blocks
0 (0%)
1 (1%)
Endotracheal intubation
0 (0%)
1 (1%)
Lymph node biopsy
0 (0%)
0 (0%)
Prostate biopsy
0 (0%)
0 (0%)
Thoracentesis
0 (0%)
0 (0%)
Peripherally inserted central catheter (PICC) placement
0 (0%)
0 (0%)
Lumbar puncture
0 (0%)
0 (0%)
Liver biopsy
0 (0%)
0 (0%)
Breast biopsy
0 (0%)
0 (0%)
Thyroid biopsy
0 (0%)
0 (0%)
Pericardiocentesis
0 (0%)
0 (0%)
Skin/soft tissues/musculoskeletal
Joint effusion
2 (2%)
22 (21%)
Bursitis
2 (2%)
14 (13%)
Abscess
2 (2%)
13 (12%)
Synovitis
2 (2%)
12 (11%)
Shoulder/rotator cuff
2 (2%)
12 (11%)
Tendinopathies
2 (2%)
11 (10%)
Foreign body
1 (1%)
9 (9%)
Cellulitis
1 (1%)
8 (8%)
Lymph nodes
1 (1%)
5 (5%)
Fractures
0 (0%)
7 (7%)
Pulmonary
Pleural effusion
1 (1%)
11 (10%)
Pulmonary edema
1 (1%)
7 (7%)
Pneumonia
1 (1%)
7 (7%)
Pneumothorax
1 (1%)
5 (5%)
Cardiac
Volume status (inferior vena cava/internal jugular)
Prevalence and scope of point-of-care ultrasound education in internal medicine, pediatric, and medicine-pediatric residency programs in the United States.
Funding: NJS receives funding from the US Department of Veterans Affairs, Quality Enhancement Research Initiative (QUERI) Partnered Evaluation Initiative Grant (HX002263-01A1). JSB receives funding from an Agency for Healthcare Research and Quality (AHRQ) Grant (1R01HS025979-01A1) and a Centers or Disease Control and Prevention (CDC) Grant (75D301-20-C-07637). BPL receives funding from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development. This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System in San Antonio, Texas.
Conflicts of Interest: None.
Authorship: All authors had access to the data and a role in writing this manuscript. RN: Methodology, Formal analysis, Writing – original draft, Visualization; JPW: Methodology, Formal analysis, Writing – original draft, review, & editing; NG: Writing – original draft, review, & editing; AR: Writing – original draft, review, & editing; MJM: Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, review, & editing, Visualization; EKH: Conceptualization, Methodology, Writing – review & editing; BD: Conceptualization, Methodology, Investigation, Data curation, Writing – review & editing, Supervision, Project administration; EO: Conceptualization, Methodology, Investigation, Data curation, Writing – review & editing, Supervision, Project administration; RK: Writing – review & editing; JSB: Conceptualization, Writing – review & editing; BB: Writing – review & editing; EW: Writing – review & editing; HS: Writing – review & editing; CKS: Conceptualization, Writing – review & editing; ZB: Writing – review & editing; DR: Writing – review & editing; BPL: Methodology, Formal analysis, Writing – review & editing; NJS: Conceptualization, Methodology, Formal analysis, Investigation, Data curation, Writing – original draft, review, & editing; Supervision, Project administration, Funding acquisition.
High-complexity facilities have high levels of patient volume, patient risk, specialists, teaching, and research. Low-complexity facilities have medium to low levels of patient volume and patient risk, and some to little teaching or research.
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