Birth of a Social Mediatrician: Adopting Slack, Twitter, and Instagram for Residents

Introduction Physicians have increasingly used social media platforms to review new research, expand networks, and communicate. However, few studies have evaluated how the integration of social media into residency programs affects training. This is relevant during the COVID-19 pandemic, with a shift towards virtual formats for medical education, community building, and recruitment. Objective The objective of this study was to evaluate how the integration of social media platforms, including Slack, Twitter, and Instagram, influences education, social connectedness, and recruitment within a residency program. Methods In 2020, pediatric residents at one institution were encouraged to create personal Twitter and Instagram accounts if they did not already have one and follow the residency program's Twitter and Instagram accounts. Residents were also encouraged to enroll in a private Slack network within the residency program. We surveyed residents in May and June 2020 (pre-intervention) and March 2021 (post-intervention). Analytics from the residency program's social media accounts and Slack were recorded. Data were analyzed using a mixed-methods approach. Results Response rates from residents regarding the impact of social media interventions on education, connectedness, and recruitment were 98% (100/102) pre-intervention and 74.5% (76/102) post-intervention. During the study period from May 2020 to March 2021, chief resident posts on the residency program's Twitter and Instagram accounts garnered 447,467 and 151,341 impressions, respectively. Posts with the highest average impressions were those related to advocacy. After the intervention, residents reported increased connectedness to residents in other classes and increased usage of their personal Twitter and Slack accounts for learning and education. Residents rated the program's Instagram account as a useful recruitment tool. Feasibility of posting was assessed by the number of posts by chief residents during the study period (Twitter n=806, Instagram n=67). There were no costs. Conclusion Our data shows that social media in residency is feasible, cost-effective, and valuable for education, connectedness, and recruitment. We outlined specific ways social media was feasible and useful in these domains.

A preponderance of gastrointestinal cancer patients transition into cachexia syndrome

BACKGROUND

Cancer cachexia is frequently documented by self-reported, single time-point weight histories. This approach lacks the granularity needed to fully elucidate the progression of cachexia syndrome. This study aimed to longitudinally assess body weight changes pre- and post-cancer diagnosis in gastrointestinal (GI) cancer patients.

METHODS

Body weights and relevant clinical data recorded in the electronic health record 12 months pre- and post-GI cancer (colorectal, gastroesophageal, hepatobiliary and pancreatic) diagnosis were extracted. Weight loss was categorized by the International Consensus Definition for cachexia.

RESULTS

A total of 879 patients were included in the final cohort including patients diagnosed with colorectal (n = 317), hepatocellular (n = 185), biliary (n = 72), pancreatic (n = 186) or gastroesophageal (n = 119) cancer. Stage of disease was equally distributed. Patients without cachexia at diagnosis (n = 608) remained weight stable during the 12 months pre-diagnosis (+0.5 ± 0.5% body weight; P = 0.99). Patients with cachexia at diagnosis (n = 271) remained weight stable 6 to 12 months prior to diagnosis (+0.4 ± 0.8%; P > 0.9999) and lost 8.7 ± 0.6% (P < 0.0001) within the 6 months pre-diagnosis. Patients without cachexia at diagnosis lost more weight post-diagnosis (6.3 ± 0.6%) than patients with cachexia at diagnosis (4.7 ± 1.0%; P = 0.01). Pre-diagnosis weight trajectories did not differ between primary malignancies or stage of disease in patients without or with cachexia at diagnosis (all P ≥ 0.05). Post-diagnosis weight trajectories did differ by primary malignancy (P ≤ 0.0002) and stage (P < 0.0001). In both patients without and with cachexia at diagnosis, colorectal patients lost the least amount of weight post-diagnosis and gastroesophageal patients lost the most amount of weight post-diagnosis. Stage 4 patients without or with cachexia at diagnosis lost the most weight post-diagnosis (P ≤ 0.0003). Regardless of cachexia status at diagnosis, patients lost more weight when treated with systemic therapy (7.1 ± 0.7%; P < 0.0001; n = 419) or radiation therapy (8.4 ± 1.4%; P = 0.02; n = 116) compared to those who did not. Patients who did not have surgery lost more weight post-diagnosis (7.6 ± 1.1%; P < 0.0001; n = 355) compared to those who did have surgery. By 12 months post-diagnosis, 83% of the surviving GI cancer patients in this cohort had transitioned into cachexia syndrome.

CONCLUSIONS

Significant weight loss in patients with GI cancer cachexia at diagnosis initiates at least 6 months prior to diagnosis, and most patients will transition into cachexia syndrome post-diagnosis, regardless of pre-diagnosis weight change and stage of disease. These findings punctuate the importance of weight surveillance in cancer detection and earlier palliative interventions post-diagnosis in the GI cancer patient population.

Feasibility of implementing a web-based tool built from pharmacy claims data (e-MEDRESP) to monitor adherence to respiratory medications in primary care

OBJECTIVE

e-MEDRESP is a novel web-based tool that provides easily interpretable information on patient adherence to asthma/chronic obstructive pulmonary disease (COPD) medications, using pharmacy claims data. This study investigated the feasibility of implementing e-MEDRESP in primary care.

MATERIAL AND METHODS

In this 16-month prospective cohort study, e-MEDRESP was integrated into electronic medical records. Nineteen family physicians and 346 of their patients were enrolled. Counters embedded in the tool tracked physician use during the follow-up. Patient/physician satisfaction with e-MEDRESP was evaluated though telephone interviews and online questionnaires. The capacity of e-MEDRESP to improve adherence was explored using a pre-post analysis.

RESULTS

Overall, 245 patients had at least one medical visit during follow-up. e-MEDRESP was consulted by 15 (79%) physicians for 85 (35%) patients during clinic visits. Seventy-three patients participated in telephone interviews; 84% reported discussing their medication use with their physician; 33% viewed their e-MEDRESP report and indicated that it was easy to interpret. The physicians reported that the tool facilitated their evaluation of their patients' medication adherence (mean ± standard deviation rating: 4.8 ± 0.7, on a 5-point Likert scale). Although the pre-post analysis did not reveal improved adherence in the overall cohort, adherence improved significantly in patients whose adherence level was <80% and who were prescribed inhaled corticosteroids (26.9% [95% CI 14.3-39.3%]) or long-acting muscarinic agents (26.4% [95% CI 12.4-40.2%]).

CONCLUSIONS

e-MEDRESP was successfully integrated in clinical practice. It could serve as a useful tool to help physicians monitor their patients' medication adherence.

Mortality in COVID-19 among women on hormone replacement therapy: a retrospective cohort study

BACKGROUND

Limited recent observational data have suggested that there may be a protective effect of oestrogen on the severity of COVID-19 disease. Our aim was to investigate the association between hormone replacement therapy (HRT) or combined oral contraceptive pill (COCP) use and the likelihood of death in women with COVID-19.

METHODS

We undertook a retrospective cohort study using routinely collected computerized medical records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care database. We identified a cohort of 1,863,478 women over 18 years of age from 465 general practices in England. Mixed-effects logistic regression models were used to quantify the association between HRT or COCP use and all-cause mortality among women diagnosed with confirmed or suspected COVID-19 in unadjusted and adjusted models.

RESULTS

There were 5,451 COVID-19 cases within the cohort. HRT was associated with a reduction in all-cause mortality in COVID-19 (adjusted OR 0.22, 95% CI 0.05 to 0.94). There were no reported events for all-cause mortality in women prescribed COCPs. This prevented further examination of the impact of COCP.

CONCLUSIONS

We found that HRT prescription within 6 months of a recorded diagnosis of COVID-19 infection was associated with a reduction in all-cause mortality. Further work is needed in larger cohorts to examine the association of COCP in COVID-19, and to further investigate the hypothesis that oestrogens may contribute a protective effect against COVID-19 severity.

Prevalence of multimorbidity combinations and their association with medical costs and poor health: A population-based study of U.S. adults

Background

Multimorbidity is common, but the prevalence and burden of the specific combinations of coexisting disease has not been systematically examined in the general U.S. adult population.

Objective

To identify and estimate the burden of highly prevalent combinations of chronic conditions that are treated among one million or more adults in the United States.

Methods

Cross-sectional analysis of U.S. households in the Medical Expenditure Panel Survey (MEPS), 2016-2019, a large nationally-representative sample of the community-dwelling population. Association rule mining was used to identify the most common combinations of 20 chronic conditions that have high relevance, impact, and prevalence in primary care. The main measures and outcomes were annual treated prevalence, total medical expenditures, and perceived poor health. Logistic regression models with poor health as the outcome and each multimorbidity combination as the exposure were used to calculate adjusted odds ratios and 95% confidence intervals.

Results

Frequent pattern mining yielded 223 unique combinations of chronic disease, including 74 two-way (dyad), 115 three-way (triad), and 34 four-way combinations that are treated in one million or more U.S. adults. Hypertension-hyperlipidemia was the most common two-way combination occurring in 30.8 million adults. The combination of diabetes-arthritis-cardiovascular disease was associated with the highest median annual medical expenditures ($23,850, interquartile range: $11,593-$44,616), and the combination of diabetes-arthritis-asthma/COPD had the highest age-race-sex adjusted odds ratio of poor self-rated health (adjusted odd ratio: 6.9, 95%CI: 5.4-8.8).

Conclusion

This study demonstrates that many multimorbidity combinations are highly prevalent among U.S. adults, yet most research and practice-guidelines remain single disease focused. Highly prevalent and burdensome multimorbidity combinations could be prioritized for evidence-based research on optimal prevention and treatment strategies.

Towards Safe Patient Identification Practices: the Development of a Conceptual Framework from the Findings of a Ph.D. Project

Patient identification errors are considered the root cause of other patient safety incidents. Despite the development, recommendation, and application of several initiatives to reduce and prevent misidentification in hospital settings, errors continue to occur. They directly impact the quality of care provided, resulting in delays in care, added costs, unnecessary injuries, misdiagnosis or wrong treatment, and other serious and irreversible types of harm and death. Furthermore, the certainty of the evidence of the effectiveness of interventions to reduce patient identification errors is considered very low.

This paper reports on the development of a conceptual framework for safe practices in the area of patient identification. The proposed conceptual framework was developed based on presuppositions regarding learning health systems and the available evidence from the published systematic reviews of the effectiveness of interventions in reducing patient identification errors in hospital settings. The core circle of the framework represents the partnership between managers, healthcare professionals, patients, and families working toward integrative and collaborative efforts for safe patient identification practices. The inner dimension states the recommendations for practice sustained by applying technological resources and educational strategies to raise awareness of the importance of accurate patient identification and interdisciplinarity, which works as an axis that supports integrated and collective work between healthcare professionals aiming for safe care. The outer dimension represents recommendations for teaching and research to develop effective patient identification practices that can enhance patient safety and the quality of care provided in hospital settings.

This framework provides a valuable method for engaging interdisciplinary teams to improve the safety of patient identification systems.

Exploring the challenges to safer prescribing and medication monitoring in prisons: A qualitative study with health care staff

Introduction

Research suggests that patients who are prisoners experience greater morbidity, increased health inequalities and frequent preventable harm, compared to the general population. Little is known about the process and influencing factors for safe prescribing in the unique prison environment, which may limit the development efforts to improve the quality of care in prisons. This study aimed to understand the process and challenges associated with prescribing in prisons, explore the causes and impact of these challenges, and explore approaches to improve prescribing safety in prisons.

Methods

Grounded theory informed data collection and analysis of a nominal group discussion by seven participants and semi-structured telephone interviews with twenty prison healthcare staff, including GPs, pharmacists, psychiatrists and nurses.

Findings

The underlying complexity of prescribing in prison settings increased the level of challenge and influenced the safety of this process. Multiple contributors to the challenges of safe prescribing were identified (comprising governance and policy; the prison structure; staff retention, training and skill mix; IT systems and interface; polypharmacy and co-morbidity; tradability and patient behaviour) with overarching constructs of variations in practice/policy and the influence of prison culture. Participants identified measures to address these challenges through multi-disciplinary collaborative working, increased consistency in processes, and the need for more innovation and education/training.

Conclusions

Our study highlighted that healthcare provision in prisons is unique and needs to tailor the care provided to patients without enforcing a model focused on primary, secondary or tertiary care. Participants emphasised a necessary shift in workplace culture and behaviour change to support improvements. The COM-B model of behaviour change may be effectively applied to develop interventions in organisations that have in-depth understanding of their own unique challenges.

Creating a culture of support for nursing surveillance

BACKGROUND

An estimated 98,000 deaths annually result from medical errors. Preventing these deaths must be a US healthcare goal. Surveillance decreases adverse events. Surveillance is essential for patient safety. Creating a unit culture that supports surveillance requires attention to its antecedents (nurse education, nurse expertise, nurse staffing, as well as organizational culture).

METHOD

The current literature on topics salient to creating a culture of nursing surveillance including its antecedents and its attributes were reviewed. The findings are summarized and presented.

DISCUSSION

Suggestions and tools enhancing a culture of safety allow the transition from one set of behaviors to another. An organizational culture that strives for excellence promotes surveillance which results in improved patient outcomes and better qualified nurses.

CONCLUSION

Unit change resulting in support for surveillance can minimize failure to rescue and promote interruption of adverse events. The patient outcomes include decreased morbidity and mortality.

Use of Cross-sectional and Perspective Mapping to Spatially and Statistically Represent Inpatient Glucose Control

BACKGROUND

The use of inpatient location for the depiction of glycemic control is an alternative approach to the traditional analysis of hospital-derived glucometric data. Our aim was to develop a method of spatial representation and to test for corresponding statistical variation in inpatient glucose control data.

METHODS

Point-of-care blood glucose data from inpatients with diabetes mellitus were extracted. Calculations included patient-day weighted means (PDWMs) and percentage of patient hospital days with hypoglycemia. Results were overlaid onto hospital floor plans, and room numbers were used as geolocators to generate cross-sectional (2-dimensional) and perspective (3-dimensional) views of the data. Linear mixed and mixed-effects logistic regression models were used to compare the location effect and to assess statistical variation in the data after adjusting for age, sex, and severity of illness.

RESULTS

Visual inspection of cross-sectional and perspective maps demonstrated variation in glucometric outcomes across areas within the hospital. Statistical analysis confirmed significant variation between some hospital wings and floors.

CONCLUSIONS

Spatial depiction of glucometric data within the hospital could yield insights into hot spots of poor glycemic control. Future studies on how to operationalize this approach, and whether this method of analysis can drive changes in glycemic management practices, need to be conducted.

What can healthcare systems learn from looking at tensions in innovation processes? A systematic literature review

Background

Until now, scholarship on innovation processes in healthcare systems lack an in-depth appreciation of tensions. Tensions often revolve around barriers and result from individual assessments and prioritizations that guide actions to eventually overcome these barriers. In order to develop a more differentiated understanding of tensions’ role in healthcare innovation processes, this paper aims to shed light on the multifaceted ways in which tensions emerge, are being dealt with, and how they hinder or, at times, facilitate innovation processes.

Methods

A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. The review involved searching three databases for original research articles and manually searching citations. Twenty-nine original full texts were identified, evaluated, and coded. These include papers on innovation in healthcare systems that investigated innovation-related organizational tensions. The findings were synthesized into different types of tensions in healthcare system innovation and the descriptions of the conflicting elements. We also analyzed the investigated innovations by type, process stages, and across different countries and healthcare systems.

Results

A total of forty-two tensions were identified and grouped into nine categories. Organizing tensions were predominant, followed by learning/belonging, performing, and performing/organizing tensions. Tensions most frequently occurred in the implementation phase and in the form of a dilemma. Included studies were conducted mainly in government-funded healthcare systems.

Conclusion

Our data suggest that innovation processes in healthcare systems are impaired by conflicts between contradictory elements, working cultures, and convictions and the organizational and regulatory context. Since the majority of the tensions we collected in our study can be addressed, future policy-making and research should take advantage of this fact and develop strategies that significantly influence the successful management of tensions and thus improve the implementation of innovations.

Engagement and attrition with eHealth tools for remote monitoring in chronic arthritis: a systematic review and meta-analysis

Objectives

Although eHealth tools are potentially useful for remote disease monitoring, barriers include concerns of low engagement and high attrition. We aimed to summarise evidence on patients’ engagement and attrition with eHealth tools for remotely monitoring disease activity/impact in chronic arthritis.

Methods

A systematic literature search was conducted for original articles and abstracts published before September 2022. Eligible studies reported quantitative measures of patients’ engagement with eHealth instruments used for remote monitoring in chronic arthritis. Engagement rates were pooled using random effects meta-analysis.

Results

Of 8246 references, 45 studies were included: 23 using smartphone applications, 13 evaluating wearable activity trackers, 7 using personal digital assistants, 6 including web-based platforms and 2 using short message service. Wearable-based studies mostly reported engagement as the proportion of days the tracker was worn (70% pooled across 6 studies). For other eHealth tools, engagement was mostly reported as completion rates for remote patient-reported outcomes (PROs). The pooled completion rate was 80%, although between-study heterogeneity was high (I² 93%) with significant differences between eHealth tools and frequency of PRO-collection. Engagement significantly decreased with longer study duration, but attrition varied across studies (0%–89%). Several predictors of higher engagement were reported. Data on the influence of PRO-reporting frequency were conflicting.

Conclusion

Generally high patient engagement was reported with eHealth tools for remote monitoring in chronic arthritis. However, we found considerable between-study heterogeneity and a relative lack of real-world data. Future studies should use standardised measures of engagement, preferably assessed in a daily practice setting.

Trial registeration number

The protocol was registered on PROSPERO (CRD42021267936).

Robots in Healthcare: a Scoping Review

Purpose of Review

Robots are increasingly being adopted in healthcare to carry out various tasks that enhance patient care. This scoping review aims to establish the types of robots being used in healthcare and identify where they are deployed.

Recent Findings

Technological advancements have enabled robots to conduct increasingly varied and complex roles in healthcare. For instance, precision tasks such as improving dexterity following stroke or assisting with percutaneous coronary intervention.

Summary

This review found that robots have played 10 main roles across a variety of clinical environments. The two predominant roles were surgical and rehabilitation and mobility. Although robots were mainly studied in the surgical theatre and rehabilitation unit, other settings ranged from the hospital ward to inpatient pharmacy. Healthcare needs are constantly evolving, as demonstrated by COVID-19, and robots may assist in adapting to these changes. The future will involve increased telepresence and infrastructure systems will have to improve to allow for this.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43154-022-00095-4.

The mental health associations of vitiligo: UK population-based cohort study

BACKGROUND

Vitiligo is an acquired, autoimmune depigmenting skin disorder that may affect psychological well-being.

AIMS

To determine the risk and impact of psychological comorbidity in people with new-onset vitiligo.

METHOD

We conducted a retrospective observational study, using UK general practice data (2004-2020). Adults diagnosed with vitiligo (n = 7224) were matched 1:4 with controls (n = 28 880). Associations within 2 years of diagnosis were assessed for psychological conditions: recurrent depressive disorder (RDD), depressive episodes, non-phobia-related anxiety disorder, social phobia, adjustment disorder, substance misuse, self-harm and suicide attempts. Healthcare utilisation, time off work and unemployment within 1 year were compared in those with and without a mental health condition at vitiligo diagnosis.

RESULTS

At diagnosis, people with vitiligo had a similar prevalence of mental health conditions as controls, except for anxiety disorder (cases 7.9%, controls 7.0%; P = 0.014). Incident RDD and anxiety disorder were more common in people with vitiligo (RDD: adjusted hazard ratio (aHR) 1.25, 95% CI 1.01-1.55; anxiety disorder: aHR 1.23, 95% CI 1.00-1.51). Risk was highest in Black and minority ethnic individuals (RDD: aHR 1.72, 95% CI 1.06-2.79; depressive episodes: aHR 1.56, 95% CI 1.03-2.37). No association was found with other mental health conditions. People with vitiligo and psychological comorbidity had more primary care encounters, more time off workand higher unemployment.

CONCLUSIONS

People with vitiligo have a higher incidence of RDD and anxiety disorder than controls, and this risk increase may be greatest in Black and minority ethnic populations.

Surgical implementation gap: an interrupted time series analysis with interviews examining the impact of surgical trials on surgical practice in England

Objectives

Landmark studies published near the turn of the 21st century found an implementation gap concerning the effect of evidenced-based findings on clinical practice. The current study examines the uptake of six trials that produced actionable findings to describe the effects of evidence on practice and the reasons for those effects.

Design

A sequential, explanatory mixed methods study was conducted. First, a quantitative study assessed whether actionable findings from large, publicly funded elective surgical trials influenced practice. Subsequently, qualitative interviews were conducted to explain the quantitative findings.

Setting

Changes in NHS-funded practice were tracked across hospitals in England. Interviews were conducted online.

Data and participants

The six surgical trials were funded and published by England’s National Institute for Health Research’s Health Technology Assessment programme between 2006 and 2015. Quantitative time series analyses used data about the frequencies or proportions of relevant surgical procedures conducted in England between 2001 and 2020. Subsequently, qualitative interviews were conducted with 25 participants including study authors, surgeons and other healthcare staff in the supply chain. Transcripts were coded to identify major temporal events and Consolidated Framework for Implementation Research (CFIR) domains/constructs that could influence implementation. Findings were synthesised by clinical area.

Results

The quantitative analyses reveal that practice changed in accordance with findings for three trials. In one trial (percutaneous vs nasogastric tube feed after stroke), the change took a decade to occur. In another (patella resurfacing), change anticipated the trial findings. In the third (abdominal aortic aneurysm repair), changes tracked the evolving evidence base. In the remaining trials (two about varicose veins and one about gastric reflux), practice did not change in line with findings. For varicose veins, the results were superseded by a further trial. For gastric reflux, surgical referrals declined as medical treatment increased. The exploratory qualitative analysis informed by CFIR found that evidence from sources apart from the trial in question was mentioned as a reason for non-adoption in the three trials where evidence did not affect practice and in the trial where uptake was delayed. There were no other consistent patterns in the qualitative data.

Conclusion

While practice does not always change in the direction indicated by clinical trials, our results suggest that individuals, official committees and professional societies do assimilate trial evidence. Decision-makers seem to respond to the totality of evidence such that there are often plausible reasons for not adopting the evidence of any one trial in isolation.

Using Unified Modeling Language to Analyze Business Processes in the Delivery of Child Health Services

Business Process Management (BPM) has been increasingly used in recent years in the healthcare domain to analyze, optimize, harmonize and compare clinical and healthcare processes. The main aim of this methodology is to model the interactions between medical and organizational activities needed to deliver health services, measure their complexity, variability and deviations to improve the quality of care and its efficiency. Among the different tools, languages and notations developed in the decades, UML (Unified Modeling Language) represents a widely adopted technique to model, analyze and compare business processes in healthcare. We adopted its diagrams in the MOCHA project to compare the different ways of organizing, coordinating and delivering child care across 30 EU/EEA countries both from an organization and control-flow perspectives. This paper provides an overview of the main components used to represent the business process using UML diagrams, also highlighting how we customized them to capture the specificity of the healthcare domain taking into account that processes are reconstructed on the basis of country experts' responses to questionnaires. The benefits of the application of this methodology are demonstrated by providing examples of comparing different aspects of child care.

Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability

Introduction

Medication errors are an important cause of morbidity and mortality. The pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention was shown to reduce medication errors when tested in a cluster randomised controlled trial and when implemented across one region of England. Now that it has been rolled out nationally, and to enhance findings from evaluations with staff and stakeholders, this paper is the first to report patients’ perceived acceptability on the use of PINCER in primary care and proposes suggestions on how delivery of PINCER related care could be delivered in a way that is acceptable and not unnecessarily burdensome.

Methods

A total of 46 participants living with long-term health conditions who had experience of medication reviews and/or monitoring were recruited through patient participant groups and social media. Semi-structured, qualitative interviews and focus groups were conducted face-to-face or via telephone. A thematic analysis was conducted and findings mapped to the constructs of the Theoretical Framework of Acceptability (TFA).

Results

Two themes were identified and interpreted within the most relevant TFA construct: Perceptions on the purpose and components of PINCER (Affective Attitude and Intervention Coherence) and Perceived patient implications (Burden and Self-efficacy). Overall perceptions on PINCER were positive with participants showing good understanding of the components. Access to medication reviews, which PINCER related care can involve, was reported to be limited and a lack of consistency in practitioners delivering reviews was considered challenging, as was lack of communication between primary care and other health-care providers. Patients thought it would be helpful if medication reviews and prescription renewal times were synchronised. Remote medication review consultations were more convenient for some but viewed as a barrier to communication by others. It was acknowledged that some patients may be more resistant to change and more willing to accept changes initiated by general practitioners.

Conclusions

Participants found the concept of PINCER acceptable; however, acceptability could be improved if awareness on the role of primary care pharmacists is raised and patient-pharmacist relationships enhanced. Being transparent with communication and delivering streamlined and consistent but flexible PINCER related care is recommended.

Conceptualising learning healthcare systems and organisations in the context of rehabilitation: a scoping review protocol

Background: Transformative system wide action is needed for healthcare systems to meet the needs of an increasing aging population and changing health needs. One idea is that health systems can become “learning organisations” (LO) or “learning healthcare systems” (LHS) that continuously generate and apply evidence, innovation, quality, and value to provide better care. This is of value to non-acute healthcare settings such as rehabilitation, which are complex, multi-dimensional and multi-disciplinary in nature. Little is known about how these frameworks have been applied to rehabilitation settings. Objective and inclusion criteria: The aim of this scoping review is to systematically map and summarise the literature conceptualising and operationalising LHS and LO in rehabilitation settings. Studies will be included which define a LO or LHS; or describe an operating LHS/LO; or include the translation of research evidence generated from LHS/LO data into healthcare improvement within a rehabilitation context will be included. Study designs such as quantitative, qualitative, mixed method studies, and case studies will be included. Methods: The guidelines from the Joanna Briggs institute methodology for scoping reviews will be used for this review. The literature search will be performed using a three-step search strategy: an initial limited search of two databases has been performed to identify relevant key words and index terms. The developed search string will be adapted and applied across the following databases: OVID MEDLINE, EMBASE, CINAHL Plus, APA PsycINFO and COCHRANE Database of Systematic Reviews. This will be followed by search of the reference lists of selected sources and relevant data-hubs. A draft data extraction framework will be used and updated iteratively to extract data. Frequency counts and qualitative content analysis will be employed to address the research question of how LHS and LO have been conceptualised and operationalised in the context of rehabilitation.

Mapping continuous learning using social network research: a social network study of Australian Genomics as a Learning Health System

OBJECTIVES

To explore a macrolevel Learning Health System (LHS) and examine if an intentionally designed network can foster a collaborative learning community over time. The secondary aim was to demonstrate the application of social network research to the field of LHS.

DESIGN

Two longitudinal online questionnaires of the Australian Genomics learning community considering relationships between network members at three time points: 2016, 2018, 2019. The questionnaire included closed Likert response questions on collaborative learning patterns and open-response questions to capture general perceptions of the community. Social network data were analysed and visually constructed using Gephi V.0.9.2 software, Likert questions were analysed using SPSS, and open responses were analysed thematically using NVivo.

SETTING

Australian Genomic Health Alliance.

PARTICIPANTS

Clinicians, scientists, researchers and community representatives.

RESULTS

Australian Genomics members highlighted the collaborative benefits of the network as a learning community to foster continuous learning in the ever-evolving field of clinical genomics. The learning community grew from 186 members (2016), to 384 (2018), to 439 (2019). Network density increased (2016=0.023, 2018=0.043), then decreased (2019=0.036). Key players remained consistent with potential for new members to achieve focal positions in the network. Informal learning was identified as the most influential learning method for genomic practice.

CONCLUSIONS

This study shows that intentionally building a network provides a platform for continuous learning-a fundamental component for establishing an LHS. The Australian Genomics learning community shows evidence of maturity and sustainability in supporting the continuous learning culture of clinical genomics. The network provides a practical means to spread new knowledge and best practice across the entire field. We show that intentionally designed networks provide the opportunity and means for interdisciplinary learning between diverse agents over time and demonstrate the application of social network research to the LHS field.

Exploring Adult Patients’ Perceptions and Experiences of Telemedicine Consultations in Primary Care: A Qualitative Systematic Review

The COVID-19 pandemic transformed a gradual uptake of telemedicine, into a sudden worldwide implementation of telemedicine consultations. Primary care is a particular area affected and one where telemedicine consultations are expected to be the future. However, for effective long-term implementation it is vital that patient perceptions and experiences are understood. The aim of this qualitative systematic review was to explore the perceptions and experiences of adults who have used telemedicine consultations in primary care. Studies were identified through a search of four electronic databases (MEDLINE, EMBASE, CINAHL, and CENTRAL) alongside reference list and citation searches. Quality assessment was conducted using the CASP checklist and data was synthesized using a simplified approach to thematic analysis. From 2492 identified records, ten studies met the eligibility criteria all of which were judged as either good or moderate quality. Three themes were identified which were potential benefits, potential barriers, and beneficial prerequisites for telemedicine consultations in primary care. Within these themes, sixteen sub-themes were identified with examples including accessibility and convenience for potential benefits, lack of face-to-face interaction and impersonal consultations for potential barriers, and continuity of care for beneficial prerequisites. Analysing these subthemes, four main recommendations for practice can be made which are to utilise continuity of care, offer both video and telephone consultations, provide adequate support, and that healthcare professionals should demonstrate an explicit understanding of the patient’s health issues. Further research is needed to explore and expand on this topic area and future research should be viewed as a continuous process.

The Value of Electronic Health Records Since the Health Information Technology for Economic and Clinical Health Act: Systematic Review

Background

Electronic health records (EHRs) are the electronic records of patient health information created during ≥1 encounter in any health care setting. The Health Information Technology Act of 2009 has been a major driver of the adoption and implementation of EHRs in the United States. Given that the adoption of EHRs is a complex and expensive investment, a return on this investment is expected.

Objective

This literature review aims to focus on how the value of EHRs as an intervention is defined in relation to the elaboration of value into 2 different value outcome categories, financial and clinical outcomes, and to understand how EHRs contribute to these 2 value outcome categories.

Methods

This literature review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The initial search of key terms, EHRs, values, financial outcomes, and clinical outcomes in 3 different databases yielded 971 articles, of which, after removing 410 (42.2%) duplicates, 561 (57.8%) were incorporated in the title and abstract screening. During the title and abstract screening phase, articles were excluded from further review phases if they met any of the following criteria: not relevant to the outcomes of interest, not relevant to EHRs, nonempirical, and non–peer reviewed. After the application of the exclusion criteria, 80 studies remained for a full-text review. After evaluating the full text of the residual 80 studies, 26 (33%) studies were excluded as they did not address the impact of EHR adoption on the outcomes of interest. Furthermore, 4 additional studies were discovered through manual reference searches and were added to the total, resulting in 58 studies for analysis. A qualitative analysis tool, ATLAS.ti. (version 8.2), was used to categorize and code the final 58 studies.

Results

The findings from the literature review indicated a combination of positive and negative impacts of EHRs on financial and clinical outcomes. Of the 58 studies surveyed for this review of the literature, 5 (9%) reported on the intersection of financial and clinical outcomes. To investigate this intersection further, the category “Value–Intersection of Financial and Clinical Outcomes” was generated. Approximately 80% (4/5) of these studies specified a positive association between EHR adoption and financial and clinical outcomes.

Conclusions

This review of the literature reports on the individual and collective value of EHRs from a financial and clinical outcomes perspective. The collective perspective examined the intersection of financial and clinical outcomes, suggesting a reversal of the current understanding of how IT investments could generate improvements in productivity, and prompted a new question to be asked about whether an increase in productivity could potentially lead to more IT investments.

Development and validation of a novel model for characterizing migraine outcomes within real-world data

BACKGROUND

In disease areas with 'soft' outcomes (i.e., the subjective aspects of a medical condition or its management) such as migraine or depression, extraction and validation of real-world evidence (RWE) from electronic health records (EHRs) and other routinely collected data can be challenging due to how the data are collected and recorded. In this study, we aimed to define and validate a scalable framework model to measure outcomes of migraine treatment and prevention by use of artificial intelligence (AI) algorithms within EHR data.

METHODS

Headache specialists defined descriptive features based on routinely collected clinical data. Data elements were weighted to define a 10-point scale encompassing headache severity (1-7 points) and associated features (0-3 points). A test data set was identified, and a reference standard was manually produced by trained annotators. Automation (i.e., AI) was used to extract features from the unstructured data of patient encounters and compared to the reference standard. A threshold of 70% close agreement (within 1 point) between the automated score and the human annotator was considered to be a sufficient extraction accuracy. The accuracy of AI in identifying features used to construct the outcome model was also evaluated and success was defined as achieving an F1 score (i.e., the weighted harmonic mean of the precision and recall) of 80% in identifying encounters.

RESULTS

Using data from 2,006 encounters, 11 features were identified and included in the model; the average F1 scores for automated extraction were 92.0% for AI applied to unstructured data. The outcome model had excellent accuracy in characterizing migraine status with an exact match for 77.2% of encounters and a close match (within 1 point) for 82.2%, compared with manual extraction scores-well above the 70% match threshold set prior to the study.

CONCLUSION

Our findings indicate the feasibility of technology-enabled models for validated determination of soft outcomes such as migraine progression using the data elements typically captured in the real-world clinical setting, providing a scalable approach to credible EHR-based clinical studies.

Is primary health care ready for artificial intelligence? What do primary health care stakeholders say?

Background

Effective deployment of AI tools in primary health care requires the engagement of practitioners in the development and testing of these tools, and a match between the resulting AI tools and clinical/system needs in primary health care. To set the stage for these developments, we must gain a more in-depth understanding of the views of practitioners and decision-makers about the use of AI in primary health care. The objective of this study was to identify key issues regarding the use of AI tools in primary health care by exploring the views of primary health care and digital health stakeholders.

Methods

This study utilized a descriptive qualitative approach, including thematic data analysis. Fourteen in-depth interviews were conducted with primary health care and digital health stakeholders in Ontario. NVivo software was utilized in the coding of the interviews.

Results

Five main interconnected themes emerged: (1) Mismatch Between Envisioned Uses and Current Reality—denoting the importance of potential applications of AI in primary health care practice, with a recognition of the current reality characterized by a lack of available tools; (2) Mechanics of AI Don’t Matter: Just Another Tool in the Toolbox– reflecting an interest in what value AI tools could bring to practice, rather than concern with the mechanics of the AI tools themselves; (3) AI in Practice: A Double-Edged Sword—the possible benefits of AI use in primary health care contrasted with fundamental concern about the possible threats posed by AI in terms of clinical skills and capacity, mistakes, and loss of control; (4) The Non-Starters: A Guarded Stance Regarding AI Adoption in Primary Health Care—broader concerns centred on the ethical, legal, and social implications of AI use in primary health care; and (5) Necessary Elements: Facilitators of AI in Primary Health Care—elements required to support the uptake of AI tools, including co-creation, availability and use of high quality data, and the need for evaluation.

Conclusion

The use of AI in primary health care may have a positive impact, but many factors need to be considered regarding its implementation. This study may help to inform the development and deployment of AI tools in primary health care.

Long term follow up of direct oral anticoagulants and warfarin therapy on stroke, with all-cause mortality as a competing risk, in people with atrial fibrillation: Sentinel network database study

Background

We investigated differences in risk of stroke, with all-cause mortality as a competing risk, in people newly diagnosed with atrial fibrillation (AF) who were commenced on either direct oral anticoagulants (DOACs) or warfarin treatment.

Methods and results

We conducted a retrospective cohort study of the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database (a network of 500 English general practices). We compared long term exposure to DOAC (n = 5,168) and warfarin (n = 7,451) in new cases of AF not previously treated with oral anticoagulants. Analyses included: survival analysis, estimating cause specific hazard ratios (CSHR), Fine-Gray analysis for factors affecting cumulative incidence of events occurring over time and a cumulative risk regression with time varying effects.We found no difference in CSHR between stroke 1.08 (0.72–1.63, p = 0.69) and all-cause mortality 0.93 (0.81–1.08, p = 0.37), or between the anticoagulant groups. Fine-Gray analysis produced similar results 1.07 (0.71–1.6 p = 0.75) for stroke and 0.93 (0.8–1.07, p = 0.3) mortality. The cumulative risk of mortality with DOAC was significantly elevated in early follow-up (67 days), with cumulative risk decreasing until 1,537 days and all-cause mortality risk significantly decreased coefficient estimate:: -0.23 (-0.38–0.01, p = 0.001); which persisted over seven years of follow-up.

Conclusions

In this large, contemporary, real world primary care study with longer follow-up, we found no overall difference in the hazard of stroke between warfarin and DOAC treatment for AF. However, there was a significant time-varying effect between anti-coagulant regimen on all-cause mortality, with DOACs showing better survival. This is a key methodological observation for future follow-up studies, and reassuring for patients and health care professionals for longer duration of therapy

Redesigning culturally tailored intervention in the precision health era: Self-management science context

BACKGROUND

Nurse scientists have significantly contributed to health equity and ensuring cultural tailoring of interventions to meet unique needs of individuals. Methodologies for cultural tailoring of self-mangament interventions among marginalized populations have limitedly accommodated intersectionality and group heterogeneity when addressing health needs.

PURPOSE

Identify methodological limitations in cultural tailoring of interventions among priority populations and issue recommendations on cultural elements that researchers can target to ensure valid cultural tailoring approaches.

METHODS

Synthesis of literature on health equity, self-management, and implementation and dissemination research.

FINDINGS

Among priority populations, intersectionality and group heterogeneity has made group-based cultural tailoring approaches less effective in eliciting desirable health outcomes. Precision health methodology could be useful for cultural tailoring of interventions due to the methodology's focus on individual-level tailoring approaches.

DISCUSSION

We offer ways to advance health equity research using precision health approaches in cultural tailoring through targeting unique elements of culture and relevant psychosocial phenotypes.

Learning health systems in low-income and middle-income countries: exploring evidence and expert insights

Introduction

Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings.

Methods

We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge.

Results

The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels.

We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions.

Conclusion

Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.

Mortality from angiotensin-converting enzyme-inhibitors and angiotensin receptor blockers in people infected with COVID-19: a cohort study of 3.7 million people

BACKGROUND

Concerns have been raised that angiotensin-converting enzyme-inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) might facilitate transmission of severe acute respiratory syndrome coronavirus 2 leading to more severe coronavirus disease (COVID-19) disease and an increased risk of mortality. We aimed to investigate the association between ACE-I/ARB treatment and risk of death amongst people with COVID-19 in the first 6 months of the pandemic.

METHODS

We identified a cohort of adults diagnosed with either confirmed or probable COVID-19 (from 1 January to 21 June 2020) using computerized medical records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care database. This comprised 465 general practices in England, United Kingdom with a nationally representative population of 3.7 million people. We constructed mixed-effects logistic regression models to quantify the association between ACE-I/ARBs and all-cause mortality among people with COVID-19, adjusted for sociodemographic factors, comorbidities, concurrent medication, smoking status, practice clustering, and household number.

RESULTS

There were 9,586 COVID-19 cases in the sample and 1,463 (15.3%) died during the study period between 1 January 2020 and 21 June 2020. In adjusted analysis ACE-I and ARBs were not associated with all-cause mortality (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 0.85-1.21 and OR 0.84, 95% CI 0.67-1.07, respectively).

CONCLUSION

Use of ACE-I/ARB, which are commonly used drugs, did not alter the odds of all-cause mortality amongst people diagnosed with COVID-19. Our findings should inform patient and prescriber decisions concerning continued use of these medications during the pandemic.

Applying process mining in health technology assessment

Objective

Propose a process mining-based method for Health Technology Assessment.

Methods

Articles dealing with prior studies in Health Technology Assessment using Process Mining were identified. Five research questions were defined to investigate these studies and present important points and desirable characteristics to be addressed in a proposal. The was defined method with five steps and was submitted to a case study for evaluation.

Results

The Literature search identified six main characteristics. As a result, the five-step method proposed was applied in the radical prostatectomy surgical procedure between the robot assisted technique and laparoscopy.

Conclusion

It was demonstrated in this article the creation of the proposal of an efficient method with its replication for other health technologies, coupled with the good interpretation of the specialists in terms of comprehensibility of the discovered patterns and their correlation with clinical protocols and guidelines.

The Interplay of Work, Digital Health Usage, and the Perceived Effects of Digitalization on Physicians' Work: Network Analysis Approach

Background

In health care, the benefits of digitalization need to outweigh the risks, but there is limited knowledge about the factors affecting this balance in the work environment of physicians. To achieve the benefits of digitalization, a more comprehensive understanding of this complex phenomenon related to the digitalization of physicians’ work is needed.

Objective

The aim of this study was to examine physicians’ perceptions of the effects of health care digitalization on their work and to analyze how these perceptions are associated with multiple factors related to work and digital health usage.

Methods

A representative sample of 4630 (response rate 24.46%) Finnish physicians (2960/4617, 64.11% women) was used. Statements measuring the perceived effects of digitalization on work included the patients’ active role, preventive work, interprofessional cooperation, decision support, access to patient information, and faster consultations. Network analysis of the perceived effects of digitalization and factors related to work and digital health usage was conducted using mixed graphical modeling. Adjusted and standardized regression coefficients are denoted by b. Centrality statistics were examined to evaluate the relative influence of each variable in terms of node strength.

Results

Nearly half of physicians considered that digitalization has promoted an active role for patients in their own care (2104/4537, 46.37%) and easier access to patient information (1986/4551, 43.64%), but only 1 in 10 (445/4529, 9.82%) felt that the impact has been positive on consultation times with patients. Almost half of the respondents estimated that digitalization has neither increased nor decreased the possibilities for preventive work (2036/4506, 45.18%) and supportiveness of clinical decision support systems (1941/4458, 43.54%). When all variables were integrated into the network, the most influential variables were purpose of using health information systems, employment sector, and specialization status. However, the grade given to the electronic health record (EHR) system that was primarily used had the strongest direct links to faster consultations (b=0.32) and facilitated access to patient information (b=0.28). At least 6 months of use of the main EHR was associated with facilitated access to patient information (b=0.18).

Conclusions

The results highlight the complex interdependence of multiple factors associated with the perceived effects of digitalization on physicians’ work. It seems that a high-quality EHR system is critical for promoting smooth clinical practice. In addition, work-related factors may influence other factors that affect digital health success. These factors should be considered when developing and implementing new digital health technologies or services for physicians’ work. The adoption of digital health is not just a technological project but a project that changes existing work practices.

Developing a Long COVID Phenotype for Postacute COVID-19 in a National Primary Care Sentinel Cohort: Observational Retrospective Database Analysis

BACKGROUND

Following COVID-19, up to 40% of people have ongoing health problems, referred to as postacute COVID-19 or long COVID (LC). LC varies from a single persisting symptom to a complex multisystem disease. Research has flagged that this condition is underrecorded in primary care records, and seeks to better define its clinical characteristics and management. Phenotypes provide a standard method for case definition and identification from routine data and are usually machine-processable. An LC phenotype can underpin research into this condition.

OBJECTIVE

This study aims to develop a phenotype for LC to inform the epidemiology and future research into this condition. We compared clinical symptoms in people with LC before and after their index infection, recorded from March 1, 2020, to April 1, 2021. We also compared people recorded as having acute infection with those with LC who were hospitalized and those who were not.

METHODS

We used data from the Primary Care Sentinel Cohort (PCSC) of the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database. This network was recruited to be nationally representative of the English population. We developed an LC phenotype using our established 3-step ontological method: (1) ontological step (defining the reasoning process underpinning the phenotype, (2) coding step (exploring what clinical terms are available, and (3) logical extract model (testing performance). We created a version of this phenotype using Protégé in the ontology web language for BioPortal and using PhenoFlow. Next, we used the phenotype to compare people with LC (1) with regard to their symptoms in the year prior to acquiring COVID-19 and (2) with people with acute COVID-19. We also compared hospitalized people with LC with those not hospitalized. We compared sociodemographic details, comorbidities, and Office of National Statistics-defined LC symptoms between groups. We used descriptive statistics and logistic regression.

RESULTS

The long-COVID phenotype differentiated people hospitalized with LC from people who were not and where no index infection was identified. The PCSC (N=7.4 million) includes 428,479 patients with acute COVID-19 diagnosis confirmed by a laboratory test and 10,772 patients with clinically diagnosed COVID-19. A total of 7471 (1.74%, 95% CI 1.70-1.78) people were coded as having LC, 1009 (13.5%, 95% CI 12.7-14.3) had a hospital admission related to acute COVID-19, and 6462 (86.5%, 95% CI 85.7-87.3) were not hospitalized, of whom 2728 (42.2%) had no COVID-19 index date recorded. In addition, 1009 (13.5%, 95% CI 12.73-14.28) people with LC were hospitalized compared to 17,993 (4.5%, 95% CI 4.48-4.61; P<.001) with uncomplicated COVID-19.

CONCLUSIONS

Our LC phenotype enables the identification of individuals with the condition in routine data sets, facilitating their comparison with unaffected people through retrospective research. This phenotype and study protocol to explore its face validity contributes to a better understanding of LC.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the "primary effects" of AMR. Previous estimates of the burden of AMR have largely ignored the potential "secondary effects," such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

Quantifying the primary and secondary effects of antimicrobial resistance on surgery patients: Methods and data sources for empirical estimation in England

Antimicrobial resistance (AMR) may negatively impact surgery patients through reducing the efficacy of treatment of surgical site infections, also known as the “primary effects” of AMR. Previous estimates of the burden of AMR have largely ignored the potential “secondary effects,” such as changes in surgical care pathways due to AMR, such as different infection prevention procedures or reduced access to surgical procedures altogether, with literature providing limited quantifications of this potential burden. Former conceptual models and approaches for quantifying such impacts are available, though they are often high-level and difficult to utilize in practice. We therefore expand on this earlier work to incorporate heterogeneity in antimicrobial usage, AMR, and causative organisms, providing a detailed decision-tree-Markov-hybrid conceptual model to estimate the burden of AMR on surgery patients. We collate available data sources in England and describe how routinely collected data could be used to parameterise such a model, providing a useful repository of data systems for future health economic evaluations. The wealth of national-level data available for England provides a case study in describing how current surveillance and administrative data capture systems could be used in the estimation of transition probability and cost parameters. However, it is recommended that such data are utilized in combination with expert opinion (for scope and scenario definitions) to robustly estimate both the primary and secondary effects of AMR over time. Though we focus on England, this discussion is useful in other settings with established and/or developing infectious diseases surveillance systems that feed into AMR National Action Plans.

The role of geographic information system and global positioning system in dementia care and research: a scoping review

Background

Geographic Information System (GIS) and Global Positioning System (GPS), vital tools for supporting public health research, provide a framework to collect, analyze and visualize the interaction between different levels of the health care system. The extent to which GIS and GPS applications have been used in dementia care and research is not yet investigated. This scoping review aims to elaborate on the role and types of GIS and GPS applications in dementia care and research.

Methods

A scoping review was conducted based on Arksey and O’Malley’s framework. All published articles in peer-reviewed journals were searched in PubMed, Scopus, and Web of Science, subject to involving at least one GIS/GPS approach focused on dementia. Eligible studies were reviewed, grouped, and synthesized to identify GIS and GPS applications. The PRISMA standard was used to report the study.

Results

Ninety-two studies met our inclusion criteria, and their data were extracted. Six types of GIS/GPS applications had been reported in dementia literature including mapping and surveillance (n = 59), data preparation (n = 26), dementia care provision (n = 18), basic research (n = 18), contextual and risk factor analysis (n = 4), and planning (n = 1). Thematic mapping and GPS were most frequently used techniques in the dementia field.

Conclusions

Even though the applications of GIS/GPS methodologies in dementia care and research are growing, there is limited research on GIS/GPS utilization in dementia care, risk factor analysis, and dementia policy planning. GIS and GPS are space-based systems, so they have a strong capacity for developing innovative research based on spatial analysis in the area of dementia. The existing research has been summarized in this review which could help researchers to know the GIS/GPS capabilities in dementia research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12942-022-00308-1.

Inequity in Access and Delivery of Virtual Care Interventions: A Scoping Review

The objectives of this review were to map and summarize the existing evidence from a global perspective about inequity in access and delivery of virtual care interventions and to identify strategies that may be adopted by virtual care services to address these inequities. We searched MEDLINE, EMBASE, and CINAHL using both medical subject headings (MeSH) and free-text keywords for empirical studies exploring inequity in ambulatory services offered virtually. Forty-one studies were included, most of them cross-sectional in design. Included studies were extracted using a customized extraction tool, and descriptive analysis was performed. The review identified widespread differences in accessing and using virtual care interventions among cultural and ethnic minorities, older people, socioeconomically disadvantaged groups, people with limited digital and/or health literacy, and those with limited access to digital devices and good connectivity. Potential solutions addressing these barriers identified in the review included having digitally literate caregivers present during virtual care appointments, conducting virtual care appointments in culturally sensitive manner, and having a focus on enhancing patients’ digital literacy. We identified evidence-based practices for virtual care interventions to ensure equity in access and delivery for their virtual care patients.

Real-world evaluation of weekly subcutaneous treatment with semaglutide in a cohort of Italian diabetic patients

PURPOSE

Registered trials and real-world evidence (RWE) studies provided evidence on the efficacy of once-weekly (OW) semaglutide on hyperglycaemia and cardiovascular risk factors as add-on or de-novo treatment in type 2 diabetes (T2D).

METHODS

In a retrospective analysis of electronic data files from 258 T2D patients, this RWE study aimed to explore the impact of OW semaglutide on biochemical and anthropometric outcomes after 6 and 12 months in patients receiving at least one prescription of OW semaglutide between September 2019 and May 2021.

RESULTS

During the study period, 154 and 56 consecutive patients completed the 6 and 12 months of OW semaglutide treatment. HbA1c levels decreased by -1.02±0.1% after 6 months and -1.1±0.1% after 12 months of OW semaglutide (p<0.0001 for both). At these time-points, HbA1c values were <7% in 61% and 57% of cases. HbA1c reduction was greater in patients with higher baseline HbA1c levels and it occurred irrespective of gender, age, insulin therapy and complications. The residual number of cases with HbA1c ≥9% by the study end was low (5.3% vs 18.9% at baseline). Weight loss occurred in 73.5% and 78.1% of cases and, compared to baseline, it was ≥5% in 21.2- 25.4% and ≥10% in 6.8-18.2% after 6 and 12 months, respectively. Significant predictors of HbA1c reduction after 6 months of OW semaglutide treatment were baseline HbA1c (p<0.0001), bodyweight reduction (p<0.0001) and disease duration (p<0.001), while baseline HbA1c was the only predictor of HbA1c response after 12 months (p<0.0001). Reported adverse events were consistent with the known safety profile of semaglutide.

CONCLUSIONS

Real-world evaluation of weekly subcutaneous treatment with semaglutide in a cohort of Italian diabetic patients.

Adopting mobile health applications by nurses: a scoping review

Background

The concept of mobile health has attracted considerable attention across the globe, as it provides both healthcare professionals and patients with a distinct means of information and resources.

Aim

This study was conducted with the aim of utilising mobile health (mHealth) applications by nurses and presenting a scenario of how and why they are utilised.

Methods

This study was a scoping review. Data collection was carried out by searching the related keywords in Google Scholar, Scopus, Cochrane, EMBASE, Ovid, and PubMed databases from January 2000 to March 2019.

Results

Regarding the reasons for using mobile applications by nurses, five objectives were identified, including learning and knowledge enhancement, treatment and improvement of the patient care process, diagnostic process, data and patient management, and health promotion. Effective factors in the nurses' use of mobile applications were categorised into eight themes: ease of use, usefulness, security and confidentiality, feasibility and functionality, design and use-interface, effectiveness, infrastructure, versatility, and social norms.

Conclusions

Mobile health applications have considerable potential in enhancing nurses' professional activities. This study contributes to both nursing and health policy by providing a scenario of how and why nurses use mobile health applications.

Improving adherence to guidelines for spine pain care: what tools could support primary care clinicians in conforming to guidelines?

Background

Spine pain is one of the most common conditions seen in primary care and is often treated with ineffective, aggressive interventions, such as prescription pain medications, imagery and referrals to surgery. Aggressive treatments are associated with negative side effects and high costs while conservative care has lower risks and costs and equivalent or better outcomes. Despite multiple well-publicised treatment guidelines and educational efforts recommending conservative care, primary care clinicians (PCCs) widely continue to prescribe aggressive, low-value care for spine pain.

Methods

In this qualitative study semistructured interviews were conducted with PCCs treating spine pain patients to learn what prevents clinicians from following guidelines and what tools or support could promote conservative care. Interviews were conducted by telephone, transcribed and coded for thematic analysis.

Results

Forty PCCs in academic and private practice were interviewed. Key reflections included that while familiar with guidelines recommending conservative treatment, they did not find guidelines useful or relevant to care decisions for individual patients. They believed that there is an insufficient body of real-world evidence supporting positive outcomes for conservative care and guidance recommendations. They indicated that spine pain patients frequently request aggressive care. These requests, combined with the PCCs’ commitment to reaching shared treatment decisions with patients, formed a key reason for pursuing aggressive care. PCCs reported not being familiar with risk-screening tools for spine patients but indicated that such screens might increase their confidence to recommend conservative care to low-risk patients.

Conclusions

PCCs may be more willing to give conservative, guideline-consistent care for spine pain if they had tools to assist in making patient-specific evaluations and in countering requests for unneeded aggressive care. Such tools would include both patient risk screens and shared decision-making aids that include elements for resolving patient demands for inappropriate care.

National rates and disparities in childhood vaccination and vaccine-preventable disease during the COVID-19 pandemic: English sentinel network retrospective database study

OBJECTIVES

To describe rates and variation in uptake of pneumococcal and measles, mumps and rubella (MMR) vaccines in children and associated change in vaccine-preventable diseases (VPDs) across the first and second waves of the COVID-19 pandemic.

METHODS

Retrospective database study of all children aged <19 registered with a general practice in the Oxford Royal College of General Practitioners Research and Surveillance Centre English national sentinel surveillance network between 2 November 2015 and 18 July 2021.

RESULTS

Coverage of booster dose of pneumococcal vaccine decreased from 94.5% (95% CI 94.3% to 94.7%) at its height on International Organization for Standardization (ISO) week 47 (2020) to 93.6% (95% CI 93.4% to 93.8%) by the end of the study. Coverage of second dose of MMR decreased from 85.0% (95% CI 84.7% to 85.3%) at its height on ISO week 37 (2020) to 84.1% (95% CI 83.8% to 84.4%) by the end of the study. The break point in trends for MMR was at ISO week 34 (2020) (95% CI weeks 32-37 (2020)), while for pneumococcal vaccine the break point was later at ISO week 3 (2021) (95% CI week 53 (2020) to week 8 (2021)). Vaccination coverage for children of white ethnicity was less likely to decrease than other ethnicities. Rates of consultation for VPDs fell and remained low since August 2020.

CONCLUSION

Childhood vaccination rates started to fall ahead of the onset of the second wave; this fall is accentuating ethnic, socioeconomic and geographical disparities in vaccine uptake and risks widening health disparities. Social distancing and school closures may have contributed to lower rates of associated VPDs, but there may be increased risk as these measures are removed.

Teleconsultation in orthopaedic surgery: A systematic review and meta-analysis of patient and physician experiences

INTRODUCTION

The primary purpose of this review was to evaluate patient and physician preference and satisfaction for teleconsultation in orthopaedic surgery compared to traditional face-to-face consultation. In addition, we evaluated the effects of teleconsultation on patient length of visit, healthcare costs, range of motion (ROM), pain, quality of life (QOL), and ongoing management plans.

METHODS

A systematic review of MEDLINE, Embase, Web of Science, and Cochrane Library was conducted according to PRISMA guidelines. Randomised control trials and case control studies comparing teleconsultation with traditional, face-to-face consultation in the management of orthopaedic conditions were included. The primary outcome measures were patient and physician preference and satisfaction. Secondary outcomes included patient length of visit, healthcare costs, ROM, pain, QOL, and ongoing management plans.

RESULTS

A total of 13 articles meeting the eligibility criteria were included for systematic review and 8 for meta-analysis. There was no significant difference in patient satisfaction, length of visit, or time spent with the physician between the telemedicine and in-office control group. The mean difference of patient preference for telemedicine was significantly higher in the telemedicine group compared to the in-office visit group (OR 1.44, 95% CI 1.12-1.87, p = 0.005).

DISCUSSION

Telemedicine was not inferior to face-to-face office visits in regard to patient and physician preference and satisfaction. Therefore, it would be an effective adjunct to face-to-face office visits, serving as a mechanism of triage and long-term continuity of care.

Patient outcomes following emergency admission to hospital for COVID-19 compared with influenza: retrospective cohort study

BACKGROUND

We examine differences in posthospitalisation outcomes, and health system resource use, for patients hospitalised with COVID-19 during the UK's first pandemic wave in 2020, and influenza during 2018 and 2019.

METHODS

This retrospective cohort study used routinely collected primary and secondary care data. Outcomes, measured for 90 days follow-up after discharge were length of stay in hospital, mortality, emergency readmission and primary care activity.

RESULTS

The study included 5132 patients admitted to hospital as an emergency, with COVID-19 and influenza cohorts comprising 3799 and 1333 patients respectively. Patients in the COVID-19 cohort were more likely to stay in hospital longer than 10 days (OR 3.91, 95% CI 3.14 to 4.65); and more likely to die in hospital (OR 11.85, 95% CI 8.58 to 16.86) and within 90 days of discharge (OR 7.92, 95% CI 6.20 to 10.25). For those who survived, rates of emergency readmission within 90 days were comparable between COVID-19 and influenza cohorts (OR 1.07, 95% CI 0.89 to 1.29), while primary care activity was greater among the COVID-19 cohort (incidence rate ratio 1.30, 95% CI 1.23 to 1.37).

CONCLUSIONS

Patients admitted for COVID-19 were more likely to die, more likely to stay in hospital for over 10 days and interact more with primary care after discharge, than patients admitted for influenza. However, readmission rates were similar for both groups. These findings, while situated in the context of the first wave of COVID-19, with the associated pressures on the health system, can inform health service planning for subsequent waves of COVID-19, and show that patients with COVID-19 interact more with healthcare services as well as having poorer outcomes than those with influenza.

Telemedicine Is Becoming an Increasingly Popular Way to Resolve the Unequal Distribution of Healthcare Resources: Evidence From China

Background

Few studies focused on the general situation of telemedicine in China.

Objectives

The purpose of this review is to investigate telemedicine in China, from the aspects of necessity, history, scale, and operation procedure, to improve the further development and implementation of telemedicine service.

Methods

A literature search for peer-reviewed studies was conducted using the primary electronic databases. Additional documents from the official websites of Chinese government departments involved telemedicine was also collected. We extracted telemedicine related information focused on China from the final retrieved materials, and the general situation of telemedicine was drawn.

Results

In China, telemedicine offers a feasible solution to the unequal allocation of healthcare resources, which makes telemedicine increasingly become an important alternative to close the gap between rural and urban in the capability and quality of medical services. China initiated telemedicine in the late 1980s. In 2018, China's telemedicine network has covered more than 3,000 hospitals across the country. As of 2019, almost all of the 31 provinces and municipalities in mainland have established regional telemedicine centers, and the market size of telemedicine reached about USD 2.68 billion. Based on the telemedicine network, remote rural patients can apply for healthcare services of top-tier urban hospitals through local county-level medical institutions.

Conclusions

Through improving the capacity, quality, and efficiency of healthcare in underserved areas, and reducing the unequal distribution of medical resources, telemedicine can help solve the problems of the difficulty and high cost to access to medical services in China.

Implementation of interprofessional digital communication tools in primary care for frail older adults: An interview study

Communication and coordination between primary healthcare professionals and informal caregivers involved in the care for frail older adults is suboptimal and could benefit from interprofessional digital communication tools. Implementation in daily practice however frequently fails. We aim to identify generic barriers and facilitators experienced by healthcare professionals and informal caregivers during implementation of interprofessional communication tools to improve their long-term use. Qualitative content analysis using individual semi-structured interviews was used for evaluating three different digital communication tools used by interprofessional primary care networks for frail older adults by 28 professionals and 10 caregivers. After transcription and open coding, categories and themes were identified. Barriers and facilitators were related to: tool characteristics, context of use, involvement of professionals and caregivers. The tool improved availability, approachability and users' involvement. The large number of digital systems professionals simultaneously use, and different work agreements hampered tool use. The tools facilitated care coordination, and professionals declared to be better informed about patients' current situations. Overall, interprofessional digital communication tools can facilitate communication in networks for primary elderly care. However, integration between digital systems is needed to reduce the number of tools. Organizations and policy makers have an important role in realizing the tools' long-term use.

'As Long as It's Used for Beneficial Things': An Investigation of non-Māori, Māori and Young People's Perceptions Regarding the Research use of the Aotearoa New Zealand Integrated Data Infrastructure (IDI)

The Aotearoa New Zealand Integrated Data Infrastructure (IDI) is a national database containing a wide range of data about people and households. There is limited information about public views regarding its use for research.A qualitative study was undertaken to examine the views of forty individuals attending a large hospital in Auckland, including those of Māori ethnicity and young people. Semi-structured interview data were analysed using Braun and Clarke's method of thematic analysis.Seven key themes emerged: 1) Limited knowledge about medical data held in national databases; 2) Conditional support for the use of the IDI, including for research; 3) Concerns regarding the misuse of IDI data; 4) The importance of privacy; 5) Different views regarding consent for use of data for research; 6) Desire for access to personal data and the results of research; and 7) Concerns regarding third party and commercial use. Young people and those of Māori ethnicity were more wary of data misuse than others.Although there is reasonable support for the secondary use of public administrative data in the IDI for research, there is more work to be done to ensure ethical and culturally appropriate use of this data via improved consent privacy management processes and researcher training.

Secondary use of health care data and left-over biosamples within the 'Medical Informatics Initiative' (MII): a quasi-randomized controlled evaluation of patient perceptions and preferences regarding the consent process

Background

Data collected during routine health care and ensuing analytical results bear the potential to provide valuable information to improve the overall health care of patients. However, little is known about how patients prefer to be informed about the possible usage of their routine data and/or biosamples for research purposes before reaching a consent decision. Specifically, we investigated the setting, the timing and the responsible staff for the information and consent process.

Methods

We performed a quasi-randomized controlled trial and compared the method by which patients were informed either in the patient admission area following patient admission by the same staff member (Group A) or in a separate room by another staff member (Group B). The consent decision was hypothetical in nature. Additionally, we evaluated if there was the need for additional time after the information session and before taking the consent decision. Data were collected during a structured interview based on questionnaires where participants reflected on the information and consent process they went through.

Results

Questionnaire data were obtained from 157 participants in Group A and 106 participants in Group B. Overall, participants in both groups were satisfied with their experienced process and with the way information was provided. They reported that their (hypothetical) consent decision was freely made. Approximately half of the interested participants in Group B did not show up in the separate room, while all interested participants in Group A could be informed about the secondary use of their routine data and left-over samples. No participants, except for one in Group B, wanted to take extra time for their consent decision. The hypothetical consent rate for both routine data and left-over samples was very high in both groups.

Conclusions

The willingness to support medical research by allowing the use of routine data and left-over samples seems to be widespread among patients. Information concerning this secondary data use may be given by trained administrative staff immediately following patient admission. Patients mainly prefer making a consent decision directly after information is provided and discussed. Furthermore, less patients are informed when the process is organized in a separate room.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01922-6.

Diabetes Technology Meeting 2021

Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 4 to November 6, 2021. This meeting brought together speakers to discuss various developments within the field of diabetes technology. Meeting topics included blood glucose monitoring, continuous glucose monitoring, novel sensors, direct-to-consumer telehealth, metrics for glycemia, software for diabetes, regulation of diabetes technology, diabetes data science, artificial pancreas, novel insulins, insulin delivery, skin trauma, metabesity, precision diabetes, diversity in diabetes technology, use of diabetes technology in pregnancy, and green diabetes. A live demonstration on a mobile app to monitor diabetic foot wounds was presented.

Evaluating the usability of a national health information system with heuristic method

BACKGROUND

Hospital Statistics and Information System is one of the most important health information systems in Iran used in all hospitals in this country. Usability problems can reduce the speed and precision of users when interacting with this system. This study aimed to identify the usability problems of a national health system called "AVAB".

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted in 2020, and three experts evaluated the usability of this system independently by the heuristic evaluation method. Nielsen's usability principles were used to identify usability problems and to classify their severity.

RESULTS

A total of 86 unique problems were identified. The highest number of problems were related to the two principles of "help and documentation" and "match between system and the real world" with 23 and 11 usability problems, respectively. The lowest number of problems were related to the two principles of "visibility of system status" and "help users recognize, diagnose, and recover from errors," each with three problems. 58.1% of the identified problems were in the group of major and catastrophic problems.

CONCLUSIONS

With the help of heuristic evaluation method, a significant number of usability problems of Hospital Statistics and Information System were identified. Most of the identified problems were major and catastrophic, and it is necessary to solve these problems by the designers and developers of this system.

How do electronic risk assessment tools affect the communication and understanding of diagnostic uncertainty in the primary care consultation? A systematic review and thematic synthesis

OBJECTIVES

To conduct a systematic review and synthesise qualitative research of electronic risk assessment tools (eRATs) in primary care, examining how they affect the communication and understanding of diagnostic risk and uncertainty. eRATs are computer-based algorithms designed to help clinicians avoid missing important diagnoses, pick up possible symptoms early and facilitate shared decision-making.

DESIGN

Systematic search, using predefined criteria of the published literature and synthesis of the qualitative data, using Thematic Synthesis. Database searches on 27 November 2019 were of MEDLINE, Embase, CINAHL and Web of Science, and a secondary search of the references of included articles. Included studies were those involving electronic risk assessment or decision support, pertaining to diagnosis in primary care, where qualitative data were presented. Non-empirical studies and non-English language studies were excluded. 5971 unique studies were identified of which 441 underwent full-text review. 26 studies were included for data extraction. A further two were found from citation searches. Quality appraisal was via the CASP (Critical Appraisal Skills Program) tool. Data extraction was via line by line coding. A thematic synthesis was performed.

SETTING

Primary care.

RESULTS

eRATs included differential diagnosis suggestion tools, tools which produce a future risk of disease development or recurrence or calculate a risk of current undiagnosed disease. Analytical themes were developed to describe separate aspects of the clinical consultation where risk and uncertainty are both central and altered via the use of an eRAT: 'Novel risk', 'Risk refinement', 'Autonomy', 'Communication', 'Fear' and 'Mistrust'.

CONCLUSION

eRATs may improve the understanding and communication of risk in the primary care consultation. The themes of 'Fear' and 'Mistrust' could represent potential challenges with eRATs.

TRIAL REGISTRATION NUMBER

CRD219446.

Analysis of two diverse nursing records applications: Mixed methods approach

Introduction

Poor adoption of electronic health records among healthcare workers can diminish their impact. Healthcare informatics solutions development should diligently acknowledge end-user needs. This study compares a user experience and perceived quality of the nursing process integration in two different applications for electronic documentation of the nursing care plan. Both applications were designed and tested in Slovenia.

Methods

In the first phase, final year undergraduate nursing students were recruited (n=73) and randomly assigned into two groups. Each group used one of the applications for a duration of five hours. A survey among students was conducted. In the second phase, additional students were recruited (n=40) and invited to participate in qualitative analysis of the unfavourably rated application.

Results

The modern, visually improved application was favourably rated by students in terms of all aspects of application usability. However, students reported a significant number of inadequacies regarding the nursing process methodology integration. On the contrary, the students using the poorly rated and visually outdated application reported no such concerns. Qualitative analysis of student reflections identified additional positive features of software design that were not detected in survey results analysis.

Conclusion

This study showed that a user-centred approach can be used to compare diverse electronic solutions. Detected discrepancies in findings using qualitative and quantitative analysis show the importance of integrating diverse research approaches for adequate evaluation of software solutions. Furthermore, this study design promotes empowerment of healthcare workers to participate in the development and critical evaluations of software solutions.