Ensuring the continuation of routine primary care during the COVID-19 pandemic: a review of the international literature

Impact of the COVID-19 Pandemic on Lifestyle Behavior and Clinical Care Pathway Management in Type 2 Diabetes: A Retrospective Cross-Sectional Study

Background and Objectives: In Italy, as in the rest of the world, government restrictions aimed at containing the spread of COVID-19 primarily imposed limitations on social relationships and personal behavior. This situation significantly affected the management of chronic illnesses, including type 2 diabetes (T2D). The objective was to evaluate the perceptions of patients with T2D regarding the quality of care received during the COVID-19 pandemic and the impact on dietary and physical activity behaviors. Materials and Methods: We conducted a retrospective cross-sectional survey. Data were collected from June to July 2023 using the convenience sampling of patients with T2D, and the Patient Assessment of Chronic Illness Care (PACIC) and Medi-Lite questionnaires were administered. Results: During the research period, out of the 130 subjects who met all enrollment criteria, 103 patients were included in this study (79.23%). The results of the administered questionnaires were heterogeneous. The average scores from the PACIC Questionnaire for each question displayed significant variability, indicating a range of experiences in the quality of care. In the Medi-Lite survey, fruit, cereals, and olive oil showed the highest adherence levels, with mean scores ranging from 2.58 (SD ± 1.18) for fruit to 1.89 (SD ± 0.34) for olive oil and 1.97 (SD ± 0.17) for cereals. Patients who reported increased food intake during the lockdown attributed it to having more time to prepare meals. Physical activity levels remained unchanged for 48 patients, decreased for 45 patients, and only 9 patients managed to exercise more during the COVID-19 restrictions. Conclusions: Healthcare systems must prioritize comprehensive care plans for T2D that address not only physical health, but also emotional and social well-being. Post-pandemic, promoting healthier lifestyles and empowering patients to manage their condition is crucial. A multidisciplinary and multidimensional approach could support the care of vulnerable individuals, such as patients with T2D, especially during crises like pandemics or other dramatic events.

Effects of COVID-19 on Irish general practice activity from 2019 to 2021: a retrospective analysis of 500,000 consultations using electronic medical record data

BACKGROUND

General practice (GP) is crucial to primary care delivery in the Republic of Ireland and is almost fully computerised. General practice teams were the first point of contact for much COVID-19-related care and there were concerns routine healthcare activities could be disrupted due to COVID-19 and related restrictions.

AIMS

The study aimed to assess effects of the pandemic on GP activity through analysis of electronic medical record data from general practice clinics in the Irish Midwest.

METHODS

A retrospective, descriptive study of electronic medical record data relating to patient record updates, appointments and medications prescribed across 10 GP clinics over the period 2019-2021 inclusive.

RESULTS

Data relating to 1.18 million record transactions for 32 k patients were analysed. Over 500 k appointments were examined, and demographic trends presented. Overall appointment and prescribing activity increased over the study period, while a dip was observed immediately after the pandemic's arrival in March 2020. Delivery of non-childhood immunisations increased sixfold as a result of COVID-19, childhood immunisation activity was maintained, while cervical smears decreased in 2020 as the screening programme was halted. A quarter of consultations in 2020 and 2021 were teleconsultations, and these were more commonplace for younger patients.

CONCLUSIONS

General practice responded robustly to the pandemic by taking on additional activities while maintaining routine services where possible. The shift to teleconsulting was a significant change in workflow. Analysing routinely collected electronic medical record data can provide valuable insights for service planning, and access to these insights would be beneficial for future pandemic responses.

Media depictions of primary care teleconsultation safety: a thematic analysis of UK newspapers

BACKGROUND

The COVID-19 pandemic necessitated the widespread roll-out of teleconsultations across primary care services in the UK. The media's depiction of remote consultations, especially regarding their safety, is not well established. These insights are important: newspapers' coverage of healthcare-related news can influence public perception, national policy, and clinicians' job satisfaction.

AIM

To explore how the national newspapers in the UK depicted both the direct and indirect consequences of the remote-first approach on patient safety.

DESIGN AND SETTING

We performed thematic analysis of newspaper articles that discussed patient safety in primary care teleconsultations, which were published between 21 January 2021 and 22 April 2022.

METHOD

We identified relevant articles using the LexisNexis Academic UK database. We categorised data from these articles into codes before developing these into emergent themes through an iterative process.

RESULTS

Across the 57 articles identified, the main safety concern identified was missed and/or delayed diagnoses over tele-appointment(s), while isolated cases of inappropriate prescribing were also reported. The media reported that the transition to a remote-first approach reduced the accessibility to primary care appointments for some groups (especially patients with lower digital literacy or access) and heightened the burden on other healthcare services; in particular, there were reports of patient care being compromised across NHS emergency departments.

CONCLUSION

The print media predominantly reported negative impacts of remote consultations on patient safety, particularly involving missed and/ or delayed diagnoses. Our work highlights the importance of further exploration into the safety of remote consultations, and the impact of erroneous media reporting on policies and policymakers.

Improving Retention and HIV Viral Suppression: A Cluster Randomised Pilot Trial of a Lay Counsellor Motivational Interviewing Training in South Africa

We piloted a Motivational Interviewing (MI) training program for lay counsellors in South Africa (SA) to assess its impact on retention and viral suppression among newly diagnosed individuals living with HIV (PLHIV) at 12 months post-diagnosis. We randomized eight primary healthcare clinics (PHC) in Johannesburg to either the intervention clinics (n=4) where all lay counsellors were supported for 12 months before the PLHIV enrolment or the standard of care (n=4 clinics). Overall, 548 adults (≥ 18 years) PLHIV were recruited after HIV diagnosis from March 2020 to August 2021 (n=291 intervention, n=257 control). We conducted Poisson regression modelling to assess the intervention effect on patient attendance status (out of care - being ≥28 days late for the last appointment) and viral suppression (<50 copies/ml) at 12 months, reporting risk ratios (RR) with 95% confidence intervals (CIs). Of the 548 eligible participants enrolled, 56.3% were ≥28 days late (52.9% intervention vs 60.9% controls, RR 0.9, 95% CI: 0.7-1.0). Retention at 12 months positively correlated with baseline counselor MI skill levels (Cultivating change talk, RR 1.6, 95%CI: 1.1-2.5; Softening sustain talk, RR 1.5, 95%CI: 0.8-2.9; Empathy, RR 1.4, 95%CI: 1.0-1.8; Partnership RR 1.5, 95%CI: 1.2-1.9). Among those retained at 12 months, 65.3% of intervention participants were virally suppressed compared to 49.3% controls (RR 1.3, 95%CI: 1.0-1.7). Compared to control participants, the intervention group reported more positive counseling experiences, fewer concerns about HIV disclosure (RR 0.8 for high vs low-medium concerns, 95% CI: 0.7-1.0) and ART (RR 0.8, 95% CI: 0.7-1.0), and were more likely to express high confidence to take treatment in public (47.4% vs 28.8%, RR 1.4, 95% CI: 1.0-1.8) after counselling.

Effects of the COVID-19 Pandemic on the Medical Use of Elderly Patients with Hypertension: A Nationwide Cohort Study in Korea

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare services, including chronic disease management, for vulnerable groups, such as older individuals with hypertension. This study aimed to evaluate hypertension management in South Korea's elderly population during the pandemic using treatment consistency indices such as the continuity of care (COC), modified, modified continuity index (MMCI), and most frequent provider continuity (MFPC).

METHODS

This study used the Korea Disease Control and Prevention Agency-COVID-19-National Health Insurance Service cohort (K-COV-N cohort) from the National Health Insurance Service between 2017 and 2021. The research included a total of 4,097,299 hypertensive patients aged 65 years or older. We defined 2018 and 2019 as the baseline period before the COVID-19 pandemic and 2020 and 2021 as the COVID-19 period and calculated the indices of medical continuity (number of visits, COC, MMCI, and MFPC) on a yearly basis.

RESULTS

The number of visits decreased during the COVID-19 period compared to the baseline period (59.64±52.75 vs. 50.49±50.33, P<0.001). However, COC, MMCI, and MFPC were not decreased in the baseline period compared to the COVID-19 period (0.71±0.21 vs. 0.71±0.22, P<0.001; 0.97±0.05 vs. 0.96±0.05, P<0.001; 0.8±0.17 vs. 0.8±0.17, P<0.001, respectively).

CONCLUSION

COVID-19 had no significant impact on the continuity of care but affected the frequency of outpatient visits for older patients with hypertension. However, this study highlights the importance of addressing healthcare inequalities, especially in older patients with hypertension, during pandemics and advocates for policy changes to ensure continued care for vulnerable populations.

Changes in reasons for visits to primary care after the start of the COVID-19 pandemic: An international comparative study by the International Consortium of Primary Care Big Data Researchers (INTRePID)

BACKGROUND

The COVID-19 pandemic has reshaped healthcare delivery worldwide.

OBJECTIVE

To explore potential changes in the reasons for visits and modality of care in primary care settings through the International Consortium of Primary Care Big Data Researchers (INTRePID).

METHODS

We conducted a cross-sectional, retrospective study from 2018-2021. We examined visit volume, modality, and reasons for visits to primary care in Argentina, Australia, Canada, China, Peru, Norway, Singapore, Sweden, and the USA. The analysis involved a comparison between the pre-pandemic and pandemic periods.

RESULTS

There were more than 215 million visits from over 38 million patients during the study period in INTRePID primary care settings. Most INTRePID countries experienced a decline in monthly visit rates during the first year of the pandemic, with rate ratios (RR) and 95% confidence intervals (CI) ranging from RR:0.57 (95%CI:0.49-0.66) to RR:0.90 (95%CI:0.83-0.98), except for in Canada (RR:0.99, 95%CI:0.94-1.05) and Norway (RR:1.00, 95%CI:0.92-1.10), where rates remained stable and in Australia where rates increased (RR:1.19, 95%CI:1.11-1.28). Argentina, China, and Singapore had limited or no adoption of virtual care, whereas the remaining INTRePID countries varied in the extent of virtual care utilization. In Peru, virtual visits accounted for 7.34% (95%CI:7.33%-7.35%) of all interactions in the initial year of the pandemic, dipping to 5.22% (95%CI:5.21%-5.23%) in the subsequent year. However, in Canada 75.30% (95%CI:75.20%-75.40%) of the visits in the first year were virtual, decreasing to 62.77% (95%CI:62.66%-62.88%) in the second year. Diabetes, hypertension and/or hyperlipidemia and general health exams were in the top 10 reasons for visits in 2019 for all countries. Anxiety, depression and/or other mental health related reasons were among the top 10 reasons for virtual visits in all countries that had virtual care.

CONCLUSIONS

The pandemic resulted in changes in reasons for visits to primary care, with virtual care mitigating visit volume disruptions in many countries.

[Changes in the provision and utilization of health care in German primary care practices during the COVID-19 pandemic - A survey of patients in three federal states]

INTRODUCTION

During the COVID-19 pandemic general practitioners (GP) practice teams were temporally confronted with major challenges which were accompanied by changes in practice organization and service provision. So far, little has been known about the views of patients who visited the GP practice for other than COVID-related reasons with regard to provision and use of GP services, the adjustments in the practice and the work of the practice team members.

METHODS

The patient survey is a sub-study of the mixed-methods study VeCo-Praxis (GP healthcare for patients not suffering from COVID during the Corona pandemic) of the research practice network RESPoNsE (Research Practice Network East), which was conducted in the federal states of Berlin, Brandenburg and Thuringia. The questionnaire-based survey was carried out among patients who visited their GP practice in November 2022. The topics covered in the survey were developed by two focus groups consisting of 13 members of the RESPoNsE patient advisory board. The questionnaire was developed and piloted in a participatory approach with the RESPoNsE Patient Advisory Board. The results were analyzed descriptively using SPSS and discussed with the advisory board.

RESULTS

1,405 questionnaires from 37 practices were analyzed. 97% of respondents felt that the treatment they received at their GP practice during the COVID-19 pandemic was good. For the vast majority, appointments and acute consultations, prescriptions, laboratory tests, discussions of diagnostic results, routine follow-up check-ups and health checks were available to a sufficient extent. From the patients' perspective, the practices have successfully adapted to the challenges caused by COVID-19. Overall, the patients' trust in and their appreciation of the work of the practice staff have increased since the pandemic. Patients stated that GP practices should continue hygiene procedures, such as wearing a mask or keeping physical distance, in the future.

DISCUSSION

Despite multiple reports of a significant decline in both provision and utilization of standard care in GP practices during the pandemic, our survey showed that the majority of patients felt that they received adequate GP care and were highly satisfied. The results should be interpreted against the background of possible selection bias.

CONCLUSION

In this survey, GP patients were predominantly appreciative of GP care during the COVID-19 pandemic. The patients' assessment of the provision and use of GP services during the pandemic complements the corresponding perspective of GPs and medical practice assistants.

Trends in decision-making by primary care physicians regarding common infectious complaints

BACKGROUND

Primary care physicians played an important role in the global response during the COVID-19 pandemic, but with the absence of laboratory and diagnostics services, the move to telehealth and the focus on respiratory assessment, they faced increased uncertainty when making clinical decisions.

OBJECTIVES

This paper aims to examine the impact of the pandemic on decisions made by primary care physicians, as measured by referrals to chest X-ray and laboratory tests and by prescriptions of antibiotics.

METHODS

We conducted a retrospective study of all visits recorded with fever or cough, presenting to 209 community clinics in Southern Israel during the years 2018-2022. We describe changes in outcome rates across time and use multivariate generalised linear mixed effects model to compare the odds of referrals and prescriptions between periods, while accounting for gender, age, clinic sector, visit type, diagnosis, and season.

RESULTS

In total, 609,823 visits to primary care physicians complied with the cohort definitions. Social restrictions were associated with a decline in all measured outcomes for primary care physician decisions, most prominently among ages 20-59, for throat culture referral during the first lockdown (OR = 0.46) and for cephalosporine prescription during the second lockdown (OR = 0.55). This trend persisted following the cancellation of the restrictions.

CONCLUSIONS

Despite higher uncertainty during the COVID-19 social restrictions, the overall course of clinical decision-making processes was maintained, and was associated with a reduction in the use of auxiliary resources, which can improve the quality of patient care by lowering costs and supporting prevention of future antibiotics resistance.

Patient satisfaction and digital health in primary health care: a scoping review protocol

Introduction

Using digital health in primary health care (PHC) contributes to reducing costs and travel time, achieving global development goals, improving access, quality and longitudinality of care, and managing health crises. Its evaluation must go beyond the technical-operational aspects to include patient satisfaction, a key element in assessing the quality of care.

Objective

To identify and map patient satisfaction (expectations, desires, cultural values) about the adoption of digital health strategies and assess their impact on the quality of care in PHC.

Methods

The review will follow the recommendations proposed by the Joanna's Briggs Institute (JBI) manual, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) and the methodology proposed by Arksey and O'Malley and Levac et al. and will be conducted in nine stages. The search will be conducted in health studies databases (MEDLINE via PubMed, EMBASE, CINAHL, Web of Science, and BVS), gray literature, and preprint repositories (Google Scholar and MedRxiv). Two reviewers will select the studies, and the third will analyze possible conflicts. The inclusion criteria comprise studies that have been made available in their entirety, whether they are primary studies or short communications, as well as the following materials extracted from the gray literature: preprints, manuals, government documents, books, guidelines, theses and dissertations. Exclusion criteria include literature reviews, abstracts, books, conference archives, letters to the editor, duplicates and opinion articles. Data will be analyzed by content analysis and inferential statistics. This protocol is registered on the Open Science Framework (OSF) under DOI 10.17605/OSF.IO/PUJDB.

Results

The study aims to understand aspects related to the expectations, desires, and cultural values of patients from different countries, as well as the strengths and critical nodes of the use of digital health on the quality of care in PHC.

Service disruptions, trauma and burnout during the COVID-19 pandemic among healthcare providers delivering immunisation and maternal and child health services in Indonesia

BACKGROUND

The COVID-19 pandemic resulted in extreme strain on health systems including the health workforce, essential health services and vaccination coverage. We examined disruptions to immunisation and maternal and child health (MCH) services, concerns of personal well-being and delivery of healthcare during the pandemic as well as factors associated with self-reported trauma or burnout among healthcare providers (HCPs).

METHODS

In March-April 2022, we conducted a cross-sectional survey among HCPs in two provinces of Indonesia. HCPs involved in COVID-19 or routine immunisation and MCH services were randomly selected from district/city health office registration lists. We descriptively analysed service disruptions experienced by HCPs as well as trauma, burnout and concerns of personal well-being and delivery of healthcare during the pandemic. Multivariate logistic regression analyses were undertaken to identify factors associated with trauma or burnout.

RESULTS

We recruited 604 HCPs. Mobilisation of staff from routine health services to COVID-19 response duties was a key reason for service disruptions (87.9%). Strategies such as community outreach and task shifting were implemented to overcome disruptions. Trauma or burnout during the pandemic was reported by 64.1% HCPs, with 23.5% reporting worse mental or emotional health.Factors associated with trauma or burnout included delivery of COVID-19 immunisation (adjusted OR (aOR) 2.54, 95% CI 1.08 to 5.94); and delivery of both COVID-19 immunisation and routine immunisation compared with no involvement in vaccination programmes (aOR 2.42, 95% CI 1.06 to 5.52); poor treatment in the workplace (aOR 2.26, 95% CI 1.51 to 3.38) and lower confidence to respond to patient queries on COVID-19 immunisation (aOR 1.51, 95% CI 1.03 to 2.22).

CONCLUSION

HCPs experienced service disruptions, trauma and burnout and implemented strategies to minimise disruptions to service delivery and improve patient experiences. Our study highlights the need to ensure that workforce resilience and strategies to protect and support HCPs are considered for pandemic planning, preparedness and management.

Patients' and professionals' experiences with remote care during COVID-19: a qualitative study in general practices in low-income neighborhoods

AIM

To explore how patients and general practice professionals in low-income neighborhoods experienced the increase of remote care during COVID-19.

BACKGROUND

As the GP (general practitioner) is the first point of contact in Dutch health care, there are concerns about access to remote care for patients from low-income neighborhoods. Now that general practice professionals have returned to the pre-pandemic ways of healthcare delivery, this paper looks back at experiences with remote care during COVID-19. It investigates experiences of both patients and general practice professionals with the approachability and appropriateness of remote care and their satisfaction.

METHODS

In this qualitative study, 78 patients and 18 GPs, 7 nurse practitioners and 6 mental health professionals were interviewed. Interviews were held on the phone and face-to-face in the native language of the participants.

FINDINGS

Remote care, especially telephone consultation, was generally well-approachable for patients from low-income neighborhoods. Contrarily, video calling was rarely used. This was partly because patients did not know how to use it. The majority of patients thought remote care was possible for minor ailments but would also still like to see the doctor face-to-face regularly. Patients were generally satisfied with remote care at the time, but this did not necessarily reflect their willingness to continue using it in the future. Moreover, there was lack in consensus among general practice professionals on the appropriateness of remote care for certain physical and mental complaints. Nurse practitioners and mental health professionals had a negative attitude toward remote care. In conclusion, it is important to take the opinions and barriers of patients and care providers into account and to increase patient-centered care elements and care provider satisfaction in remote care. Integrating remote care is not only important in times of crisis but also for future care that is becoming increasingly digitalized.

Impact of COVID-19 on essential healthcare services at the primary healthcare level in Armenia: a qualitative study

BACKGROUND

The COVID-19 pandemic has presented significant global healthcare challenges, particularly impacting the continuity of essential health services in low- and middle-income countries. This study investigates the impact of the COVID-19 pandemic on the utilization and provision of essential health services in Armenia.

METHODS

We employed a conventional qualitative study design, conducting semi-structured in-depth interviews (n = 17) within public and private primary healthcare (PHC) facilities in Armenia in 2021. Our study participants encompassed physicians providing specialty services in PHC facilities (e.g. endocrinologists, gynecologists/obstetricians, and pediatricians), regular visitors to PHC facilities (e.g. adults with chronic diseases, parents of children), and policymakers. Thematic analysis was conducted, yielding five emergent categories: mobilization and organization of PHC services during COVID-19; PHC visits during COVID-19; worsening of chronic conditions due to the decline in PHC visits; problems with routine childhood vaccinations; and patient-provider communication challenges.

RESULTS

The number of in-person visits to PHC facilities declined due to adaptations in service delivery, imposed lockdown measures, and the public's fear of visiting healthcare facilities. Maternal and child health services continued with no major disruptions. PHC providers deliberately limited the number of maternal and child visits to essential antenatal care, newborn screenings, and routine childhood immunizations. Still, children experienced some delays in vaccination administration. The pandemic resulted in a notable reduction in follow-up visits and monitoring of patients with chronic conditions, thereby exacerbating their chronic conditions. Phone calls were the primary method of patient-provider communication during the pandemic.

CONCLUSIONS

The COVID-19 pandemic has had a profound impact on the delivery and utilization of essential healthcare services at PHC facilities, especially for those with chronic conditions who needed continuous care. Unified national-level guidance and technical capacity are needed to direct the provision of essential services at the PHC level, promote effective health communication, and implement digital platforms for the uninterrupted provision of essential care during public health emergencies.

Quality of care in Belgian general practices during the COVID-19 pandemic: results of the cross-sectional PRICOV-19 study

BACKGROUND

The COVID-19 pandemic immensely impacted care provision, including quality of care in general practice. This paper aimed: (1) to assess how Belgian general practices acted upon the six dimensions of quality of care during COVID-19; (2) to study differences between the three Belgian regions; and (3) to benchmark the performance of the Belgian practices against the performance in other European countries.

METHODS

The data collected from 479 Belgian practices during 2020-2021 using an online survey as part of the international cross-sectional PRICOV-19 study were analyzed.  Hereby, descriptive statistics, chi-squared tests, and binary logistic regression analyses were performed. Thirty-four survey questions related to the six dimensions of quality of care were selected as outcome variables. The adjusted regression models included four practice characteristics as covariates: practice type, being a teaching practice for GP trainees, multidisciplinarity of the team, and payment system.

RESULTS

Belgian practices made important organizational changes to deliver high-quality care during COVID-19. Most practices (n = 259; 56.1%) actively reached out to vulnerable patients. Limitations to the practice building or infrastructure threatened high-quality care in 266 practices (55.5%). Infection prevention measures could not always be implemented during COVID-19, such as using a cleaning protocol (n = 265; 57.2%) and providing a separate doctor bag for infection-related home visits (n = 130; 27.9%). Three hundred and sixty practices (82.0%) reported at least one safety incident related to a delayed care process in patients with an urgent condition. The adjusted regression analysis showed limited significant differences between the Belgian regions regarding the quality of care delivered. Belgian practices demonstrated varied performance compared to other European countries. For example, they excelled in always checking the feasibility of isolation at home but reported more patient safety incidents related to timely care than at least three-quarters of the other European countries.

CONCLUSIONS

Future studies using different design methods are crucial to investigate which country and practice characteristics are associated with delivering high-quality care.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond

INTRODUCTION

Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice.

METHODS

We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach.

RESULTS

We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward.

CONCLUSIONS

The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

Alcohol and smoking brief interventions by socioeconomic position: a population-based, cross-sectional study in Great Britain

BACKGROUND

Alcohol and smoking brief interventions (BIs) in general practice have been shown to be effective in lowering alcohol and smoking-related harm.

AIM

To assess prevalence of self-reported BI receipt among increasing or higher-risk drinkers and past-year smokers in England, Scotland, and Wales, and associations between intervention receipt and socioeconomic position.

DESIGN & SETTING

Cross-sectional study using data from a monthly population-based survey in England, Scotland, and Wales.

METHOD

The study comprised 47 799 participants (15 573 increasing or higher-risk drinkers [alcohol use disorders identification test consumption score ≥5] and 7791 past-year smokers) surveyed via telephone in 2020-2022 (during the COVID-19 pandemic). All data were self-reported. Prevalence of self-reported BI receipt was assessed descriptively; associations between receipt and socioeconomic position were analysed using logistic regression.

RESULTS

Among adults in England, Scotland, and Wales, 32.2% (95% confidence interval [CI] = 31.8 to 32.7) reported increasing or higher-risk drinking and 17.7% (95% CI = 17.3 to 18.1) past-year smoking. Among increasing or higher-risk drinkers, 58.0% (95% CI = 57.1 to 58.9) consulted with a GP in the past year, and of these, 4.1% (95% CI = 3.6 to 4.6) reported receiving BIs. Among past-year smokers, 55.8% (95% CI = 54.5 to 57.1) attended general practice in the past year; of these, 41.0% (95% CI = 39.4 to 42.7) stated receiving BIs. There was a tendency for patients from socioeconomically disadvantaged backgrounds to receive more alcohol (adjusted odds ratio [aOR] 1.38, 95% CI = 1.10 to 1.73) or smoking BIs (aOR 1.11, 95% CI = 0.98 to 1.26), but for the latter the results were statistically non-significant. Results did not differ notably by nation within Great Britain.

CONCLUSION

BIs in general practice are more common for smoking than for alcohol. A greater proportion of BIs for alcohol were found to be delivered to people who were from socioeconomically disadvantaged backgrounds and who were increasing or higher-risk drinkers.

Change in testing for blood glucose during the COVID-19 pandemic, United States 2019-2021

AIM

This study assessed changes in testing for blood glucose in the United States (US) from 2019 to 2021.

METHODS

We conducted a serial cross-sectional analysis of the 2019-2021 National Health Interview Survey by including adults aged ≥ 18 years without reported diagnosed diabetes. We estimated the prevalence of testing for blood glucose within 12 months and the difference in the testing prevalence between 2019 and 2021.

RESULTS

The study sample included 82,594 respondents without diabetes in 2019--2021, with a mean age between 46.4 and 46.8 years. Overall, the prevalence of testing for blood glucose decreased significantly from 64.2 % (95 % confidence interval [CI] 63.3 %, 65.1 %) in 2019 to 60.0 % (95 % CI 59.1 %, 60.9 %) in 2021. Among adults who met the United States Preventive Services Task Force's 2015 screening recommendation, the prevalence decreased from 73.4 % (95 % CI 72.2 %, 74.6 %) to 69.5 % (95 % CI 68.3 %, 70.6 %). Although decreases in testing were observed in most groups, the extent of the decline differed by subgroups.

CONCLUSIONS

Testing for blood glucose decreased in the US during the COVID-19 pandemic. This may have delayed diagnosis and treatment of prediabetes and diabetes, underscoring the importance of continued access to diabetes screening during pandemics.

Changes in work tasks and organization of general practice in Norway during the COVID-19 pandemic: results from a comparative international study

BACKGROUND

The COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. This paper aims to explore to what extent the COVID-19 pandemic changed the work tasks and organization of Norwegian general practice.

MATERIAL AND METHOD

We analysed data from the Norwegian part of the international, cross-sectional PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. In the analyses, we focused on items related to the use of alternatives to face-to-face consultations, changes in the workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices.

RESULTS

There was a large and significant increase in the use of all forms of alternative consultation forms (digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities.

CONCLUSION

Norwegian GPs adapted well to the need for increased use of alternatives to face-to-face consultations, and reported a high acceptance of their increased responsibilities. However, only one in four received adequate support from the government, which is an important learning point for similar situations in the future.

Nursing practice and teleconsultations in a pandemic context: A mixed-methods study

AIM

To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic.

BACKGROUND

Teleconsultation use increased rapidly during the COVID-19 pandemic. Its implementation has been documented for physicians and specialists, but knowledge is still limited in nursing practice.

DESIGN

A sequential mixed-methods study.

METHODS

Phase 1: A cross-sectional e-survey with 98 nurses (64 nurse clinicians [NCs] and 34 nurse practitioners [NPs]) was conducted in 2020 in 48 teaching primary care clinics in Quebec (Canada). Phase 2: Semi-structured interviews with four NCs and six NPs were conducted in 2021 in three primary care clinics. This study adheres to STROBE and COREQ guidelines.

RESULTS

During the pandemic, telephone was the principal teleconsultation modality used by NPs and NCs compared to other teleconsultation modalities (text messages, email and video). The only variable associated with a higher likelihood of using teleconsultations was type of professional (NCs). Video consultation was almost absent from the modalities used. The majority of participants reported several facilitators to using teleconsultations in their work (e.g. web platforms and work-family balance) and for patients (e.g. rapid access). Some barriers to utilisation were identified (e.g. lack of physical resources) for successful integration of teleconsultations at the organisational, technological and systemic levels. Participants also reported positive (e.g. assessment of cognitive deficiency) and negative (e.g. rural population) impacts of using teleconsultations during a pandemic that made the use of teleconsultations complex.

CONCLUSION

This study highlights the potential for nurses to use teleconsultations in primary care practice and suggests concrete solutions to encourage their implementation after the pandemic.

RELEVANCE TO CLINICAL PRACTICE

Findings emphasize the need for updated nursing education, easy-to-use technology and the strengthening of policies for the sustainable use of teleconsultations in primary health care.

IMPLICATIONS FOR THE PROFESSION

This study could promote the sustainable use of teleconsultations in nursing practice.

REPORTING METHOD

The study adhered to relevant EQUATOR guidelines; the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies were used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as the study focused on the use of teleconsultation among health professionals, specifically primary care nurses.

Impact of COVID-19 on routine childhood immunisations in low- and middle-income countries: A scoping review

Routine vaccines are critical to child health. The COVID-19 pandemic significantly impacted essential health services, particularly in low-and middle-income countries (LMICs). We reviewed literature to determine the impact of COVID-19 on service delivery and uptake of routine childhood immunisation in LMICs. We reviewed papers published between March 2020 and June 2022 using a scoping review framework, and assessed each paper across the World Health Organisation health system strengthening framework. Our search identified 3,471 publications; 58 studies were included. One-quarter of studies showed routine childhood immunisation coverage declined (10% to 38%) between 2019 to 2021. Declines in the number of vaccine doses administered (25% to 51%), timeliness (6.2% to 34%), and the availability of fixed and outreach services were also reported. Strategies proposed to improve coverage included catch-up activities, strengthening supply chain and outreach services. Re-focusing efforts on increasing coverage is critical to improve child health and reduce the likelihood of disease outbreaks.

Telemedicine impact on post-stroke outpatient follow-up in an academic healthcare network during the COVID-19 pandemic

BACKGROUND

The expansion of telemedicine associated with the COVID-19 pandemic has influenced outpatient medical care. The objective of our study was to determine the impact of telemedicine on post-acute stroke clinic follow-up.

METHODS

We retrospectively evaluated the impact of telemedicine in Emory Healthcare, an academic healthcare system of comprehensive and primary stroke centers in Atlanta, Georgia, on post-hospital stroke clinic follow-up. We compared the frequency of 90-day follow-up in a centralized subspecialty stroke clinic among patients hospitalized before the local COVID-19 pandemic (January 1, 2019- February 28, 2020), during (March 1- April 30, 2020) and after telemedicine implementation (May 1- December 31, 2020). A comparison was made across hospitals less than 1 mile, 10 miles, and 25 miles from the stroke clinic.

RESULTS

Of 1096 ischemic stroke patients discharged home or to a rehab facility during the study period, 342 (31%) had follow-up in the Emory Stroke Clinic (comprehensive stroke center 46%, primary stroke center 10 miles away 18%, primary stroke center 25 miles away 14%). Overall, 90-day follow-up increased from 19% to 41% after telemedicine implementation (p<0.001) with telemedicine appointments amounting for up to 28% of all follow-up visits. In multivariable analysis, factors associated with teleneurology follow-up (vs no follow-up) included discharge from the comprehensive stroke center, thrombectomy treatment, private insurance, private transport to the hospital, NIHSS 0-5 and history of dyslipidemia.

CONCLUSIONS

Despite telemedicine implementation at an academic healthcare network successfully increasing post-stroke discharge follow-up in a centralized subspecialty stroke clinic, the majority of patients did not complete 90-day follow-up during the COVID-19 pandemic.

Understanding the impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity: protocol for a mixed methods study

BACKGROUND

Primary care and other health services have been disrupted during the COVID-19 pandemic, yet the consequences of these service disruptions on patients' care experiences remain largely unstudied. People with mental-physical multimorbidity are vulnerable to the effects of the pandemic, and to sudden service disruptions. It is thus essential to better understand how their care experiences have been impacted by the current pandemic. This study aims to improve understanding of the care experiences of people with mental-physical multimorbidity during the pandemic and identify strategies to enhance these experiences.

METHODS

We will conduct a mixed-methods study with multi-phase approach involving four distinct phases. Phase 1 will be a qualitative descriptive study in which we interview individuals with mental-physical multimorbidity and health professionals in order to explore the impacts of the pandemic on care experiences, as well as their perspectives on how care can be improved. The results of this phase will inform the design of study phases 2 and 3. Phase 2 will involve journey mapping exercises with a sub-group of participants with mental-physical multimorbidity to visually map out their care interactions and experiences over time and the critical moments that shaped their experiences. Phase 3 will involve an online, cross-sectional survey of care experiences administered to a larger group of people with mental disorders and/or chronic physical conditions. In phase 4, deliberative dialogues will be held with key partners to discuss and plan strategies for improving the delivery of care to people with mental-physical multimorbidity. Pre-dialogue workshops will enable us to synthesize an prepare the results from the previous three study phases.

DISCUSSION

Our study results will generate much needed evidence of the positive and negative impacts of the COVID-19 pandemic on the care experiences of people with mental-physical multimorbidity and shed light on strategies that could improve care quality and experiences.

Resilience among primary care professionals in a time of pandemic: a qualitative study in the Spanish context

OBJECTIVES

This study explores the impact of the COVID-19 pandemic on the Spanish primary care structure and services and the mechanisms implemented by the primary care workforce to restore and reinforce their reference care model.

DESIGN

An exploratory, qualitative study with semistructured interviews and a focus group discussion conducted during the fall semester of 2020.

SETTING

Primary health centres in Madrid (Spain), chosen based on factors such as infection rates during the earliest stages of the pandemic and demographic and socioeconomic aspects.

PARTICIPANTS

A total of 19 primary health and social care professionals were purposively selected. Criteria for inclusion were gender (male/female), at least 5 years of experience in their current position, category (health/social/administrative worker), and whether they worked in a rural or urban healthcare setting.

RESULTS

Two main themes were identified: (1) reflecting on a model in crisis-particularly the reopening of centres to users and the proactive, participative strategies implemented by primary care professionals to reach their community; and (2) regaining a sense of purpose-how healthcare professionals implemented strategies to sustain their vision of their reference model. The COVID-19 pandemic exposed leadership deficiencies that, together with the initial unavailability of resources and difficulties maintaining face-to-face contact with users, triggered a sense of loss of professional identity. On the other hand, the analysis revealed potential strategies to restore and reinforce the traditional model, such as the adoption of digital technologies and reliance on community networks.

CONCLUSION

This study highlights the importance of a solid reference framework and enhances the strengths and skills of the workforce to reinforce the community-based service provision model.

The road to achieving epidemic-ready primary health care

Millions of avoidable deaths arising from the COVID-19 pandemic emphasise the need for epidemic-ready primary health care aligned with public health to identify and stop outbreaks, maintain essential services during disruptions, strengthen population resilience, and ensure health worker and patient safety. The improvement in health security from epidemic-ready primary health care is a strong argument for increased political support and can expand primary health-care capacities to improve detection, vaccination, treatment, and coordination with public health-needs that became more apparent during the pandemic. Progress towards epidemic-ready primary health care is likely to be stepwise and incremental, advancing when opportunity arises based on explicit agreement on a core set of services, improved use of external and national funds, and payment based in large part on empanelment and capitation to improve outcomes and accountability, supplemented with funding for core staffing and infrastructure and well designed incentives for health improvement. Health-care worker and broader civil society advocacy, political consensus, and bolstering government legitimacy could promote strong primary health care. Epidemic-ready primary health-care infrastructure that is able to help prevent and withstand the next pandemic will require substantial financial and structural reforms and sustained political and financial commitment. Governments, advocates, and bilateral and multilateral agencies should seize this window of opportunity before it closes.

Difference in general practice telehealth utilisation associated with birth country during COVID-19 from two Australian states

Objective

Telehealth has been an integral part of ensuring continued general practice access during the COVID-19 pandemic. Whether telehealth was similarly adopted across different ethnic, cultural, and linguistic groups in Australia is unknown. In this study, we assessed how telehealth utilisation differed by birth country.

Methods

In this retrospective observational study, electronic health record data from 799 general practices across Victoria and New South Wales, Australia between March 2020 to November 2021 were extracted (12,403,592 encounters from 1,307,192 patients). Multivariate generalised estimating equation models were used to assess the likelihood of a telehealth consultation (against face-to-face consultation) by birth country (relative to Australia or New Zealand born patients), education index, and native language (English versus others).

Results

Patients born in Southeastern Asia (aOR: 0.54; 95% CI: 0.52-0.55), Eastern Asia (aOR: 0.63; 95% CI: 0.60-0.66), and India (aOR: 0.64; 95% CI: 0.63-0.66) had a lower likelihood of having a telehealth consultation compared to those born in Australia or New Zealand. Northern America, British Isles, and most European countries did not present with a statistically significant difference. Additionally, higher education levels (aOR: 1.34; 95% CI: 1.26-1.42) was associated with an increase in the likelihood of a telehealth consultation, while being from a non-English-speaking country was associated with a reduced likelihood (aOR: 0.83; 95% CI: 0.81-0.84).

Conclusions

This study provides evidence showing differences in telehealth use associated with birth country. Strategies to ensure continued healthcare access for patients, whose native language is not English, such as providing interpreter services for telehealth consultations, would be beneficial.

Perspectives

Understanding cultural and linguistic differences may reduce health disparities in telehealth access in Australia and could present an opportunity to promote healthcare access in diverse communities.

Unintended Consequences of COVID-19 Non-Pharmaceutical Interventions (NPIs) for Population Health and Health Inequalities

Since the start of the COVID-19 pandemic in early 2020, governments around the world have adopted an array of measures intended to control the transmission of the SARS-CoV-2 virus, using both pharmaceutical and non-pharmaceutical interventions (NPIs). NPIs are public health interventions that do not rely on vaccines or medicines and include policies such as lockdowns, stay-at-home orders, school closures, and travel restrictions. Although the intention was to slow viral transmission, emerging research indicates that these NPIs have also had unintended consequences for other aspects of public health. Hence, we conducted a narrative review of studies investigating these unintended consequences of NPIs, with a particular emphasis on mental health and on lifestyle risk factors for non-communicable diseases (NCD): physical activity (PA), overweight and obesity, alcohol consumption, and tobacco smoking. We reviewed the scientific literature using combinations of search terms such as 'COVID-19', 'pandemic', 'lockdowns', 'mental health', 'physical activity', and 'obesity'. NPIs were found to have considerable adverse consequences for mental health, physical activity, and overweight and obesity. The impacts on alcohol and tobacco consumption varied greatly within and between studies. The variability in consequences for different groups implies increased health inequalities by age, sex/gender, socioeconomic status, pre-existing lifestyle, and place of residence. In conclusion, a proper assessment of the use of NPIs in attempts to control the spread of the pandemic should be weighed against the potential adverse impacts on other aspects of public health. Our findings should also be of relevance for future pandemic preparedness and pandemic response teams.

Prevention and screening during the COVID-19 pandemic: qualitative findings from the BETTER WISE project

BACKGROUND

The COVID-19 pandemic challenged healthcare systems worldwide and disrupted primary care, particularly prevention, screening, and lifestyle counselling. BETTER WISE is a comprehensive and structured approach that proactively addresses cancer and chronic disease prevention and screening (CCDPS), including cancer survivorship and screening for poverty and lifestyle risks for patients aged 40 to 65. Patients from 13 primary care clinics (urban, rural, and remote) in Alberta, Ontario, and Newfoundland & Labrador, Canada were invited for a 1-hour visit with a prevention practitioner (PP), a member of the primary care team with specialized training in CCDPS to provide patients an overview of eligible screening and assist with lifestyle counselling. This qualitative sub-study describes how the COVID-19 pandemic impacted BETTER WISE in a constantly changing medical landscape.

METHODS

We conducted 17 focus groups and 48 key informant interviews with a total of 132 primary care providers (PPs, physicians, allied health professionals, and clinic staff) over three different time points to better understand their perspectives on the BETTER WISE project. We also received 585 patient feedback forms of the 1005 patients who agreed to participate in the study. We also collected field notes and memos and employed thematic analysis using a constant comparative method focused on the impact of the pandemic on BETTER WISE.

RESULTS

We identified four themes related to how the COVID-19 pandemic impacted the BETTER WISE study: 1) Switch of in-person visits to visits over the phone; 2) Lack of access to preventive care and delays of screening tests; 3) Changes in primary care providers' availability and priorities; 4) Mental health impacts of the pandemic on patients and primary care providers.

CONCLUSIONS

The COVID-19 pandemic had and, at the time of writing, continues to have an impact on primary care, particularly on prevention, screening, and lifestyle counselling. Despite structural, procedural, and personal challenges throughout different waves of the pandemic, the primary care clinics participating in BETTER WISE were able to complete the study. Our results underscore the importance of the role of primary care providers in adapting to changing circumstances and support of patients in these challenging times.

TRIAL REGISTRATION

This qualitative study is a sub-component of the BETTER WISE pragmatic, cRCT, trial registration ISRCTN21333761 (date of registration 19/12/2016).

COVID-19 Continues to Burden General Practitioners: Impact on Workload, Provision of Care, and Intention to Leave

General practitioners (GPs), already in a profession with a high workload, have been at the frontline of providing COVID-19-related healthcare in addition to routine care. Our study examined the impact of pandemic-related consultations and changes in practice organization on GPs' current workload and provision of healthcare in summer 2021 (May 2021-July 2021) and early 2022 (January 2022-February 2022). In total, 143 German GPs participated in an online survey in the summer of 2021. Of these, 51 GPs participated in the follow-up survey in 2022. Most GPs perceived an increase in consultation frequency, consultation times, and workload since the pandemic outbreak. Increased consultation times were related to the reduced provision of medical care to other patients with chronic diseases. More SARS-CoV-2 vaccination consultations were associated with reduced home visits, acute consultation times, and cancer screenings. A quarter of GPs considered leaving their job. Pandemic-related bureaucracy, restricted access to therapy and rehabilitation services specialized on COVID-19, unreliable vaccine deliveries, mandatory telematics-infrastructure implementation, and frequent changes in official regulations were the main reasons reported for dissatisfaction. Our results provide insights into how the pandemic continues to burden GPs' work routines and how better working conditions in times of high demand could be achieved in future pandemics.

French General Practitioners' Adaptations for Patients with Suspected COVID-19 in May 2020

In France, towards the end of the first lockdown, COVID-19 management was largely transferred from hospitals to primary care. Primary care actors adapted their practices to ensure patients' access to care, while limiting contamination. In this study, we aimed to identify patterns of adaptations implemented by French general practitioners (GPs) in May 2020 for outpatients with confirmed or suspected COVID-19, and factors associated with these adaptions. A French survey concerning care organization adaptations, and individual, organizational, and territorial characteristics, was sent to GPs. Data were analyzed by multiple correspondence analysis followed by agglomerative hierarchical clustering to identify GPs' adaptation clusters. A multinomial logistic regression model estimated the associations between clusters and individual, organizational, and territorial factors. Finally, 3068 surveys were analyzed (5.8% of French GPs). Four GPs' adaptation clusters were identified: autonomous medical reorganization (64.2% of responders), interprofessional reorganization (15.9%), use of hospital (5.1%), and collaboration with COVID-19 outpatient centers (14.8%). Age, practice type and size, and territorial features were significantly associated with adaptation clusters. Our results suggest that healthcare systems should consider organizational features of primary care to effectively deal with future challenges, including healthcare crises, such as the COVID-19 pandemic, but also those linked to epidemiologic and societal changes.

COVID-19 Impacts on Primary Care Clinic Care Management Processes

PURPOSE

To learn whether the COVID-19 pandemic's disruptions and associated reduced health outcomes for people with chronic conditions might have been caused by a decrease in care management processes (CMPs) in primary care clinics METHODS: Longitudinal cohort design with repeated survey-based measures of CMPs from 2017, 2019, and 2021 in 269 primary care clinics in Minnesota.

RESULTS

There were only small differences in organizational characteristics and no differences in overall CMPs between the 269 clinics analyzed and the 287 that only completed surveys in 1 or 2 years. Overall CMP scores rose by similar amounts (1.6% and 2.1%) from 2017 to 2019 and from 2019 to 2021. In 2021, CMP scores were lower in small medical groups than in large medical groups in 2017 (66.1% vs 78.5%, P <.001), a similar difference to that in 2017. Care management process scores were also lower in clinics in urban areas compared with rural areas (73.9% vs 79.0%, P <.001), but overall scores in all subgroups were higher in 2021 than in 2017. This improvement occurred despite reports from 55% of clinic leaders that the pandemic had been very or extremely disruptive.

CONCLUSIONS

Although quite disrupted by the pandemic, care management processes for chronic disease care in these resilient primary care clinics actually increased from 2019 to 2021, at least in clinics that were part of large organizations. However, that was not true for clinics from smaller groups and perhaps for other areas of care.

A systematic scoping review of digital health technologies during COVID-19: a new normal in primary health care delivery

This scoping review compiled information concerning digital health technologies (DHTs) evolution to support primary health care (PHC) during COVID-19 and lessons for the future of PHC. The identified literature was published during the COVID-19 peak years (2019-2021), retrieved from PubMed, Scopus, and Google Scholar, as well as hand searched on the internet. Predefined inclusion criteria were used, thematic analysis was applied, and reporting followed the PRISMA for Scoping Reviews. A total of 46 studies were included in the final synthesis (40 articles, one book, two book chapters, one working paper, and two technical reports). These studies scrutinized various aspects of DHTs, entailing 19 types of DHTs with 20 areas of use that can be compressed into five bigger PHC functions: general PHC service delivery (teleconsultations, e-diagnosis, e-prescription, etc.); behavior promotion and digital health literacy (e.g., combating vaccine hesitancy); surveillance functions; vaccination and drugs; and enhancing system decision-making for proper follow-up of ongoing PHC interventions during COVID-19. DHTs have the potential to solve some of the problems that have plagued us even prior to COVID-19. Therefore, this study uses a forward-looking viewpoint to further stimulate the use of evidence-based DHT, making it more inclusive, educative, and satisfying to people's needs, both under normal conditions and during outbreaks. More research with narrowed research questions is needed, with a particular emphasis on quality assurance in the use of DHTs, technical aspects (standards for digital health tools, infrastructure, and platforms), and financial perspectives (payment for digital health services and adoption incentives).

Supplementary Information

The online version contains supplementary material available at 10.1007/s12553-023-00725-7.

Primary Care's Challenges and Responses in the Face of the COVID-19 Pandemic: Insights From AHRQ's Learning Community

The COVID-19 pandemic dramatically disrupted health care systems and delivery in the United States. Despite emotional, psychological, logistical, and financial stress, primary care clinicians responded to the challenges that COVID-19 presented and continued to provide essential health services to their communities. As the lead federal agency for primary care research, the Agency for Healthcare Research and Quality (AHRQ) identified a need to engage and support primary care in responding to COVID-19. AHRQ initiated a learning community from December 2020-November 2021 to connect professionals and organizations that support primary care practices and clinicians. The learning community provided a forum for participants to share learning and peer support, better understand the stressors and challenges confronting practices, ascertain needs, and identify promising solutions in response to the pandemic. We identified challenges, responses, and innovations that emerged through learning community engagement, information sharing, and dialog. We categorized these across 5 domains that reflect core areas integral to primary care delivery: patient-centeredness, clinician and practice, systems and infrastructure, and community and public health; health equity was crosscutting across all domains. The engagement of the community to identify real-time response and innovation in the context of a global pandemic has provided valuable insights to inform future research and policy, improve primary care delivery, and ensure that the community is better prepared to respond and contribute to ongoing and future health challenges.

Economic Migrants and Clinical Course of SARS-CoV-2 Infection: A Follow-Up Study

Objective: To analyze whether social deprivation and economic migrant (EM) status influence the risk of being hospitalized with COVID-19. Methods: This was a retrospective follow-up study including all patients older than 18 years attending the Daroca Health Center in Madrid, Spain, diagnosed with COVID-19 during September 2020. Data on EM status and other sociodemographic, lifestyle and comorbidities that could affect the clinical course of the infection were obtained from electronic medical records. Results: Of the 796 patients positive for COVID-19, 44 (5.53%) were hospitalized. No significant differences were observed between those who were hospitalized and those who were not in the mean of social deprivation index or socioeconomic status, but EM status was associated with the risk of being hospitalized (p = 0.028). Logistic regression models showed that years of age (OR = 1.07; 95% CI: 1.04-1.10), EM status (OR = 5.72; 95% CI: 2.56-12.63) and hypertension (OR = 2.22; 95% CI: 1.01-4.85) were the only predictors of hospitalization. Conclusion: Our data support that EM status, rather than economic deprivation, is the socioeconomic factor associated with the probability of hospital admission for COVID-19 in Madrid, Spain.

"Talking on the Phone Is Very Cold"-Primary Health Care Nurses' Approach to Enabling Patient Participation in the Context of Chronic Diseases during the COVID-19 Pandemic

Strengthening patient participation is considered a crucial element of primary health care (PHC) nurses' practice when working with chronically ill patients. The COVID-19 pandemic had extraordinary effects on PHC nursing routines and how chronically ill patients' could be involved in their own care. This study investigates the adaptation of Spanish PHC nurses' approaches to supporting the participation of patients living with chronic illness during the COVID-19 pandemic. To reach this goal, we interviewed 13 PHC nurses who practiced in PHC centers in Spain. The interviews were analyzed using thematic coding. Three themes emerged from the descriptions of the nurses: (1) High COVID-19-related workload, decreasing health promotion, and chronic care, (2) Emphasis on patients' and families' self-responsibility, (3) Expanded digital and telephone communication with fewer in-person consultations. Nurses felt especially challenged to uphold the support for vulnerable groups, such as older people or patients without family support. Future research should focus on how the participation of the most vulnerable chronic patients can be supported in the context of the growing relevance of remote care.

Disruption to the doctor-patient relationship in primary care: a qualitative study

BACKGROUND

Starfield described the importance of system-level components of primary care (first contact, continuous, comprehensive, coordinated), on countries' health systems. It is postulated that, at the individual level, interpersonal interactions and relationship-centred care are central to primary care.

AIM

To explore the impact of COVID-19 on disruption to the doctor-patient relationship and subsequent development of new models of care.

DESIGN & SETTING

A series of 11 cross-sectional surveys of New Zealand (NZ) urban and rural primary care doctors, nurses, and managers, from May 2020 to February 2021, to understand and monitor responses to the pandemic.

METHOD

Using inductive content analysis, cumulated qualitative data from doctors were examined through the lenses of the doctor-patient relationship, its disruption, and resulting changes in models of care.

RESULTS

There were 1519 responses to the surveys, representing 482 unique participants. The majority (86%) of responses were from doctors. The following four key themes emerged: moving to transactional consultations; task-shifting with team changes; creating a production line; and diminished communication and coordination across services.

CONCLUSION

The advent of the pandemic led to severe and ongoing strain on practices requiring rapid change to the model of care. Team members took on new roles for triaging, testing, and separating patients with respiratory and non-respiratory symptoms. There was a rapid move to telehealth, with policies developed on where face-to-face consultations were necessary. Practice strain was exacerbated by disruption to coordination with secondary and other referral services. As new models of general practice develop, further disruptions to development of doctor-patient relationships must be avoided. This work extends Starfield's system-level paradigm to the individual level, with the core value of primary care the doctor-patient relationship. Successful sustainable models are likely to be where relationships are treated as of central importance.

Patient experiences during the COVID-19 pandemic: a qualitative study in Dutch primary care

BACKGROUND

Changes in primary care provision during the COVID-19 pandemic could have affected patient experience of primary care both positively and negatively.

AIM

To assess the experiences of patients in primary care during the COVID-19 pandemic.

DESIGN & SETTING

A qualitative study of patients from regions with high and low COVID-19 prevalence in the Netherlands.

METHOD

A qualitative study using a phenomenological framework was performed among purposively sampled patients. Individual semi-structured interviews were performed and transcribed. Data were thematically analysed by means of an inductive approach.

RESULTS

Twenty-eight patients were interviewed (13 men and 15 women, aged 27-91 years). After thematic analysis, two main themes emerged: accessibility and continuity of primary care. Changes considered positive during the pandemic regarding accessibility and continuity of primary care included having a quieter practice, having more time for consultations, and the use of remote care for problems with low complexity. However, patients also experienced decreases in both care accessibility and continuity, such as feeling unwelcome, the GP postponing chronic care, seeing unfamiliar doctors, and care being segregated.

CONCLUSION

Despite bringing several benefits, patients indicated that the changes to primary care provision during the COVID-19 pandemic could have threatened care accessibility and continuity, which are core values of primary care. These insights can guide primary care provision not only in this and future pandemics, but also when implementing permanent changes to care provision in primary care.

Virtual family physician care during COVID-19: a mixed methods study using health administrative data and qualitative interviews

BACKGROUND

The onset of the COVID-19 pandemic necessitated a rapid shift in primary health care from predominantly in-person to high volumes of virtual care. The pandemic afforded the opportunity to conduct a deep regional examination of virtual care by family physicians in London and Middlesex County, Ontario, Canada that would inform the foundation for virtual care in our region post-pandemic.

OBJECTIVES

(1) to determine volumes of in-person and virtual family physicians visits and characteristics of the family physicians and patients using them during the early COVID-19 pandemic; (2) to determine how virtual visit volumes changed over the pandemic, compared to in-person; and (3) to explore family physicians' experience in virtual visit adoption and implementation.

METHODS

We conducted a concurrent mixed-methods study of family physicians from March to October 2020. The quantitative component examined mean weekly number of total, in-person and virtual visits using health administrative data. Differences in outcomes according to physician and practice characteristics for pandemic periods were compared to pre-pandemic. The qualitative study employed Constructivist Grounded Theory, conducting semi-structured family physicians interviews; analyzing data iteratively using constant comparative analysis. We mapped themes from the qualitative analysis to quantitative findings.

RESULTS

Initial volumes of patients decreased, driven by fewer in-person visits. Virtual visit volumes increased dramatically; family physicians described using telephone almost entirely. Rural family physicians reported video connectivity issues. By early second wave, total family physician visit volume returned to pre-pandemic volumes. In-person visits increased substantially; family physicians reported this happened because previously scarce personal protective equipment became available. Patients seen during the pandemic were older, sicker, and more materially deprived.

CONCLUSION

These results can inform the future of virtual family physician care including the importance of continued virtual care compensation, the need for equitable family physician payment models, and the need to attend to equity for vulnerable patients. Given the move to virtual care was primarily a move to telephone care, the modality of care delivery that is acceptable to both family physicians and their patients must be considered.

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study

OBJECTIVE

When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change.

DESIGN

Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September-December 2020, the second round from January-April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2-4 months apart. To analyze the data, we used thematic analysis.

RESULTS

The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal.

CONCLUSIONS

Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response.Key PointsFacing the COVID-19 pandemic, the primary health care service in Norway had to reorganize to ensure safe patient treatment and maintain infection control.Several GPs experienced challenges in collaboration with the municipalities.There is a need for clarification of responsibilities between GPs and the municipality.

The effect of the COVID-19 pandemic on primary care physicians in Israel, with comparison to an international cohort: a cross-sectional study

BACKGROUND

The COVID-19 pandemic had a major impact on primary care and primary care physicians (PCPs) in Israel and around the world. There is paucity of information regarding treatment of patients with COVID-19 in the community, since most research was performed in hospitals. The aim of this study was to describe the Israeli PCPs' experience.

METHODS

This study is a part of an international cross-sectional study, the PRICOV-19. A translated version of the questionnaire was distributed among Israeli PCPs from December 2020 to July 2021. In this study, we describe the Israeli results and compare them to the international results.

RESULTS

5,961 respondents from 29 countries answered the questionnaire, 94 from Israel, with an Israeli response rate of 16%. Israeli PCPs reported an increase in use of telemedicine from 11 to 49% during the COVID epidemic. PCPs also reported a decline in their wellbeing; absence of secured time slots for keeping updated; perception that the Ministry of Health guidelines were a threat to the staff wellbeing and organization of practice and delays in the examination of non-COVID urgent cases.

CONCLUSIONS

The findings of this study raise concerns regarding the PCPs experience and may form the basis for an improved process of care. Guidelines for proper usage of telemedicine, substitutes for the physical examination and procedures for minimizing delayed patient examination for urgent conditions should be developed. Government directives and clinical guidelines should be communicated in a timely manner, with secured timeslots for physicians' self-learning or updating. Ensuring physicians' well-being in general should be an organization priority.

A real world analysis of COVID-19 impact on hospitalizations in older adults with chronic conditions from an Italian region

Healthcare delivery reorganization during the COVID-19 emergency may have had a significant impact on access to care for older adults with chronic conditions. We investigated such impact among all adults with chronic conditions aged ≥ 65 years, identified through the electronic health databases of two local health agencies—ATS Brianza and ATS Bergamo—from the Lombardy region, Italy. We considered hospitalizations for 2020 compared to the average 2017–2019 and quantified differences using rate ratios (RRs). Overall, in 2017–2019 there were a mean of 374,855 older adults with  ≥ 1 chronic condition per year in the two ATS and 405,371 in 2020. Hospitalizations significantly decreased from 84,624 (225.8/1000) in 2017–2019 to 78,345 (193.3/1000) in 2020 (RR 0.86). Declines were reported in individuals with many chronic conditions and for most Major Diagnostic Categories, except for diseases of the respiratory system. The strongest reductions were observed in hospitalizations for individuals with active tumours, particularly for surgical ones. Hospitalization rates increased in individuals with diabetes, likely due to COVID-19-related diseases. Although determinants of the decrease in demand and supply for care among chronic older adults are to be further explored, this raises awareness on their impacts on chronic patients’ health in the medium and long run.

Establishment of primary health information in the COVID-19 outbreak: A cross-sectional study of population awareness of self-testing

The global pandemic of the Corona Virus Disease 2019 is a severe threat to human health. This paper aims to investigate the status of mass health self-examination awareness and its influencing factors during the COVID-19 epidemic and establish complete health information to intervene in the prevention and control of the COVID-19 epidemic. The study used a simple random sampling method to survey permanent residents (9761 people) aged 15–70 years in a region of Jiangsu Province, China. The survey collected data using a questionnaire with acceptable reliability and validity. The data were entered into SPSS 26, and the data were analyzed using the chi-square test, ANOVA, and logistic regression. The differences in the status of mass health self-examination during COVID-19 were statistically significant (P < 0.05) in terms of the literacy level of the grassroots population, ease of access to medical care, primary medical and health conditions, the situation of medical examination programs, and the construction of primary health information technology. The establishment of comprehensive and systematic primary health information can effectively assist in raising people's awareness of health self-examination and promoting health behaviors, which is essential for enhancing COVID-19 prevention and intervention.

Mild Cognitive Disorder in Post-COVID-19 Syndrome: A Retrospective Cohort Study of 67,000 Primary Care Post-COVID Patients

Background:

Little is known about the impact of COVID-19 on mild cognitive disorder.

Objective:

The aim of this retrospective cohort study was to investigate whether COVID-19 diagnosis is associated with subsequent mild cognitive disorder (MCD) compared to acute upper respiratory infections (AURI).

Methods:

This retrospective cohort study used data from the Disease Analyzer database (IQVIA) and included 67,046 patients with first-time symptomatic or asymptomatic COVID-19 diagnoses in 1,172 general practices in Germany between March 2020 and September 2021. Diagnoses were based on ICD-10 codes. Patients diagnosed with AURI were matched to 67,046 patients with COVID-19 using propensity scores based on sex, age, index month, and comorbidities. The index date was the diagnosis date for either COVID-19 or AURI. Associations between the COVID-19 and MCD were studied using conditional Poisson regression models.

Results:

The incidence of MCD was 7.6 cases per 1,000 person-years in the COVID-19 group and 5.1 cases per 1,000 person-years in the AURI group (IRR = 1.49, 95% CI = 1.22–1.82). The incidence rate ratio decreased strongly with increasing age from 10.08 (95% CI = 4.00–24.42) in the age group≤50 to 1.03 (95% CI = 0.81–1.31) in the age group > 70. In addition, the association between COVID-19 and MCD was significant in women (IRR: 1.70, 95% CI: 1.34–2.16) but not in men (IRR: 1.08, 95% CI: 0.75–1.56).

Conclusion

The incidence of MCD was low but significantly higher in COVID-19 than in AURI patients, especially among younger patients. If a cognitive disorder is suspected, referral to a specialist is recommended.

International examples of primary care COVID-19 preparedness and response: a comparison of four countries

We report the learnings gleaned from a four-country panel (Australia, South Africa, Egypt and Nigeria) sharing their countries' COVID-19 primary healthcare approaches and implementation of policy at the World Organization of Family Doctor's World virtual conference in November. The countries differ considerably with respect to size, national economies, average age, unemployment rates and proportion of people living rurally. South Africa has fared the worst with respect to waves of COVID-19 cases and deaths. All countries introduced strategies such as border closure, COVID-19 testing, physical distancing and face masks. Australia and Nigeria mobilised primary care, but the response was mostly public health and hospital-based in South Africa and Egypt. All countries rapidly adopted telehealth. All countries emphasised the critical importance of an integrated response between primary care and public health to conduct surveillance, diagnose cases through testing, provide community-based care unless hospitalisation is required and vaccinate the population to reduce infection spread.