Feasibility, acceptability and effectiveness of an online alternative to face-to-face consultation in general practice: a mixed-methods study of webGP in six Devon practices

A theory-based analysis of the implementation of online asynchronous telemedicine platforms into primary care practices using Normalisation Process Theory

BACKGROUND

Online asynchronous telemedicine platforms are effective and have been implemented in primary care practices, but it is unclear whether implementation was successful. Implementation has not been studied on a large scale in primary care practice. Normalisation Process Theory is a sociological theory used to understand how complex practices can be embedded into routine practice. We aimed to identify and evaluate factors affecting, and make recommendations for, implementation of online asynchronous telemedicine platforms in primary care practice using Normalisation Process Theory.

METHODS

A systematic search was carried out across four databases. Studies included were empirical research, published between January 2015 and November 2022, of qualitative, quantitative and mixed methods designs, focusing on implementation of online asynchronous telemedicine platforms designed for two-way secure communication between patients and healthcare professionals to give or receive medical advice in primary care. Data extraction was guided by the domains of Normalisation Process Theory: context, mechanisms, outcomes.

RESULTS

25 reports from 21 primary studies were obtained. COVID-19 changed the context in which asynchronous platforms were implemented into primary care, due to restrictions on face-to-face contact. Coherence is supported by online platforms providing benefits for patients. Healthcare staff felt confident using platforms and better teamworking added to cognitive participation, however patient 'misuse' of platforms hindered this. Collective action was negatively affected by poor usability and integration of platforms into practice systems. Reflexive action through large- and small-scale studies had allowed improvements to be made, but poor response rates inhibit this. Outcomes include changed roles and responsibilities for staff and patients and high patient satisfaction. There are concerns regarding confidentiality and health inequities.

CONCLUSIONS

Increased workload, lack of integration into existing systems and poor usability affect implementation. Widespread implementation of online platforms in primary care practices can be supported by policy-makers through consistent guidelines to improve platforms' content, functionality and compatibility with clinical systems to try to enable improvements in practice. Further research should explore patient groups or needs for which online platforms are most suitable, reasons why online platforms work better for different patients and how different patient groups can be supported to benefit from asynchronous telemedicine.

Designing AI-powered healthcare assistants to effectively reach vulnerable populations with health care services: A discrete choice experiment among South African university students

Introduction

South African young adults are at increased risk for HIV acquisition and other non-communicable diseases and face significant barriers to accessing healthcare services. The rapid development of artificial intelligence (AI), in particular AI-powered healthcare assistants (AIPHA), presents a unique opportunity to increase access to health information and linkage to healthcare services and providers. While successful implementation and uptake of such tools require understanding user preferences, limited understanding of these preferences exist. We sought to understand what preferences are important to university students in South Africa when engaging with a hypothetical AIPHA to access health information using a discrete choice experiment.

Methods

We conducted an unlabeled, forced choice discrete choice experiment among adult South African university students through Prolific Academic, an online research platform, in 2024. Each choice option described a hypothetical AIPHA using eight attribute characteristics (cost, confidentiality, security, healthcare topics, language, persona, access, services). Participants were presented with ten choice sets each comprised of two choice options and asked to choose between the two. A conditional logit model was used to evaluate preferences.

Results

300 participants were recruited and enrolled. Most participants were Black, born in South Africa, heterosexual, working for a wage, and a mean age of 26.5 years (SD: 6.0). Results from the discrete choice experiment identified that language, security, and receiving personally tailored advice were the most important attributes for AIPHA. Participants strongly preferred the ability to communicate with the AIPHA in any South African language of their choosing instead of only English and to receive information about health topics specific to their context including information on clinics geographically near them. Results were consistent when stratified by sex and socioeconomic status.

Conclusions

Participants had strong preferences for security and language which is in line with previous studies where successful uptake and implementation of such health interventions clearly addressed these concerns. These results build the evidence base for how we might engage young adults in healthcare through technology effectively.

Patients' suggestions for improvements to text-based e-consultations. An online survey of users of the national health portal in Norway

Background

In recent years, text-based e-consultations have been widely implemented in general practice and are appreciated by patients for their convenience and efficiency. Policymakers aim to enhance patient access to clinical services with the general practitioner (GP) through text-based e-consultations. However, concerns are raised about their efficiency and security. We aimed to investigate users' perceptions of potential improvements in the text-based e-consultation service provided by the national health portal in Norway.

Method

We conducted an online survey among users of text-based e-consultations with the GP on the national health portal Helsenorge. The survey was available from January-February 2023 and consisted of 20 questions. This study focused on the free-text answers to the question "Do you have any suggestions to improve the service?" The framework method was used for a thematic analysis of the answers.

Results

The analysis of 2,954 free-text answers from users of the national e-consultation service resulted in six areas where suggestions for improvement were expressed. According to users, the service would benefit from: (1) a better set-up to facilitate the formulation of the patient's problem, (2) better value for money (in regards to both price and quality), (3) faster response time, (4) improved information and predictability about the status of the e-consultation (e.g., if it is received and when to expect an answer), (5) improvement in technical issues, and (6) improvement of access to dialogue-based services to replace or complement e-consultations.

Conclusion

The analysis of users' suggestions for improvements to the e-consultation service emphasised the need to customise the service to address individual patient needs. Users found a one-size-fits-all approach with mandatory questions, fixed pricing, and inflexible response times less appreciated. Some also felt forced to rely on e-consultations due to the perceived poor availability of other GP services. This highlights the importance of perceiving e-consultations not as a replacement for dialogue-enabled services, but rather as a potentially efficient addition, ensuring a well-tailored setup for appropriate patient use.

Access systems in general practice: a systematic scoping review

BACKGROUND

Access to GP appointments is increasingly challenging in many high-income countries, with an overstretched workforce and rising demand. Various access systems have been developed and evaluated internationally.

AIM

To systematically consolidate the current international evidence base related to different types of GP access systems.

DESIGN AND SETTING

Scoping review examining international literature.

METHOD

Literature searches were run across relevant databases in May 2022. Title, abstract, and full-text screenings were carried out. Data from included studies were extracted and mapped to synthesise the components and aims within different GP access systems.

RESULTS

In total, 49 studies were included in the review. The majority of these were set in the UK. Some access systems featured heavily in the literature, such as Advanced Access, telephone triage, and online consultations, and others less so. There were two key strategies adopted by systems that related to either changing appointment capacity or modifying patient pathways. Components related to these strategies are summarised and illustrated as a schematic representation. Most rationales behind access systems were practice, rather than patient, focused. 'Add-on' systems and aims for efficiency have become more popular in recent years.

CONCLUSION

This synthesis provides a useful tool in understanding access systems' aims, design, and implementation. With focus on alleviating demand, patient-focused outcomes appear to be underinvestigated and potentially overlooked during design and implementation. More recently, digital services have been promoted as offering patient choice and convenience. But a context where demand outweighs resources challenges the premise that extending choice is possible.

The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review

BACKGROUND

In recent years, eHealth has received much attention as an opportunity to increase efficiency within healthcare organizations. Adoption of eHealth might consequently help to solve perceived health workforce challenges, including labor shortages and increasing workloads among primary care professionals, who serve as the first point of contact for healthcare in many countries. The purpose of this systematic review was to investigate the impact of general eHealth use and specific eHealth services use on general practice workload in the pre-COVID-19 era.

METHODS

The databases of CINAHL, Cochrane, Embase, IEEE Xplore, Medline ALL, PsycINFO, Web of Science, and Google Scholar were searched, using combinations of keywords including 'eHealth', 'workload', and 'general practice'. Data extraction and quality assessment of the included studies were independently performed by at least two reviewers. Publications were included for the period 2010 - 2020, before the start of the COVID-19 pandemic.

RESULTS

In total, 208 studies describing the impact of eHealth services use on general practice workload were identified. We found that two eHealth services were mainly investigated within this context, namely electronic health records and digital communication services, and that the largest share of the included studies used a qualitative study design. Overall, a small majority of the studies found that eHealth led to an increase in general practice workload. However, results differed between the various types of eHealth services, as a large share of the studies also reported a reduction or no change in workload.

CONCLUSIONS

The impact of eHealth services use on general practice workload is ambiguous. While a small majority of the effects indicated that eHealth increased workload in general practice, a large share of the effects also showed that eHealth use reduced workload or had no impact. These results do not imply a definitive conclusion, which underscores the need for further explanatory research. Various factors, including the study setting, system design, and the phase of implementation, may influence this impact and should be taken into account when general practices adopt new eHealth services.

STUDY REGISTRATION NUMBER

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020199897; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199897 .

Current experience and future potential of facilitating access to digital NHS primary care services in England: the Di-Facto mixed-methods study

Background

Current National Health Service policy in England encourages enhanced digital access in primary care service provision. In this study, we investigate 'digital facilitation' - that range of processes, procedures and personnel which seeks to support National Health Service primary care patients in their uptake and use of online services.

Objectives

Identify, characterise and explore the potential benefits and challenges associated with different models of digital facilitation currently in use in general practice which are aimed at improving patient access to online services in general practice in England. Use the resulting intelligence to design a framework for future evaluations of the effectiveness and cost effectiveness of such interventions. Explore how patients with mental health conditions experience digital facilitation and gauge their need for this support.

Design

Observational mixed-methods study (literature review, surveys, ethnographic observation and interviews); formal synthesis of findings.

Setting

General practice in four regions of England.

Participants

Practice survey: 156 staff. Patient survey: 3051 patients. Mental health survey: 756 patients. General practitioner patient survey: 3 million responders. Ethnographic case-studies: 8 practices; interviews with 36 staff, 33 patients and 10 patients with a mental health condition. Stakeholder interviews: 19 participants.

Intervention

Digital facilitation as undertaken in general practice.

Main outcome measures

Patient and practice staff reported use of, and views of, digital facilitation.

Data sources

Surveys, qualitative research; national General Practitioner Patient Survey (2019-22).

Review methods

Scoping-review methodology applied to academic and grey literature published 2015-20.

Results

While we did find examples of digital facilitation in routine practice, these often involved using passive or reactive modes of support. The context of COVID, and the necessary acceleration (at that time) of the move to a digital-first model of primary care, shaped the way digital facilitation was delivered. There was lack of clarity over where the responsibility for facilitation efforts lay; it was viewed as the responsibility of 'others'. Patients living with mental health conditions had similar needs and experiences regarding digital facilitation to other patients.

Limitations

The context of the COVID pandemic placed limitations on the project. Fewer practices responded to the practice survey than anticipated; reconfiguration of general practices to support COVID measures was a key consideration during non-participant observation with social distancing and other measures still in place during fieldwork.

Conclusions

Digital facilitation, while not a widely recognised concept, is important in supporting the move to a National Health Service with enhanced digital opportunities and enhanced digital access. General practice staff are allocating resources to provide such efforts in general practices in England. The establishment of clear lines of responsibility, the development of digital tools and platforms that work for patients and practice staff, and investment in staff time and training are needed if digital facilitation is to support the intended digital revolution.

Future work

We did not find one single dominant or preferred model of digital facilitation which might reasonably be considered to form the basis of an intervention to be tested. Rather, there is a need to co-develop such an intervention with patients, general practice staff and relevant policy experts. We outline a framework for a future evaluation of such an intervention.

Study registration

This study is registered as ResearchRegistry6523 (www.researchregistry.com/browse-the-registry#home/?view_2_search=Di-Facto&view_2_page=1) and PROSPERO CRD42020189019 (www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128268) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 32. See the NIHR Funding and Awards website for further award information.

Patient experiences of an online consultation system: a qualitative study in English primary care post-COVID-19

BACKGROUND

Online consultation systems (OCSs) allow patients to contact their healthcare teams online. Since 2020 they have been rapidly rolled out in primary care following policy initiatives and the COVID-19 pandemic. In-depth research of patients' experiences using OCSs is lacking.

AIM

Explore patients' experiences of using an OCS.

DESIGN AND SETTING

Qualitative study in English GP practices using the Patchs OCS (www.Patchs.ai) from March 2020 to July 2022.

METHOD

Thematic analysis of 25 patient interviews and 21 467 written comments from 11 851 patients who used the OCS from nine and 240 GP practices, respectively.

RESULTS

Patients cited benefits of using the OCS as speed, flexibility, and efficiency. Nevertheless, some patients desired a return to traditional consultation methods. GP practices often did not clearly advertise the OCS or use it as patients expected, which caused frustration. Patients reported advantages of having a written record of consultations and the opportunity to communicate detailed queries in free text. Views differed on how the OCS influenced clinical safety and discussions of sensitive topics. Patients who struggled to communicate in traditional consultations often preferred using the OCS, and male patients reported being more likely to use it.

CONCLUSION

Globally, this is the largest in-depth study of patient experiences of an OCS. It contributes new knowledge that the patient experience of using OCSs can be influenced by previously unreported patient characteristics and the conditions they consult about. Further, it contributes recommendations on the design and implementation of the OCS in practice.

Effectiveness and safety of asynchronous telemedicine consultations in general practice: a systematic review

BACKGROUND

There is a focus on increasing asynchronous telemedicine use, which allows medical data to be transmitted, stored, and interpreted later; however, limited evidence of the quality of care it allows in general practice hinders its use.

AIM

To investigate uses and effectiveness of asynchronous telemedicine in general practice, according to the domains of healthcare quality, and describe how the COVID-19 pandemic changed its use.

DESIGN & SETTING

Systematic review in general practice.

METHOD

A systematic search was carried out across four databases using terms related to general practice, asynchronous telemedicine, uses, and effectiveness, and supported by citation searching. This was followed by screening according to pre-defined criteria, data extraction, and critical appraisal. Narrative synthesis was then undertaken guided by the six domains of healthcare quality and exploring differences in use before and following the COVID-19 pandemic.

RESULTS

Searches yielded 6864 reports; 27 reports from 23 studies were included. Asynchronous telemedicine is used by a range of staff and patients across many countries. Safety and equity are poorly reported but there were no major safety concerns. Evidence from other domains of healthcare quality show effectiveness in making diagnoses, prescribing medications, replacing other consultations, providing timely care, and increased convenience for patients. Efficiency is impacted by negative effects on workflow, through poor implementation and patient non-adherence, limiting usability and requiring new administrative approaches from healthcare staff. Asynchronous telemedicine use increased rapidly from March 2020, following the COVID-19 pandemic outbreak.

CONCLUSION

Asynchronous telemedicine provides quality care for patients but is limited by reports of increased workload and inefficient workflow compared with face-to-face consultations. Limits of evidence include heterogeneity and small-scale studies. Further research into cost-effectiveness, equity, safety, and sustained implementation will influence future policy and practice.

Short- and intermediate-term impact of DTC telemedicine consultations on subsequent healthcare consumption

AIM

The use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting.

METHODS

We constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group.

RESULTS

DTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2-6 months after the initial consultation). The results were robust across age and disease groups.

CONCLUSION

The results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.

A digital platform to support communication and organization in the general practice: Evaluation of healthcare usage and costs using claims data of a health insurer

INTRODUCTION

The pressure on general practitioners (GPs) is rising due to the increasing demand for care and a decreasing availability of GPs. eHealth is seen as one of the solutions to enhance accessibility and reduce workload. A platform supporting the organization and communication in general practice has been developed offering services, such as econsultations. This study aims to evaluate healthcare usage and costs of patients using this platform by comparing these outcomes (1) before and after implementation and (2) an intervention with a matched control group.

MATERIAL AND METHODS

This study is a retrospective observational cohort study. To evaluate the longitudinal impact of the implementation on healthcare usage, mixed model Poisson analyses were used with time as a factor term for the within-subject analysis and exposure to the platform as a factor term and an interaction term (i.e., exposure X 6-months) in the between-subject analysis. Cost analyses were done with mixed model analyses of variance over time.

RESULTS

The total number of GP consultations significantly increased after compared to before implementation (i.e., Rate = 1.52; p < 0.001). The number of GP consultations was higher in the intervention compared to the control group (respectively, Rate = 1.23; p = 0.035). Healthcare costs increased for GP consultations after compared to before implementation (€13,57; p < 0.001). The costs for GP consults were significantly higher in the intervention compared to the control group (€7,06; p 0.018).

CONCLUSION

This study showed a rise in GP consultations and costs when implementing a digital platform. This increase was presumably and partly caused by circumstances in one of the two included practices. Moreover, creating new options for contacting and communicating with the GP can enhance care accessibility and thereby driving an increase in consultations. This digital platform is a promising working method in general practice to facilitate patients and provide GPs with more flexibility.

How could online NHS 111 reduce demand for the telephone NHS 111 service? Qualitative study of user and staff views

BACKGROUND

Online NHS111 was introduced in 2018 in response to increasing and unsustainable demand for telephone NHS111. Despite high levels of use, there is little evidence of channel shift from the telephone to the online service. We explored user and staff perspectives of online NHS111 to understand how and why online NHS111 is used and whether there may be potential for shift from the telephone to online service.

METHODS

As part of a wider mixed-methods study, we used qualitative semistructured interviews to explore perspectives of recent users of online 111 who had responded to a user survey (n=32) and NHS 111 staff (n=16) between November 2019 and June 2020. Interviews were recorded and transcribed verbatim. The data sets were analysed separately using framework analysis (user interviews) and thematic analysis (staff interviews).

RESULTS

Telephone NHS111 health adviser skills in probing and obtaining 'soft information' were perceived as key to obtaining advice that was considered more appropriate and trusted than advice from online interactions, which relied on oversimplified or irrelevant questions.Online NHS111 was perceived to provide a useful and convenient adjunct to the telephone service and widened access to NHS111 services for some subgroups of users who would not otherwise access the telephone service (eg, communication barriers, social anxiety) or were concerned about 'bothering' a health professional. The nature of the online consultation meant that online NHS111 was perceived as more disposable and used more speculatively.

CONCLUSION

Online 111 was perceived as a useful adjunct but not a replacement for telephone NHS 111 with potential for channel shift hindered by reduced confidence in the online service due to the lack of human interaction. Further development of OL111 algorithms will be required if it is to meet the needs of people with more complex health needs.

Workload effects of online consultation implementation from a Job-Characteristics Model perspective: a qualitative study

BACKGROUND

Online consultation (OC) was previously promoted by the NHS to solve primary care workload challenges. Its implementation was sped up during the COVID-19 pandemic. Workload effects are widely debated. Using a job design perspective may enhance understandings of workload effect.

AIM

To qualitatively interrogate the workload experiences of primary care staff involved in OC implementation, using the Job Characteristics Model (JCM) to enable the following: a clearer understanding of the primary care staff psychological experiences; and recommendations informing the design of digital implementations and continued use.

DESIGN & SETTING

A qualitative interview study of GP practices using OC within South West England.

METHOD

Thirteen participants representing seven practices completed JCM-based semi-structured telephone interviews. An abductive theoretically driven thematic analysis was completed.

RESULTS

Participants experienced different tasks pre- and post-implementation of OC, and adapted differently to them. Differences included the following: contact modality change, some administrative staff felt removed from patient contact; and in perceived autonomy, some GPs valued increased workload control. Variation in workload experience was affected by job role and practice context, and the form of and rationale for implementation. Use of a psychological model (the JCM) allowed clearer consideration of the effects of change, as well as OC on workload.

CONCLUSION

Psychological theory may be helpful in interpreting workload effects of technology implementation such as OC. Designing change to include consideration of technology effects, psychological experiences, differences across roles, and individual and practice contexts may be important for technology implementation and evaluation of its workload effects.

Face-to-Face and Tele-Consults: A Study of the Effects on Diagnostic Activity and Patient Demand in Primary Healthcare

Primary healthcare services have changed from face-to-face to tele-consults during the two COVID-19 years. We examined trends before and during the COVID-19 pandemic years based on groups of professionals, patient ages, and the associations with the diagnostic registry. We analyzed proportions for both periods, and ratios of the type of consults in 2017-2019 and 2020-2021 were calculated. The COVID-19 period was examined using monthly linear time trends. The results showed that consults in 2020-2021 increased by 24%. General practitioners saw significant falls in face-to-face consults compared with 2017-2019 (ratio 0.44; 95% CI: 0.44 to 0.45), but the increase was not proportional across age groups; patients aged 15-44 years had 45.8% more tele-consults, and those aged >74 years had 18.2% more. Trends in linear regression models of face-to-face consults with general practitioners and monthly diagnostic activity were positive, while the tele-consult trend was inverse to the trend of the diagnostic registry and face-to-face consults. Tele-consults did not resolve the increased demand for primary healthcare services caused by COVID-19. General practitioners, nurses and primary healthcare professionals require better-adapted tele-consult tools for an effective diagnostic registry to maintain equity of access and answer older patients' needs and priorities in primary healthcare.

Digital Facilitation to Support Patient Access to Web-Based Primary Care Services: Scoping Literature Review

BACKGROUND

The use of web-based services within primary care (PC) in the National Health Service in England is increasing, with medically underserved populations being less likely to engage with web-based services than other patient groups. Digital facilitation-referring to a range of processes, procedures, and personnel that seek to support patients in the uptake and use of web-based services-may be a way of addressing these challenges. However, the models and impact of digital facilitation currently in use are unclear.

OBJECTIVE

This study aimed to identify, characterize, and differentiate between different approaches to digital facilitation in PC; establish what is known about the effectiveness of different approaches; and understand the enablers of digital facilitation.

METHODS

Adopting scoping review methodology, we searched academic databases (PubMed, EMBASE, CINAHL, Web of Science, and Cochrane Library) and gray literature published between 2015 and 2020. We conducted snowball searches of reference lists of included articles and articles identified during screening as relevant to digital facilitation, but which did not meet the inclusion criteria because of article type restrictions. Titles and abstracts were independently screened by 2 reviewers. Data from eligible studies were analyzed using a narrative synthesis approach.

RESULTS

A total of 85 publications were included. Most (71/85, 84%) were concerned with digital facilitation approaches targeted at patients (promotion of services, training patients to improve their technical skills, or other guidance and support). Further identified approaches targeted PC staff to help patients (eg, improving staff knowledge of web-based services and enhancing their technical or communication skills). Qualitative evidence suggests that some digital facilitation may be effective in promoting the uptake and use of web-based services by patients (eg, recommendation of web-based services by practice staff and coaching). We found little evidence that providing patients with initial assistance in registering for or accessing web-based services leads to increased long-term use. Few studies have addressed the effects of digital facilitation on health care inequalities. Those that addressed this suggested that providing technical training for patients could be effective, at least in part, in reducing inequalities, although not entirely. Factors affecting the success of digital facilitation include perceptions of the usefulness of the web-based service, trust in the service, patients' trust in providers, the capacity of PC staff, guidelines or regulations supporting facilitation efforts, and staff buy-in and motivation.

CONCLUSIONS

Digital facilitation has the potential to increase the uptake and use of web-based services by PC patients. Understanding the approaches that are most effective and cost-effective, for whom, and under what circumstances requires further research, including rigorous evaluations of longer-term impacts. As efforts continue to increase the use of web-based services in PC in England and elsewhere, we offer an early typology to inform conceptual development and evaluations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020189019; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=189019.

Primary care consultations for respiratory tract symptoms during the COVID-19 pandemic: a cohort study including 70,000 people in South West England

BACKGROUND

Primary care consultations for respiratory tract symptoms including identifying and managing COVID-19 during the pandemic have not been characterized.

METHODS

A retrospective cohort analysis using routinely collected records from 70,431 adults aged 18+ in South England within the Electronic Care and Health Information Analytics (CHIA) database. Total volume and type of consultations (face-to-face, home visits, telephone, email/video, or out of hours) for respiratory tract symptoms between 1 January and 31 July 2020 (during the first wave of the pandemic) were compared with the equivalent period in 2019 for the same cohort. Descriptive statistics were used to summarize consultations by sociodemographic and clinical characteristics, and by COVID-19 diagnosis and outcomes (death, hospitalization, and pneumonia).

RESULTS

Overall consultations for respiratory tract symptoms increased by 229% during the pandemic compared with the preceding year. This included significant increases in telephone consultations by 250%, a 1,574% increase in video/email consultations, 105% increase in home visits, and 92% increase in face-to-face consultations. Nearly 60% of people who presented with respiratory symptoms were tested for COVID-19 and 16% confirmed or clinically suspected to have the virus. Those with complications including pneumonia, requiring hospitalization, and who died were more likely to be seen in-person.

CONCLUSION

During the pandemic, primary care substantially increased consultations for respiratory tract symptoms to identify and manage people with COVID-19. These findings should be balanced against national reports of reduced GP workload for non-COVID care.

Gaps to Best Practices for Teleconsultations Performed by General Practitioners: A Descriptive Cross-Sectional Study

The COVID-19 pandemic led to large increases in telemedicine activity worldwide. This rapid growth, however, may have impacted the quality of care where compliance with guidelines and best practices are concerned. The aim of this study was to describe the recent practices of a telemedicine activity (teleconsultations) and the breaches of best practice guidelines committed by general practitioners (GPs) in the Greater Eastern Region of France. A cross-sectional study was conducted using a 33-item questionnaire and was provided to the Regional Association of Healthcare Professionals, Union Régionale des Professionnels de Santé (URPS) to be shared amongst the GPs. Between April and June 2021, a total of 233 responses were received, showing that (i) by practicing telemedicine in an urban area, (ii) performing a teleconsultation at the patient's initiative, and (iii) carrying out more than five teleconsultations per week were factors associated with a significantly higher level of best practices in telemedicine. All in all, roughly a quarter of GPs (25.3%, n = 59) had a self-declared good telemedicine practice, and the rules of good practice are of heterogeneous application. Despite the benefits of learning on the job for teleconsultation implementation during the COVID-19 lockdowns, there may be a clear need to develop structured and adapted telemedicine training programs for private practice GPs.

Use and usability of GP online services: a mixed-methods sequential study, before and during the COVID-19 pandemic, based on qualitative interviews, analysis of routine eConsult usage and feedback data, and assessment of GP websites in Devon and Cornwall, England

OBJECTIVES

We explored use and usability of general practitioner (GP) online services.

SETTING

Devon and Cornwall, England.

DESIGN

Mixed-methods sequential study based on qualitative interviews, analysis of routine eConsult usage and feedback data, and assessment of GP websites.

METHODS

First, we interviewed 32 staff and 18 patients from seven practices in June 2018. Second, we used routinely collected consultation meta-data and, third, patient feedback data for all practices using eConsult from June 2018 to March 2021. Lastly, we examined GP websites' usability in January 2020 and September 2021.

RESULTS

Interviews suggested practices infrequently involved patients in eConsult implementation. Some patients 'gamed' the system to achieve what they wanted. Usage data showed a major increase in eConsult resulting from COVID-19. Women used eConsult twice as much as men. Older had similar eConsult consultation rates to younger patients. Patient feedback forms were completed for fewer than 3% of consultations. Patients were mostly satisfied with eConsult but some had concerns about its length and repetitiveness, lack of continuity over time and between eConsult and medical records. We did not find clear evidence that patients' suggested improvements were acted on. Finally, few GP websites met accessibility guidelines and may hinder access to online national services such as eConsult.

CONCLUSION

Given that, face to face, older people consult more, usage data suggest that older people have reduced online access. That the female-to-male ratio of eConsult use use was even greater than 'traditional' face-to-face ratio was unexpected and needs further research. Although eConsult collects and uses routine patient feedback to improve the system, more open systems for patient feedback, such as Care Opinion, may be more effective in helping online systems evolve. Lastly, we question the need for GP websites and suggest that national or regional services are better placed to maintain accessible services.

Health chatbots acceptability moderated by perceived stigma and severity: A cross-sectional survey

Background

Chatbots and virtual voice assistants are increasingly common in primary care without sufficient evidence for their feasibility and effectiveness. We aimed to assess how perceived stigma and severity of various health issues are associated with the acceptability for three sources of health information and consultation: an automated chatbot, a General Practitioner (GP), or a combination of both.

Methods

Between May and June 2019, we conducted an online study, advertised via Facebook, for UK citizens. It was a factorial simulation experiment with three within-subject factors (perceived health issue stigma, severity, and consultation source) and six between-subject covariates. Acceptability rating for each consultation source was the dependant variable. A single mixed-model ANOVA was performed.

Results

Amongst 237 participants (65% aged over 45 years old, 73% women), GP consultations were seen as most acceptable, followed by GP-chatbot service. Chatbots were seen least acceptable as a consultation source for severe health issues, while the acceptability was significantly higher for stigmatised health issues. No associations between participants’ characteristics and acceptability were found.

Conclusions

Although healthcare professionals are perceived as the most desired sources of health information, chatbots may be useful for sensitive health issues in which disclosure of personal information is challenging. However, chatbots are less acceptable for health issues of higher severity and should not be recommended for use within that context. Policymakers and digital service designers need to recognise the limitations of health chatbots. Future research should establish a set of health topics most suitable for chatbot-led interventions and primary healthcare services.

Clinical Trends Over the First Year of a Psychiatric Electronic Consult Service

BACKGROUND

Electronic consultations (e-consultations) offer rapid, direct, and documented communication through the electronic medical record between primary care physicians (PCPs) and specialists. Psychiatric e-consultations are increasingly being implemented across hospital networks with the recommendation for face-to-face psychiatric evaluation periodically being made by the consulted psychiatrist. It remains to be seen what clinical factors lead the consultant to make this type of recommendation and whether the question asked by the PCP and the diagnosis of the patient has any bearing.

OBJECTIVES

To determine which psychiatric diagnoses are most commonly electronically consulted on, what types of questions are being asked by primary care providers to electronically consulted psychiatrists, and what questions and which diagnoses result in an electronically consulted psychiatrist to recommend further in-person evaluation.

METHODS

A retrospective chart review of an e-consultation service was conducted. One hundred sixty-four charts were reviewed. Data were collected on the psychiatric diagnosis, type of question posed by the PCP to the psychiatrist, the number of recommendations for an in-person evaluation made, and the percentages of the diagnoses and questions that were associated with a recommendation for in-person evaluation.

RESULTS

Two hundred twenty-three diagnoses were consulted on. The most common diagnoses were anxiety disorders (34.5%, N = 77), depressive disorders (32.3%, N = 72), and bipolar disorders (13.5%, N = 30). One hundred eighty-one questions were asked by PCPs. One hundred fifty-one (83.4%) questions regarded pharmacological management. Of the 164 charts, 40 (24.4%) e-consultations resulted in the psychiatrist recommending an in-person evaluation. The in-person evaluation recommendation rates did not change with increasing provider familiarity as the inaugural year went on. Three (7.5%) patients who were recommended for an outpatient psychiatry evaluation were scheduled to be seen by the consulted psychiatrist. Depressive (N = 12) and anxiety disorders (N = 13) were both recommended for in-person follow-up 17% of the time. Bipolar disorder was recommended for follow-up 53% (N = 16) of the time. Of the 181 question types posed by PCPs, 34 (22.5%) pharmacological management questions were recommended for in-person follow-up.

CONCLUSIONS

Certain diagnoses and question types appear to influence the likelihood that an electronically consulted psychiatrist will recommend a face-to-face evaluation. It also suggests that e-consultation services can be particularly serviceable for certain diagnoses, that is, depression and anxiety, as well as certain question types, that is, pharmacological management. This information can guide PCPs and psychiatrists about which patients are best suited for an e-consultation versus an in-person referral from the outset.

Artificial Intelligence Techniques That May Be Applied to Primary Care Data to Facilitate Earlier Diagnosis of Cancer: Systematic Review

BACKGROUND

More than 17 million people worldwide, including 360,000 people in the United Kingdom, were diagnosed with cancer in 2018. Cancer prognosis and disease burden are highly dependent on the disease stage at diagnosis. Most people diagnosed with cancer first present in primary care settings, where improved assessment of the (often vague) presenting symptoms of cancer could lead to earlier detection and improved outcomes for patients. There is accumulating evidence that artificial intelligence (AI) can assist clinicians in making better clinical decisions in some areas of health care.

OBJECTIVE

This study aimed to systematically review AI techniques that may facilitate earlier diagnosis of cancer and could be applied to primary care electronic health record (EHR) data. The quality of the evidence, the phase of development the AI techniques have reached, the gaps that exist in the evidence, and the potential for use in primary care were evaluated.

METHODS

We searched MEDLINE, Embase, SCOPUS, and Web of Science databases from January 01, 2000, to June 11, 2019, and included all studies providing evidence for the accuracy or effectiveness of applying AI techniques for the early detection of cancer, which may be applicable to primary care EHRs. We included all study designs in all settings and languages. These searches were extended through a scoping review of AI-based commercial technologies. The main outcomes assessed were measures of diagnostic accuracy for cancer.

RESULTS

We identified 10,456 studies; 16 studies met the inclusion criteria, representing the data of 3,862,910 patients. A total of 13 studies described the initial development and testing of AI algorithms, and 3 studies described the validation of an AI algorithm in independent data sets. One study was based on prospectively collected data; only 3 studies were based on primary care data. We found no data on implementation barriers or cost-effectiveness. Risk of bias assessment highlighted a wide range of study quality. The additional scoping review of commercial AI technologies identified 21 technologies, only 1 meeting our inclusion criteria. Meta-analysis was not undertaken because of the heterogeneity of AI modalities, data set characteristics, and outcome measures.

CONCLUSIONS

AI techniques have been applied to EHR-type data to facilitate early diagnosis of cancer, but their use in primary care settings is still at an early stage of maturity. Further evidence is needed on their performance using primary care data, implementation barriers, and cost-effectiveness before widespread adoption into routine primary care clinical practice can be recommended.

Limited evidence of benefits of patient operated intelligent primary care triage tools: findings of a literature review

Introduction

There is consistent evidence that the workload in general practices is substantially increasing. The digitalisation of healthcare including the use of artificial intelligence has been suggested as a solution to this problem. We wanted to explore the features of intelligent online triage tools in primary care by conducting a literature review.

Method

A systematic literature search strategy was formulated and conducted in the PubMed database and the Cochrane Library. Articles were selected according to inclusion/exclusion criteria. Results and data were systematically extracted and thematically analysed. 17 articles of that reported large multimethod studies or smaller diagnostic accuracy tests on clinical vignettes were included. Reviews and expert opinions were also considered.

Results

There was limited evidence on the actual effects and performance of triage tools in primary care. Several aspects can guide further development: concepts of system design, system implementation and diagnostic performance. The most important findings were: a need to formulate evaluation guidelines and regulations; their assumed potential has not yet been met; a risk of increased or redistribution of workloads and the available symptom checker systems seem overly risk averse and should be tested in real-life settings.

Conclusion

This review identified several features associated with the design and implementation of intelligent online triage tools in a primary care context, although most of the investigated systems seemed underdeveloped and offered limited benefits. Current online triage systems should not be used by individuals who have reasonable access to traditional healthcare. Systems used should be strictly evaluated and regulated like other medical products.

Barriers and Enablers in Implementing Electronic Consultations in Primary Care: Scoping Review

BACKGROUND

Often promoted as a way to address increasing demands, improve patient accessibility, and improve overall efficiency, electronic consultations are becoming increasingly common in primary care, particularly in light of the current COVID-19 pandemic. However, despite their increasing use, a theoretically informed understanding of the factors that support and inhibit their effective implementation is severely limited.

OBJECTIVE

With this scoping review, we sought to identify the factors that support and inhibit the implementation of electronic consultations in primary care.

METHODS

In total, 5 electronic databases (PubMed, Medline, Embase, CINAHL, and PsycINFO) were systematically searched for studies published in 2009-2019 that explored the impact and/or implementation of electronic consultations in primary care. Database searches were supplemented by reference list and grey literature searches. Data were analyzed using inductive thematic analysis and synthesized using Normalization Process Theory (NPT).

RESULTS

In total, 227 articles were initially identified and 13 were included in this review. The main factors found to hinder implementation included awareness and expectations; low levels of engagement; perceived suitability for all patient groups, conditions, and demographics; cost; and other contextual factors. Reports of information technology reliability and clinical workload duplication (as opposed to reduction) also appeared detrimental. Conversely, the development of protocols and guidance; patient and staff education; strategic marketing; and patient and public involvement were all identified as beneficial in facilitating electronic consultation implementation.

CONCLUSIONS

This review highlights the need for proactive engagement with patients and staff to facilitate understanding and awareness, process optimization, and delivery of coherent training and education that maximizes impact and success. Although the necessity to use online methods during the COVID-19 pandemic may have accelerated awareness, concerns over workload duplication and inequality of access may remain. Future research should explore health inequalities in electronic consultations and their economic impacts from multiple perspectives (eg, patient, professional, and commissioner) to determine their potential value. Further work to identify the role of meaningful patient involvement in digital innovation, implementation, and evaluation is also required following the rapid digitization of health and social care.

Exploring how virtual primary care visits affect patient burden of treatment

BACKGROUND

There is growing emphasis on the role of digital solutions in supporting chronic disease management. This has the potential to increase the burden patients experience in managing their health by offloading care from the health system to patients. This paper explores the effects of virtual visits on patient burden using an explicit framework measuring both the work patients do to care for their health and the challenges they experience that exacerbate burden.

METHODS

This mixed methods study evaluates a large pilot implementation of virtual visits (video, audio, and asynchronous messaging with providers) in primary care in Ontario, Canada. Participants were recruited using convenience sampling from patients using a virtual visit platform to complete a semi-structured interview or a survey including a free-text response. We conducted 17 interviews and reviewed 427 free text responses related to explore patients' perceived value and burden of these visits. We used qualitative analyses to map patients' feedback on their experience to the framework on patient burden.

MAIN FINDINGS

Virtual visits appear to reduce the work patients must do to manage their care by 1) improving access, convenience, and time needed for medical appointments, and 2) making it easier to access information and support for chronic disease management. Virtual visits also alleviate patients' perceived burden by improving continuity of care, experience of care, and providing some cost savings.

CONCLUSIONS

Virtual visits reduced overall patient burden of treatment by decreasing the required patient effort of managing medical appointments and monitoring their health, and by minimizing challenges experienced when accessing care. For regions that want to improve patient experience of care, virtual visits are likely to be of benefit. There is need for further research on the generalizability of the findings herein, particularly for high-needs populations under-represented such as those of low socioeconomic status and those in rural and remote locations.

Uptake and patient and provider communication modality preferences of virtual visits in primary care: a retrospective cohort study in Canada

OBJECTIVES

To evaluate the uptake of a platform for virtual visits in primary care, examine patient and physician preferences for virtual communication methods and report on characteristics of visits and patients experience of care.

DESIGN

A retrospective cohort study.

SETTING

Primary care practices within five regions in Ontario, Canada after 18 months of access to virtual care services.

PARTICIPANTS

326 primary care providers and 14 291 registered patients.

INTERVENTIONS

Providers used a platform that allowed them to connect with their patients through synchronous (audio/video) and/or asynchronous (secure messaging) communication.

MAIN OUTCOME MEASURES

User-level data from the platforms including patient demographics, practice characteristics, communication modality used, visit characteristics and patients' satisfaction.

RESULTS

Among the participants, 44% of registered patients and 60% of registered providers used the platform at least once. Among patient users, 51% completed at least one virtual visit. The majority of virtual visits (94%) involved secure messaging. The most common patient requests were for medication prescriptions (24%) and follow-up from previous appointment (22%). The most common provider request was to follow-up on test results (59%). Providers indicated that 81% of virtual visits required no follow-up for that issue and 99% of patients reported that they would use virtual care services again.

CONCLUSIONS

While there are a growing number of primary care video visit services, our study found that both patients and providers in rostered practices prefer secure messaging over video. Despite fears that virtual visits would be overused by patients, when patients connected with their own primary care provider, many virtual visits appeared to replace in-person visits, and patients did not overwhelm physicians with requests. This approach may improve access and continuity in primary care.

The Impact of Digital-First Consultations on Workload in General Practice: Modeling Study

Background

Health services in many countries are promoting digital-first models of access to general practice based on offering online, video, or telephone consultations before a face-to-face consultation. It is claimed that this will improve access for patients and moderate the workload of doctors. However, improved access could also potentially increase doctors’ workload.

Objective

The aim of this study was to explore whether and under what circumstances digital-first access to general practice is likely to decrease or increase general practice workload.

Methods

A process map to delineate primary care access pathways was developed and a model to estimate general practice workload constructed in Microsoft Excel (Microsoft Corp). The model was populated using estimates of key variables obtained from a systematic review of published studies. A MEDLINE search was conducted for studies published in English between January 1, 2000, and September 30, 2019. Included papers provided quantitative data about online, telephone, or video consultations for unselected patients requesting a general practice in-hours consultation for any problem. We excluded studies of general practitioners consulting specialists, consultations not conducted by doctors, and consultations conducted after hours, in secondary care, in specialist services, or for a specific health care problem. Data about the following variables were extracted from the included papers to form the model inputs: the proportion of consultations managed digitally, the proportion of digital consultations completed without a subsequent consultation, the proportion of subsequent consultations conducted by telephone rather than face-to-face, consultation duration, and the proportion of digital consultations that represent new demand. The outcome was general practice workload. The model was used to test the likely impact of different digital-first scenarios, based on the best available evidence and the plausible range of estimates from the published studies. The model allows others to test the impact on workload of varying assumptions about model inputs.

Results

Digital-first approaches are likely to increase general practice workload unless they are shorter, and a higher proportion of patients are managed without a subsequent consultation than observed in most published studies. In our base-case scenarios (based on the best available evidence), digital-first access models using online, telephone, or video consultations are likely to increase general practitioner workload by 25%, 3%, and 31%, respectively. An important determinant of workload is whether the availability of digital-first approaches changes the demand for general practice consultations, but there is little robust evidence to answer this question.

Conclusions

Digital-first approaches to primary care could increase general practice workload unless stringent conditions are met. Justification for these approaches should be based on evidence about the benefits in relation to the costs, rather than assumptions about reductions in workload. Given the potential increase in workload, which in due course could worsen problems of access, these initiatives should be implemented in a staged way alongside careful evaluation.

Mobile health application to support CPAP therapy in obstructive sleep apnoea: design, feasibility and perspectives

Background

Current continuous positive airway pressure (CPAP) devices can be monitored remotely; however, in-person visits are kept for clinical follow-up in order to promote CPAP use and resolve potential side-effects. Mobile health is a promising way to provide remote and easy clinical control for CPAP follow-up and support. We aimed to evaluate the feasibility and acceptance by obstructive sleep apnoea (OSA) patients and healthcare professionals of a newly designed mobile app (Appnea-Q) to promote clinical control through a self-monitoring tool for patients with CPAP supervised by sleep professionals.

Methods

Appnea-Q incorporates a simple follow-up questionnaire with automated responses, together with frequent problems and lifestyle recommendations sections. Feasibility, acceptance and usefulness were assessed. First, an internal validation was performed during outpatient CPAP follow-up visits with sleep professionals from various sleep units. Second, an external validation was performed in a subgroup of 15 patients at home.

Results

Most patients (n=75) considered the app useful and were willing to use it and recommend it (72-88%). Up to 64.87% agreed on its capacity to reduce hospital visits. Appnea-Q was rated as acceptable (79.37±19.29) by the system usability score. Sleep professionals (n=30) concurred on its usefulness for OSA patient follow-up, particularly during the first month of CPAP therapy. The external validation showed its feasibility among 11 out of 15 patients and their data were received accordingly on the professionals' web platform.

Conclusions

According to our validation process, and the viewpoints of the patients and professionals, our new mobile app is a feasible and well-received tool for personal OSA management. Future clinical trials should substantiate its performance and cost-effectiveness in the clinical arena.

Informing NHS policy in ‘digital-first primary care’: a rapid evidence synthesis

Background

In ‘digital-first primary care’ models of health-care delivery, a patient’s first point of contact with a general practitioner or other health professional is through a digital channel, rather than a face-to-face consultation. Patients are able to access advice and treatment remotely from their home or workplace via a number of different technologies.

Objectives

This rapid responsive evidence synthesis was undertaken to inform NHS England policy in ‘digital-first primary care’. It was conducted in two stages: (1) scoping the published evidence and (2) addressing a refined set of questions produced by NHS England from the evidence retrieved during the scoping stage.

Data sources

Searches were conducted of five electronic databases (MEDLINE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and PROSPERO were searched in July 2018) and relevant research/policy and government websites, as well as the National Institute for Health Research Health Service and Delivery Research programme database of ongoing and completed projects. No date or geographical limitations were applied.

Review methods

After examining the initial scoping material, NHS England provided a list of questions relating to the potential effects of digital modes and models of engagement, and the contracting and integration of these models into primary care. Systematic reviews and evidence syntheses, including evidence on the use of digital (online) modes and models of engagement between patients and primary care, were examined more closely, as was ongoing research and any incidentally identified primary studies focused on the use of digital (online) modes and models of engagement. All records were screened by two reviewers, with disagreements resolved by consensus or consulting a third reviewer.

Results

Evidence suggests that uptake of existing digital modes of engagement is currently low. Patients who use digital alternatives to face-to-face consultations are likely to be younger, female and have higher income and education levels. There is some evidence that online triage tools can divert demand away from primary care, but results vary between interventions and outcome measures. A number of potential barriers exist to using digital alternatives to face-to-face consultations, including inadequate NHS technology and staff concerns about workload and confidentiality. There are currently insufficient empirical data to either substantiate or allay such concerns. Very little evidence exists on outcomes related to quality of care, service delivery, benefits or harms for patients, or on financial costs/cost-effectiveness. No studies examining how to contract and commission alternatives to face-to-face consultations were identified.

Limitations

The quality of the included reviews was variable. Poor reporting of methodology and a lack of adequate study details were common issues. Much of the evidence focused on exploring stakeholder views rather than on objective measurement of potential impacts. The current evidence synthesis is based on a rapid scoping exercise and cannot provide the breadth or depth of insight that might have been achieved with a full systematic review.

Conclusions

Rapid scoping of the literature suggests that there is little high-quality evidence relating to ‘digital-first primary care’ as defined by NHS England. The broader evidence on alternatives to face-to-face consultation addresses certain policy-maker concerns, such as the possible impact of new technologies on workload and workforce, inequalities, local implementation and integration with existing services. However, although this evidence gives an insight into the views and experiences of health professionals in relation to such concerns, quantitative empirical data are lacking.

Funding

The National Institute for Health Research Health Service and Delivery Research programme.

Digital and online symptom checkers and health assessment/triage services for urgent health problems: systematic review

OBJECTIVES

In England, the NHS111 service provides assessment and triage by telephone for urgent health problems. A digital version of this service has recently been introduced. We aimed to systematically review the evidence on digital and online symptom checkers and similar services.

DESIGN

Systematic review.

DATA SOURCES

We searched Medline, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Management Information Consortium, Web of Science and ACM Digital Library up to April 2018, supplemented by phrase searches for known symptom checkers and citation searching of key studies.

ELIGIBILITY CRITERIA

Studies of any design that evaluated a digital or online symptom checker or health assessment service for people seeking advice about an urgent health problem.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment (using the Cochrane Collaboration version of QUADAS for diagnostic accuracy studies and the National Heart, Lung and Blood Institute tool for observational studies) were done by one reviewer with a sample checked for accuracy and consistency. We performed a narrative synthesis of the included studies structured around pre-defined research questions and key outcomes.

RESULTS

We included 29 publications (27 studies). Evidence on patient safety was weak. Diagnostic accuracy varied between different systems but was generally low. Algorithm-based triage tended to be more risk averse than that of health professionals. There was very limited evidence on patients' compliance with online triage advice. Study participants generally expressed high levels of satisfaction, although in mainly uncontrolled studies. Younger and more highly educated people were more likely to use these services.

CONCLUSIONS

The English 'digital 111' service has been implemented against a background of uncertainty around the likely impact on important outcomes. The health system may need to respond to short-term changes and/or shifts in demand. The popularity of online and digital services with younger and more educated people has implications for health equity.

PROSPERO REGISTRATION NUMBER

CRD42018093564.

Digital and online symptom checkers and assessment services for urgent care to inform a new digital platform: a systematic review

Background

Digital and online symptom checkers and assessment services are used by patients seeking guidance about health problems. NHS England is planning to introduce a digital platform (NHS111 Online) to operate alongside the NHS111 urgent-care telephone service. This review focuses on digital and online symptom checkers for urgent health problems.

Objectives

This systematic review was commissioned to provide NHS England with an independent review of previous research in this area to inform strategic decision-making and service design.

Data sources

Focused searches of seven bibliographic databases were performed and supplemented by phrase searching for names of symptom checker systems and citation searches of key included studies. The bibliographic databases searched were MEDLINE, EMBASE, The Cochrane Library, CINAHL (Cumulative Index to Nursing and Allied Health Literature), HMIC (Health Management Information Consortium), Web of Science and the Association of Computing Machinery (ACM) Digital Library, from inception up to April 2018.

Review methods

Brief inclusion criteria were (1) population – general population seeking information online or digitally to address an urgent health problem; (2) intervention – any online or digital service designed to assess symptoms, provide health advice and direct patients to appropriate services; and (3) comparator – telephone or face-to-face assessment, comparative performance in tests or simulations (studies with no comparator were included if they reported relevant outcomes). Outcomes of interest included safety, clinical effectiveness, costs or cost-effectiveness, diagnostic and triage accuracy, use of and contacts with health services, compliance with advice received, patient/carer satisfaction, and equity and inclusion. Inclusion was not restricted by study design. Screening studies for inclusion, data extraction and quality assessment were carried out by one reviewer with a sample checked for accuracy and consistency. Final decisions on study inclusion were taken by consensus of the review team. A narrative synthesis of the included studies was performed and structured around the predefined research questions and key outcomes. The overall strength of evidence for each outcome was classified as ‘stronger’, ‘weaker’, ‘conflicting’ or ‘insufficient’, based on study numbers and design.

Results

In total, 29 publications describing 27 studies were included. Studies were diverse in their design and methodology. The overall strength of the evidence was weak because it was largely based on observational studies and with a substantial component of non-peer-reviewed grey literature. There was little evidence to suggest that symptom checkers are unsafe, but studies evaluating their safety were generally short term and small scale. Diagnostic accuracy was highly variable between different systems but was generally low. Algorithm-based triage tended to be more risk averse than that of health professionals. Inconsistent evidence was found on effects on service use. There was very limited evidence on patients’ reactions to online triage advice. The studies showed that younger and more highly educated people are more likely to use these services. Study participants generally expressed high levels of satisfaction with digital and online triage services, albeit in uncontrolled studies.

Limitations

Findings from symptom checker systems for specific conditions may not be applicable to more general systems and vice versa. Studies of symptom checkers as part of electronic consultation systems in general practice were also included, which is a slightly different setting from a general ‘digital 111’ service. Most studies were screened by one reviewer.

Conclusions

Major uncertainties surround the probable impact of digital 111 services on most outcomes. It will be important to monitor and evaluate the services using all available data sources and by commissioning high-quality research.

Future work

Priorities for research include comparisons of different systems, rigorous economic evaluations and investigations of patient pathways.

Study registration

The study is registered as PROSPERO CRD42018093564.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient use of an online triage platform: a mixed-methods retrospective exploration in UK primary care

Background

Recent years have seen the introduction of online triage allowing patients to describe their problem via an online form. Subsequently, a GP telephones the patient, conducting a telephone consultation or arranging a face-to-face consultation.

Aim

This study aimed to explore patterns-of-use and patients’ experiences of using an online triage system.

Design and setting

This retrospective study analysed routinely collected data (from all practices using the ‘askmyGP’ platform for the duration of the study period, 19 May 2017 to 31 July 2017), using both quantitative and qualitative approaches. Data originated from an online triaging platform used by patients in nine general practices across the UK.

Method

Data from 5447 patients were quantitatively analysed to describe characteristics of users, patterns-of-use, and reasons given by patients for using the platform. Free-text comments left by patients (n = 569) on their experience of use were qualitatively analysed.

Results

Highest levels of use were observed in females (65.5%, n = 3570) and those aged 25–34 years. Patterns of use were high between 0800 and 0959, and on Mondays and Tuesdays. Use outside of GP practice opening hours was low. Common reasons for using the platform were for medication-related enquiries, for administrative requests, and to report a specific symptom. Comments left by patients suggested advantages to using the platform, for example, convenience and the written format, but these did not extend to all users.

Conclusion

Patterns-of-use and patient types were in line with typical contacts to GP practices. Though the age of users was broad, highest levels of use were from younger patients. The perceived advantages to using online triage, such as convenience and ease of use, are often context dependent.