Changes in the top 25 reasons for primary care visits during the COVID-19 pandemic in a high-COVID region of Canada

Does Trust Mediate the Relationship Between Experiences of Discrimination and Health Care Access and Utilization Among Minoritized Canadians During COVID-19 Pandemic?

OBJECTIVES

We sought to determine if trust in government institutions mediate the relationship between experiences of discrimination and health care utilization during the COVID-19 pandemic.

METHODS

We used data from Statistics Canada's Crowdsourcing Data: Impacts of COVID-19 on Canadians-Experiences of Discrimination. We used generalized linear latent and mixed models (Gllamm) with a binomial and logit link function as well as generalized structural equation modeling (GSEM) to determine if reported discrimination and trust were associated with difficulties in accessing health services, health care, and the likelihood of experiencing negative health impacts. We also examined if trust mediated the relationship between experiences of discrimination and these health outcomes. Our analytical sample consisted of 2568 individuals who self-identified as belonging to a visible minority group.

RESULTS

The multivariate results indicate that experiences of discrimination during COVID-19 were associated with higher odds of reporting difficulties in accessing general health services (OR = 1.99, p ≤ 0.01), receiving care (OR = 1.65, p ≤ 0.01), and higher likelihood of reporting negative health impacts (OR = 1.68, p ≤ 0.01). Our mediation analysis indicated that trust in public institutions explained a substantial portion of the association between reported discrimination and all the health outcomes, although the effects of experiencing discrimination remain significant and robust.

CONCLUSION

The findings show that building and maintaining trust is important and critical in a pandemic recovery world to build back better.

Impact of COVID-19 Pandemic on Healthcare Utilization in People with Diabetes: A Time-Segmented Longitudinal Study of Alberta's Tomorrow Project

OBJECTIVE

The objective is to characterize the impact of COVID-19 on major healthcare for diabetes, including hospitalization, emergency department (ED) visits and primary care visits in Alberta, Canada.

METHODS

Participants from Alberta's Tomorrow Project (ATP) with pre-existing diabetes prior to 1 April 2018 were included and followed up to 31 March 2021. A time-segmented regression model was used to characterize the impact of COVID-19 on healthcare utilization after adjusting for seasonality, socio-demographic factors, lifestyle behaviors and comorbidity profile of patients.

RESULTS

Among 6099 participants (53.5% females, age at diagnosis 56.1 ± 9.9 y), the overall rate of hospitalization, ED visits and primary care visits was 151.5, 525.9 and 8826.9 per 1000 person-year during the COVID-19 pandemic (up to 31 March 2021), which means they reduced by 12% and 22% and increased by 6%, compared to pre-pandemic rates, respectively. Specifically, the first COVID-19 state of emergency (first wave of the outbreak) was associated with reduced rates of hospitalization, ED visits and primary care visits, by 79.4% (95% CI: 61.3-89.0%), 93.2% (95% CI: 74.6-98.2%) and 65.7% (95% CI: 47.3-77.7%), respectively. During the second state of emergency, healthcare utilization continued to decrease; however, a rebound (increase) of ED visits was observed during the period when the public health state of emergency was relaxed.

CONCLUSION

The declared COVID-19 states of emergency had a negative impact on healthcare utilization for people with diabetes, especially for hospital and ED services, which suggests the importance of enhancing the capacity of these two healthcare sectors during future COVID-19-like public health emergencies.

From the COVID-19 lockdown to the new normal: Two-year changes in daily stress and positive event processes

The emergence of the novel COVID-19 disease and the social distancing measures implemented to curb its spread affected most aspects of daily life. Past work suggests that during times of more severe stress, people respond to daily stressors with relatively higher negative affect. However, little is known about how people responded to daily stressors and positive events at different moments in time during the COVID-19 pandemic. Thus, we examined longitudinal changes in daily event-related affect (covariation of daily stressors or positive events with same-day affect) from Spring 2020 (wave 1) to 2022 (wave 2). The sample consisted of 324 adults aged 18-80 (mean = 52 years; 89% women) from the US and Canada who completed weeklong daily diaries at both waves. The results revealed improvements in affective well-being, stressor-related affect (i.e., smaller fluctuations in affect on stressor days vs. nonstressor days), and positive event-related affect (i.e., lower negative affect on days with vs. without positive events). Furthermore, as people gradually resumed their social activities from 2020 to 2022, people reported being exposed to an increased frequency of both stressors and positive events. This study highlights the potential influence of socio-historical phenomena, such as an ongoing pandemic, on the events that people encounter and how they emotionally respond to them.

Family physicians' perspectives on the impact of COVID-19 on preventative care in primary care: findings from a qualitative study

INTRODUCTION

Health system disruptions, caused by unexpected emergencies such as disease outbreaks, natural disasters, and cybercrimes, impact the delivery of routine preventative care. As comprehensive care providers, family physicians (FPs) devote significant time to prevention. However, without emergency and pandemic plans in place in primary care, FPs face added barriers to prioritizing and sustaining preventative care when health systems are strained, which was evident during the COVID-19 pandemic. This study aims to describe FPs' experiences providing preventative care during the COVID-19 pandemic and their perceptions of the impacts of disrupted preventative care in primary care settings.

METHODS

Using a qualitative descriptive approach, we conducted semistructured interviews with FPs across 4 provinces in Canada (i.e. Newfoundland and Labrador, Nova Scotia, Ontario, British Columbia) between October 2020 and June 2021 as part of a larger multiple case study. These interviews broadly explored the roles and responsibilities of FPs during the COVID-19 pandemic. Interviews were coded thematically and codes from the larger study were analysed further using an iterative, phased process of thematic analysis.

RESULTS

Interviews averaged 58 min in length (range 17-97 min) and FPs had a mean of 16.9 years of experience. We identified 4 major themes from interviews with FPs (n = 68): (i) lack of capacity and coordination across health systems, (ii) patient fear, (iii) impacts on patient care, and (iv) negative impacts on FPs. Physicians voiced concerns with managing patients' prevention needs when testing availability and coordination of services was limited. Early in the pandemic, patients were also missing or postponing their own primary care appointments. Change in the provision and coordination of routine preventative care had negative impacts on both patients and physicians, affecting disease incidence/progression, physician workload, and psychological wellbeing.

CONCLUSION

During the COVID-19 pandemic, upstream care efforts were impacted, and FPs were forced to reduce their provision of preventative care. FPs contribute direct insight to primary care delivery that can support pandemic planning to ensure preventative care is sustained during future emergencies.

Changes in Primary Care Health Services During the COVID-19 Pandemic: A Longitudinal Analysis of Data From Ontario

The COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.

Assessing the effectiveness of "BETTER Women", a community-based, primary care-linked peer health coaching programme for chronic disease prevention: protocol for a pragmatic, wait-list controlled, type 1 hybrid effectiveness-implementation trial

INTRODUCTION

The Building on Existing Tools to Improve Cancer and Chronic Disease Prevention and Screening in Primary Care (BETTER) programme trains allied health professionals working in primary care settings to develop personalised chronic disease 'prevention prescriptions' with patients. However, maintenance of health behaviour changes is difficult without ongoing support. Sustainable options to enhance the BETTER programme and ensure accessibility to underserved populations are needed. We designed the BETTER Women programme, which uses a digital app to match patients with a trained peer health coach (PHC) who provides ongoing support for health behaviour change after receipt of a BETTER prevention prescription in primary care.

METHODS AND ANALYSIS

We will conduct a type 1 hybrid implementation-effectiveness patient-randomised trial. Interested women aged 40-68 years will be recruited from three large, sociodemographically distinct primary care clinics (urban, suburban and rural). Patients will be randomised 1:1 to intervention or wait-list control after receipt of their BETTER prevention prescription. We will aim to recruit 204 patients per group (408 total). Effectiveness will be assessed by the primary outcome of targeted behaviours achieved for each participant at 6 months, consisting of three cancer screening tests (cervical, breast and colorectal) and four behavioural determinants of cancer and chronic disease (diet, smoking, alcohol use and physical activity). Data will be collected through patient survey and clinical chart review, measured at 3, 6 and 12 months. Implementation outcomes will be assessed through patient surveys and interviews with patients, peer health coaches and healthcare providers. An embedded economic evaluation will examine cost per quality-adjusted life-year and per additional health behavioural targets achieved.

ETHICS AND DISSEMINATION

This study has been approved by Women's College Hospital Research Ethics Board (REB), the Royal Victoria Regional Health Centre REB and the University of Toronto REB. All participants will provide informed consent prior to enrolment. Participation is voluntary and withdrawal will have no impact on the usual care received from their primary care provider. The results of this trial will be published in peer-reviewed journals and shared via conference presentations. Deidentified datasets will be shared on request, after publication of results.

TRIAL REGISTRATION NUMBER

NCT04746859.

Physicians' perspectives on COVID-19 vaccinations for children: a qualitative exploration in Ontario, Canada

OBJECTIVES

Parents' decisions to vaccinate their children against COVID-19 are complex and often informed by discussions with primary care physicians. However, little is known about physicians' perspectives on COVID-19 vaccinations for children or their experiences counselling parents in their decision-making. We explored physicians' experiences providing COVID-19 vaccination recommendations to parents and their reflections on the contextual factors that shaped these experiences.

DESIGN

We conducted an interpretive qualitative study using in-depth interviews. We analyzed the data using reflexive thematic analysis and a socioecological framework.

SETTING

This study involved primary care practices associated with The Applied Research Group for Kids (TARGet Kids!) primary care research network in the Greater Toronto Area, Ontario, Canada.

PARTICIPANTS

Participants were 10 primary care physicians, including family physicians, paediatricians and paediatric subspecialists.

RESULTS

Participants discussed elements at the individual level (their identity, role, and knowledge), the interpersonal level (their relationships with families, responsiveness to parents' concerns, and efforts to build trust) and structural level (contextual factors related to the evolving COVID-19 climate, health system pandemic response, and constraints on care delivery) that influenced their experiences providing recommendations to parents. Our findings illustrated that physicians' interactions with families were shaped by a confluence of their own perspectives, their responses to parents' perspectives, and the evolving landscape of the broader pandemic.

CONCLUSIONS

Our study underscores the social and relational nature of vaccination decision-making and highlights the multiple influences on primary care physicians' experiences providing COVID-19 vaccination recommendations to parents. Our findings offer suggestions for future COVID-19 vaccination programmes for children. Delivery of new COVID-19 vaccinations for children may be well suited within primary care offices, where trusting relationships are established, but physicians need support in staying knowledgeable about emerging information, communicating available evidence to parents to inform their decision-making and dedicating time for vaccination counselling.

Understanding the impact of COVID-19 on antibiotic use in Canadian primary care: a matched-cohort study using EMR data

BACKGROUND

Inappropriate or overuse of antibiotic prescribing in primary care highlights an opportunity for antimicrobial stewardship (AMS) programs aimed at reducing unnecessary use of antimicrobials through education, policies and practice audits that optimize antibiotic prescribing. Evidence from the early part of the pandemic indicates a high rate of prescribing of antibiotics for patients with COVID-19. It is crucial to surveil antibiotic prescribing by primary care providers from the start of the pandemic and into its endemic stage to understand the effects of the pandemic and better target effective AMS programs.

METHODS

This was a matched pair population-based cohort study that used electronic medical record (EMR) data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Participants included all patients that visited their primary care provider and met the inclusion criteria for COVID-19, respiratory tract infection (RTI), or non-respiratory or influenza-like-illness (negative). Four outcomes were evaluated (a) receipt of an antibiotic prescription; (b) receipt of a non-antibiotic prescription; (c) a subsequent primary care visit (for any reason); and (d) a subsequent primary care visit with a bacterial infection diagnosis. Conditional logistic regression was used to evaluate the association between COVID-19 and each of the four outcomes. Each model was adjusted for location (rural or urban), material and social deprivation, smoking status, alcohol use, obesity, pregnancy, HIV, cancer and number of chronic conditions.

RESULTS

The odds of a COVID-19 patient receiving an antibiotic within 30 days of their visit is much lower than for patients visiting for RTI or for a non-respiratory or influenza-like-illnesses (AOR = 0.08, 95% CI[0.07, 0.09] compared to RTI, and AOR = 0.43, 95% CI[0.38, 0.48] compared to negatives). It was found that a patient visit for COVID-19 was much less likely to have a subsequent visit for a bacterial infection at all time points.

CONCLUSIONS

Encouragingly, COVID-19 patients were much less likely to receive an antibiotic prescription than patients with an RTI. However, this highlights an opportunity to leverage the education and attitude change brought about by the public health messaging during the COVID-19 pandemic (that antibiotics cannot treat a viral infection), to reduce the prescribing of antibiotics for other viral RTIs and improve antibiotic stewardship.

Prolonged increase in psychotropic drug use among young women following the COVID-19 pandemic: a French nationwide retrospective study

BACKGROUND

The COVID-19 pandemic has had a significant impact on mental health, with evidence suggesting an enduring mental health crisis. Studies worldwide observed increased usage of antidepressants, anxiolytics, and hypnotics during the pandemic, notably among young people and women. However, few studies tracked consumption post-2021. Our study aimed to fill this gap by investigating whether the surge in the number psychotropic drug consumers in France persisted 2 years after the first lockdown, particularly focusing on age and gender differences.

METHODS

We conducted a national retrospective observational study based on the French national insurance database. We retrieved all prescriptions of anxiolytics, hypnotics, and antidepressants dispensed in pharmacies in France for the period 2015-2022. We performed interrupted time series analyses based on Poisson models for five age classes (12-18; 19-25; 26-50; 51-75; 76 and more) to assess the trend before lockdown, the gap induced and the change in trend after.

RESULTS

In the overall population, the number of consumers remained constant for antidepressants while it decreased for anxiolytics and hypnotics. Despite this global trend, a long-term increase was observed in the 12-18 and 19-25 groups for the three drug classes. Moreover, for these age classes, the increases were more pronounced for women than men, except for hypnotics where the trends were similar.

CONCLUSIONS

The number of people using antidepressants continues to increase more than 2 years after the first lockdown, showing a prolonged effect on mental health. This effect is particularly striking among adolescents and young adults confirming the devastating long-term impact of the pandemic on their mental health.

Changes in primary care visits for respiratory illness during the COVID-19 pandemic: a multinational study by the International Consortium of Primary Care Big Data Researchers (INTRePID)

Objectives

The majority of patients with respiratory illness are seen in primary care settings. Given COVID-19 is predominantly a respiratory illness, the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID), assessed the pandemic impact on primary care visits for respiratory illnesses.

Design

Definitions for respiratory illness types were agreed on collectively. Monthly visit counts with diagnosis were shared centrally for analysis.

Setting

Primary care settings in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden and the United States.

Participants

Over 38 million patients seen in primary care settings in INTRePID countries before and during the pandemic, from January 1st, 2018, to December 31st, 2021.

Main outcome measures

Relative change in the monthly mean number of visits before and after the onset of the pandemic for acute infectious respiratory disease visits including influenza, upper and lower respiratory tract infections and chronic respiratory disease visits including asthma, chronic obstructive pulmonary disease, respiratory allergies, and other respiratory diseases.

Results

INTRePID countries reported a marked decrease in the average monthly visits for respiratory illness. Changes in visits varied from -10.9% [95% confidence interval (CI): -33.1 to +11.3%] in Norway to -79.9% (95% CI: -86.4% to -73.4%) in China for acute infectious respiratory disease visits and - 2.1% (95% CI: -12.1 to +7.8%) in Peru to -59.9% (95% CI: -68.6% to -51.3%) in China for chronic respiratory illness visits. While seasonal variation in allergic respiratory illness continued during the pandemic, there was essentially no spike in influenza illness during the first 2 years of the pandemic.

Conclusion

The COVID-19 pandemic had a major impact on primary care visits for respiratory presentations. Primary care continued to provide services for respiratory illness, although there was a decrease in infectious illness during the COVID pandemic. Understanding the role of primary care may provide valuable information for COVID-19 recovery efforts and planning for future global emergencies.

Prescription Trends of Thiazide Diuretics in a Canadian Primary Care Population From 2015 to 2021

Background

Hypertension Canada 2017 guidelines favoured the use of thiazide (TZ)-like diuretics, such as CLTD (chlorthalidone) and indapamide (IND) over hydrochlorothiazide (HCTZ). Health Canada warned in 2019 that HCTZ may be associated with increased risk of skin cancer. Our study looked at the changes in TZ prescriptions from 2015 to 2021 in Ontario, Canada.

Methods

A retrospective cohort study was conducted of adults with hypertension, using electronic medical record data from the University of Toronto Practice-Based Research Network database covering mostly the Greater Toronto area. Outcomes included the proportion of patients who received a prescription of HCTZ, CLTD, or IND each month. Interrupted time-series analysis was used to evaluate the change in outcomes after publication of the 2017 guidelines and 2019 safety warning. Prescription trends were stratified by prescribing physicians' sex and year of medical school graduation.

Results

A total of 100,428 patients with hypertension were included in the cohort, with 31,700 patients who received at least one TZ prescription from 343 family physicians. We found a declining trend in HCTZ prescriptions over time, accompanied by an increase in IND and CLTD prescriptions, with statistically significant but transient changes in prescription rates after publication of the 2017 guidelines and the 2019 safety warning for all 3 medications. Female physician and early-career physician prescription rates changed faster than that of their counterparts immediately after the Health Canada safety warning was issued.

Conclusions

TZ diuretic prescription patterns have changed in recent years, but Hypertension Canada's 2017 guidelines and the 2019 Health Canada safety warning did not have a sustained significant impact on the change in prescription rates of HCTZ, IND, and CLTD.

Inequalities in access to prenatal care during the COVID-19 pandemic: Analysis of a population-based cohort

BACKGROUND

Before the COVID-19 pandemic, access to prenatal care was lower among some socio-demographic groups. This pandemic caused disruptions to routine preventative care, which could have increased inequalities.

OBJECTIVES

To investigate if the COVID-19 pandemic increased inequalities in access to prenatal care among those who are younger, live in rural areas, have a lower socio-economic situation (SES) and are recent immigrants.

METHODS

We used linked administrative datasets from ICES to identify a population-based cohort of 455,245 deliveries in Ontario from January 2018 to December 2021. Our outcomes were first-trimester prenatal visits, first-trimester ultrasound and adequacy of prenatal care. We used joinpoint analysis to examine outcome time trends and identify trend change points. We stratified analyses by age, rural residence, SES and recent immigration, and examined risk differences (RD) with 95% confidence intervals (CI) between groups at the beginning and end of the study period.

RESULTS

For all outcomes, we noted disruptions to care beginning in March or April 2020 and returning to previous trends by November 2020. Inequalities were stable across groups, except recent immigrants. In July 2017, 65.0% and 69.8% of recent immigrants and non-immigrants, respectively, received ultrasounds in the first trimester (RD -4.8%, 95% CI -8.0, -1.5). By October 2020, this had increased to 75.4%, with no difference with non-immigrants (RD 0.4%, 95% CI -2.4, 3.2). Adequacy of prenatal care showed more intensive care as of November 2020, reflecting a higher number of visits.

CONCLUSIONS

We found no evidence that inequalities between socio-economic groups that existed prior to the pandemic worsened after March 2020. The pandemic may be associated with increased access to care for recent immigrants. The introduction of virtual visits may have resulted in a higher number of prenatal care visits.

Prevalence and Incidence Trends of Attention Deficit/Hyperactivity Disorder in Children and Youth Aged 1-24 Years in Ontario, Canada: A Validation Study of Health Administrative Data Algorithms: Tendances de la prévalence et de l'incidence du trouble de déficit de l'attention/hyperactivité chez les enfants et les jeunes âgés de 1 à 24 ans, en Ontario, Canada: une étude de validation des algorithmes de données administratives de santé

OBJECTIVE

To estimate prevalence and incidence rates over time in children and youth with attention deficit/hyperactivity disorder from the validation of population-based administrative data algorithms using family physicians' electronic medical records as a reference standard.

METHODS

A retrospective cohort study was conducted in Ontario, Canada to identify attention deficit/hyperactivity disorder among children and youth aged 1-24 years in health administrative data derived from case-finding algorithms using family physicians' electronic medical records. Multiple administrative data algorithms identifying attention deficit/hyperactivity disorder cases were developed and tested from physician-diagnosis of attention deficit/hyperactivity disorder in the electronic medical record to determine their diagnostic accuracy. We calculated algorithm performance using sensitivity, specificity, and predictive values. The most optimal algorithm was used to estimate prevalence and incidence rates of attention deficit/hyperactivity disorder from 2014 to 2021 in Ontario.

RESULTS

The optimal performing algorithm was "2 physician visits for attention deficit/hyperactivity disorder in 1 year or 1 attention deficit/hyperactivity disorder-specific prescription" with sensitivity: 83.2% (95% confidence interval [CI], 81.8% to 84.5%), specificity: 98.6% (95% CI, 98.5% to 98.7%), positive predictive value: 78.6% (95% CI, 77.1% to 80.0%) and negative predictive value: 98.9% (95% CI, 98.8% to 99.0%). From 2014, prevalence rates for attention deficit/hyperactivity disorder increased from 5.29 to 7.48 per 100 population in 2021 (N = 281,785). Males had higher prevalence rates (7.49 to 9.59 per 100 population, 1.3-fold increase) than females (2.96-5.26 per 100 population, 1.8-fold increase) from 2014 to 2021. Incidence rates increased from 2014 (0.53 per 100 population) until 2018, decreased in 2020 then rose steeply in 2021 (0.89 per 100 population, N = 34,013). Males also had higher incidence rates than females from 2014 to 2020 with females surpassing males in 2021 (0.70-0.81 per 100 male population,1.2-fold increase versus 0.36-0.97 per 100 female population, 2.7-fold increase).

CONCLUSIONS

Attention deficit/hyperactivity disorder is increasing in prevalence. We developed an administrative data algorithm that can reliably identify children and youth with attention deficit/hyperactivity disorder with good diagnostic accuracy.

Guidelines and recommendations about virtual mental health services from high-income countries: a rapid review

OBJECTIVES

This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services.

DESIGN

We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings.

METHODS

Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes.

RESULTS

The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients' access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients.

CONCLUSIONS

This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.

Trends and Components of Thyroid Status Evaluation in Commercially Insured Adults in the United States, 2006-2020

CONTEXT

Thyroid-stimulating hormone (TSH) is one of the most ordered laboratory tests.

OBJECTIVE

Determine trends of TSH testing rates and components of thyroid function testing.

METHODS

This was a retrospective analysis of adults 18-64 years old without evidence of thyroid disease with at least 365 days of continuous enrollment between 2006 and 2020 in the IBM MarketScan Claims Database. The main outcome measures were trends of TSH tests/1000 eligible patient-months stratified by age, sex, and region and composition of thyroid function testing.

RESULTS

Among 67 353 280 patients meeting eligibility criteria, we identified 25 606 518 TSH tests and 15 138 211 patients with ≥1 TSH test. Patients contributing an episode of TSH testing were most commonly 45-54 years old (29.8%) and female (63.6%). TSH testing rates remained consistent throughout the study period with 11.4 and 11.7 TSH tests/1000 person-months in the first and last study months, respectively (mean 12.2 TSH tests/1000 person-months). TSH testing rates dropped sharply in the spring of 2020 (4.2 TSH tests/1000 person-months). Females showed a nearly 2-fold higher rate of TSH testing than males (16.1 TSH tests/1000 person-months vs 8.6 TSH tests/1000 person-months). TSH testing rates increased with age (8.2 TSH tests/1000 person-months among individuals 18-34 years old vs 15.4 TSH tests/1000 person-months among individuals 55-64 years old). No difference in TSH testing rates was noted between regions. Thyroid function testing episodes included only TSH in most cases (70.8%).

CONCLUSION

TSH testing rates among commercially insured individuals without known thyroid disease appears stable over time, with higher frequency in females and with increasing age.

Self-care interventions to assist family physicians with mental health care of older patients during the COVID-19 pandemic: Feasibility, acceptability, and outcomes of a pilot randomized controlled trial

BACKGROUND

The COVID-19 pandemic has required family physicians to rapidly address increasing mental health problems with limited resources. Vulnerable home-based seniors with chronic physical conditions and commonly undermanaged symptoms of anxiety and depression were recruited in this pilot study to compare two brief self-care intervention strategies for the management of symptoms of depression and/or anxiety.

METHODS

We conducted a pilot RCT to compare two tele-health strategies to address mental health symptoms either with 1) validated CBT self-care tools plus up to three telephone calls from a trained lay coach vs. 2) the CBT self-guided tools alone. The interventions were abbreviated from those previously trialed by our team, to enable their completion in 2 months. Objectives were to assess the feasibility of delivering the interventions during a pandemic (recruitment and retention); and assess the comparative acceptability of the interventions across the two groups (satisfaction and tool use); and estimate preliminary comparative effectiveness of the interventions on severity of depression and anxiety symptoms. Because we were interested in whether the interventions were acceptable to a wide range of older adults, no mental health screening for eligibility was performed.

RESULTS

90 eligible patients were randomized. 93% of study completers consulted the self-care tools and 84% of those in the coached arm received at least some coaching support. Satisfaction scores were high among participants in both groups. No difference in depression and anxiety outcomes between the coached and non-coached participants was observed, but coaching was found to have a significant effect on participants' use and perceived helpfulness of the tools.

CONCLUSION

Both interventions were feasible and acceptable to patients. Trained lay coaching increased patients' engagement with the tools. Self-care tools offer a low cost and acceptable remote activity that can be targeted to those with immediate needs. While effectiveness results were inconclusive, this may be due to the lack of eligibility screening for mental health symptoms, abbreviated toolkit, and fewer coaching sessions than those used in our previous effective interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT0460937.

A comparison between different patient groups for diabetes management during phases of the COVID-19 pandemic: a retrospective cohort study in Ontario, Canada

BACKGROUND

With the onset of the COVID-19 pandemic and the large uptake in virtual care in primary care in Canada, the care of patients with type 2 diabetes has been greatly affected. This includes decreased in-person visits, laboratory testing and in-person assessments such as blood pressure (BP). No studies have investigated if these changes persisted with pandemic progression, and it is unclear if shifts impacted patient groups uniformly. The purpose of this paper was to examine changes in diabetes care pre, early, and later pandemic across different patient groups.

METHODS

A repeated cross-sectional design with an open cohort was used to investigate diabetes care in adults with type 2 diabetes for a 6-month interval from March 14 to September 13 over three consecutive years: 2019 (pre-pandemic period), 2020 (early pandemic period), and 2021 (later pandemic period). Data for this study were abstracted from the University of Toronto Practice-Based Research Network (UTOPIAN) Data Safe Haven, a primary care electronic medical records database in Ontario, Canada. Changes in diabetes care, which included primary care total visits, in-person visits, hemoglobin A1c (HbA1c) testing, and BP measurements were evaluated across the phases of the pandemic. Difference in diabetes care across patient groups, including age, sex, income quintile, prior HbA1c levels, and prior BP levels, were assessed.

RESULTS

A total of 39,401 adults with type 2 diabetes were included in the study. Compared to the 6-month pre-pandemic period, having any in-person visits decreased significantly early pandemic (OR = 0.079 (0.076-0.082)), with a partial recovery later pandemic (OR = 0.162 (95% CI: 0.157-0.169). Compared to the pre-pandemic period, there was a significant decrease early pandemic for total visits (OR = 0.486 (95% CI: 0.470-0.503)), HbA1c testing (OR = 0.401 (95% CI: 0.389-0.413)), and BP measurement (OR = 0.121 (95% CI: 0.116-0.125)), with partial recovery later pandemic.

CONCLUSIONS

All measures of diabetes care were substantially decreased early pandemic, with a partial recovery later pandemic across all patient groups. With the increase in virtual care due to the COVID-19 pandemic, diabetes care has been negatively impacted over 1-year after pandemic onset.

"Not doing it justice": Perspectives of Recent Family Medicine Graduates on Mental Health and Addictions Training in Residency

OBJECTIVES

Family physicians report feeling inadequately prepared to meet the evolving mental health care needs of the population. Little scholarship exists evaluating the effectiveness of curricula designed to teach mental health and addiction (MH&A) care to family medicine (FM) residents. As such, the purpose of this study was to explore the experiences of recent FM residency graduates in providing mental health care, and their perceptions of mental health training gaps during their residencies.

METHODS

A qualitative descriptive study design was conducted by 8 recent graduates of the University of Toronto's FM residency program, who participated in semi-structured video interviews. A thematic analysis approach was used to collect and analyze the data.

RESULTS

Through thematic analysis, 3 overarching themes were developed: (1) barriers in providing mental health and addiction care, (2) curriculum renewal, and (3) the role of FPs and professional identity. Consistent with the literature, the majority of recent FM graduates expressed discomfort when managing patients with mental health and addiction concerns. Additionally, participants perceived residency program time constraints, rotational site differences, and limited exposure to marginalized populations all impacted learning and mastery of skills.

CONCLUSION

The findings of this study underscore current gaps within the FM residency curriculum and highlight the need to address current curricular deficits.

The impact of the COVID-19 pandemic on the rate of primary care visits for substance use among patients in Ontario, Canada

The COVID-19 pandemic has led to an increase in the prevalence of substance use presentations. This study aims to assess the impact of the COVID-19 pandemic on the rate of primary care visits for substance use including tobacco, alcohol, and other drug use among primary care patients in Ontario, Canada. Diagnostic and service fee code data were collected from a longitudinal cohort of family medicine patients during pre-pandemic (March 14, 2019-March 13, 2020) and pandemic periods (March 14, 2020-March 13, 2021). Generalized linear models were used to compare the rate of substance-use related visits pre-pandemic and during the pandemic. The effects of demographic characteristics including age, sex, and income quintile were also assessed. Relative to the pre-pandemic period, patients were less likely to have a primary care visit during the pandemic for tobacco-use related reasons (OR = 0.288, 95% CI [0.270-0.308]), and for alcohol-use related reasons (OR = 0.851, 95% CI [0.780-0.929]). In contrast, patients were more likely to have a primary care visit for other drug-use related reasons (OR = 1.150, 95% CI [1.080-1.225]). In the face of a known increase in substance use during the COVID-19 pandemic, a decrease in substance use-related primary care visits likely represents an unmet need for this patient population. This study highlights the importance of continued research in the field of substance use, especially in periods of heightened vulnerability such as during the COVID-19 pandemic.

The association between patients' frailty status, multimorbidity, and demographic characteristics and changes in primary care for chronic conditions during the COVID-19 pandemic: a pre-post study

BACKGROUND

The purpose of this study was to assess the impact of SARS-COV-2 (Severe acute respiratory syndrome coronavirus 2) pandemic on primary care management (frequency of monitoring activities, regular prescriptions, and test results) of older adults with common chronic conditions (diabetes, hypertension, and chronic kidney disease) and to examine whether any changes were associated with age, sex, neighbourhood income, multimorbidity, and frailty.

METHODS

A research database from a sub-set of McMaster University Sentinel and Information Collaboration family practices was used to identify patients ≥65 years of age with a frailty assessment and 1 or more of the conditions. Patient demographics, chronic conditions, and chronic disease management information were retrieved. Changes from 14 months pre to 14 months since the pandemic were described and associations between patient characteristics and changes in monitoring, prescriptions, and test results were analysed using regression models.

RESULTS

The mean age of the 658 patients was 75 years. While the frequency of monitoring activities and prescriptions related to chronic conditions decreased overall, there were no clear trends across sub-groups of age, sex, frailty level, neighbourhood income, or number of conditions. The mean values of disease monitoring parameters (e.g. blood pressure) did not considerably change. The only significant regression model demonstrated that when controlling for all other variables, patients with 2 chronic conditions and those with 4 or more conditions were twice as likely to have reduced numbers of eGFR (Estimated glomerular filtration rate) measures compared to those with only 1 condition ((OR (odds ratio) = 2.40, 95% CI [1.19, 4.87]); (OR = 2.19, 95% CI [1.12, 4.25]), respectively).

CONCLUSION

In the first 14 months of the pandemic, the frequency of common elements of chronic condition care did not notably change overall or among higher-risk patients.

The impact of COVID-19 pandemic on the indications of non-COVID-19 obstetric and gynecological admissions to the intensive care unit (ICU) and its overall consequences

Since COVID-19 outbreak caused a substantial reduction in intensive care unit (ICU) bed capacity, a significant change in triaging ICU admissions has become necessary for obstetric and gynecologic (OG) patients, as well. In the present study, we aimed to analyze the patients admitted to ICU for non-COVID-19 OG pathologies to understand the probable effects of the pandemic on demographics, admission rates and indications, complications, and the overall outcome. Medical records of patients who were admitted to ICU for OG diseases between 2018 and 2022 were reviewed. This four-year time was divided into two equal periods; Group I (March 2018 to March 2020, before the pandemic starts) and Group II (March 2020 to March 2022, during pandemic). Demographics, indications for admissions to ICU, length of stay, acute physiology and chronic health evaluation II (APACHE-II) scores and the factors contributing to their morbidity and mortality were recorded. Chi-square Kolmogorov-Smirno and Shapiro-Wilk tests were used to compare the variables. p < 0.05 was considered statistically significant. 511 patients were in Group I (61.94%) and 314 in Group II (38.06%). Between 2020 and 2022, our ICU admitted 38.56% fewer OG inpatients, compared with the pre-pandemic period (p < 0.05). While number of patients with gynecological pathologies increased (50 vs 57%), obstetric patients' admission to ICU decreased (49 vs 42%). In gynecologic patients, postoperative complications and sepsis showed a significant rise (57 vs 69% and 7 vs 12%, p < 0.05), and most were after oncological operations (81%). There was a significant rise in numbers of pregnancy-induced hypertension and placental pathologies (29 vs 36% and 41 vs 58%, p < 0.05). Outcome of obstetric patients in ICU was good (99% survival rate). Mortality was higher in gynecologic patients (4 vs 9%, p < 0.05), correlated with the increased APACHE-II score (8 vs 10, p < 0.05). Older age and oncologic operations were the primary factors increasing mortality. Length of stay in ICU prolonged in these patients, as well (1 vs 3 days, p < 0.05). Selection of priority patients by gynecologists and intensive care specialists in cooperation, and meticulous implementation of the rule of only accepting patients with strict indications may explain the change in OG admissions during the outbreak. These findings will question the accuracy of wider indications for ICU admissions in pre-pandemic period, and help in planning the policy for future post-pandemic days.

Variability in changes in physician outpatient antibiotic prescribing from 2019 to 2021 during the COVID-19 pandemic in Ontario, Canada

Objective

To evaluate inter-physician variability and predictors of changes in antibiotic prescribing before (2019) and during (2020/2021) the coronavirus disease 2019 (COVID-19) pandemic.

Methods

We conducted a retrospective cohort analysis of physicians in Ontario, Canada prescribing oral antibiotics in the outpatient setting between January 1, 2019 and December 31, 2021 using the IQVIA Xponent data set. The primary outcome was the change in the number of antibiotic prescriptions between the prepandemic and pandemic period. Secondary outcomes were changes in the selection of broad-spectrum agents and long-duration (>7 d) antibiotic use. We used multivariable linear regression models to evaluate predictors of change.

Results

There were 17,288 physicians included in the study with substantial inter-physician variability in changes in antibiotic prescribing (median change of -43.5 antibiotics per physician, interquartile range -136.5 to -5.0). In the multivariable model, later career stage (adjusted mean difference [aMD] -45.3, 95% confidence interval [CI] -52.9 to -37.8, p < .001), family medicine (aMD -46.0, 95% CI -62.5 to -29.4, p < .001), male patient sex (aMD -52.4, 95% CI -71.1 to -33.7, p < .001), low patient comorbidity (aMD -42.5, 95% CI -50.3 to -34.8, p < .001), and high prescribing to new patients (aMD -216.5, 95% CI -223.5 to -209.5, p < .001) were associated with decreases in antibiotic initiation. Family medicine and high prescribing to new patients were associated with a decrease in selection of broad-spectrum agents and prolonged antibiotic use.

Conclusions

Antibiotic prescribing changed throughout the COVID-19 pandemic with overall decreases in antibiotic initiation, broad-spectrum agents, and prolonged antibiotic courses with inter-physician variability. These findings present opportunities for community antibiotic stewardship interventions.

Gaps in childhood immunizations and preventive care visits during the COVID-19 pandemic: a population-based cohort study of children in Ontario and Manitoba, Canada, 2016-2021

OBJECTIVE

We aimed to estimate the changes to the delivery of routine immunizations and well-child visits through the pandemic.

METHODS

Using linked administrative health data in Ontario and Manitoba, Canada (1 September 2016 to 30 September 2021), infants <12 months old (N=291,917 Ontario, N=33,994 Manitoba) and children between 12 and 24 months old (N=293,523 Ontario, N=33,001 Manitoba) exposed and unexposed to the COVID-19 pandemic were compared on rates of receipt of recommended a) vaccinations and b) well-child visits after adjusting for sociodemographic measures. In Ontario, vaccinations were captured using physician billings database, and in Manitoba they were captured in a centralized vaccination registry.

RESULTS

Exposed Ontario infants were slightly more likely to receive all vaccinations according to billing data (62.5% exposed vs. 61.6% unexposed; adjusted Relative Rate (aRR) 1.01 [95% confidence interval (CI) 1.00-1.02]) whereas exposed Manitoba infants were less likely to receive all vaccines (73.5% exposed vs. 79.2% unexposed; aRR 0.93 [95% CI 0.92-0.94]). Among children exposed to the pandemic, total vaccination receipt was modestly decreased compared to unexposed (Ontario aRR 0.98 [95% CI 0.97-0.99]; Manitoba aRR 0.93 [95% CI 0.91-0.94]). Pandemic-exposed infants were less likely to complete all recommended well-child visits in Ontario (33.0% exposed, 48.8% unexposed; aRR 0.67 [95% CI 0.68-0.69]) and Manitoba (55.0% exposed, 70.7% unexposed; aRR 0.78 [95% CI 0.77-0.79]). A similar relationship was observed for rates of completed well-child visits among children in Ontario (aRR 0.78 [95% CI 0.77-0.79]) and Manitoba (aRR 0.79 [95% CI 0.77-0.80]).

CONCLUSION

Through the first 18 months of the pandemic, routine vaccines were delivered to children < 2 years old at close to pre-pandemic rates. There was a high proportion of incomplete well-child visits, indicating that developmental surveillance catch-up is crucial.

Delivering Primary Health Care (PHC) Services for Controlling NCDs During the COVID-19 Pandemic: A Scoping Review

Non-communicable diseases (NCDs) are the leading cause of death worldwide. NCDs also increase mortality from COVID-19 and primary health care (PHC) services are an important component in the prevention and control of long-term NCDs. The main goal of the present study was to review primary healthcare services for the NCDs patients via primary healthcare network during COVID-19 pandemic. In this scoping review, Search engines including PubMed, Scopus, and Science-direct up to 1st February 2022 were searched to identify studies regarding primary care services for NCDs patients via primary health care during COVID-19 pandemic. A total of 42 studies met the inclusion criteria and were included in our analysis. 24 studies were about the status and changes of primary health services for NCDs patients in PHC settings, while 18 studies focused on adaptive strategies used during COVID-19 in different countries including United States, Canada, United Kingdom, Portugal, Georgia, South Africa, Thailand, Mexico, India, Kenya, Guatemala and Saudi Arabia. These strategies included remote monitoring, follow up, consultation, empowerment and educational services as well as home visiting Disruption of NCDs services in PHC during the COVID-19 pandemic was observed in different countries, which highlights the urgency of attention of researchers and policy-makers to development of appropriate and adaptive policies to improve PHC service coverage and its quality during the pandemics.

Policy and practices in primary care that supported the provision and receipt of care for older persons during the COVID-19 pandemic: a qualitative case study in three Canadian provinces

BACKGROUND

The effects of the COVID-19 pandemic on older adults were felt throughout the health care system, from intensive care units through to long-term care homes. Although much attention has been paid to hospitals and long-term care homes throughout the pandemic, less attention has been paid to the impact on primary care clinics, which had to rapidly change their approach to deliver timely and effective care to older adult patients. This study examines how primary care clinics, in three Canadian provinces, cared for their older adult patients during the pandemic, while also navigating the rapidly changing health policy landscape.

METHODS

A qualitative case study approach was used to gather information from nine primary care clinics, across three Canadian provinces. Interviews were conducted with primary care providers (n = 17) and older adult patients (n = 47) from October 2020 to September 2021. Analyses of the interviews were completed in the language of data collection (English or French), and then summarized in English using a coding framework. All responses that related to COVID-19 policies at any level were also examined.

RESULTS

Two main themes emerged from the data: (1) navigating the noise: understanding and responding to public health orders and policies affecting health and health care, and (2) receiving and delivering care to older persons during the pandemic: policy-driven challenges & responses. Providers discussed their experiences wading through the health policy directives, while trying to provide good quality care. Older adults found the public health information overwhelming, but appreciated the approaches adapted by primary care clinics to continue providing care, even if it looked different.

CONCLUSIONS

COVID-19 policy and guideline complexities obliged primary care providers to take an important role in understanding, implementing and adapting to them, and in explaining them, especially to older adults and their care partners.

Emergency department utilization and hospital admissions for ambulatory care sensitive conditions among people seeking a primary care provider during the COVID-19 pandemic

BACKGROUND

Primary care attachment improves health care access and health outcomes, but many Canadians are unattached, seeking a provider via provincial wait-lists. This Nova Scotia-wide cohort study compares emergency department utilization and hospital admission associated with insufficient primary care management among patients on and off a provincial primary care wait-list, before and during the first waves of the COVID-19 pandemic.

METHODS

We linked wait-list and Nova Scotian administrative health data to describe people on and off wait-list, by quarter, between Jan. 1, 2017, and Dec. 24, 2020. We quantified emergency department utilization and ambulatory care sensitive condition (ACSC) hospital admission rates by wait-list status from physician claims and hospital admission data. We compared relative differences during the COVID-19 first and second waves with the previous year.

RESULTS

During the study period, 100 867 people in Nova Scotia (10.1% of the provincial population) were on the wait-list. Those on the wait-list had higher emergency department utilization and ACSC hospital admission. Emergency department utilization was higher overall for individuals aged 65 years and older, and females; lowest during the first 2 COVID-19 waves; and differed more by wait-list status for those younger than 65 years. Emergency department contacts and ACSC hospital admissions decreased during the COVID-19 pandemic relative to the previous year, and for emergency department utilization, this difference was more pronounced for those on the wait-list.

INTERPRETATION

People in Nova Scotia seeking primary care attachment via the provincial wait-list use hospital-based services more frequently than those not on the wait-list. Although both groups have had lower utilization during COVID-19, existing challenges to primary care access for those actively seeking a provider were further exacerbated during the initial waves of the pandemic. The degree to which forgone services produces downstream health burden remains in question.

Building implementable packages for universal health coverage

Since no country or health system can provide every possible health service to everyone who might benefit, the prioritisation of a defined subset of services for universal availability is intrinsic to universal health coverage (UHC). Creating a package of priority services for UHC, however, does not in itself benefit a population-packages have impact only through implementation. There are inherent tensions between the way services are formulated to facilitate criteria-driven prioritisation and the formulations that facilitate implementation, and service delivery considerations are rarely well incorporated into package development. Countries face substantial challenges bridging from a list of services in a package to the elements needed to get services to people. The failure to incorporate delivery considerations already at the prioritisation and design stage can result in packages that undermine the goals that countries have for service delivery. Based on a range of country experiences, we discuss specific choices about package structure and content and summarise some ideas on how to build more implementable packages of services for UHC, arguing that well-designed packages can support countries to bridge effectively from intent to implementation.

Hypertension care during the COVID-19 pandemic in an integrated health care system

Retention in hypertension care, medication adherence, and blood pressure (BP) may have been affected by the COVID-19 pandemic. In a retrospective cohort study of 64 766 individuals with treated hypertension from an integrated health care system, we compared hypertension care during the year pre-COVID-19 (March 2019-February 2020) and the first year of COVID-19 (March 2020-February 2021). Retention in hypertension care was defined as receiving clinical BP measurements during COVID-19. Medication adherence was measured using prescription refills. Clinical care was assessed by in-person and virtual visits and changes in systolic and diastolic BP. The cohort had a mean age of 67.8 (12.2) years, 51.2% were women, and 73.5% were White. In 60 757 individuals with BP measurements pre-COVID-19, 16618 (27.4%) had no BP measurements during COVID-19. Medication adherence declined from 86.0% to 80.8% (p < .001). In-person primary care visits decreased from 2.7 (2.7) to 1.4 (1.9) per year, while virtual contacts increased from 9.5 (12.2) to 11.2 (14.2) per year (both p < .001). Among individuals with BP measurements, mean (SD) systolic BP was 126.5 mm Hg (11.8) pre-COVID-19 and 127.3 mm Hg (12.6) during COVID-19 (p = .14). Mean diastolic BP was 73.5 mm Hg (8.5) pre-COVID-19 and 73.5 mm Hg (8.7) during COVID-19 (p = .77). Even in this integrated health care system, many individuals did not receive clinical BP monitoring during COVID-19. Most individuals who remained in care maintained pre-COVID BP. Targeted outreach may be necessary to restore care continuity and hypertension control at the population level.

A comparison of family physician and dermatologist topical corticosteroid prescriptions: A population-based cross-sectional study

BACKGROUND

Topical corticosteroids (TCS) are commonly prescribed to treat inflammatory skin diseases, and appropriate prescription is necessary for treatment success.

OBJECTIVE

To quantify differences between TCS prescribed by dermatologists at consultation and family physicians for patients treated for any skin condition.

METHODS

Using administrative health data in Ontario, we included all Ontario Drug Benefit recipients who filled at least one TCS prescription from a dermatologist at consultation and a family physician in the year prior between January 2014 and December 2019. We estimated mean differences and 95% confidence intervals in amount (in grams) and potency between the index dermatologist prescription and the highest and most recent family physician prescription amounts and potencies in the preceding year using linear mixed-effect models.

RESULTS

A total of 69,335 persons were included. The mean dermatologist amount was 34% larger than the highest amount and 54% larger than the most recent amount prescribed by family physicians. There were small but statistically significant differences in potency using established 7-category and 4-category potency classification systems.

CONCLUSIONS

Compared to family physicians, dermatologists prescribed substantially larger amounts and similarly potent TCS at consultation. Further research is needed to determine the effect of these differences on clinical outcomes.

The Impact of the COVID-19 Pandemic on the Registration and Care Provision of Mental Health Problems in General Practice: Registry-Based Study

BACKGROUND

The impact of the COVID-19 pandemic on mental health in general practice remains uncertain. Several studies showed an increase in terms of mental health problems during the pandemic. In Belgium, especially during the first waves of the pandemic, access to general practice was limited. Specifically, it is unclear how this impacted not only the registration of mental health problems itself but also the care for patients with an existing mental health problem.

OBJECTIVE

This study aimed to know the impact of the COVID-19 pandemic on (1) the incidence of newly registered mental health problems and (2) the provision of care for patients with mental health problems in general practice, both using a pre-COVID-19 baseline.

METHODS

The prepandemic volume of provided care (care provision) for patients with mental health problems was compared to that from 2020-2021 by using INTEGO, a Belgian general practice morbidity registry. Care provision was defined as the total number of new registrations in a patient's electronic medical record. Regression models evaluated the association of demographic factors and care provision in patients with mental health problems, both before and during the pandemic.

RESULTS

During the COVID-19 pandemic as compared to before the COVID-19 pandemic, the incidence of registered mental health problems showed a fluctuating course, with a sharp drop in registrations during the first wave. Registrations for depression and anxiety increased, whereas the incidence of registered eating disorders, substance abuse, and personality problems decreased. During the 5 COVID-19 waves, the overall incidence of registered mental health problems dropped during the wave and rose again when measures were relaxed. A relative rise of 8.7% and 40% in volume of provided care, specifically for patients with mental health problems, was seen during the first and second years of the COVID-19 pandemic, respectively. Care provision for patients with mental health problems was higher in older patients, male patients, patients living in center cities (centrumsteden), patients with lower socioeconomic status (SES), native Belgian patients, and patients with acute rather than chronic mental health problems. Compared to prepandemic care provision, a reduction of 10% was observed in people with a low SES.

CONCLUSIONS

This study showed (1) a relative overall increase in the registrations of mental health problems in general practice and (2) an increase in care provision for patients with mental health problems in the first 2 years of the COVID-19 pandemic. Low SES remained a determining factor for more care provision, but care provision dropped significantly in people with mental health problems with a low SES. Our findings suggest that the pandemic in Belgium was also largely a "syndemic," affecting different layers of the population disproportionately.

Family physicians' responses to personal protective equipment shortages in four regions in Canada: a qualitative study

BACKGROUND

Despite well-documented increased demands and shortages of personal protective equipment (PPE) during previous disease outbreaks, health systems in Canada were poorly prepared to meet the need for PPE during the COVID-19 pandemic. In the primary care sector, PPE shortages impacted the delivery of health services and contributed to increased workload, fear, and anxiety among primary care providers. This study examines family physicians' (FPs) response to PPE shortages during the first year of the COVID-19 pandemic to inform future pandemic planning.

METHODS

As part of a multiple case study, we conducted semi-structured qualitative interviews with FPs across four regions in Canada. During the interviews, FPs were asked to describe the pandemic-related roles they performed over different stages of the pandemic, facilitators and barriers they experienced in performing these roles, and potential roles they could have filled. Interviews were transcribed and a thematic analysis approach was employed to identify recurring themes. For the current study, we examined themes related to PPE.

RESULTS

A total of 68 FPs were interviewed across the four regions. Four overarching themes were identified: 1) factors associated with good PPE access, 2) managing PPE shortages, 3) impact of PPE shortages on practice and providers, and 4) symbolism of PPE in primary care. There was a wide discrepancy in access to PPE both within and across regions, and integration with hospital or regional health authorities often resulted in better access than community-based practices. When PPE was limited, FPs described rationing and reusing these resources in an effort to conserve, which often resulted in anxiety and personal safety concerns. Many FPs expressed that PPE shortages had come to symbolize neglect and a lack of concern for the primary care sector in the pandemic response.

CONCLUSIONS

During the COVID-19 pandemic response, hospital-centric plans and a lack of prioritization for primary care led to shortages of PPE for family physicians. This study highlights the need to consider primary care in PPE conservation and allocation strategies and to examine the influence of the underlying organization of primary care on PPE distribution during the pandemic.

Examining the immediate and ongoing impact of the COVID-19 pandemic on population-based estimates of dementia: a population-based time series analysis in Ontario, Canada

OBJECTIVES

Population-based chronic disease surveillance systems were likely disrupted by the COVID-19 pandemic. The objective of this study was to examine the immediate and ongoing impact of the COVID-19 pandemic on the claims-based incidence of dementia.

METHODS

We conducted a population-based time series analysis from January 2015 to December 2021 in Ontario, Canada. We calculated the monthly claims-based incidence of dementia using a validated case ascertainment algorithm drawing from routinely collected health administrative data. We used autoregressive linear models to compare the claims-based incidence of dementia during the COVID-19 period (2020-2021) to the expected incidence had the pandemic not occurred, controlling for seasonality and secular trends. We examined incidence by source of ascertainment and across strata of sex, age, community size and number of health conditions.

RESULTS

The monthly claims-based incidence of dementia dropped from a 2019 average of 11.9 per 10 000 to 8.5 per 10 000 in April 2020 (32.6% lower than expected). The incidence returned to expected levels by late 2020. Across the COVID-19 period there were a cumulative 2990 (95% CI 2109 to 3704) fewer cases of dementia observed than expected, equivalent to 1.05 months of new cases. Despite the overall recovery, ascertainment rates continued to be lower than expected among individuals aged 65-74 years and in large urban areas. Ascertainment rates were higher than expected in hospital and among individuals with 11 or more health conditions.

CONCLUSIONS

The claims-based incidence of dementia recovered to expected levels by late 2020, suggesting minimal long-term changes to population-based dementia surveillance. Continued monitoring of claims-based incidence is necessary to determine whether the lower than expected incidence among individuals aged 65-74 and in large urban areas, and higher than expected incidence among individuals with 11 or more health conditions, is transitory.

Crisis management: the perspectives of physicians working in family physician teams in Lithuania

AIM

To assess the opinions of physicians working in family physician teams regarding COVID-19 (threat perception, overall work satisfaction, patient satisfaction with services provided, patient access to services, and the need for new tools for service provision).

METHODS

An anonymous survey of physicians (N = 191) working in family physician teams. Questionnaires were distributed among family physicians with the permission of the managers of their institutions and were collected by the lead researcher within 1-8 weeks. The quantitative study was conducted from 21 June 2021 to 17 September 2021. In total, 398 questionnaires were distributed, yielding a response rate of 48%, or 9% of the total population. Thirty-nine primary health care institutions (PHCIs) were randomly selected for the study: 11 public and 28 private.

FINDINGS

Older respondents and those with more years of work experience strongly agreed that the COVID-19 pandemic threatened their lives and safety, as well as that of their colleagues. Work satisfaction decreased during the pandemic among older respondents, those with more years of work experience, and those who had been employed at their current institution for longer. Respondents with more work experience believed that patient satisfaction with the services provided by their family medical institution decreased. Older respondents with more work experience asserted that patient access to services decreased during the pandemic. Physicians working further away from urban centers indicated a greater need for new tools in the effort to provide consultations compared to city-based physicians.

CONCLUSIONS

The current health care crisis prompted by the COVID-19 pandemic is defined by the perception of threats to life and safety among physicians, an overall drop in their work satisfaction, decreased patient satisfaction with services provided, reduced patient access to services, and a greater need for new tools for providing consultations.

Patient visits and prescriptions for attention-deficit/hyperactivity disorder from 2017-2021: Impacts of COVID-19 pandemic in primary care

OBJECTIVE

To determine whether more patients presented with Attention-deficit/hyperactivity disorder (ADHD)-related visits and/or sought care from family physicians more frequently during the COVID-19 pandemic.

METHODS

Electronic medical records from the University of Toronto Practice-Based Research Network were used to characterize changes in family physician visits and prescriptions for ADHD medications. Annual patient prevalence and visit rates pre-pandemic (2017-2019) were used to calculate the expected rates in 2020 and 2021. The expected and observed rates were compared to identify any pandemic-related changes.

RESULTS

The number of patients presenting for ADHD-related visits during the pandemic was consistent with pre-pandemic trends. However, observed ADHD-related visits in 2021 were 1.32 times higher than expected (95% CI: 1.05-1.75), suggesting that patients visited family physicians more frequently than before the pandemic.

CONCLUSION

Demand for primary care services related to ADHD has continued to increase during the pandemic, with increased health service use among those accessing care.

Characterizing the use of virtual care in primary care settings during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

In March 2020, Canada implemented restrictions to curb viral transmission of COVID-19, which resulted in abrupt disruptions to conventional (in-person) clinical care. To retain continuity of care the delivery of primary care services shifted to virtual care. This study examined the nature of virtual visits, characterizing the use and users of virtual care in primary care settings from March 14/20 to June 30/20 of the COVID-19 pandemic.  METHODS: Retrospective cohort study of primary care providers in Manitoba, Canada that participate in the Manitoba Primary Care Research Network (MaPCReN) and offered ≥ 1 virtual care visit between 03/14/20 and 06/30/20 representing 142,616 patients. Tariff codes from billing records determined the visit type (clinic visit, virtual care). Between 03/14/20, and 06/30/20, we assessed each visit for a follow-up visit between the same patient and provider for the same diagnosis code. Patient (sex, age, comorbidities, visit frequency, prescriptions) and provider (sex, age, clinic location, provider type, remuneration, country of graduation, return visit rate) characteristics describe the study population by visit type. Generalized estimating equation models describe factors associated with virtual care.  RESULTS: There were 146,372 visits provided by 154 primary care providers between 03/14/20 and 06/30/20, of which 33.6% were virtual care. Female patients (OR 1.16, CI 1.09-1.22), patients with ≥ 3 comorbidities (OR 1.71, CI 1.44-2.02), and patients with ≥ 10 prescriptions (OR 2.71, 2.2-1.53) had higher odds of receiving at least one virtual care visit compared to male patients, patients with no comorbidities and patients with no prescriptions. There was no significant difference between the number of follow-up visits that were provided as a clinic visit compared to a virtual care visit (8.7% vs. 5.8%) (p = 0.6496).

CONCLUSION

Early in the pandemic restrictions, approximately one-third of visits were virtual. Virtual care was utilized by patients with more comorbidities and prescriptions, suggesting that patients with chronic disease requiring ongoing care utilized virtual care. Virtual care as a primary care visit type continues to evolve. Ongoing provision of virtual care can enhance quality, patient-centered care moving forward.

Prevalence of Depression and Related Factors among Patients with Chronic Disease during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

The management of chronic diseases in the midst of the COVID-19 pandemic is especially challenging, and reducing potential psychological harm is essential. This review aims to determine the prevalence of depression during the COVID-19 pandemic in patients with chronic disease, and to characterize the impacts of related factors. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The meta-analysis was performed using StatsDirect software. The review identified 33 articles with a total of 50,905 patients with chronic diseases. Four meta-analyses were performed to estimate the prevalence of depression. In diabetic patients, the prevalence ranged from 17% (95% CI = 7-31) (PHQ-9) to 33% (95% CI = 16-51) (PHQ-8); in obese patients, the prevalence was 48% (95% CI = 26-71); and in hypertensive patients, the prevalence was 18% (95% CI = 13-24). The factors significantly associated with depression were female sex, being single, deterioration in the clinical parameters of diabetes, a decrease in self-care behavior, reduced physical activity and sleep time and fear of contagion. The COVID-19 pandemic has significantly increased levels of depression among persons with chronic disease. Pandemics and other emergency events have a major impact on mental health, so early psychological interventions and health management policies are needed to reinforce chronic patients' physical and mental health.

Disruptions in Primary Care among People with Schizophrenia in Ontario, Canada, During the COVID-19 Pandemic

OBJECTIVE

To investigate how primary care access, intensity and quality of care changed among patients living with schizophrenia before and after the onset of the COVID-19 pandemic in Ontario, Canada.

METHODS

This cohort study was performed using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN), a network of > 500 family physicians in Ontario, Canada. Data were collected during primary care visits from 2643 patients living with schizophrenia. Rates of primary care health service use (in-person and virtual visits with family physicians) and key preventive health indices indicated in antipsychotic monitoring (blood pressure readings, hemoglobin A1c, cholesterol and complete blood cell count [CBC] tests) were measured and compared in the 12 months before and after onset of the COVID-19 pandemic.

RESULTS

Access to in-person care dropped with the onset of the COVID-19 pandemic. During the first year of the pandemic only 39.5% of patients with schizophrenia had at least one in-person visit compared to 81.0% the year prior. There was a corresponding increase in virtual visits such that 78.0% of patients had a primary care appointment virtually during the pandemic period. Patients prescribed injectable antipsychotics were more likely to continue having more frequent in-person appointments during the pandemic than patients prescribed only oral or no antipsychotic medications. The proportion of patients who did not have recommended tests increased from 41.0% to 72.4% for blood pressure readings, from 48.9% to 60.2% for hemoglobin A1c, from 57.0% to 67.8% for LDL cholesterol and 45.0% to 56.0% for CBC tests during the pandemic.

CONCLUSIONS

There were substantial decreases in preventive care after the onset of the pandemic, although primary care access was largely maintained through virtual care. Addressing these deficiencies will be essential to promoting health equity and reducing the risk of poor health outcomes.

The long-term impact of the COVID-19 pandemic on primary and specialized care provision and disease recognition in Germany

Background

The COVID-19 pandemic and the imposed lockdowns severely affected routine care in general and specialized physician practices.

Objective

To describe the long-term impact of the COVID-19 pandemic on the physician services provision and disease recognition in German physician practices and perceived causes for the observed changes.

Design

Observational study based on medical record data and survey data of general practitioners and specialists' practices.

Participants

996 general practitioners (GPs) and 798 specialist practices, who documented 6.1 million treatment cases for medical record data analyses and 645 physicians for survey data analyses.

Main measures

Within the medical record data, consultations, specialist referrals, hospital admissions, and documented diagnoses were extracted for the pandemic (March 2020-September 2021) and compared to corresponding pre-pandemic months in 2019. The additional online survey was used to assess changes in practice management during the COVID-19 pandemic and physicians' perceived main causes of affected primary and specialized care provision.

Main results

Hospital admissions (GPs: -22% vs. specialists: -16%), specialist referrals (-6 vs. -3%) and recognized diseases (-9 vs. -8%) significantly decreased over the pandemic. GPs consultations initially decreased (2020: -7%) but compensated at the end of 2021 (+3%), while specialists' consultation did not (-2%). Physicians saw changes in patient behavior, like appointment cancellation, as the main cause of the decrease. Contrary to this, they also mentioned substantial modifications of practice management, like reduced (nursing) home visits (41%) and opening hours (40%), suspended checkups (43%), and delayed consultations for high-risk patients (71%).

Conclusion

The pandemic left its mark on primary and specialized healthcare provision and its utilization. Both patient behavior and organizational changes in practice management may have caused decreased and non-compensation of services. Evaluating the long-term effect on patient outcomes and identifying potential improvements are vital to better prepare for future pandemic waves.

An analysis of the causes of exhaustion among physicians working in family physician teams during the COVID-19 pandemic in Lithuania

Background

The COVID-19 pandemic had a severe impact on public life around the world, influencing medicine and health, the economy, employment, science, and education. Health care specialists are key workers who faced extreme challenges posed by the pandemic, including threats to their own lives due to the rapid spread of the virus, a huge increase in workload, and professional burnout syndrome. Analysis of the factors that physicians found most exhausting during the pandemic could lay the groundwork for the effective management of future crises.

Objective

To identify the factors that physicians working in family physician (family and internal medicine) teams found most exhausting during the COVID-19 pandemic in Lithuania and assess their causes.

Methods

An anonymous survey of physicians (n = 191) working in family physician teams was carried out from 21 June 2021 to 17 September 2021. Physicians signed an informed consent form prior to completion of the questionnaire. Mixed data analysis was performed, consisting of statistical analysis using the SPSS 27 software and a qualitative causal analysis.

Results

During the pandemic, physicians were most exhausted by: chaotic vaccination priorities (44.5%); unsatisfied patients (52.4%); constantly changing legislation (71.7%); the large workload (75.9%); and the malfunctioning of online systems (81.2%).

Conclusions

Physicians in family physician teams indicated the following aspects that require improvement: service provision; effective work organization for physicians; and the satisfaction of patients with decisions made during the pandemic.

Investigating the leading reasons for primary health care encounters and its implications for health care in Trinidad and Tobago. A systematic review

This systematic review aims at offering a comparative analysis of the leading reasons for encounters (RFEs) of patients presenting to primary care facilities. A systemic search was carried out using MEDLINE/PUBMED, CINAHL, Google Scholar, LILACS, and PROQUEST to identify the studies relevant to RFEs in primary health care in June 2020. Fifteen studies met the eligibility criteria which included originality, published between 2015 and 2020, listed two to five RFEs at a primary health care facility, and included patients with acute and/or chronic conditions. The mean total RFEs recorded were 6753.07 (Standard deviation = 17446.38, 95% Confidence Interval 6,753.0667 ± 8,829.088 [± 130.74%]). The most common RFE chapters recorded were Respiratory and Digestive chapters. The patients recorded fever as the most frequently reported RFE while cough was ranked as most common. The physicians reported hypertension as the most frequently reported and most common RFE. The most frequently physician and patient reported RFEs to the primary health care are hypertension and fever. Respiratory and Digestive were the most frequently reported chapters. The findings are useful for the proper implementation of services, facilities, and equipment utilized in Trinidad and Tobago primary health care.

Underuse of primary healthcare in France during the COVID-19 epidemic in 2020 according to individual characteristics: a national observational study

Background

The organization of healthcare systems changed significantly during the COVID-19 pandemic. The impact on the use of primary care during various key periods in 2020 has been little studied.

Methods

Using individual data from the national health database, we compared the numbers of people with at least one consultation, deaths, the total number of consultations for the population of mainland France (64.3 million) and the mean number of consultations per person (differentiating between teleconsultations and consultations in person) between 2019 and 2020. We performed analyses by week, by lockdown period (March 17 to May 10, and October 30 to December 14 [less strict]), and for the entire year. Analyses were stratified for age, sex, deprivation index, epidemic level, and disease.

Results

During the first lockdown, 26% of the population consulted a general practitioner (GP) at least once (-34% relative to 2019), 7.4% consulted a nurse (-28%), 1.6% a physiotherapist (-80%), and 5% a dentist (-95%). For specialists, consultations were down 82% for ophthalmologists and 37% for psychiatrists. The deficit was smaller for specialties making significant use of teleconsultations. During the second lockdown, the number of consultations was close to that in 2019, except for GPs (-7%), pediatricians (-8%), and nurses (+ 39%). Nurses had already seen a smaller increase in weekly consultations during the summer, following their authorization to perform COVID-19 screening tests. The decrease in the annual number of consultations was largest for dentists (-17%), physiotherapists (-14%), and many specialists (approximately 10%). The mean number of consultations per person was slightly lower for the various specialties, particularly for nurses (15.1 vs. 18.6). The decrease in the number of consultations was largest for children and adolescents (GPs: -10%, dentists: -13%). A smaller decrease was observed for patients with chronic diseases and with increasing age. There were 9% excess deaths, mostly in individuals over 60 years of age.

Conclusions

There was a marked decrease in primary care consultations in France, especially during the first lockdown, despite strong teleconsultation activity, with differences according to age and healthcare profession. The impact of this decrease in care on morbidity and mortality merits further investigation.

Changes in the quality of cancer care as assessed through performance indicators during the first wave of the COVID-19 pandemic in 2020: a scoping review

BACKGROUND

Cancer comprises a high burden on health systems. Performance indicators monitoring cancer outcomes are routinely used in OECD countries. However, the development of process and cancer-pathway based information is essential to guide health care delivery, allowing for better monitoring of changes in the quality of care provided. Assessing the changes in the quality of cancer care during the COVID-19 pandemic requires a structured approach considering the high volume of publications. This study aims to summarize performance indicators used in the literature to evaluate the impact of the COVID-19 pandemic on cancer care (January-June 2020) in OECD countries and to assess changes in the quality of care as reported via selected indicators.

METHODS

Search conducted in MEDLINE and Embase databases. Performance indicators and their trends were collated according to the cancer care pathway.

RESULTS

This study included 135 articles, from which 1013 indicators were retrieved. Indicators assessing the diagnostic process showed a decreasing trend: from 33 indicators reporting on screening, 30 (91%) signalled a decrease during the pandemic (n = 30 indicators, 91%). A reduction was also observed in the number of diagnostic procedures (n = 64, 58%) and diagnoses (n = 130, 89%). The proportion of diagnoses in the emergency setting and waiting times showed increasing trends (n = 8, 89% and n = 14, 56%, respectively). A decreasing trend in the proportion of earliest stage cancers was reported by 63% of indicators (n = 9), and 70% (n = 43) of indicators showed an increasing trend in the proportion of advanced-stage cancers. Indicators reflecting the treatment process signalled a reduction in the number of procedures: 79%(n = 82) of indicators concerning surgeries, 72%(n = 41) of indicators assessing radiotherapy, and 93%(n = 40) of indicators related to systemic therapies. Modifications in cancer treatment were frequently reported: 64%(n = 195) of indicators revealed changes in treatment.

CONCLUSIONS

This study provides a summary of performance indicators used in the literature to assess the cancer care pathway from January 2020 to June 2020 in OECD countries, and the changes in the quality of care signalled by these indicators. The trends reported inform on potential bottlenecks of the cancer care pathway. Monitoring this information closely could contribute to identifying moments for intervention during crises.

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.

Changes in primary care visits arising from the COVID-19 pandemic: an international comparative study by the International Consortium of Primary Care Big Data Researchers (INTRePID)

INTRODUCTION

Through the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID), we compared the pandemic impact on the volume of primary care visits and uptake of virtual care in Australia, Canada, China, Norway, Singapore, South Korea, Sweden, the UK and the USA.

METHODS

Visit definitions were agreed on centrally, implemented locally across the various settings in INTRePID countries, and weekly visit counts were shared centrally for analysis. We evaluated the weekly rate of primary care physician visits during 2019 and 2020. Rate ratios (RRs) of total weekly visit volume and the proportion of weekly visits that were virtual in the pandemic period in 2020 compared with the same prepandemic period in 2019 were calculated.

RESULTS

In 2019 and 2020, there were 80 889 386 primary care physician visits across INTRePID. During the pandemic, average weekly visit volume dropped in China, Singapore, South Korea, and the USA but was stable overall in Australia (RR 0.98 (95% CI 0.92 to 1.05, p=0.59)), Canada (RR 0.96 (95% CI 0.89 to 1.03, p=0.24)), Norway (RR 1.01 (95% CI 0.88 to 1.17, p=0.85)), Sweden (RR 0.91 (95% CI 0.79 to 1.06, p=0.22)) and the UK (RR 0.86 (95% CI 0.72 to 1.03, p=0.11)). In countries that had negligible virtual care prepandemic, the proportion of visits that were virtual were highest in Canada (77.0%) and Australia (41.8%). In Norway (RR 8.23 (95% CI 5.30 to 12.78, p<0.001), the UK (RR 2.36 (95% CI 2.24 to 2.50, p<0.001)) and Sweden (RR 1.33 (95% CI 1.17 to 1.50, p<0.001)) where virtual visits existed prepandemic, it increased significantly during the pandemic.

CONCLUSIONS

The drop in primary care in-person visits during the pandemic was a global phenomenon across INTRePID countries. In several countries, primary care shifted to virtual visits mitigating the drop in in-person visits.

Virtual care use during the COVID-19 pandemic and its impact on healthcare utilization in patients with chronic disease: A population-based repeated cross-sectional study

Purpose

It is currently unclear how the shift towards virtual care during the 2019 novel coronavirus (COVID-19) pandemic may have impacted chronic disease management at a population level. The goals of our study were to provide a description of the levels of use of virtual care services relative to in-person care in patients with chronic disease across Ontario, Canada and to describe levels of healthcare utilization in low versus high virtual care users.

Methods

We used linked health administrative data to conduct a population-based, repeated cross-sectional study of all ambulatory patient visits in Ontario, Canada (January 1, 2018 to January 16, 2021). Further stratifications were also completed to examine patients with COPD, heart failure, asthma, hypertension, diabetes, mental illness, and angina. Patients were classified as low (max 1 virtual care visit) vs. high virtual care users. A time-series analysis was done using interventional autoregressive integrated moving average (ARIMA) modelling on weekly hospitalizations, outpatient visits, and diagnostic tests.

Results

The use of virtual care increased across all chronic disease patient populations. Virtual care constituted at least half of the total care in all conditions. Both low and high virtual care user groups experienced a statistically significant reduction in hospitalizations and laboratory testing at the start of the pandemic. Hospitalization volumes increased again only among the high users, while testing increased in both groups. Outpatient visits among high users remained unaffected by the pandemic but dropped in low users.

Conclusion

The decrease of in-person care during the pandemic was accompanied by an increase in virtual care, which ultimately allowed patients with chronic disease to return to the same visit rate as they had before the onset of the pandemic. Virtual care was adopted across various chronic conditions, but the relative adoption of virtual care varied by condition with highest rates seen in mental health.

Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives

This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population.

Methods

For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017–2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017–2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists.

Results

In 2020, IRR significantly decreased for initiations of antihypertensives (−11.1%[CI95%, −11.4%;−10.8%]), lipid-lowering drugs (−5.2%[CI95%, −5.5%;−4.8%]), oral anticoagulants in atrial fibrillation (−8.6%[CI95%, −9.1%;−8.0%]), and smoking cessation medications (−50.9%[CI95%, −51.1%;−50.7%]) compared to 2017–2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017–2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women.

Conclusion

The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

Effects of COVID-19 pandemic on anxiety and depression in primary care: A retrospective cohort study

BACKGROUND

Population-based surveys indicate that many people experienced increased psychological distress during the COVID-19 pandemic. We aimed to determine if there was a corresponding increase in patients receiving services for anxiety and depression from their family physicians.

METHODS

Electronic medical records from the University of Toronto Practice Based-Research Network (UTOPIAN; N = 322,920 patients) were used to calculate incidence rates for anxiety/depression related visits and antidepressant prescriptions before the COVID-19 pandemic (January 2018-February 2020) and during the COVID-19 pandemic (March-December 2020). Data from the pre-pandemic period were used to predict expected rates during the pandemic period which was compared to the observed rate.

RESULTS

The number of patients presenting with anxiety/depression symptoms in primary care varied across age groups, sex, and time since pandemic onset. Among the youngest patients (ages 10-18 years), there were fewer patients than pre-pandemic visiting for new episodes of anxiety/depression and being prescribed antidepressants in April 2020, but by the end of 2020 this trend had reversed such that incidence rates for anxiety/depression related visits were higher than pre-pandemic levels. Among older adults, incidence rates of anxiety/depression related visits increased in April 2020 with the onset of the pandemic, and remained higher than expected throughout 2020.

LIMITATIONS

A convenience sample of 362 family physicians in Ontario was used.

CONCLUSION

Demand for mental health services from family physicians varied by patient age and sex and changed with the onset of the COVID-19 pandemic. By the end of 2020, more patients were seeking treatment for anxiety/depression related concerns.

Changes in inpatient admissions before and during COVID-19 outbreak in a large tertiary hospital in Shanghai

Background

The coronavirus disease 2019 (COVID-19) outbreak caused a significant strain on healthcare resources and utilization worldwide. However, the impact of COVID-19 outbreak on patient hospitalization was barely known. This study aimed to determine the impact of the outbreak on the pattern of inpatient hospital admissions to help allocate health care resources during a pandemic.

Methods

This retrospective study included patients who were hospitalized in a tertiary teaching hospital in Shanghai between 1 January and 30 April across the years 2017 to 2020. The number of hospitalizations during the study period from 2017 to 2020 were 30,605, 31,464, 32,812 and 24,163, respectively. Changes in patient volumes and the frequency of the International Classification of Diseases and Related Health Problem Tenth Edition (ICD-10) codes before and after the onset of the COVID-19 outbreak were analyzed and presented as absolute and relative differences with 95% confidence intervals between periods of different years.

Results

Overall inpatient hospital admissions decreased by 26.35% between January and April 2020, compared to the same period in 2019. The average age of patients in 2020 was higher compared to those from 2017 to 2019. Conversely, the proportions of self-paying patients and non-local patients were significantly lower between January and April 2020 compared to the same period in the previous three years. The top five ICD-10 codes remained common before and during the pandemic. Admissions associated with antineoplastic radiation therapy, chemotherapy, and immunotherapy increased in frequency and proportion by 2020 (difference, 5.6%, 95% CI: 4.4% to 6.8%), and increased proportions were observed for liver and intrahepatic bile duct malignancies (2.18%, 95% CI: 1.15% to 3.21%), cerebral infarction (2.27%, 95% CI: 0.54% to 4.00%), and chronic kidney disease (3.56%, 95% CI: 1.79% to 5.33%).

Conclusions

There was a significant reduction in the number of inpatients and a marked change in admission diagnoses during the COVID-19 outbreak. Our findings are useful for making informed decisions on hospital management and reallocation of available health care resources during a pandemic.

Impact of the COVID-19 pandemic on routine immunization coverage in children under 2 years old in Ontario, Canada: A retrospective cohort study

BACKGROUND

The COVID-19 pandemic has caused a disruption in childhood immunization coverage around the world. This study aimed to determine the change in immunization coverage for children under 2 years old in Ontario, Canada, comparing time periods pre-pandemic to during the first year of the pandemic.

METHODS

Observational retrospective open cohort study, using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN) database, from January 2019 to December 2020. Children under 2 years old who had at least 2 visits recorded in UTOPIAN were included. We measured up-to-date (UTD) immunization coverage rates, overall and by type of vaccine (DTaP-IPV-Hib, PCV13, Rota, Men-C-C, MMR, Var), and on-time immunization coverage rates by age milestone (2, 4, 6, 12, 15, 18 months). We compared average coverage rates over 3 periods of time: January 2019-March 2020 (T1); March-July 2020 (T2); and August-December 2020 (T3).

RESULTS

12,313 children were included. Overall UTD coverage for all children was 71.0% in T1, dropped by 5.7% (95% CI: -6.2, -5.1) in T2, slightly increased in T3 but remained lower than in T1. MMR vaccine UTD coverage slightly decreased in T2 and T3 by approximately 2%. The largest decreases were seen at ages 15-month and 18-month old, with drops in on-time coverage of 14.7% (95% CI: -18.7, -10.6) and 16.4% (95% CI: -20.0, -12.8) respectively during T2. When stratified by sociodemographic characteristics, no specific subgroup of children was found to have been differentially impacted by the pandemic.

CONCLUSION

Childhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic and only partially recovered during the rest of 2020. Public health and educational interventions for providers and parents are needed to ensure adequate catch-up of delayed/missed immunizations to prevent potential outbreaks of vaccine-preventable diseases.

Herpes Zoster Ophthalmicus: A Devastating Disease Coming Back with Vengeance or Finding Its Nemesis?

Herpes zoster ophthalmicus is a frequent, painful, and debilitating condition caused by the reactivation of the varicella-zoster virus alongside the ophthalmic branch of the trigeminal nerve. Twenty-five percent of adults will develop the disease during their lifetime with the risk increasing to one in two over the age of 50. Herpes zoster ophthalmicus presents with a plethora of ocular manifestations ranging from the characteristic rash in the distribution of the ophthalmic branch of the fifth cranial nerve to more severe keratouveitis, disciform keratitis, and even retinal necrosis. Up to 20% of affected patients develop post-herpetic neuralgia which can persist for years after the acute episode, resulting in potentially devastating consequences for the patient's social, financial, and professional circumstances, as well as their quality of life and daily activities. Shingles prevention studies indicated that the herpes zoster vaccine markedly reduces the burden of the disease, as well as the incidence of both infection and post-herpetic neuralgia. Here we review the vaccinations available for herpes zoster, the reasons behind their limited adoption so far, as well as the future perspectives and challenges associated with this debilitating disease in the era of herpes zoster vaccination and coronavirus disease pandemic.