Improving Data Surveillance Resilience Beyond COVID-19: Experiences of Primary heAlth Care quAlity Cohort In ChinA (ACACIA) Using Unannounced Standardized Patients

Quality of asynchronous webchats vs in-person consultations for postpartum depression in China: a cross-sectional, mixed methods study using standardized patients

Background

Prompt professional care for postpartum depression (PPD) is difficult to obtain in China. Though online consultations improve accessibility and reduce stigma, the quality of services compared to in-person consultations is unclear.

Methods

Five trained, undisclosed "standardized patients" (SPs) made "asynchronous webchats" visits and in-person visits with psychiatrists. Visits were made to 85 psychiatrists who were based in 69 hospitals in ten provincial capital cities. The care between online and in-person consultations with the same psychiatrist was compared, including diagnosis, guideline adherence, and patient-centeredness. False discovery rate (FDR) was used to adjust p values. Third visits using asynchronous webchats were made to psychiatrists who offered discrepant diagnoses. Thematic content analysis was used for the discrepancies.

Findings

The proportion of diagnostic accuracy was lower for online than in-person visits (76.5% [65/85] vs 91.8% [78/85]; pFDR = 0.0066), as were the proportions of completing questions involving clinical history (16.6% vs 42.7%; pFDR < 0.0001), and management decisions (16.2% vs 27.5%; pFDR < 0.0001) consistent with recommended guidelines. Patient-centeredness was lower online than in-person (pFDR < 0.0001). Fifteen of 16 psychiatrists completed third visits, most of them considered lack of nonverbal information online as a key barrier.

Interpretation

Online consultations using asynchronous webchats were inferior to in-person consultations, with respect to diagnostic accuracy, adherence to recommended clinical guidelines, and patient-centeredness. To fully realise the potential benefits of online consultations and to prevent safety issues, there is an urgent need for major improvement in the quality and oversight of these consultations.

Funding

China Medical Board, National Natural Science Foundation of China, and Swiss Agency for Development and Cooperation Global Cooperation Department.

Quality in screening and measuring blood pressure in China's primary health care: a national cross-sectional study using unannounced standardized patients

Background

This study aims to evaluate primary care providers' adherence to the standard of measuring blood pressure for people aged 35 or above during their initial visit, as per Chinese guidelines, and to identify factors affecting their practices.

Methods

We developed 11 standardized patients (SP) cases as tracer conditions to evaluate primary care, and deployed trained SPs for unannounced visits to randomly selected providers in seven provinces of China. The SPs used a checklist based on guidelines to record whether and how blood pressure was measured. Data were analyzed descriptively and regression analysis was performed to examine the association between outcomes and factors such as provider, patient, facility, and clinical case characteristics.

Findings

The SPs conducted 1201 visits and found that less than one-third of USPs ≥35 had their blood pressure measured. Only 26.9% of migraine and 15.4% of diabetes cases received blood pressure measurements. Additionally, these measurements did not follow the proper guidelines and recommended steps. On average, 55.6% of the steps were followed with few providers considering influencing factors before measurement and only 6.0% of patients received both-arm measurements. The use of wrist sphygmomanometers was associated with poor blood pressure measurement.

Interpretation

In China, primary care hypertension screening practices fall short of guidelines, with infrequent initiation of blood pressure measurements and inadequate adherence to proper measurement steps. To address this, priority should be placed on adopting, implementing, and upholding guidelines for hypertension screening and measurement.

Funding

National Natural Science Foundation of China, Swiss Agency for Development and Cooperation, Doctoral Fund Project of Inner Mongolia Medical University, China Postdoctoral Science Foundation.

Preparedness, impacts, and responses of public health emergencies towards health security: qualitative synthesis of evidence

BACKGROUND

Natural and human-made public health emergencies (PHEs), such as armed conflicts, floods, and disease outbreaks, influence health systems including interruption of delivery and utilization of health services, and increased health service needs. However, the intensity and types of impacts of these PHEs vary across countries due to several associated factors. This scoping review aimed to synthesise available evidence on PHEs, their preparedness, impacts, and responses.

METHODS

We conducted a scoping review of published evidence. Studies were identified using search terms related to two concepts: health security and primary health care. We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines to select studies. We adapted the review framework of Arksey and O'Malley. Data were analyzed using a thematic analysis approach and explained under three stages of PHEs: preparedness, impacts, and responses.

RESULTS

A total of 64 studies were included in this review. Health systems of many low- and middle-income countries had inadequate preparedness to absorb the shocks of PHEs, limited surveillance, and monitoring of risks. Health systems have been overburdened with interrupted health services, increased need for health services, poor health resilience, and health inequities. Strategies of response to the impact of PHEs included integrated services such as public health and primary care, communication and partnership across sectors, use of digital tools, multisectoral coordination and actions, system approach to responses, multidisciplinary providers, and planning for resilient health systems.

CONCLUSIONS

Public health emergencies have high impacts in countries with weak health systems, inadequate preparedness, and inadequate surveillance mechanisms. Better health system preparedness is required to absorb the impact, respond to the consequences, and adapt for future PHEs. Some potential response strategies could be ensuring need-based health services, monitoring and surveillance of post-emergency outbreaks, and multisectoral actions to engage sectors to address the collateral impacts of PHEs. Mitigation strategies for future PHEs could include risk assessment, disaster preparedness, and setting digital alarm systems for monitoring and surveillance.

Validity of patients' online reviews at direct-to-consumer teleconsultation platforms: a protocol for a cross-sectional study using unannounced standardised patients

INTRODUCTION

As direct-to-consumer teleconsultation (hereafter referred to as 'teleconsultation') has gained popularity, an increasing number of patients have been leaving online reviews of their teleconsultation experiences. These reviews can help guide patients in identifying doctors for teleconsultation. However, few studies have examined the validity of online reviews in assessing the quality of teleconsultation against a gold standard. Therefore, we aim to use unannounced standardised patients (USPs) to validate online reviews in assessing both the technical and patient-centred quality of teleconsultations. We hypothesise that online review results will be more consistent with the patient-centred quality, rather than the technical quality, as assessed by the USPs.

METHODS AND ANALYSIS

In this cross-sectional study, USPs representing 11 common primary care conditions will randomly visit 253 physicians via the three largest teleconsultation platforms in China. Each physician will receive a text-based and a voice/video-based USP visit, resulting in a total of 506 USP visits. The USP will complete a quality checklist to assess the proportion of clinical practice guideline-recommended items during teleconsultation. After each visit, the USP will also complete the Patient Perception of Patient-Centeredness Rating. The USP-assessed results will be compared with online review results using the intraclass correlation coefficient (ICC). If ICC >0.4 (p<0.05), we will assume reasonable concordance between the USP-assessed quality and online reviews. Furthermore, we will use correlation analysis, Lin's Coordinated Correlation Coefficient and Kappa as supplementary analyses.

ETHICS AND DISSEMINATION

This study has received approval from the Institutional Review Board of Southern Medical University (#Southern Medical Audit (2022) No. 013). Results will be actively disseminated through print and social media, and USP tools will be made available for other researchers.

TRIAL REGISTRATION

The study has been registered at the China Clinical Trials Registry (ChiCTR2200062975).

The Agreement Between Virtual Patient and Unannounced Standardized Patient Assessments in Evaluating Primary Health Care Quality: Multicenter, Cross-sectional Pilot Study in 7 Provinces of China

BACKGROUND

The unannounced standardized patient (USP) is the gold standard for primary health care (PHC) quality assessment but has many restrictions associated with high human and resource costs. Virtual patient (VP) is a valid, low-cost software option for simulating clinical scenarios and is widely used in medical education. It is unclear whether VP can be used to assess the quality of PHC.

OBJECTIVE

This study aimed to examine the agreement between VP and USP assessments of PHC quality and to identify factors influencing the VP-USP agreement.

METHODS

Eleven matched VP and USP case designs were developed based on clinical guidelines and were implemented in a convenience sample of urban PHC facilities in the capital cities of the 7 study provinces. A total of 720 USP visits were conducted, during which on-duty PHC providers who met the inclusion criteria were randomly selected by the USPs. The same providers underwent a VP assessment using the same case condition at least a week later. The VP-USP agreement was measured by the concordance correlation coefficient (CCC) for continuity scores and the weighted κ for diagnoses. Multiple linear regression was used to identify factors influencing the VP-USP agreement.

RESULTS

Only 146 VP scores were matched with the corresponding USP scores. The CCC for medical history was 0.37 (95% CI 0.24-0.49); for physical examination, 0.27 (95% CI 0.12-0.42); for laboratory and imaging tests, -0.03 (95% CI -0.20 to 0.14); and for treatment, 0.22 (95% CI 0.07-0.37). The weighted κ for diagnosis was 0.32 (95% CI 0.13-0.52). The multiple linear regression model indicated that the VP tests were significantly influenced by the different case conditions and the city where the test took place.

CONCLUSIONS

There was low agreement between VPs and USPs in PHC quality assessment. This may reflect the "know-do" gap. VP test results were also influenced by different case conditions, interactive design, and usability. Modifications to VPs and the reasons for the low VP-USP agreement require further study.