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

Primary care physicians' experiences of video and online chat consultations: a qualitative descriptive study

OBJECTIVES

To explore the perceptions and views of remote consultations and patient care of primary care physicians (PCPs) who work remotely regularly and have experience performing remote consultations.

DESIGN

A qualitative study using thematic analysis.

SETTING

Four online focus group interviews with 17 PCPs, working with one private health care provider, with public and private primary care patients.

SUBJECTS

PCPs who had performed video or online chat consultations with primary care patients for at least 6 months.

MAIN OUTCOME MEASUREMENTS

PCPs' perceptions and views working remotely in online chat and video consultations.

RESULTS

Two main themes describing how PCPs perceived remote consultations emerged: 1) remote consultations have an impact on the way physicians work, and 2) remote consultations have an impact on the service system and patients. The subthemes of the first main theme included the physicians' new way of working, impacts on physicians' well-being, and impacts on communication and physician competences. The subthemes for the second main theme were the importance of smoothness of services for the patients, patient suitability, and technical liabilities.

CONCLUSION

Remote consultations provide PCPs with a new way of working that could improve work-life balance. However, it is important to maintain sufficient clinical competence through versatile work. Digital consultations can make contacting healthcare smoother and easier for patients if the patient selection is performed carefully. Online chat seems suitable for singular contacts and simple issues, but remote consultations could be used to sustain continuity of care.

Enhancing access to primary care is critical to the future of an equitable health service: using process visualisation to understand the impact of national policy in the UK

Access to UK general practice is complicated by the need to provide equitable and universal care within a system adapting to workforce challenges, digital innovation, and unprecedented demand. Despite the importance of accessing primary care in meeting the overall aim of delivering equitable care, this is the first time the direct and indirect influence of policies intended to facilitate access have been systematically explored. Further consideration by policymakers is needed to accommodate the difference between what patients need and what patients want when accessing primary care, and the differences in their ability to utilise digital options. The designation of care was hindered by long-standing issues of reliable data and variations in the interpretation of local and national protocols and guidelines.

Patients' Use of e-Consultations as an Alternative to Other General Practitioner Services: Cross-Sectional Survey Study

BACKGROUND

e-Consultations, defined as asynchronous text-based messaging, have transformed how patients interact with their general practitioner (GP). While e-consultations can improve patient access to GP care, concerns about increased workload for GPs are raised.

OBJECTIVE

This study aimed to address three research questions: (1) For what purpose and with what expectations do patients initiate e-consultations? (2) If e-consultations had not been available, what alternative actions would the patient have taken? and (3) How are the alternative actions associated with patient and e-consultation characteristics?

METHODS

A cross-sectional study was conducted through a web-based survey on Helsenorge. Helsenorge is the national citizen portal for digital health services in Norway, including e-consultations with the GP. All users who sent e-consultations through Helsenorge were invited to participate between January and February 2023. The survey addressed questions on users' expectations and experience with e-consultations. The association between patient and e-consultation characteristics and alternative actions to e-consultations were analyzed using multinomial logistic regression.

RESULTS

Overall, 13,011 users answered the survey. The most common reason for initiating an e-consultation was requesting a sick certificate (4940/13,011, 38%). Overall, 68.7% (8802/13,011) of respondents expected an answer within 24 hours, and 17.7% (2310/13,011) anticipated that the GP would ask them to attend a physical examination. If e-consultations had not been available, 45.5% (5917/13,011) of respondents would have booked a GP appointment, and 44.9% (5846/13,011) would have called the front desk. Users who expected a quicker response (odds ratio [OR] 1.64, 95% CI 1.46-1.85) and were less concerned about their health issues (OR 1.29, 95% CI 1.18-1.40) were more likely to call the front desk. Only 2.5% (323/13,011) of respondents would have contacted out-of-hours services. Users with longer travel time to the GP office (OR 6.08, 95% CI 3.46-10.66) and with a new health problem (OR 2.71, 95% CI 2.09-3.51) were more likely to choose this option. In addition, 4.7% (609/13,011) of the users would not have sought help if e-consultations had not been available. Younger patients (OR 2.16, 95% CI 1.38-3.37) and those with a longer travel time to the GP office (OR 2.19, 95% CI 1.27-3.80) or a new health issue (OR 1.74, 95% CI 1.43-2.12) had higher odds for not seeking help.

CONCLUSIONS

e-Consultations were often the patients' first choice of access route, and users expected a fast response. e-Consultations were mostly perceived as an alternative to GP appointments or calling the front desk. Patients with lower availability to the GP office had higher odds of using e-consultations as an alternative to out-of-hours service or waiting and not seeking GP care. Guidance for patient use should be developed to ensure appropriate and safe use. Further research should assess the effect of e-consultations on health outcomes and efficiency.

Transitioning to a virtual post-intensive care rehabilitation service in response to the COVID-19 pandemic: results of multidisciplinary focus-groups

Background

Telehealth has vastly expanded since the SARS-CoV-2 (COVID-19) pandemic and has been widely implemented as an efficient, cost-effective and accepted means of health care delivery, including rehabilitation. Although telerehabilitation is recommended across national guidelines, there is a lack of practical guidance to support clinicians with virtual adaptations.

Aims

This study aimed to describe the key components of a safe and effective virtual post-intensive-care rehabilitation service, through qualitative exploration.

Methods

This is a qualitative study using a focus-group design based upon grounded theory. This study is nested within a service development project, taking place during the COVID-19 pandemic. Focus groups were held after the first wave of the COVID-19 pandemic with key stakeholders from the physiotherapy and critical care departments of a large tertiary hospital in the United Kingdom. Semi-structured questions were used to guide discussions, led by a facilitator and scribe. Transcripts were thematically analysed using an exploratory inductive approach by two researchers then crosschecked.

Findings

Three focus groups were attended by 12 multidisciplinary stakeholders, including six physiotherapists, two administration staff members, two critical-care follow-up nurses and two critical care consultants. Thematic analysis identified seven critical elements for virtual adaptations: (1) safety and risk assessment, (2) assessment and outcome measures, (3) virtual platform, (4) resources and equipment, (5) exercise programme adaptation, (6) exercise monitoring and safety, and (7) privacy and information governance.

Conclusion

Our findings provide practical recommendations for virtual rehabilitation service development and delivery.

Challenges to quality in contemporary, hybrid general practice a multi-site longitudinal case study

BACKGROUND

Since 2022, general practice has shifted from responding to the acute challenges of COVID-19 to restoring full services using a hybrid of remote, digital, and in-person care.

AIM

To examine how quality domains are addressed in contemporary UK general practice.

DESIGN AND SETTING

Multi-site, mostly qualitative longitudinal case study, placed in UK national policy context.

METHOD

Data were collected from longitudinal ethnographic case studies of 12 general practices (2021-2023), multi-stakeholder workshops, stakeholder interviews, patient surveys, official reports, and publicly accessible patient experience data. Data were coded thematically and analysed using multiple theories of quality.

RESULTS

Quality efforts in UK general practice occur in the context of cumulative impacts of financial austerity, loss of resilience, increasingly complex patterns of illness and need, a diverse and fragmented workforce, material and digital infrastructure that is unfit for purpose, and physically distant and asynchronous ways of working. Providing the human elements of traditional general practice (such as relationship-based care, compassion, and support) is difficult and sometimes even impossible. Systems designed to increase efficiency have introduced new forms of inefficiency and have compromised other quality domains such as accessibility, patient-centredness, and equity. Long-term condition management varies in quality. Measures to mitigate digital exclusion (such as digital navigators) are welcome but do not compensate for extremes of structural disadvantage. Many staff are stressed and demoralised.

CONCLUSION

Contemporary hybrid general practice features changes (digitalisation, physical distancing, extension of roles, and protocolisation) that have had the unintended effect of dehumanising, compromising, and fragmenting care. Policymakers and practices should urgently address the risks to patients and the traditional core values of general practice should be urgently addressed.

The Impact and Wider Implications of Remote Consultations for General Practice in Norway: Qualitative Study Among Norwegian Contract General Practitioners

BACKGROUND

The digital shift toward remote consultations in general practice needs ongoing monitoring to understand its impact on general practice organizations and the wider health care system.

OBJECTIVE

This study aimed to explore how remote consultations impact on contracted general practitioner (GP) practices and how GPs perceive the implications of this uptake for the overall health care system.

METHODS

In total, 5 focus groups were conducted with a total of 18 GPs from all 4 health regions of Norway in 2022. The material was subjected to Braun and Clarke's thematic analysis.

RESULTS

The analysis yielded six themes: (1) the design of novel effective clinical pathways: remote consultations empower GPs to tailor new effective clinical trajectories, blending modalities to address diverse needs across clinical episodes-from initial triage, through investigations to case closure; (2) increased workday flexibility: remote consultations introduce variability into daily work, allowing GPs to adjust patient contact intensity, and leading to a less stressful work-home balance; (3) erosion of organizational boundaries: easy remote access to GPs appears to reduce patients' tolerance for minor illness and self-care, hindering effective gatekeeping and shifting GPs' focus from proactive to more reactive work, increasing work-related stress; (4) degradation of clinical shrewdness: confronted with an increasing amount of unsorted and trivial remote inquiries, GPs observe challenges in detecting and prioritizing serious cases; (5) dilemmas related to responsibility, ethics, and legislation: remote consultations highlight a tension for contract GPs between legal responsibilities and ethical obligations, with implications for patients with limited health literacy; this may entail suboptimal evaluation or delayed treatment-potentially contributing to increased health care inequity; and (6) retaining clinical core values in a changing world. Overall, GPs affirm that remote consultations have come to stay and describe efforts to effectively manage the advantages and disadvantages inherent in such interactions to safeguard clinical effectiveness and organizational sustainability of primary health care.

CONCLUSIONS

The widespread adoption of remote consultations in the Norwegian contract GP scheme fundamentally reshapes the dynamics of GP work and the overall health care system. Awareness and proactive management of these changes are essential for maintaining sustainable, high-quality primary health care.

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

Background

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

Method

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

Results

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

Conclusion

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

Quality of the digital gp visits and characteristics of the users: retrospective observational study

OBJECTIVES

This study compares the demographics, diagnoses, re-admission rates, sick leaves, and prescribed medications of patients accessing digital general practitioner (GP) visits with those of patients opting for traditional face-to-face appointments in a primary health care setting.

DESIGN

The study adopted a retrospective analysis of patient record data collected in 2019, comparing visits to a digital primary health center with traditional health center visits.

SETTING

Primary health care.

PARTICIPANTS

The data encompassed patients who utilized the digital clinic and those who visited public health centers for primary health care services.

MAIN OUTCOME MEASURES

The study assessed demographics, health diagnoses, prescribed medications, sick leave recommendations, re-admission rates, and differences in costs between digital clinic and face-to-face visits. Secondary outcomes included a comparative analysis of medication categories, resolution rates for health problems, and potential impacts on health care utilization.

RESULTS

Digital clinic users were typically younger, more educated, and predominantly female compared with health centre users. Digital visits were well-suited for uncomplicated infections, while health centre appointments were associated with a higher prevalence of chronic conditions. Medication patterns differed between the two modalities, with digital clinic users receiving generic over-the-counter drugs and antibiotics, whereas health centre visits commonly involved cardiac and antihypertensive medications. Sick leave recommendations were slightly higher in the digital clinic, but the difference was not significant. Approximately 70% of health problems addressed in the digital clinic were successfully resolved, and the cost of digital visits was about 50,3% of face-to-face appointments.

CONCLUSION

Digital health care services offer a cost-efficient alternative for specific health problems, appealing to younger, educated individuals, when compared to the users of public health center, and may enable improvement of cost-effectiveness combined with acceptable demand management and patient segmentation practices. The results highlight the potential benefits of digital clinics, particularly for uncomplicated cases, while also emphasizing the importance of suitable referral mechanisms for in-person consultations.

Access systems in general practice: a systematic scoping review

BACKGROUND

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

AIM

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

DESIGN AND SETTING

Scoping review examining international literature.

METHOD

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

RESULTS

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

CONCLUSION

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

A Cost Evaluation of COVID-19 Remote Home Monitoring Services in England

BACKGROUND

Remote home monitoring services emerged as critical components of health care delivery from NHS England during the COVID-19 pandemic, aiming to provide timely interventions and reduce health care system burden. Two types of service were offered: referral by community health services to home-based care to ensure the right people were admitted to the hospital at the right time (called COVID Oximetry@home, CO@h); and referral by hospital to support patients' transition from hospital to home (called COVID-19 Virtual Ward, CVW). The information collected for the oxygen levels and other symptoms was provided via digital means (technology-enabled) or over the phone (analogue-only submission mode). This study aimed to evaluate the costs of implementing remote home monitoring for COVID-19 patients across 26 sites in England during wave 2 of the pandemic. Understanding the operational and financial implications of these services from the NHS perspective is essential for effective resource allocation and service planning.

METHODS

We used a bottom-up costing approach at the intervention level to describe the costs of setting up and running the services. Twenty-six implementation sites reported the numbers of patients and staff involved in the service and other resources used. Descriptive statistics and multivariable regression analysis were used to assess cost variations and quantify the relationship between the number of users and costs while adjusting for other service characteristics.

RESULTS

The mean cost per patient monitored was lower in the CO@h service compared with the CVW service (£527 vs £599). The mean cost per patient was lower for implementation sites using technology-enabled and analogue data submission modes compared with implementation sites using analogue-only modes for both CO@h (£515 vs £561) and CVW (£584 vs £612) services. The number of patients enrolled in the services and the service type significantly affected the mean cost per patient.

CONCLUSIONS

Our analysis provides a framework for evaluating the costs of similar services in the future and shows that the implementation of these services benefit from the employment of tech-enabled data submission modes.

Healthcare professional and commissioners' perspectives on the factors facilitating and hindering the implementation of digital tools for self-management of long-term conditions within UK healthcare pathways

Physical activity is important in the self-management of long-term conditions (LTCs). However, implementing physical activity into clinical practice is challenging, due to complex barriers including access to programmes, time pressures, and transport costs, for people with comorbidities, managing multiple responsibilities. Various digital tools exist to overcome these barriers and support wide-scale implementation to help people stay physically active. We explored the experiences, needs and preferences of healthcare professionals and commissioners, regarding the use of digital tools to support people with LTCs to self-manage using physical activity. This included barriers and facilitators to implementing digital tools to support people with LTCs in NHS settings. Semi-structured interviews were conducted (April 2021 to January 2022) in Wessex, southern England, UK. Purposive sampling was used to recruit general practitioners and healthcare professionals, and convenience sampling to recruit commissioners (n = 15). Transcripts were coded to develop conceptual themes allowing comparisons between and among perspectives, with the Normalisation Process Theory (NPT)'s four constructs used to aid interpretation. Results showed that most digital tools supporting physical activity for LTCs, are not well implemented clinically. Current digital tools were seen to lack condition-specificity, usability/acceptability evidence-base, and voluntary sector involvement (i.e., NPT: coherence or 'making sense'). Healthcare professionals and commissioners were unlikely to engage with use of digital tools unless they were integrated into health service IT systems and professional networks (i.e., NPT: cognitive participation), or adaptable to the digital literacy levels of service users and staff (i.e., NPT: collective action-needs for implementation). In practice, this meant being technically, easy to use and culturally accessible (i.e., NPT: collective action-promoting healthcare work). COVID-19 changed professional attitudes towards digital tools, in that they saw them being viable, feasible and critical options in a way they had not done before the pandemic. Implementation was also influenced by endorsement and trustworthiness enhancing the perception of them as secure and evidence-based (i.e., NPT: reflective monitoring). Our findings highlight that consideration must be given to ensuring that digital tools are accessible to both healthcare professionals and patients, have usability/acceptability, and are adaptable to specific LTCs. To promote clinical engagement, digital tools must be evidence-based, endorsed by professional networks, and integrated into existing health systems. Digital literacy of patients and professionals is also crucial for cross-service implementation.

Unveiling the heterogeneous utilisation of the same digital patient management platform: case studies in primary healthcare in Sweden

BACKGROUND

The utilisation of digital technology in primary healthcare, particularly digital patient management platforms, has gained prominence, notably due to the global pandemic. These platforms are positioned as substitutes for face-to-face consultations and telephone triage. They are seen as a potential solution to the escalating costs associated with an aging population, increasing chronic conditions, and a shrinking healthcare workforce. However, a significant knowledge gap exists concerning the practical aspects of their implementation and their effect on the utilisation of digital patient management in primary healthcare.

METHODS

This study addresses this gap by conducting a comprehensive analysis of three case studies involving the implementation of a specific digital patient management platform. Over a period of three years, we examine how the practicalities of implementation shape the adoption and utilisation of a digital patient management platform in three different clinics.

RESULTS

Our findings revealed that differences in implementation strategies directly influenced variations in utilisation. The successful utilisation of the platform was achieved through a bottom-up decision-making process that involved the employees of the primary healthcare clinics. Onsite training, close collaboration with the eHealth provider, and a structured patient onboarding process played crucial roles in this utilisation. In contrast, a top-down approach at two of the primary healthcare clinics led to limited utilisation of the platform into daily workflows. Furthermore, making the platform a part of everyday work meant putting accessibility, by working as a team of physicians, at the forefront of continuity of care, with patients being managed by their designated physician. Additionally, it was observed that digital patient management proved most effective for addressing simple patient issues such as skin rashes, rather than complex cases, and did not reduce the demand for phone triage.

CONCLUSION

Only one of the three clinics studied effectively integrated digital patient management into its daily operations, and did so by aligning objectives among management and all categories of healthcare professionals, employing a bottom-up decision-making process, collaborating with the eHealth service provider for regular platform adjustments to clinic needs, and implementing active patient onboarding. This sociotechnical integration resulted in high platform utilisation. In contrast, the other two clinics faced challenges due to incoherent objectives among diverse healthcare professional employees and top management, a top-down decision-making approach during implementation, limited collaboration with the eHealth service provider, and passive patient onboarding. The findings indicate that these factors negatively affected utilisation and led to low platform adoption as well as disrupted the sociotechnical balance.

Remote and technology-mediated working during the COVID-19 pandemic: A qualitative exploration of the experiences of nurses working in general practice (the GenCo Study)

AIM

To explore how nurses working in general practice experienced remote and technology-mediated working during the COVID-19 pandemic.

DESIGN

Exploratory qualitative study with nursing team members working in general practices in England and national nurse leaders.

METHODS

Data were collected between April and August 2022. Forty participants took part in either semi-structured interviews or focus groups. Data were analysed using Framework Analysis informed by the PERCS (Planning and Evaluating Remote Consultation Services) Framework. University of York ethics approval [HSRGC/2021/458/I] and Health Research Authority approval were obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. The study was funded by The General Nursing Council for England and Wales Trust.

RESULTS

Participants continued to deliver a significant proportion of patient care in-person. However, remote and technology-mediated care could meet patients' needs and broaden access in some circumstances. When remote and technology-mediated working were used this was often part of a blended model which was expected to continue. This could support some workforce issues, but also increase workload. Participants did not always have access to remote technology and were not involved in decision-making about what was used and how this was implemented. They rarely used video consultations, which were not seen to add value in comparison to telephone consultations. Some participants expressed concern that care had become more transactional than therapeutic and there were potential safety risks.

CONCLUSION

The study explored how nurses working in general practice during the COVID-19 pandemic engaged with remote and technology-mediated working. It identifies specific issues of access to technology, workload, hybrid working, disruption to therapeutic relationships, safety risks and lack of involvement in decision-making. Changes were implemented quickly with little strategic input from nurses. There is now an opportunity to reflect and build on what has been learned in relation to remote and technology-mediated working to ensure the future development of safe and effective nursing care in general practice.

IMPACT

The paper contributes to understanding of remote and technology-mediated working by nurses working in general practice during the COVID-19 pandemic and indicates to employers and policy makers how this can be supported moving forward.

REPORTING METHOD

Standards for Reporting Qualitative Research (O'Brien et al., 2014).

PATIENT OR PUBLIC CONTRIBUTION

This was a workforce study so there was no patient or public contribution.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The paper highlights specific issues which have implications for the development of remote, technology-mediated and blended working for nurses in general practice, care quality and patient safety. These require full attention to ensure the future development of safe and effective nursing care in general practice moving forward.

General practice service use at the end-of-life before and during the COVID-19 pandemic: a population-based cohort study using primary care electronic health records

BACKGROUND

Globally, the COVID-19 pandemic has caused unprecedented strain in healthcare systems, but little is known about how it affected patients requiring palliative and end-of-life care from GPs.

AIM

To evaluate the impact of the pandemic on primary care service use in the last 3 months of life, including consultations and prescribing, and to identify associated factors.

DESIGN AND SETTING

A retrospective cohort study in UK, using data from the Clinical Practice Research Datalink.

METHOD

The study cohort included those who died between 2019 and 2020. Poisson regression models using generalised estimation equations were used to examine the association between primary care use and patient characteristics. Adjusted rate ratios (aRRs) and 95% confidence intervals (95% CIs) were estimated.

RESULTS

A total of 44 534 patients died during the study period. The pandemic period was associated with an 8.9% increase in the rate of consultations from 966.4 to 1052.9 per 1000 person-months, and 14.3% longer telephone consultation duration (from 10.1 to 11.5 minutes), with a switch from face-to-face to telephone or video consultations. The prescription of end-of-life care medications increased by 6.3%, from 1313.7 to 1396.3 per 1000 person-months. The adjusted rate ratios for consultations (aRR = 1.08, 95% CI = 1.06 to 1.10, P<0.001) and prescriptions (aRR 1.05: 95% CI = 1.03 to 1.07, P<0.001) also increased during the pandemic.

CONCLUSION

The pandemic had a major impact on GP service use, leading to longer consultations, shifts from face-to-face to telephone or video consultations, and increased prescriptions. GP workload-related issues must be addressed urgently to ease the pressure on GPs.

The relationship between general practitioner movement behaviours with burnout and fatigue

BACKGROUND

Physical inactivity is associated with feelings of burnout and fatigue, which in turn are associated with reduced performance among healthcare practitioners. This study explored movement behaviours of general practitioners (GPs) and the association between these behaviours with burnout and fatigue.

METHODS

GPs in Northern Ireland were asked to wear a thigh-worn accelerometer for seven days and complete validated questionnaires to assess the association between daily number of steps, time spent sitting and standing with feelings of burnout and fatigue.

RESULTS

Valid accelerometer data were obtained from 47 (77.0%) participants. Average workday sitting time, standing time and number of steps were 10.6 h (SD 1.5), 3.8 h (SD 1.3), and 7796 steps (SD 3116) respectively. Participants were less sedentary (8.0 h (SD 1.6)) and more active (4.7 h (SD 1.4) standing time and 12,408 steps (SD 4496)) on non-workdays. Fourteen (30.4%) participants reported burnout and sixteen (34.8%) reported severe fatigue. There were no significant associations between sitting, standing and step counts with burnout or fatigue (p > 0.05).

CONCLUSION

GPs were less active on workdays compared to non-workdays and exhibited high levels of sitting. Feelings of burnout and fatigue were highly prevalent, however movement behaviours were not found to be associated with burnout and fatigue. Given the increased sedentariness among GPs on workdays compared to non-workdays, GPs should consider how they can improve their movement behaviours on workdays to help optimise their wellbeing.

Navigating the doctor-patient-AI relationship - a mixed-methods study of physician attitudes toward artificial intelligence in primary care

BACKGROUND

Artificial intelligence (AI) is a rapidly advancing field that is beginning to enter the practice of medicine. Primary care is a cornerstone of medicine and deals with challenges such as physician shortage and burnout which impact patient care. AI and its application via digital health is increasingly presented as a possible solution. However, there is a scarcity of research focusing on primary care physician (PCP) attitudes toward AI. This study examines PCP views on AI in primary care. We explore its potential impact on topics pertinent to primary care such as the doctor-patient relationship and clinical workflow. By doing so, we aim to inform primary care stakeholders to encourage successful, equitable uptake of future AI tools. Our study is the first to our knowledge to explore PCP attitudes using specific primary care AI use cases rather than discussing AI in medicine in general terms.

METHODS

From June to August 2023, we conducted a survey among 47 primary care physicians affiliated with a large academic health system in Southern California. The survey quantified attitudes toward AI in general as well as concerning two specific AI use cases. Additionally, we conducted interviews with 15 survey respondents.

RESULTS

Our findings suggest that PCPs have largely positive views of AI. However, attitudes often hinged on the context of adoption. While some concerns reported by PCPs regarding AI in primary care focused on technology (accuracy, safety, bias), many focused on people-and-process factors (workflow, equity, reimbursement, doctor-patient relationship).

CONCLUSION

Our study offers nuanced insights into PCP attitudes towards AI in primary care and highlights the need for primary care stakeholder alignment on key issues raised by PCPs. AI initiatives that fail to address both the technological and people-and-process concerns raised by PCPs may struggle to make an impact.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Continuity of care and consultation mode in general practice: a cross-sectional and longitudinal study using patient-level and practice-level data from before and during the COVID-19 pandemic in England

OBJECTIVES

Investigate trends in continuity of care with a general practitioner (GP) before and during the COVID-19 pandemic. Identify whether continuity of care is associated with consultation mode, controlling for other patient and practice characteristics.

DESIGN

Retrospective cross-sectional and longitudinal observational studies.

SETTING

Primary care records from 389 general practices participating in Clinical Practice Research Datalink Aurum in England.

PARTICIPANTS

In the descriptive analysis, 100 000+ patients were included each month between April 2018 and April 2021. Modelling of the association between continuity of care and consultation mode focused on 153 475 and 125 298 patients in index months of February 2020 (before the pandemic) and February 2021 (during the pandemic) respectively, and 76 281 patients in both index months.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome measure was the Usual Provider of Care index. Secondary outcomes included the Bice-Boxerman index and count of consultations with the most frequently seen GP.

RESULTS

Continuity of care was gradually declining before the pandemic but stabilised during it. There were consistent demographic, socioeconomic and regional differences in continuity of care. An average of 23% of consultations were delivered remotely in the year to February 2020 compared with 76% in February 2021. We found little evidence consultation mode was associated with continuity at the patient level, controlling for a range of covariates. In contrast, patient characteristics and practice-level supply and demand were associated with continuity.

CONCLUSIONS

We set out to examine the association of consultation mode with continuity of care but found that GP supply and patient demand were much more important. To improve continuity for patients, primary care capacity needs to increase. This requires sufficient, long-term investment in clinicians, staff, facilities and digital infrastructure. General practice also needs to transform ways of working to ensure continuity for those that need it, even in a capacity-constrained environment.

Healthcare professional and manager perceptions on drivers, benefits, and challenges of telemedicine: results from a cross-sectional survey in the Italian NHS

BACKGROUND

The Covid-19 pandemic provided new challenges and opportunities for patients and healthcare providers while accelerating the trend of digital healthcare transformation. This study explores the perspectives of healthcare professionals and managers on (i) drivers to the implementation of telemedicine services and (ii) perceived benefits and challenges related to the use of telemedicine across the Italian National Health Service.

METHODS

An online cross-sectional survey was distributed to professionals working within 308 healthcare organisations in different Italian regions. Quantitative and qualitative data were collected through a self-administered questionnaire (June-September 2021). Responses were analysed using summary statistics and thematic analysis.

RESULTS

Key factors driving the adoption of telemedicine have been grouped into (i) organisational drivers (reduce the virus spread-80%; enhance care quality and efficiency-61%), (ii) technological drivers (ease of use-82%; efficacy and reliability-64%; compliance with data governance regulations-64%) and (iii) regulatory drivers (regulations' semplification-84%). Nearly all respondents perceive telemedicine as useful in improving patient care (96%). The main benefits reported by respondents are shorter waiting lists, reduced Emergency Department attendance, decreased patient and clinician travel, and more frequent patient-doctor interactions. However, only 7% of respondents believe that telemedicine services are more effective than traditional care and 66% of the healthcare professionals believe that telemedicine can't completely substitute in-person visits due to challenges with physical examination and patient-doctor relationships. Other reported challenges include poor quality and interoperability of telemedicine platforms and scarce integration of telemedicine with traditional care services. Moreover, healthcare professionals believe that some groups of patients experience difficulties in accessing and using the technologies due to socio-cultural factors, technological and linguistic challenges and the absence of caregivers.

CONCLUSIONS

Respondents believe that telemedicine can be useful to complement and augment traditional care. However, many challenges still need to be overcome to fully consider telemedicine a standard of care. Strategies that could help address these challenges include additional regulations on data governance and reimbursements, evidence-based guidelines for the use of telemedicine, greater integration of tools and processes, patient-centred training for clinicians, patient-facing material to assist patients in navigating virtual sessions, different language options, and greater involvement of caregivers in the care process.

The impact of remote consultations on the health and wellbeing of first contact physiotherapists in primary care: A mixed methods study

BACKGROUND

First Contact Physiotherapists (FCPs) were introduced to reduce demands on GPs by providing improving access to expert musculoskeletal care. FCPs experience similar workplace stressors to GPs and there is an emerging concern that remote consultations are causing further impacts to their wellbeing.

AIM

To explore the impact of remote consultations on FCPs.

METHODS

A mixed methods sequential explanatory study with FCPs was conducted. An online survey measured the usage and impact of remote consultations. Semi-structured interviews explored the lived experiences of using remote consultations.

RESULTS

The online survey was completed by 109 FCPs. A key benefit of remote consultations was patient convenience; perceived challenges included IT issues, poor efficacy, FCP anxiety, isolation, and increased workload. FCPs viewed remote consultations as a 'challenge' rather than a 'threat'. Nearly two thirds of the FCPs had not received relevant training, yet over half were interested. Follow-up interviews with 16 FCPs revealed 4 themes: (1) Remote consultations provide logistical benefits to the patient; (2) Compromised efficacy is the key challenge of remote consultations; (3) Challenges for FCPs working in areas of high deprivation; and (4) Remote consultations impact the health, wellbeing and work satisfaction of FCPs.

CONCLUSIONS

Remote consultations offer a convenient alternative for patients, but may add to FCP stress particularly in areas of high socioeconomic deprivation. Further research is required to understand how remote consultations can be enhanced when communication barriers and lower levels of digital literacy exist. Continued monitoring of job satisfaction and resilience levels is important to ensure FCPs remain in their role.

A contemporary ontology of continuity in general practice: Capturing its multiple essences in a digital age

Continuity is a long-established and fiercely-defended value in primary care. Traditional continuity, based on a one-to-one doctor-patient relationship, has declined in recent years. Contemporary general practice is organisationally and technically complex, with multiple staff roles and technologies supporting patient access (e.g. electronic and telephone triage) and clinical encounters (e.g. telephone, video and electronic consultations). Re-evaluation of continuity's relational, organisational, socio-technical and professional characteristics is therefore timely. We developed theory in parallel with collecting and analysing data from case studies of 11 UK general practices followed from 2021 to 2023 as they introduced (or chose not to introduce) remote and digital services. We used strategic, immersive ethnography, interviews, and material analysis of technologies (e.g. digital walk-throughs). Continuity was almost universally valued but differently defined across practices. It was invariably situated and effortful, influenced by the locality, organisation, technical infrastructure, wider system and the values and ways of working of participating actors, and often requiring articulation and 'tinkering' by staff. Remote and digital modalities provided opportunities for extending continuity across time and space and for achieving-to a greater or lesser extent-continuity of digital records and shared understandings of a patient and illness episode across the clinical team. Delivering continuity for the most vulnerable patients was sometimes labour-intensive and required one-off adaptations. Building on earlier work by Haggerty et al. we propose a novel ontology of four analytically distinct but empirically overlapping kinds of continuity-of the therapeutic relationship (based on psychodynamic and narrative paradigms), of the illness episode (biomedical-interpretive paradigm), of distributed work (sociotechnical paradigm), and of the practice's commitment to a community (political economy and ethics of care paradigm). This ontology allowed us to theorise and critique successes (continuity achieved) and failures (breaches of continuity and fragmentation of care) in our dataset.

Healthcare in England was affected by the COVID-19 pandemic across the pancreatic cancer pathway: A cohort study using OpenSAFELY-TPP

Background

Healthcare across all sectors, in the UK and globally, was negatively affected by the COVID-19 pandemic. We analysed healthcare services delivered to people with pancreatic cancer from January 2015 to March 2023 to investigate the effect of the COVID-19 pandemic.

Methods

With the approval of NHS England, and drawing from a nationally representative OpenSAFELY-TPP dataset of 24 million patients (over 40% of the English population), we undertook a cohort study of people diagnosed with pancreatic cancer. We queried electronic healthcare records for information on the provision of healthcare services across the pancreatic cancer pathway. To estimate the effect of the COVID-19 pandemic, we predicted the rates of healthcare services if the pandemic had not happened. We used generalised linear models and the pre-pandemic data from January 2015 to February 2020 to predict rates in March 2020 to March 2023. The 95% confidence intervals of the predicted values were used to estimate the significance of the difference between the predicted and observed rates.

Results

The rate of pancreatic cancer and diabetes diagnoses in the cohort was not affected by the pandemic. There were 26,840 people diagnosed with pancreatic cancer from January 2015 to March 2023. The mean age at diagnosis was 72 (±11 SD), 48% of people were female, 95% were of White ethnicity, and 40% were diagnosed with diabetes. We found a reduction in surgical resections by 25-28% during the pandemic. In addition, 20%, 10%, and 4% fewer people received body mass index, glycated haemoglobin, and liver function tests, respectively, before they were diagnosed with pancreatic cancer. There was no impact of the pandemic on the number of people making contact with primary care, but the number of contacts increased on average by 1-2 per person amongst those who made contact. Reporting of jaundice decreased by 28%, but recovered within 12 months into the pandemic. Emergency department visits, hospital admissions, and deaths were not affected.

Conclusions

The pandemic affected healthcare in England across the pancreatic cancer pathway. Positive lessons could be learnt from the services that were resilient and those that recovered quickly. The reductions in healthcare experienced by people with cancer have the potential to lead to worse outcomes. Current efforts should focus on addressing the unmet needs of people with cancer.

Funding

This work was jointly funded by the Wellcome Trust (222097/Z/20/Z); MRC (MR/V015757/1, MC_PC-20059, MR/W016729/1); NIHR (NIHR135559, COV-LT2-0073), and Health Data Research UK (HDRUK2021.000, 2021.0157). This work was funded by Medical Research Council (MRC) grant reference MR/W021390/1 as part of the postdoctoral fellowship awarded to AL and undertaken at the Bennett Institute, University of Oxford. The views expressed are those of the authors and not necessarily those of the NIHR, NHS England, UK Health Security Agency (UKHSA), or the Department of Health and Social Care. Funders had no role in the study design, collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

A rapid mixed-methods evaluation of remote home monitoring models during the COVID-19 pandemic in England

Background

Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary.

Objective

To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2).

Methods

A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites).

Results

Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls.

Limitations

Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups.

Future work

Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients.

Conclusions

We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered.

Study registration

This study is registered with the ISRCTN (14962466).

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

'It increases my ability to influence my ways of working': A qualitative study on digitally mediated patient management in primary healthcare

BACKGROUND

Digitally mediated primary healthcare is increasingly influencing working conditions, raising questions about how digitally mediated patient management is experienced.

AIM

The aim of this study was to generate insights, through the lens of postphenomenology, into how digitally mediated primary healthcare affects the work and working environment, by gathering perspectives from primary healthcare professionals who regularly manage patient errands through a digital platform.

METHODS

Two rounds of interviews were conducted with a diversified sample of primary healthcare professionals at a primary healthcare centre. The first round of interviews was conducted during the initial phase of the deployment of a digital platform for patient management, with the second round conducted a year later (n = 24). The interview transcripts were analysed using reflexive thematic analysis.

RESULTS

Four themes relating to digitally mediated care work were identified: 'positive feelings towards digitally mediated primary healthcare', 'seeing a positive work atmosphere as a prerequisite for change', 'experiencing increased control over the pace of workflow' and 'reconfiguration of previous problems'.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

Building on postphenomenology, our study adds to the understanding of how material and symbolic aspects mutually affect the mediating role of a digital platform for patient management. Thus, the results indicate that the experience of using digitally mediated care processes is conditioned by the discourse towards digitalisation at the workplace and the management's approach to and inclusion of employees in the digital transition of primary healthcare, as well as the usefulness and usability of the digital platform. The findings can inform both practice and policy.

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

BACKGROUND

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

AIM

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

DESIGN & SETTING

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

METHOD

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

RESULTS

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

CONCLUSION

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

Primary health care during the COVID-19 pandemic: A qualitative exploration of the challenges and changes in practice experienced by GPs and GP trainees

BACKGROUND

The COVID-19 pandemic has rapidly changed general practice in the UK. Research is required to understand how General Practitioners (GPs) and GP trainees adjusted to these changes, so that beneficial changes might be sustained, and Primary Health Care (PHC) can be prepared for future challenges. This study explored the experiences and perspectives of GP and GP trainees during the pandemic.

METHODS

Remote, semi-structured interviews (n = 21) were conducted with GPs (n = 11) and GP trainees (n = 10), recruited from across the UK using convenience and purposive sampling. Interviews were audio-recorded and transcribed verbatim. Interview data were analysed with an inductive thematic approach.

RESULTS

Five overarching themes were identified: (1) 'Thrown in at the deep end'; (2) Telemedicine: 'it needs to be a happy balance'; (3) Delayed referrals and 'holding' patients; (4) The Covid Cohort-training in Covid; (5) Suggestions and lessons for the future of general practice'. GPs reported a turbulent and uncertain time of major changes to PHC. They described the benefits of technology in general medicine, particularly telemedicine, when used in a balanced manner, highlighting the need for accompanying teaching and guidelines, and the importance of patient preferences. Key tools to help GPs manage patients with delayed referrals to Secondary Care were also identified.

CONCLUSION

Several key changes to general practice occurred as a result of the COVID-19 pandemic, including a rapid uptake of telemedicine. The pandemic exposed the strengths and limitations of normal general practice and highlighted the importance of workplace camaraderie. These findings contribute to the evidence base used to adapt PHC infrastructures as we emerge from the pandemic.

How COVID-19 Broke the Barriers Related to the Implementation of Telecare-Patients' Experiences with a New form of Providing Health Services in Primary Health Care

BACKGROUND

The COVID-19 pandemic has significantly contributed to accelerating the development of telemedicine and eHealth. The main aim of this study was to assess the attitudes of patients towards remote care implemented in general practice (GP) during the pandemic.

METHODS

The study was a pilot study conducted in March-April 2021, considering technical aspects of using teleconsultations, and evaluating the difficulties, advantages and disadvantages for patients. When assessing opinions, a simple Likert scale was used, where a value of 1 meant the worst possible assessment or strong disagreement and the upper value the best or full agreement of the respondent.

RESULTS

The study covered 408 respondents. Their biggest organizational challenge reaching GPs by telephone, regardless of the patients' home location (p = 0.23698). Obtaining e-documents was not problematic but was rated as worse by men (p = 0.048295). Respondents rated the overall effectiveness of teleconsultations more highly if they could speak directly with a doctor (p = 0.0005). There were no differences in willingness to recommend teleconsultations based on gender (p = 0.2432), place of residence (p = 0.7878), age (p = 0.290355) or education (p = 0.9109), but people assessing the overall effectiveness of telemedicine more highly were more willing to recommend it (p = 0.000).

CONCLUSIONS

Respondents assess teleconsultations in a differentiated way, noticing both positive and negative features of the remote form of providing health services.

Remote consultations in primary care across low-, middle- and high-income countries: Implications for policy and care delivery

The COVID-19 pandemic mandated a substantial switch in primary health care delivery from an in-person to a mainly remote telephone or video service. As the COVID-19 pandemic approaches its third year, limited progress appears to have been made in terms of policy development around consultation methods for the post-acute phase of the pandemic. In September 2020, the International Primary Care Respiratory Group convened a global panel of primary care clinicians - including family physicians, paediatricians, pharmacists, academics and patients - to consider the policy and health management implications of the move to remote consultations in the primary care setting. The group gave special consideration to how and how far remote consultations should be integrated into routine primary health care delivery. Remote consultations can be a useful alternative to in-person consultations in primary care not only in situations where there is a need for viral infection control but also for the routine delivery of chronic disease management. However, they may not be more time efficient for the clinician, and they can add to the workload and work-related stress for primary care practitioners if they remain the dominant consultation mode. Remote consultations are also less appropriate than in-person consultations for new disease diagnosis, dealing with multiple issues and providing complex care. Ensuring health care professionals have the appropriate skill set to effectively deliver remote consultations, administrative and/or IT support and appropriate reimbursement will be key to achieving optimal integration of remote consultations into routine clinical practice. Addressing digital access and digital literacy issues at a societal level will also be essential to ensure individuals have fair and equitable access to the internet and sufficient security for exchange of personal and health-related data.

The Role of Telemedicine in the Management of Patients with Chronic Diseases in Primary Care During the COVID-19 Pandemic

Introduction:The COVID-19 pandemic has rapidly spread to many countries and has led various primary healthcare services of chronic diseases to be neglected and only partially be replaced by telemedicine services. This study aims to investigate the role of telemedicine in the management of patients with noncommunicable diseases in primary health care during the COVID-19 pandemic. Method: A narrative review of the literature was carried out through searching the PubMed and Google Scholar databases. Results: From the initial stages of the pandemic, several scientific medical societies issued guidelines which urged citizens and health personnel to adopt digital means in the provision of regular chronic care as much as possible. The significant benefits of the telemedicine sessions partially only filled the gap of the deferred chronic care. On the other hand, many barriers need to be addressed in order to achieve an equitable and high-quality implementation of telemedicine services. Conclusion:The widespread application of telemedicine and self-monitoring was brought about by the COVID-19 pandemic and currently, they have become common ways of managing non-communicable diseases in primary health care. Innovations introduced need to be maintained and integrated into conventional traditional practices, so that health systems are more resilient to future public health emergencies.

Service evaluation of telehealth in a physiotherapy musculoskeletal setting: Patient outcomes and results from risk stratification

INTRODUCTION

Due to COVID-19 the ability to see all patients face-to-face (FTF) was removed. Services implemented telehealth to cater for patients requiring musculoskeletal care. A service evaluation was undertaken to assess the effectiveness of a mixed telehealth/FTF approach and identify if stratifying patients could help tailor intervention.

METHODS

Retrospective analysis of data collected from patients who were assessed by Musculoskeletal Physiotherapists in one Scottish health board was undertaken. Patients were divided into low, medium and high risk sub-groups through the Keele STarT MSK tool. Outcome measures for pain and musculoskeletal health were taken at baseline/discharge along with satisfaction/preference. Descriptive and Inferential statistical analysis was conducted to establish whether changes in the outcome measures within and between risk sub-groups were statistically significant.

RESULTS

Pain level difference from baseline to discharge demonstrated clinically and statistically significant improvements across all risk groups (N = 89). Musculoskeletal health demonstrated clinically significant improvements across all risk groups and statistically significant improvements in the medium/high risk groups but not the low risk. Patients with knee osteoarthritis and low back pain in the medium risk group had fewest appointments while patients with chronic shoulder pain had the most. The majority of patients were satisfied with all mediums but preferred FTF or an option between telehealth/FTF in the future.

CONCLUSION

Telehealth is a promising model of care when utilised in combination with FTF for patients with musculoskeletal conditions. Through stratification, identifying specific conditions and shared decision making it may be possible to treat certain patient groups via telehealth.

Protocol: Remote care as the 'new normal'? Multi-site case study in UK general practice

Background

Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices' varied experiences over time as they seek to establish remote forms of accessing and delivering care.

Methods

This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups).

Results anticipated

We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint).

Conclusion

By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.

A longitudinal qualitative study of the UK general practice workforce experience of COVID-19

Background:

The COronaVIrus Disease 2019 (COVID-19) pandemic has led to significant re-organisation of general practice in the United Kingdom and around the world. The general practice workforce has led changes to their services, often dealing with high levels of uncertainty. The way in which many practitioners consult has shifted significantly, and there has been an increase in the number of phone and online consultations. We know very little about how those working in general practice experienced the service reorganisation introduced in the first year of the COVID-19 pandemic.

Aim:

The aim of this project was to describe the changes in the delivery of general practice in the United Kingdom in the first year of the COVID-19 pandemic. Furthermore, to explore primary care practitioners’ and managers’ experiences of change within general practice during this time and investigate shifts in perceptions of professional identities.

Method:

We conducted a longitudinal qualitative study that captured narrative accounts from 17 primary care practitioners and managers across England and Scotland. Each participant submitted narrative accounts in the first year of the COVID-19 pandemic using self-recorded or written contributions, or via an interview if preferred. These were analysed using a grounded theory approach, with thematic coding used to construct common themes.

Findings:

Participants’ narratives describe the challenges COVID-19 presented to general practice. Responses mirror the shifts in the pandemic and its management – from an initial sense of autonomy but uncertainty, to a period of stability and patients’ increasing frustration. The re-organisation of general practice has affected practitioners’ views of their work and their role as clinicians. Participants’ narratives were framed profoundly by the importance of their relationships with patients. This analysis of practitioners’ and managers’ narratives highlights the need for further exploration of how to support the general practice workforce’s well-being longer term in a context of increased demand and significant change.

Evaluation of a Digital Self-management Platform for Patients With Chronic Illness in Primary Care: Qualitative Study of Stakeholders' Perspectives

BACKGROUND

Population aging and multimorbidity has led to increasing chronic care needs associated with new challenges in managing growing costs, rising health care professional workloads, and the adoption of rigorous guidelines. These issues could all benefit from greater digitalization and a more patient-centered approach to chronic care, a situation brought to the fore by the COVID-19 pandemic. Little is known about real-life use in primary care.

OBJECTIVE

This study aimed to explore the views, thoughts, usability, and experiences concerning a recently introduced digital self-care platform for chronic conditions in 3 Dutch primary care practices.

METHODS

We conducted an explorative study combining questionnaires and interviews among patients and general practitioners from 3 general practices that used the digital platform. Questionnaires were sent to patients in each practice to seek the views and experiences of both patient nonusers (n=20) and patient users (n=58) of the platform, together with standardized questionnaires about illness perception and quality of life. In addition, patients (n=15) and general practitioners (n=4) who used the platform took part in semistructured interviews. We transcribed interviews verbatim and performed qualitative content analysis using a deductive approach. The results of the questionnaires were analyzed with descriptive analysis.

RESULTS

Among patients who had not actively used the platform but had received an explanation, only 35% (7/20) would recommend its use due to concerns over communication and handling. However, this percentage increased to 76.3% (45/59) among the people who actively used the platform. Interviews with patients and general practitioners who used the platform uncovered several key benefits, including reduced time requirements, reduced workload, improved care quality, and improved accessibility due to the greater patient-centeredness and use of different communication tools. In addition, the self-management tool led to greater patient autonomy and empowerment. Although users considered the platform feasible, usable, and easy to use, some technical issues remained and some patients expressed concerns about the reduction in human contact and feedback.

CONCLUSIONS

The overall experience and usability of the platform was good. Support for the online self-management platform for chronic care increased when patients actively used the tool and could experience or identify important advantages. However, patients still noted several areas for improvement that need to be tackled in future iterations. To ensure benefit in the wider population, we must also evaluate this platform in cohorts with lower digital and health literacy.

Real-time remote outpatient consultations in secondary and tertiary care: A systematic review of inequalities in invitation and uptake

BACKGROUND

Health policies in most high income countries increasingly recommend provision of routine outpatient care via remote (video and/or telephone) appointments, especially due to the pandemic. This is thought to improve access to care and promote efficiency within resource-constrained health services. There is limited evidence about the impact on existing inequalities in the invitation and uptake of health services when remote outpatient care is offered.

AIM

To systematically review the evidence on the offer and/or uptake of real-time remote outpatient consultations in secondary and tertiary care, assessed according to key sociodemographic characteristics.

METHODS

Seven electronic bibliographic databases were searched for studies reporting the proportion of patients with key characteristics (following PROGRESS Plus criteria) who were offered and/or accepted real-time remote outpatient consultation for any chronic condition. Comparison groups included usual care (face-to-face), another intervention, or offer/uptake within a comparable time period. Study processes were undertaken in duplicate. Data are reported narratively.

RESULTS

Twenty-nine studies were included. Uptake of video consultations ranged from 5% to 78% and telephone consultations from 12% to 78%. Patients aged over 65, with lower educational attainment, on lower household incomes and without English as a first language were least likely to have a remote consultation. Females were generally more likely to have remote consultations than males. Non-white ethnicities were less likely to use remote consultations but where they did, were significantly more likely to choose telephone over video appointments (p<0.001).

CONCLUSIONS

Offering remote consultations may perpetuate or exacerbate existing health inequalities in access to healthcare. More research is needed on current health disparities by sociodemographic characteristics and to explore what works well for different patient groups and why so that processes can be designed to ameliorate these health disparities.

TRIAL REGISTRATION

PROSPERO registration no: CRD42021241791.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative virtual video visits only: a convenient option that should be offered to caregivers beyond the pandemic

Objective

During the COVID-19 pandemic, our group implemented preoperative video visits (VVs) to limit physical contact. The aim of this study was to determine caregivers’ and providers’ perceptions of this practice and to determine feasibility for continuation.

Methods

All patients who had only a preoperative VV prior to an elective surgery were identified from March–October 2020. Caregivers, surgeons, and clinic staff were surveyed about their experiences.

Results

Thirty-four preoperative VVs were followed by an elective surgery without a preceding in-person visit. Of the 31 caregiver surveys completed, the majority strongly agreed that the VV was more convenient (87%, n=27). Eighty-one percent (n=25) strongly agreed or agreed that the VV saved them money. Ninety-four percent (n=29) strongly agreed or agreed that they would choose the VV option again. Caregivers saved an average travel distance of 60.3 miles one way (range 6.1–480). Of the 13/17 providers who responded, 77% (n=10) expressed that the practice should continue.

Conclusions

Virtual health became a necessity during the pandemic, and caregivers were overwhelmingly satisfied. Continuing VVs as an option beyond the pandemic may be a reasonable and effective way to help eliminate some of the hurdles that impede healthcare-seeking behavior and should be offered.

Telemedicine and virtual respiratory care in the era of COVID-19

The World Health Organization defines telemedicine as “an interaction between a health care provider and a patient when the two are separated by distance”. The COVID-19 pandemic has forced a dramatic shift to telephone and video consulting for follow up and routine ambulatory care for reasons of infection control. Short Message Service (“text”) messaging has proved a useful adjunct to remote consulting allowing transfer of photographs and documents. Maintaining non-communicable diseases care is a core component of pandemic preparedness and telemedicine has developed to enable (for example) remote monitoring of sleep apnoea, telemonitoring of chronic obstructive pulmonary disease, digital support for asthma self-management, remote delivery of pulmonary rehabilitation. There are multiple exemplars of telehealth instigated rapidly to provide care for people with COVID-19, to manage the spread of the pandemic, or to maintain safe routine diagnostic or treatment services.

Despite many positive examples of equivalent functionality and safety, there remain questions about the impact of remote delivery of care on rapport and the longer-term impact on patient/professional relationships. Although telehealth has the potential to contribute to universal health coverage by providing cost-effective accessible care, there is a risk of increasing social health inequalities if the “digital divide” excludes those most in need of care. As we emerge from the pandemic, the balance of remote versus face-to-face consulting, and the specific role of digital health in different clinical and healthcare contexts will evolve. What is clear is that telemedicine in one form or another will be part of the “new norm”.

Clinical risk in remote consultations in general practice: findings from in-Covid-19 pandemic qualitative research

BACKGROUND

The Covid-19 pandemic-related rise in remote consulting raises questions about the nature and type of risks in remote general practice AIM: To develop an empirically-based and theory-informed taxonomy of risks associated with remote consultations.

DESIGN AND SETTING

Qualitative sub-study of data selected from the wider datasets of three large, multi-site, mixed-method studies of remote care in general practice prior to and during the Covid-19 pandemic in the UK METHOD: Semi-structured interviews and focus groups with a total of 176 clinicians, and 45 patients. We analysed data thematically, taking account of an existing framework of domains of clinical risk.

RESULTS

The Covid-19 pandemic brought changes to estates (eg, how waiting rooms were used), access pathways, technologies, and interpersonal interactions. Six domains of risk were evident in relation to[1] practice organisation and set-up (including digital inequalities of access, technology failure and reduced service efficiency); [2] communication and the therapeutic relationship (including a shift to more transactional consultations); [3] quality of clinical care (including missed diagnoses, safeguarding challenges, over-investigation and over-treatment); [4] increased burden on the patient (eg, to self-examine and navigate between services); [5] reduced opportunities for screening and managing the social determinants of health; and [6] workforce (including increased clinician stress and fewer opportunities for learning).

CONCLUSION

Notwithstanding potential benefits, if remote consultations are to work safely, risks must be actively mitigated by measures that include digital inclusion strategies, enhanced safety-netting and training and support for staff.

A web-based survey of educational opportunities of medical professionals based on changes in conference design during the COVID-19 pandemic

Owing to the coronavirus disease 2019 (COVID-19) pandemic, understanding how to hold future online academic conferences effectively is imperative. We assessed the impact of COVID-19 on academic conferences, including facilities and settings for attendance, participation status, cost burden, and preferences for future styles of holding conferences, through a web-based questionnaire survey of 2,739 Japanese medical professionals, from December 2020 to February 2021. Of the participants, 28% preferred web conferences, 60% preferred a mix of web and on-site conferences, and 12% preferred on-site conferences. Additionally, 27% of the presenters stopped presenting new findings at web conferences. The proportion of participants who audio-recorded or filmed the sessions, despite prohibition, was six times higher at web than face-to-face conferences. Since the COVID-19 outbreak, the percentage of participants attending general presentations decreased from 91 to 51%. While web conferencing offers advantages, these are offset by a decrease in presentations pertaining to novel findings and data.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10639-022-11032-5.

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

OBJECTIVES

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

SETTING

Devon and Cornwall, England.

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

Using Mobile Phone Apps to Deliver Rural General Practitioner Services: Critical Review Using the Walkthrough Method

Background

The widespread use of mobile phones represents new frontiers for improving access to health care. This includes using mobile apps to deliver general practitioner (GP) services in rural areas. However, the wider adoption of apps for increasing access to rural GP services relies on understanding how they might intersect with the rural health system context.

Objective

This research aims to critically review mobile apps for delivering GP services in a rural health service context using the walkthrough method.

Methods

The sample comprised 3 GP service apps under the top 100 list in the medical category in the Apple App Store (also available via the Google Play Store) in Australia as of June 2020. The walkthrough method was applied to extract data and critique the explicit factors, such as the app interface elements, and implicit factors, such as the embedded cultural features related to use for people in rural settings. Data analysis was undertaken between 3 researchers over 6 months applying the walkthrough method and using critical reflection.

Results

There were 3 main themes: improving rural access, addressing rural health care needs, and providing quality of care. App-based GP services may improve rural GP service availability. However, this may be at a relatively superficial level that does not encompass the scope and intensity of the services needed in rural areas (including relevant chronic and emergency care) at a cost that rural patients can afford. The apps showed signs of limited tailoring to the cultural dimensions of rural health care as a barrier to rural use. Patients generally self-selected to use GP service apps with limited support, potentially leading to inappropriate uptake especially by disadvantaged groups with lower health literacy. Although the apps claimed to avail most GP services (70%-80% in some cases), it emerged after enrollment that emergency, complex, and serious conditions might be excluded, potentially imposing more complex caseloads on in-person rural GPs. Apps provided limited information about continuity and coordination of care and sharing information with rural GPs, potentially leading to fragmented and low-quality care. There was commonly no assurance of rural skills and experience of physicians staffing apps despite the wider scope of skills needed to be effective in rural general practice.

Conclusions

GP apps may increase the availability of GP services, but they may require clearer exclusions, appropriate use through decision-making tools, more rural-tailored interfaces, and capacity to align appointment times and costs with patients with complex needs to engage and be useful in a rural context. It is also important to consider how these app-based services could share information with local health care staff for safety and continuity of rural primary care. Finally, information about the physicians’ rural training and experience is critical for quality.

Patient and clinician experiences of remote consultation during the SARS-CoV-2 pandemic: A service evaluation

Objectives

During the SARS-CoV-2 pandemic, clinicians were instructed to move all but emergency consultations to remote means to reduce the spread of the virus. The aim of this study was to evaluate patients’ and clinicians’ experiences of moving to remote means of consultation with their health care professionals during the SARS-CoV-2 pandemic.

Methods

The study design was a qualitative service evaluation. Twenty-six clinicians and forty-eight patients who met the inclusion criteria consented to be interviewed. Clinician participants were from either medical, nursing, or allied health professional backgrounds. Patients were recruited from diabetes, acute care, and haematology and cancer areas. Data analysis was conducted using a thematic analysis framework.

Results

Following coding and thematic analysis of the data collected from clinicians, five themes were identified: personal and professional well-being; providing a safe and high-quality experience; adapting to a new way of working; making remote consultations fit for purpose and an awareness of altered dynamics during consultation. Patient data was coded into 3 themes: remote consultation adds value; remote consultation brings challenges and concerns about remote consultation.

Conclusions

Clinician and patient experiences reported here are reflected in the literature. The study indicates that remote consultation is not suitable for all patients and in all contexts. Whilst maintaining the benefits to patients, remote means of consultation needs organisational support and preparation. A way forward that maintains the benefits whilst addressing concerns seems urgent.

Research policy for people with multiple long-term conditions and their carers

People with multiple long-term conditions (MLTC) are a growing population, not only in the United Kingdom but internationally. Health and care systems need to adapt to rise to this challenge. Policymakers need to better understand how medical education and training, and service configuration and delivery should change to meet the needs of people with MLTC and their carers. A series of workshops with people with MLTC and carers across the life-course identified areas of unmet need including the impact of stigma; poorly coordinated care designed around single conditions; inadequate communication and consultations that focus on clinical outcomes rather than patient-oriented goals and imperfectly integrate mental and physical wellbeing. Research which embeds the patient voice at its centre, from inception to implementation, can provide the evidence to drive the change to patient-centred, coordinated care. This should not only improve the lives of people living with MLTC and their carers but also create a health and care system which is more effective and efficient. The challenge of MLTC needs to be bought to the fore and it will require joint effort by policymakers, practitioners, systems leaders, educators, the third sector and those living with MLTC to design a health and care system from the perspective of patients and carers, and provide practitioners with the skills and tools needed to provide the highest quality care.

The value of telephone consultations during COVID-19 pandemic. An observational study

BACKGROUND

Many Spanish hospitals converted scheduled in-person visits to telephone visits during the COVID-19 lockdown. There is scarce information about the performance of those visits.

AIM

To compare telephone visits during the COVID-19 lockdown period with previous in-person visits.

DESIGN

Retrospective descriptive study.

METHODS

Telephone visits from 15 March to 31 May 2020 were compared with in-person visits during the same period in 2019.

MAIN MEASURES

The proportions of both groups were compared in term of failure to contact patient, requested diagnostic tests/referrals, discharges, admissions and emergency visits within 30-60 days. A sample of patients, and all participating physicians completed surveys. Z-score test was used (statistical significance P<0.05).

RESULTS

A total of 5602 telephone visits were conducted. In comparison to in-person visits, telephone visits showed higher rates of visit compliance (95.9% vs. 85.2%, P<0.001) and discharges (22.12% vs. 11.82%; P<0.001), and lower number of ancillary tests and referrals. During the 30- and 60-day periods following the telephone visit, a reduction of 52% and 47% in the combined number of emergency department visits and hospital admissions was observed compared to in-person visits (P<0.01). Of the 120 patients surveyed, 95% were satisfied/very satisfied with the telephone visits. Of the 26 physicians, 84.6% considered telephone visits were useful to prioritize patients.

CONCLUSIONS

During health emergencies, previously scheduled outpatient in-person visits can be converted to telephone visits, reducing absenteeism, increasing the rate of discharges and reducing ancillary tests and referrals without increasing the rate of hospital admissions or emergency department visits.

Consultation patterns and frequent attenders in UK primary care from 2000 to 2019: a retrospective cohort analysis of consultation events across 845 general practices

OBJECTIVE

To describe the distribution of consultations at the practice level and examine whether increases are uniform or driven by people who consult more frequently.

DESIGN

Retrospective cohort study.

SETTING

UK general practice data from the Clinical Practice Research Datalink (CPRD) GOLD database.

PARTICIPANTS

1 699 709 314 consultation events from 12 330 545 patients, in 845 general practices (1 April 2000 to 31 March 2019).

METHODS

Consultation information was aggregated by financial year into: all consultations/all staff; all consultations/general practitioners (GPs); face-to-face consultations/all staff; face-to-face consultations/GPs. Patients with a number of consultations above the 90th centile, within each year, were classified as frequent attenders. Negative binomial regressions examined the association between available practice characteristics and consultation distribution.

RESULTS

Among frequent attenders, all consultations by GPs increased from a median (25th and 75th centile) of 13 (10 and 16) to 21 (18 and 25) and all consultations by all staff increased from 27 (23-30) to 60 (51-69) over the study period. Approximately four out of ten consultations of any type concerned frequent attenders and the proportion of consultations attributed to them increased over time, particularly for face-to-face consultations with GPs, from a median of 38.0% (35.9%-40.3%) in 2000-2001 to 43.0% (40.6%-46.4%) in 2018-2019. Regression analyses indicated decreasing trends over time for face-to-face consultations and increasing trends for all consultation types, for both GPs and all staff. Frequent attenders consulted approximately five times more than the rest of the practice population, on average, with adjusted incidence rate ratios ranging between 4.992 (95% CI 4.917 to 5.068) for face-to-face consultations with all staff and 5.603 (95% CI 5.560 to 5.647) for all consultations with GPs.

CONCLUSIONS

Frequent attenders progressively contributed to increased workload in general practices across the UK from 2000 to 2019. Important knowledge gaps remain in terms of the demographic, social and health characteristics of frequent attenders and how UK general practices can be prepared to meet the needs of these patients.