‘Evaluation of the First Year(s) of Physicians’ Collaboration on an Interdisciplinary Electronic Consultation Platform in the Netherlands: a mixed-methods observational study. (Preprint)

Evaluation of the introduction of a single-lead ECG device and digital cardiologist consultation platform among general practitioners in the Netherlands

AIM

To evaluate the use of a single-lead electrocardiography (1L-ECG) device and digital cardiologist consultation platform in diagnosing arrhythmias among general practitioners (GPs).

BACKGROUND

Handheld 1L-ECG offers a user-friendly alternative to conventional 12-lead ECG in primary care. While GPs can safely rule out arrhythmias on 1L-ECG recordings, expert consultation is required to confirm suspected arrhythmias. Little is known about GPs' experiences with both a 1L-ECG device and digital consultation platform for daily practice.

METHODS

We used two distinct methods in this study. First, in an observational study, we collected and described all cases shared by GPs within a digital cardiologist consultation platform initiated by a local GP cooperative. This GP cooperative distributed KardiaMobile 1L-ECG devices among all affiliated GPs (n = 203) and invited them to this consultation platform. In the second part, we used an online questionnaire to evaluate the experiences of these GPs using the KardiaMobile and consultation platform.

FINDINGS

In total, 98 (48%) GPs participated in this project, of whom 48 (49%) shared 156 cases. The expert panel was able to provide a definitive rhythm interpretation in 130 (83.3%) shared cases and answered in a median of 4 min (IQR: 2-18). GPs responding to the questionnaire (n = 43; 44%) thought the KardiaMobile was of added value for rhythm diagnostics in primary care (n = 42; 98%) and easy to use (n = 41; 95%). Most GPs (n = 36; 84%) valued the feedback from the cardiologists in the consultation platform. GPs experienced this project to have a positive impact on both the quality of care and diagnostic efficiency for patients with (suspected) cardiac arrhythmias. Although we lack a comprehensive picture of experienced impediments by GPs, solving technical issues was mentioned to be helpful for further implementation. More research is needed to explore reasons of GPs not motivated using these tools and to assess real-life clinical impact.

Differences and similarities in teledermatological primary care case histories between people with different skin tones

Evaluation of teleconsultations on the Prisma platform revealed differences in the type of questions posted by Dutch general practitioners and advice received from dermatologists regarding people with skin of colour (SOC) and those with white skin. A survey of users of this interdisciplinary platform confirmed low competence in recognizing and treating problems in people with SOC, and a need for additional education to provide care for people with SOC identified.

Formalizing the curbside: digitally enhancing access to specialty care

Asynchronous medical care has increased in utilization, patient interest, and industry demand. While E-consults have been discussed extensively in the literature, there are rare examples of a multispecialty implementation within a large health system. Here, we describe our experience in implementing an internal E-consult program for asynchronous, nonurgent communication between ambulatory specialists and primary care providers in our large multispecialty regional health system. To ensure adoption of the program, patient, specialist, and primary care physician concerns were systematically addressed. The program commenced in February 2022 with three high referral rate specialties: cardiology, orthopedics, and dermatology. In the 12 months after implementation, 2243 total E-consults were ordered among 505 ordering providers. Dermatology received the most consultations, and we have expanded to 19 specialties and subspecialties available in the program in the first year. Our E-consult implementation experienced substantial growth in a short time period, demonstrating the viability of E-consult utilization for increasing asynchronous access to ambulatory specialists' expertise in a large healthcare system.

Local initiative supports case isolation and contact tracing during a SARS-CoV-2 surge in summer 2020: a community case study in Antwerp, Belgium

In Antwerp, Belgium's second largest city, a COVID-19 surge in July 2020 predominantly affected neighborhoods with high ethnic diversity. Local volunteers reacted and set up an initiative to support contact tracing and self-isolation. We describe the origin, implementation, and transfer of this local initiative, based on semi-structured interviews of five key informants and document review. The initiative started in July 2020, when family physicians signaled a surge of SARS-CoV-2 infections among people of Moroccan descent. Family physicians feared that the mainstream contact tracing organized by the Flemish government through centralized call centers would not be efficient in halting this outbreak. They anticipated language barriers, mistrust, inability to investigate case clusters, and practical problems with self-isolation. It took 11 days to start up the initiative, with logistical support from the province and city of Antwerp. Family physicians referred SARS-CoV-2-infected index cases with complex needs (including language and social situation) to the initiative. Volunteer COVID coaches contacted cases, got a contextualized understanding of their living conditions, assisted with backward and forward contact tracing, offered support during self-isolation, and checked if infected contacts also needed support. Interviewed coaches were positive about the quality of the interaction: they described extensive open conversations with cases. The coaches reported back to referring family physicians and coordinators of the local initiative, who took additional action if necessary. Although interactions with affected communities were perceived as good, respondents considered that the number of referrals by family physicians was too low to have a meaningful impact on the outbreak. In September 2020, the Flemish government assigned the tasks of local contact tracing and case support to the local health system level (primary care zones). While doing so, they adopted elements of this local initiative, such as COVID coaches, tracing system, and extended questionnaires to talk with cases and contacts. This community case study illustrates how urgency can motivate people to action yet support from people with access to resources and coordination capacity is vital for effective organization and transition to long-term sustainability. From their conception, health policies should consider adaptability of new interventions to local contexts.

Impact of digital interdisciplinary consultation on secondary care referrals by general practitioners: a protocol for a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Optimal collaboration between general practice and hospital care is crucial to maintain affordable and sustainable access to healthcare for the entire population. General practitioners (GPs) are the gatekeepers to specialist care and patients will visit hospitals mostly only after referral. However, a substantial part of these referrals may be inappropriate, as communication between GPs and medical specialists can be challenging and referring patients may be the most obvious action for a GP to perform.A new digital platform (Prisma) connects GPs and specialists in interdisciplinary groups and facilitates asynchronous, accessible and fast teleconsultation within the group. No previous research has been done to evaluate the impact of this new platform on the referral rates to the hospital.

METHODS AND ANALYSIS

A stepped-wedge randomised controlled trial (RCT) will be performed in Zwolle region in the Netherlands to analyse the effect of introduction of the platform on rate of inappropriate referrals to orthopaedic surgery. In four steps, GPs in the region will be given access to the platform. GPs will be part of the control condition until randomisation to the intervention. According to our sample size calculation, we need to include 18 practices with 1008 patients presenting with hip and knee symptoms. Routine care data of hospital registrations will be analysed to calculate the rate of inappropriate referrals (primary outcome). Secondary outcome are costs, primary and secondary care workload, posted cases and user satisfaction. Alongside this quantitative analysis, we will evaluate patient experience, facilitators and barriers for use of the platform.

ETHICS AND DISSEMINATION

The medical ethics review board of University Medical Center Groningen (UMCG), the Netherlands (METc-number: 2021/288) has confirmed that the Medical Research Involving Human Subjects Act (WMO) does not apply to the process evaluation because the study does not involve randomisation of patients or different medical treatments (letter number: M21.275351).

TRIAL REGISTRATION NUMBER

NL9704.