Unintended consequences of online consultations: a qualitative study in UK primary care

Remote consultations in primary care: Patient experiences and suggestions for improvement

The use of Remote Consultations (RCs) in primary care expanded rapidly during the Covid-19 pandemic: their ongoing use highlights a need to improve experiences of them. We interviewed 17 adults in the UK, including a sub-sample of five people with a First Language other than English (FLotE). Interpretative Phenomenological Analysis identified five major themes: (1) RCs are convenient, but they require appropriate technology and appropriate conditions of use; (2) even those with good general eHealth literacy and connectivity may struggle with systems that are not user-friendly; (3) greater reliance on verbal communication was experience as limiting empathy, and also made RCs more difficult for people with a FLotE; (4) RCs are considered inappropriate for complex conditions, or those with major psychological components; (5) continuity of care is important, but is often lacking. Overall, interviewees emphasised the need for more user-friendly processes, and greater attention to patients' preferences for consultation type.

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.

Telepharmacy versus Face-to-Face Approach in Providing Inhaler Technique Training Service: A Non-Inferiority Assessment Among German Pharmacy Students

Background

The use of telepharmacy in delivering pharmaceutical care services has grown in the past few years; however, there are perceptions of its inappropriateness for providing medical device training among pharmacy students and practicing pharmacists.

Objective

The primary objective of this study was to determine if the telepharmacy approach for providing inhaler technique training service was non-inferior to the face-to-face approach regarding pharmacy students' performance in simulated patient encounters. Secondary objectives were to determine students' self-assessment of their ability to demonstrate and practice inhaler technique between the two modes of communication and their perceptions of telepharmacy.

Methods

A randomized crossover non-inferiority trial was conducted among undergraduate pharmacy students. Outcomes were measured by comparing Objective Structured Clinical Examination (OSCE) scores of participants' performance between two modes of communication while providing inhaler technique training service. Moreover, the participants also completed self-assessment and perception questionnaires.

Results

The telepharmacy approach was non-inferior to the face-to-face approach for demonstrating and practicing the correct inhaler technique based on OSCE scores and a predefined non-inferiority margin of -10%. The results also revealed no significant differences in student self-confidence between the two modes of communication. Moreover, participants had a largely positive perception of telepharmacy and its use in providing inhaler technique training service.

Conclusion

Considering our findings, telepharmacy is a viable alternative to traditional face-to-face consultations for providing inhaler technique training service. However, to address perceived difficulties and differences between virtual and face-to-face consultations, the pharmacy curriculum should include more telepharmacy-related didactic content with experiential learning and simulations.

Exploring How Patients Are Supported to Use Online Services in Primary Care in England Through "Digital Facilitation": Survey Study

BACKGROUND

Health service policy in many jurisdictions is driving greater investment into digital primary care services. While some patients and practices may benefit, there are concerns that not all are able or wish to access primary care services online. "Digital facilitation" is the "range of processes, procedures, and personnel seeking to support patients in their uptake and use of online services" and may address such concerns.

OBJECTIVE

As part of a multimethod research program, we undertook surveys of practice staff and patients to gain insight into the support being offered by practices and explore patients' experiences of this support.

METHODS

General practices from 4 regions of England were sent a questionnaire exploring the modes of digital facilitation offered, the personnel involved in its delivery, and views on the motivations and drivers for providing support. Moreover, 12,822 patients registered with 62 general practices (predominantly those providing practice survey responses) were sent a questionnaire exploring their experiences of any support offered by their practice to use online services.

RESULTS

Almost one-third of practices (156/500, 31.2%) responded to the practice survey, with most reporting using passive modes of digital facilitation (eg, display, leaflets, and SMS text messages) and few using active modes (eg, offering tablets or computers or using practice champions). However, 90.9% (130/143) reported providing ad hoc support. Practices agreed that it was the responsibility of both the practice (105/144, 72.9%) and the wider National Health Service (118/143, 82.5%) to support patients in using online services and that providing such support benefited the practice (126/144, 87.5%) and their patients (132/144, 91.7%). Nearly a quarter of the patients (3051/12,822, 23.8%) responded to the patient survey, with few (522/3051, 17.11% or less) reporting awareness of any modes of digital facilitation apart from text messages and emails (1205/3051, 39.5%) and only 13.36% (392/2935) reporting receiving support to use online services. Adjusted logistic regression analyses showed that older patients had a lower likelihood of 4 outcomes: being aware of, or of using, digital facilitation efforts, or being told about or being helped to use online services (all P<.05), particularly with regard to being helped to use online services (adjusted odds ratio for patients aged 85 years versus those aged 55-64 years: 0.08, 95% CI 0.02-0.36). However, ethnic minority participants or those for whom their first language was not English had positive associations with these outcomes.

CONCLUSIONS

General practices recognize that patients would benefit from support to access online services. However, the support provided is often passive or ad hoc, and patients were seldom aware of digital facilitation efforts that their practice provided. There is potential to increase engagement with online primary care services by providing more support for all patients, particularly to provide targeted support for older patients.

The Use of Online Consultation Systems and Patient Experience of Primary Care: Cross-Sectional Analysis Using the General Practice Patient Survey

BACKGROUND

NHS England encourages the use of online consultation (OC) systems alongside traditional access methods for patients to contact their general practice online and for practices to manage workflow. Access is a key driver of patients' primary care experience. The use of online technology and patient experience vary by sociodemographic characteristics.

OBJECTIVE

This study aims to assess the association between OC system use and patient experience of primary care in English general practice and how that varies by OC system model and practice sociodemographic characteristics (rurality, deprivation, age, and ethnicity).

METHODS

We categorized practices as "low-use" or "high-use" according to the volume of patient-initiated contacts made via the OC system. We considered practices using one of 2 OC systems with distinct designs and implementation models-shorter "free text" input with an embedded single workflow OC system (FT practices) and longer "mixed text" input with variation in implemented workflow OC system (MT practices). We used 2022 General Practice Patient Survey data to capture 4 dimensions of patient experience-overall experience, experience of making an appointment, continuity of care, and use of self-care before making an appointment. We used logistic regression at the practice level to explore the association between OC system use and patient experience, including interaction terms to assess sociodemographic variation.

RESULTS

We included 287,194 responses from 2423 MT and 170 FT practices. The proportions of patients reporting positive experiences at MT and FT practices were similar or better than practices nationally, except at high-use MT practices. At high-use MT practices, patients were 19.8% (odds ratio [OR] 0.802, 95% CI 0.782-0.823) less likely to report a good overall experience; 24.5% (OR 0.755, 95% CI 0.738-0.773) less likely to report a good experience of making an appointment; and 18.9% (OR 0.811, 95% CI 0.792-0.83) less likely to see their preferred general practitioner; but 27.8% (OR 1.278, 95% CI 1.249-1.308) more likely to use self-care, compared with low-use MT practices. Opposite trends were seen at FT practices. Sociodemographic inequalities in patient experience were generally lower at high-use than low-use practices; for example, gaps in overall experience between practices with the most and fewest White patients decreased by 2.7 percentage points at MT practices and 6.4 percentage points at FT practices. Trends suggested greater improvements in experience for traditionally underserved groups-patients from urban and deprived areas, younger patients, and non-White patients.

CONCLUSIONS

An OC system with shorter free text input and an integrated single workflow can enhance patient experience and reduce sociodemographic inequalities. Variation in patient experience between practices with different sociodemographic characteristics and OC systems underscores the importance of tailored design and implementation. Generalizing results across different OC systems is difficult due to variations in how they are integrated into practice workflows and communicated to patients.

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

BACKGROUND

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

AIM

Explore patients' experiences of using an OCS.

DESIGN AND SETTING

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

METHOD

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

RESULTS

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

CONCLUSION

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

Implementation of a Web-Based Outpatient Asynchronous Consultation Service: Mixed Methods Study

BACKGROUND

Asynchronous outpatient patient-to-provider communication is expanding in UK health care, requiring evaluation. During the pandemic, Aberdeen Royal Infirmary in Scotland expanded its outpatient asynchronous consultation service from dermatology (deployed in May 2020) to gastroenterology and pain management clinics.

OBJECTIVE

We conducted a mixed methods study using staff, patient, and public perspectives and National Health Service (NHS) numerical data to obtain a rounded picture of innovation as it happened.

METHODS

Focus groups (3 web-based and 1 face-to-face; n=22) assessed public readiness for this service, and 14 interviews with staff focused on service design and delivery. The service's effects were examined using NHS Grampian service use data, a patient satisfaction survey (n=66), and 6 follow-up patient interviews. Survey responses were descriptively analyzed. Demographics, acceptability, nonattendance rates, and appointment outcomes of users were compared across levels of area deprivation in which they live and medical specialties. Interviews and focus groups underwent theory-informed thematic analysis.

RESULTS

Staff anticipated a simple technical system transfer from dermatology to other receptive medical specialties, but despite a favorable setting and organizational assistance, it was complicated. Key implementation difficulties included pandemic-induced technical integration delays, misalignment with existing administrative processes, and discontinuity in project management. The pain management clinic began asynchronous consultations (digital appointments) in December 2021, followed by the gastroenterology clinic in February 2022. Staff quickly learned how to explain and use this service. It was thought to function better for pain management as it fitted preexisting practices. From May to September 2022, the dermatology (adult and pediatric), gastroenterology, and pain management clinics offered 1709 appointments to a range of patients (n=1417). Digital appointments reduced travel by an estimated 44,712 miles (~71,956.81 km) compared to the face-to-face mode. The deprivation profile of people who chose to use this service closely mirrored that of NHS Grampian's population overall. There was no evidence that deprivation impacted whether digital appointment users subsequently received treatment. Only 18% (12/66) of survey respondents were unhappy or very unhappy with being offered a digital appointment. The benefits mentioned included better access, convenience, decreased travel and waiting time, information sharing, and clinical flexibility. Overall, patients, the public, and staff recognized its potential as an NHS service but highlighted informed choice and flexibility. Better communication-including the use of the term assessment instead of appointment-may increase patient acceptance.

CONCLUSIONS

Asynchronous pain management and gastroenterology consultations are viable and acceptable. Implementing this service is easiest when existing administrative processes face minimal disruption, although continuous support is needed. This study can inform practical strategies for supporting staff in adopting asynchronous consultations (eg, preparing for nonlinearity and addressing task issues). Patients need clear explanations and access to technical support, along with varied consultation options, to ensure digital inclusion.

Access and triage in contemporary general practice: A novel theory of digital candidacy

To access contemporary healthcare, patients must find and navigate a complex socio-technical network of human and digital actors linked in multi-modal pathways. Asynchronous, digitally-mediated triage decisions have largely replaced synchronous conversations between humans. In this paper, we draw on a large qualitative dataset from a multi-site study of remote and digital technologies in general practice to understand widening inequities of access. We theorise our data by bringing together traditional candidacy theory (in particular, concepts of self-assessment, help-seeking, adjudication and negotiation) and socio-technical and technology structuration theories (in particular, concepts of user configuration, articulation, distanciation, disembedding, and recursivity), thus producing a novel theory of digital candidacy. We propose that both human and technological actors (in different ways) embody social structures which affect how they 'act' in social situations. Digital technologies contain inbuilt assumptions about users' capabilities, needs, rights, and skills. Patients' ability to self-assess as sick, access digital platforms, self-advocate, and navigate multiple stages in the pathway, including adapting to and compensating for limitations in the technology, vary widely and are markedly patterned by disadvantage. Not every patient can craft an accurate digital facsimile on which the subsequent adjudication decision will be made; those who create incomplete, flawed or unpersuasive digital facsimiles may be deprioritised or misdirected. Staff who know about such patients may use articulation measures to ensure a personalised and appropriate access package, but they cannot identify or fully mitigate all such cases. The decisions and actions of human and technological agents at the time of an attempt to access care can significantly influence, disrupt, and reconstitute candidacy both immediately and recursively over time, and also recursively shape the system itself. These findings underscore the need for services to be (co-)designed with attention to the exclusionary tendencies of digital technologies and technology-supported processes and pathways.

Eating and drinking experience in patients with idiopathic pulmonary fibrosis: a qualitative study

OBJECTIVE

To explore eating and drinking experiences of patients with idiopathic pulmonary fibrosis (IPF), the impact of any changes associated with their diagnosis and any coping mechanisms developed by patients.

SETTING

Pulmonary fibrosis support groups around the UK and the regional Interstitial Lung Diseases Clinic, Newcastle upon Tyne.

PARTICIPANTS

15 patients with IPF (9 men, 6 women), median age 71 years, range (54-92) years, were interviewed. Inclusion criteria included competent adults (over the age of 18 years) with a secure diagnosis of IPF as defined by international consensus guidelines. Patients were required to have sufficient English language competence to consent and participate in an interview. Exclusion criteria were a history of other lung diseases, a history of pre-existing swallowing problem of other causes that may be associated with dysphagia and individuals with significant communication or other memory difficulties that render them unable to participate in an interview.

DESIGN

A qualitative study based on semistructured interviews used purpose sampling conducted between February 2021 and November 2021. Interviews were conducted via video videoconferencing call platform or telephone call, transcribed and data coded and analysed using a reflexive thematic analysis.

RESULTS

Three main themes were identified, along with several subthemes, which were: (1) Eating, as such, is no longer a pleasure. This theme mainly focused on the physical and sensory changes associated with eating and drinking and their effects and the subsequent emotional and social impact of these changes; (2) It is something that happens naturally and just try and get on with it. This theme centred on the self-determined strategies employed to manage changes to eating and drinking; and (3) What is normal. This theme focused on patients seeking information to better understand the changes in their eating and drinking and the patients' beliefs about what has changed their eating and drinking.

CONCLUSIONS

To our knowledge, this is the first study to report on IPF patients' lived experience of eating and drinking changes associated with their diagnosis. Findings demonstrate that some patients have substantial struggles and challenges with eating and drinking, affecting them physically, emotionally and socially. There is a need to provide better patient information for this area and further study.

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.

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

BACKGROUND

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

AIM

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

DESIGN & SETTING

Systematic review in general practice.

METHOD

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

RESULTS

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

CONCLUSION

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

Barriers and facilitators to use of digital health tools by healthcare practitioners and their patients, before and during the COVID-19 pandemic: a multimethods study

OBJECTIVES

To explore how healthcare practitioners (HCPs) made decisions about the implementation of digital health technologies (DHTs) in their clinical practice before and during the COVID-19 pandemic.

DESIGN

A multimethods study, comprising semistructured interviews conducted prior to the COVID-19 pandemic, supplemented with an online survey that was conducted during the pandemic with a different sample, to ensure the qualitative findings remained relevant within the rapidly changing healthcare context. Participants were recruited through HCP networks, snowballing and social media. Data were analysed thematically.

SETTING

Phone interviews and online survey.

PARTICIPANTS

HCPs represented a range of professions from primary and secondary care across England, with varied socioeconomic deprivation.

RESULTS

24 HCPs were interviewed, and 16 HCPs responded to the survey. In the interviews, HCPs described three levels where decisions were made, which determined who would have access to what DHTs: health organisation, HCP and patient levels. These decisions resulted in the unequal implementation of DHTs across health services, created barriers for HCPs using DHTs in their practice and influenced HCPs' decisions on which patients to supply DHTs with. In the survey, HCPs described being provided support to overcome some of the barriers at the organisation and HCP level during the pandemic. However, they cited similar concerns to pre-pandemic about barriers patients faced using DHTs (eg, digital literacy). In the absence of centralised guidance on how to manage these barriers, health services made their own decisions about how to adapt their services for those who struggled with DHTs.

CONCLUSIONS

Decision-making at the health organisation, HCP and patient levels influences inequalities in access to DHTs for HCPs and patients. The mobilisation of centralised information and resources during the pandemic can be viewed as good practice for reducing barriers to use of DHTs for HCPs. However, attention must also be paid to reducing barriers to accessing DHTs for patients.

Exploring the experiences and preferences of South Asian patients' of primary care in England since COVID-19

INTRODUCTION

Remote (digital and/or telephone) access and consultation models are being driven by national policy with the goal being that the National Health Service operate on a remote-first (digital-first) basis by 2029. Previous research has suggested that remote methods of access to care and consulting may act to widen health inequalities for certain patients and/or groups such as those from ethnic minorities. South Asian (SA) patients comprise the largest ethnic minority group in England. Understanding the experiences and needs of this group is critical to ensuring that general practice can deliver equitable, quality health care.

METHODS

Qualitative study. 37 participants (from Indian, Pakistani and/or Bangladeshi background) were recruited to take part in either in-person preferred language focus groups or remote semistructured interviews in the English language. Thematic analysis was conducted to identify themes in the qualitative data.

FINDINGS

Three major interlinked themes were identified: (1) reduced access, (2) reduced patient choice and (3) quality and safety concerns. The findings highlight access issues split by (i) general issues with appointment access via any remote means and (ii) specific issues related to language barriers creating additional barriers to access and care. Some patients valued the convenience of remote access but also raised concerns regarding appointment availability and reduced patient choice. Face-to-face consultations were preferable but less available. The findings underscore how participants perceived remote care to be of lesser quality and less safe. Concerns were greatest for those with limited English proficiency (LEP), with the removal of non-verbal aspects of communication and 'hands-on' care leading to perceptions of reduced psycho-social safety.

CONCLUSION

SA patients' experiences of remote-led primary care access and care delivery were negative with only a minority viewing it positively and for certain limited scenarios. Face-to-face models of care remain the preferred mode of consultation, particularly for those with LEP. Hybrid models of access offer patients the greatest choice, and are likely to meet the varying needs of the South-Asian patient population going forwards. The remote first approach to primary care may be achievable as a service ideal, but its limitations need to be recognised and accounted for to ensure that primary care can be an equitable service, both now and in the future.

PUBLIC CONTRIBUTION

Members of the public were involved in all phases of research in the study. This included co-working in partnership throughout the study including, reviewing patient-facing documents, recruiting participants, data facilitation, translation work, interpretation of the data and co-authors on this manuscript. The key to the success of our study was collaborative teamwork, which involved experienced members of the public with SA cultural knowledge working together with and integral to the research team for all components.

Experiences and opinions of general practitioners with patient online record access: an online survey in England

OBJECTIVE

To describe the experiences and opinions of general practitioners (GPs) in England regarding patients having access to their full online GP health records.

DESIGN

Convenience sample, online survey.

PARTICIPANTS

400 registered GPs in England.

MAIN OUTCOME MEASURES

Investigators measured GPs' experiences and opinions about online record access (ORA), including patient care and their practice.

RESULTS

A total of 400 GPs from all regions of England responded. A minority (130, 33%) believed ORA was a good idea. Most GPs believed a majority of patients would worry more (364, 91%) or find their GP records more confusing than helpful (338, 85%). Most GPs believed a majority of patients would find significant errors in their records (240, 60%), would better remember their care plan (280, 70%) and feel more in control of their care (243, 60%). The majority believed they will/already spend more time addressing patients' questions outside of consultations (357, 89%), that consultations will/already take significantly longer (322, 81%) and that they will be/already are less candid in their documentation (289, 72%) after ORA. Nearly two-thirds of GPs believed ORA would increase their litigation (246, 62%).

CONCLUSIONS

Similar to clinicians in other countries, GPs in our sample were sceptical of ORA, believing patients would worry more and find their records more confusing than helpful. Most GPs also believed the practice would exacerbate work burdens. However, the majority of GPs in this survey also agreed there were multiple benefits to patients having online access to their primary care health records. The findings of this survey also contribute to a growing body of contrastive research from countries where ORA is advanced, demonstrating clinicians are sceptical while studies indicate patients appear to derive multiple benefits.

What helps patients access web-based services in primary care? Free-text analysis of patient responses to the Di-Facto questionnaire

BACKGROUND

The National Health Service (NHS) and general practice are increasingly adopting digital services. These services can impact both positively and negatively upon patient experiences, and access to digital services is not equal amongst all groups. Within a wider project examining digital facilitation (the Di-Facto study) our team conducted a patient survey amongst English primary care practices aiming to investigate patient views of what supports uptake and use of web-based services. This paper reports on the analysis of the free-text responses from the patient survey.

METHODS

The Di-Facto patient survey was distributed to practices in eight clinical commissioning groups (CCGs) in England between 2021-2022. We examined free-text responses to two questions relating to access to primary care web-based and support for web-based services. We used qualitative reflexive thematic analysis based on a six-stage process to analyse responses.

RESULTS

Of the 3051 patients who responded to the Di-Facto survey, 2246 provided a free-text response. We present our findings in two major themes: systems and structures and their impact on use of web-based services, and 'what works for me', a description of how respondents described what worked, or did not work in terms of their interactions with web-based services. Respondents described how the technology, such as poor practice website design, confusion over multiple digital apps, data security and concerns about eConsultation offerings impacted on use of web-based services. Respondents described practice level barriers, such as a lack of or inconsistent provision, which prevented optimal use of web-based services. Respondents described personal and technical barriers that impacted on their use of digital services, and described which web-based services worked well for them. Respondents felt that web-based services were not a replacement for face-to-face interactions with a doctor.

CONCLUSIONS

This analysis of free-text responses from a large patient survey highlights the system, practice, and person level barriers and facilitators to use of digital services in primary care. With an increasing push towards digital solutions in NHS primary care, practices should consider the design, rollout and communication of their web-based services to support patient access.

General practice as a place to receive help for domestic abuse during the COVID-19 pandemic: a qualitative interview study in England and Wales

BACKGROUND

General practice is an important place for patients experiencing or perpetrating domestic violence and abuse (DVA), and for their children to seek and receive help. While the incidence of DVA may have increased during the COVID- 19 pandemic, there has been a reduction in DVA identifications and referrals to specialist services from general practice. Concurrently there has been the imposition of lockdown measures and a shift to remote care in general practices in the UK.

AIM

To understand the patient perspective of seeking and receiving help for DVA in general practice during the COVID-19 pandemic. This was then compared with experiences of general practice healthcare professionals.

DESIGN AND SETTING

A qualitative interview study in seven urban general practices in England and Wales, as part of a feasibility study of IRIS+, an integrated primary care DVA system-level training and support intervention.

METHOD

Semi-structured interviews with 21 patients affected by DVA and 13 general practice healthcare professionals who had received IRIS+ training. Analysis involved a Framework approach.

RESULTS

Patients recounted positive experiences of seeking help for DVA in general practice during the pandemic. However, there have been perceived problems with the availability of general practice and a strong preference for face-to-face consultations, over remote consultations, for the opportunities of non- verbal communication. There were also concerns from healthcare professionals regarding the invisibility of children affected by DVA.

CONCLUSION

Perspectives of patients and their families affected by DVA should be prioritised in general practice service planning, including during periods of transition and change.

Digital Health Interventions to Improve Access to and Quality of Primary Health Care Services: A Scoping Review

Global digital technology advances offer the potential to enhance primary health care (PHC) quality, reach, and efficiency, driving toward universal health coverage (UHC). This scoping review explored how digital health solutions aid PHC delivery and UHC realization by examining the context, mechanisms, and outcomes of eHealth interventions. A comprehensive literature search was conducted, capturing qualitative and quantitative studies, process evaluations, and systematic or scoping reviews. Our analysis of 65 articles revealed that a well-functioning digital ecosystem-featuring adaptable, interoperable digital tools, robust Information and Communications Technology foundations, and enabling environments-is pivotal for eHealth interventions' success. Facilities with better digital literacy, motivated staff, and adequate funding demonstrated a higher adoption of eHealth technologies, leading to improved, coordinated service delivery and higher patient satisfaction. However, eHealth's potential is often restricted by existing socio-cultural norms, geographical inequities in technology access, and digital literacy disparities. Our review underscores the importance of considering the digital ecosystem's readiness, user behavior, broader health system requirements, and PHC capacity for adopting digital solutions while assessing digital health interventions' impact.

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.

Body objectified? Phenomenological perspective on patient objectification in teleconsultation

The global crisis of COVID-19 pandemic has considerably accelerated the use of teleconsultation (consultation between the patient and the doctor via video platforms). While it has some obvious benefits and drawbacks for both the patient and the doctor, it is important to consider-how teleconsultation impacts the quality of the patient-doctor relationship? I will approach this question through the lens of phenomenology of the body, focusing on the question-what happens to the patient objectification in teleconsultation? To answer this question I will adopt a phenomenological approach combining both insights drawn from the phenomenological tradition, i.e., the concepts of the lived body and the object body, and the results from the phenomenologically informed qualitative research study on the patient experience of teleconsultation. The theoretical background against which I have developed this study comprises discussions within the field of phenomenology of medicine regarding the different sources of patient objectification within clinical encounter and the arguments concerning the negative impact that objectification has on the quality of care. I will argue that a factor that has frequently been identified within phenomenology of medicine as the main source of patient objectification in clinical encounters, namely, the internalized gaze of the clinician, is diminished during teleconsultation, increasing patient's sense of agency, decreasing her sense of alienation and opening up the possibility for a closer relationship between the patient and the health care provider, all of which lead to the transformation of the hierarchical patient-health care professional relationship.

How is primary care access changing? A retrospective, repeated cross-sectional study of patient-initiated demand at general practices in England using a modern access model, 2019-2022

OBJECTIVES

To explore trends in patient-initiated requests for general practice services and the association between patient characteristics including demographics, preferences for care and clinical needs and modes of patient contact (online vs telephone), and care delivery (face-to-face vs remote) at practices using a modern access model.

DESIGN

Retrospective repeated cross-sectional study spanning March 2019 to February 2022.

SETTING

General practices in England using the askmyGP online consultation system to implement a modern general practice access model using digital and non-digital (multimodal) access pathways and digitally supported triage to manage patient-initiated requests.

PARTICIPANTS

10 435 465 patient-initiated requests from 1 488 865 patients at 154 practices.

RESULTS

Most requests were initiated online (72.1% in 2021/2022) rather than by telephone. Online users were likely to be female, younger than 45 years, asking about existing medical problems, had used the system before and frequent attenders (familiar patients). During the pandemic, request rates for face-to-face consultations fell while those for telephone consultations and online messages increased, with telephone consultations being most popular (53.8% in 2021/2022). Video was seldom requested. More than 60% of requests were consistently delivered in the mode requested. Face-to-face consultations were more likely to be used for the youngest and oldest patients, new medical problems, non-frequent attenders (unfamiliar patients) and those who requested a face-to-face consultation. Over the course of the study, request rates for patients aged over 44 years increased, for example, by 15.4% (p<0.01) for patients aged over 74 years. Rates for younger patients decreased by 32.6% (p<0.001) in 2020/2021, compared with 2019/2020, before recovering to prepandemic levels in 2021/2022.

CONCLUSIONS

Demand patterns shed light on the characteristics of patients making requests for general practice services and the composition of the care backlog with implications for policy and practice. A modern general practice access model can be used effectively to manage patient-initiated demand.

General practice wide adaptations to support patients affected by DVA during the COVID-19 pandemic: a rapid qualitative study

BACKGROUND

Reporting of domestic violence and abuse (DVA) increased globally during the pandemic. General Practice has a central role in identifying and supporting those affected by DVA. Pandemic associated changes in UK primary care included remote initial contacts with primary care and predominantly remote consulting. This paper explores general practice's adaptation to DVA care during the COVID-19 pandemic.

METHODS

Remote semi-structured interviews were conducted by telephone with staff from six localities in England and Wales where the Identification and Referral to Improve Safety (IRIS) primary care DVA programme is commissioned.  We conducted interviews between April 2021 and February 2022 with three practice managers, three reception and administrative staff, eight general practice clinicians and seven specialist DVA staff. Patient and public involvement and engagement (PPI&E) advisers with lived experience of DVA guided the project. Together we developed recommendations for primary care teams based on our findings.

RESULTS

We present our findings within four themes, representing primary care adaptations in delivering DVA care: 1. Making general practice accessible for DVA care: staff adapted telephone triaging processes for appointments and promoted availability of DVA support online. 2. General practice team-working to identify DVA: practices developed new approaches of collaboration, including whole team adaptations to information processing and communication 3. Adapting to remote consultations about DVA: teams were required to adapt to challenges including concerns about safety, privacy, and developing trust remotely. 4. Experiences of onward referrals for specialist DVA support: support from specialist services was effective and largely unchanged during the pandemic.

CONCLUSIONS

Disruption caused by pandemic restrictions revealed how team dynamics and interactions before, during and after clinical consultations contribute to identifying and supporting patients experiencing DVA. Remote assessment complicates access to and delivery of DVA care. This has implications for all primary and secondary care settings, within the NHS and internationally, which are vital to consider in both practice and policy.

Digital exclusion as a potential cause of inequalities in access to care: a survey in people with inflammatory rheumatic diseases

Objectives

COVID-19 led to rapid uptake of digital health care. We sought to examine digital access, health and digital literacy, and impact on confidence and satisfaction with remote consultations in people with inflammatory rheumatic diseases (IRDs).

Methods

People with IRDs (n = 2024) were identified from their electronic health record and invited to participate in a cross-sectional survey, using short message service (SMS) and postal approaches. Data were collected on demographics, self-reported diagnosis, access to and use of internet-enabled devices, health and digital literacy, together with confidence and satisfaction with remote consultations. Ethical approval was obtained (Ref 21/PR/0867).

Results

Six hundred and thirty-nine (639) people completed the survey [mean (s.d.) age 64.5 (13.1) years, 384 (60.1%) female]. Two hundred and eighty-seven (44.9%) completed it online. One hundred and twenty-six (19.7%) people reported not having access to an internet-enabled device. Ninety-three (14.6%) reported never accessing the internet; this proportion was highest (23%) in people with RA. One hundred and seventeen (18%) reported limited health literacy. Even in those reporting internet use, digital literacy was only moderate. People with limited health or digital literacy or without internet access were less likely to report confidence or satisfaction with remote consultations.

Conclusion

Limited health and digital literacy, lack of digital access and low reported internet use were common, especially in older people with RA. People with limited health literacy or limited digital access reported lower confidence and satisfaction with remote consultations. Digital implementation roll-out needs to take account of people requiring extra support to enable them to access care digitally or risks exacerbating health inequalities.

Older patients' experiences of access to and use of e-consultations with the general practitioner in Norway: an interview study

OBJECTIVE

To explore older patients' experiences with accessing and using e-consultations to send text-based clinical inquiries to the general practitioner (GP) online.

DESIGN

Qualitative study based on semi-structured interviews. Results were analysed through a six-phase thematic analysis and interpreted through Levesque's framework of patient-centred access to health care.

SETTING

General practice in Norway.

SUBJECTS

Patients aged over 65 years (n = 16) with experience in using e-consultations.

RESULTS

Respondents considered e-consultations as an integrated part of general practice which helped them achieve better access to health care. We identified four themes describing older patients' access to and use of e-consultations: 1) the importance of digital health literacy to learn about and use the service - and the fear of losing it, 2) the high availability of the service as the main advantage, due to the perceived unavailability of physical GP services, 3) the importance of voluntary use of e-consultations, 4) the importance of a trusting relationship with the GP.

IMPLICATIONS

Information about e-consultations and guidelines for suitable use are recommended to ensure equal access to all patients, regardless of their digital health literacy. Availability problems and high work burdens for the GPs could affect the patients' choice for using e-consultations. If e-consultations are used for triage purposes, caution should be taken to avoid a shift in workload from the health secretary to the GP.Key points of articleThe extended use of e-consultations with the general practitioner has raised concerns that the service may not be accessible and suitable for older patients.For older users, e-consultations can represent a positive addition to physical consultation forms due to the high availability of the service in a general practice setting characterised by long waiting times.Digital health literacy is essential to learn about and use the service. Information about the service and how to use it should be available to all patients to ensure equal access.A trusting relationship with the GP is described as essential for older patients to perceive the outcome of e-consultations as appropriate and safe.

Remote care in UK general practice: baseline data on 11 case studies

Background

Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.

Methods

Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.

Results

Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.

Conclusions

General practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Remote care in UK general practice: baseline data on 11 case studies

BACKGROUND

Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.

METHODS

Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.

RESULTS

Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK's technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the 'digital front door' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.

CONCLUSIONS

General practices' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care

BACKGROUND

Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access 'digital first' primary care by 2023-2024, including online patient access to full medical records.

AIM

To identify and understand the unintended consequences of online patient access to medical records.

DESIGN AND SETTING

Qualitative interview study in 10 general practices in South West and North West England.

METHOD

Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records.

RESULTS

Online access generated unintended consequences that negatively impacted patients' understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs' documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients.

CONCLUSION

The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access.

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.

Professional perspectives on impacts, benefits and disadvantages of changes made to community continence services during the COVID-19 pandemic: findings from the EPICCC-19 national survey

BACKGROUND

The COVID-19 pandemic required changes to the organisation and delivery of NHS community continence services which assess and treat adults and children experiencing bladder and bowel difficulties. Although strong evidence exists for the physical and mental health benefits, improved quality of life, and health service efficiencies resulting from optimally organised community-based continence services, recent audits identified pre-pandemic pressures on these services. The aim of this study was to explore professional perceptions of changes made to community continence services due to the COVID-19 pandemic and consequent impacts on practice, care provision and patient experience.

METHODS

Online survey of 65 community continence services in England. Thematic analysis using constant comparison of open-ended questions. Frequency counts of closed-ended questions.

RESULTS

Sixty-five services across 34 Sustainability and Transformation Partnership areas responded to the survey. Use of remote/virtual consultations enabled continuation of continence care but aspects of 'usual' assessment (examinations, tests) could not be completed within a remote assessment, requiring professionals to decide which patients needed subsequent in-person appointments. Remote appointments could increase service capacity due to their time efficiency, were favoured by some patients for their convenience, and could increase access to care for others. However, the limited ability to complete aspects of usual assessment raised concerns that diagnoses could be missed, or inappropriate care initiated. The format also restricted opportunities to identify non-verbal cues that could inform professional interpretation; and made building a therapeutic relationship between professional and patient more challenging. Remote appointments also posed access challenges for some patient groups. A third of participating services had experienced staff redeployment, resulting in long wait times and some patients being left without care; or reported additional caseload, which had delayed care provision for patients with continence issues. Participants perceived continence care to have been deprioritised, and more generally undervalued, and called for greater recognition of the impact of continence care.

CONCLUSIONS

Remote appointments offer efficiency and convenience. However, 'in-person' approaches are highly valued for optimum quality, patient-centred continence care, and good team relationships. Failure to restore redeployed continence staff will diminish patient health and quality of life, with associated costs to the NHS.

General Practice Nurses' experiences of changing care delivery during COVID-19. Implications for future practice: Qualitative study protocol

Aim

To explore how General Practice Nurses experience implementing change at pace and scale in delivering care during consecutive waves of the COVID‐19 pandemic.

To evaluate the impact of changes to general practice nurses' working practices on professional wellbeing.

Background

In response to the COVID‐19 pandemic, general practice rapidly and extensively changed care delivery. There has been little exploration of the experiences of General Practice Nurses and care delivery, job satisfaction, workload, stress and professional support.

Design

A qualitative case study design of three to five general practice case sites will explore General Practice Nurses' experiences during the Covid‐19 pandemic. The study was funded and approved by the General Nursing Council Trust in June 2021. University ethics approval was gained in July 2021. Health Research Authority approval has been obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834].

Methods

Data will consist of focus groups and/or semi‐structured interviews with General Practice Nurses, primary healthcare team members and other key informants. Business/strategy and nurse team meetings relating to workforce planning/review will be observed. Documents will be analysed and routinely collected general practice data will provide descriptive contextualisation at each site. The study will be theoretically underpinned by the Non‐adoption, Abandonment, Scale‐up, Spread and Sustainability Framework and data analysed using framework analysis.

Discussion

General Practice Nurses have a unique sphere of knowledge and undertake specific work in primary care. This workforce is challenged by recruitment, retention and retirement issues, leading to the loss of highly experienced and knowledgeable professionals. It is important to explore how working practices brought about by Covid‐19 affect General Practice Nurses.

Impact

This study will explore working practices brought about by the Covid‐19 pandemic to inform care delivery, patient care and support General Practice Nursing workforce wellbeing and will highlight and mitigate negative aspects of novel and changing care delivery. Key factors in implementing and supporting future practice and change implementation will be developed.

Trial registration: CPMS: 51834.