Inequalities in general practice remote consultations: a systematic review

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.

Medical deserts in Finland: measuring the accessibility and availability of primary health care services

BACKGROUND

Well-functioning primary health care (PHC) systems are needed to meet the challenges of aging populations and increasing care needs. However, "medical deserts", areas with poor accessibility and availability of PHC services, remain a significant issue throughout Europe, contributing to regional inequalities. Identifying the location of these areas is crucial for effective policymaking and for improving health outcomes. Our aim was to locate underserved areas in Finland by developing a medical desert index. In addition, we examined the impact of telehealth, care needs, and multiple funding sources on the index and analyzed its association with key quality indicators.

METHODS

The index was calculated using routinely collected municipality-level PHC consultation data from 2022 adjusted for population care needs (availability) and the average travel time to the nearest PHC center (accessibility). Telehealth and occupational healthcare consultations were included separately. Standardized index values were mapped and categorized using descriptive analysis, and compared with indicators of healthcare utilization, care accessibility and availability, care satisfaction, and continuity of care using correlation analysis.

RESULTS

The index displayed clear patterns of medical deserts, primarily in the rural areas of northern and eastern Finland. Approximately 13% of the Finnish population resided in medical deserts, defined as a standard score of -0.5 or lower. The inclusion of telehealth consultations appeared to improve the index values especially in some rural areas. Better accessibility and availability of PHC services, as indicated through the index, was significantly correlated with lower proportion of acute care consultations, fewer hospital care days, and lower continuity of care among clients aged 65 years and older.

CONCLUSIONS

We were able to identify medical deserts in Finland utilizing novel methodology distinct from previous indicators, and thus providing important considerations for future research on regional inequalities in accessibility and availability of PHC services. Our findings demonstrated the potential of telehealth services in mitigating medical deserts, though its appropriateness for some population groups and care needs remains unclear. We call for health policy addressing PHC service provision especially in rural areas.

The Impact of Virtual Consultations on Quality of Care for Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis

BACKGROUND

Virtual consultations (VC) have transformed healthcare delivery, offering a convenient and effective way to manage chronic conditions such as Type 2 Diabetes (T2D). This systematic review and meta-analysis evaluated the impact of VC on the quality of care provided to patients with T2D, mapping it across the six domains of the US National Academy of Medicine (NAM) quality-of-care framework (ie, effectiveness, efficiency, patient-centeredness, timeliness, safety, and equity).

METHODS

A systematic search was conducted in PubMed/MEDLINE, Cochrane, Embase, CINAHL, and Web of Science for the period between January 2010 and December 2024. Eligible studies involved adult T2D patients, evaluated synchronous VCs, and reported outcomes relevant to NAM quality domains. Two independent reviewers performed screening, and studies were assessed using the Mixed Methods Appraisal Tool (MMAT). A narrative synthesis was conducted for each quality domain, and a meta-analysis of HbA1c levels was performed using random-effects models.

RESULTS

In total, 15 studies involving 821 014 participants were included. VCs were comparable with face-to-face care in effectiveness, efficiency, patient-centeredness, and timeliness, with improvements in accessibility and patient satisfaction. Mixed results were found for safety due to limitations in physical assessments, and for equity, with older adults and those with lower digital literacy facing more challenges. The meta-analysis showed no significant difference in HbA1c reduction between VCs and face-to-face (standardized mean difference [SMD] = -0.31, 95% confidence interval [CI]: -0.71 to 0.09, P = 0.12).

CONCLUSION

VCs offer a promising alternative to in-person care, but addressing digital disparities and improving access for older adults are essential for maximizing VC potential.

GP remote consultations with marginalised patients and the importance of place during care: a qualitative study of the role of place in GP consultations

BACKGROUND

Since the COVID-19 pandemic, there has been an increase in the use of remote consultations in general practice in the UK. This leads to the displacement of the consultation outside of the physical general practice, and its 'emplacement' elsewhere, with underexplored consequences for inequities of health care in marginalised groups.

AIM

To examine the place-making demands that remote consultations make on patients, and the ways that these affect their experiences of care, with a focus on the impact on patients from marginalised groups.

DESIGN & SETTING

Ethnography and interview study (n = 15) undertaken at three fieldwork sites in London: a foodbank, a community development organisation, and a drop-in advice centre for migrants. Additionally, GPs (n = 5) working at practices in deprived areas of London, Digital Health Hub staff (n = 4), and staff at fieldwork sites (n = 3) were interviewed.

METHOD

Ethnographic observation was undertaken for 84 hours at the fieldwork site services, and semi-structured interviews (n = 27) took place with service users and service providers. Interviews were conducted in-person and over the phone, and data were analysed through reflexive thematic analysis.

RESULTS

The core themes emerging from the data included challenges securing privacy during remote consultations and the loss of formal healthcare spaces as important places of care. These findings were closely tied to resource access, leading to inequities in experiences of care.

CONCLUSION

Remote GP consultations are not 'place-less' encounters, and inequities in access to suitable spaces may lead to inequities in experiences of care. Attention should be given to ensuring that patients without appropriate spaces for remote consultations are offered in-person care, or consultation times made more specific to allow for organisation of private space.

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.

Examining Intersectionality and Barriers to the Uptake of Video Consultations Among Older Adults From Disadvantaged Backgrounds With Limited English Proficiency: Qualitative Narrative Interview Study

BACKGROUND

The rapid shift to video consultation services during the COVID-19 pandemic has raised concerns about exacerbating existing health inequities, particularly for disadvantaged populations. Intersectionality theory provides a valuable framework for understanding how multiple dimensions of disadvantage interact to shape health experiences and outcomes.

OBJECTIVE

This study aims to explore how multiple dimensions of disadvantage-specifically older age, limited English proficiency, and low socioeconomic status-intersect to shape experiences with digital health services, focusing on video consultations.

METHODS

Following familiarization visits and interviews with service providers, 17 older people with multiple markers of disadvantage (older age, low socioeconomic status, and limited English proficiency) were recruited in the Redbridge borough of London. Data collection included narrative interviews and ethnographic observations during home visits. Field notes captured participants' living conditions, family dynamics, and technological arrangements. Guided by intersectionality theory and digital capital concepts, interviews explored participants' experiences accessing health care remotely. Intersectional narrative analysis was used to identify key themes and examine how different forms of disadvantage interact. We developed theoretically informed narrative portraits and user personas to synthesize findings.

RESULTS

Analysis revealed that the digitalization of health care can exacerbate existing inequities, erode trust, compound oppression, and reduce patient agency for multiply disadvantaged patient populations. Examining intersectionality illuminated how age, language proficiency, and socioeconomic status interact to create unique barriers and experiences. Key themes included the following: weakened presence in digital interactions, erosion of therapeutic relationships, shift from relational to distributed continuity, increased complexity leading to disorientation, engagement shaped by previous experiences of discrimination, and reduced patient agency.

CONCLUSIONS

This study provides critical insights into how the digitalization of health care can deepen disparities for older patients with low income and limited English proficiency. By applying intersectionality theory to digital health disparities, our findings underscore the need for multifaceted approaches to digital health equity that address the complex interplay of disadvantage. Recommendations include co-designing inclusive digital services, strengthening relational continuity, and developing targeted support to preserve agency and trust for marginalized groups in an increasingly digital health care landscape.

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.

Disparities in the Timeliness of Addressing Patient-Initiated Telephone Calls in a Primary Care Clinic: The Impact of Quality Improvement Interventions

A timely response to patient-initiated telephone calls can affect many aspects of patient health, including quality of care and health equity. Historically, at a family medicine residency clinic, at least 1 out of 4 patient calls remained unresolved three days after the call was placed. We sought to explore whether there were differential delays in resolution of patient concerns for certain groups and how these were affected by quality improvement interventions to increase responsiveness to patient calls. A multidisciplinary team at a primary care residency clinic applied Lean education and tools to improve the timeliness of addressing telephone encounters. Telephone encounter data were obtained for one year before and nine months after the intervention. Data were stratified by race, ethnicity, preferred language, sex, online portal activation status, age category, zip code, patient risk category, and reason for call. Stratified data revealed consistently worse performance on telephone encounter closure by 72 hours for Black/African American patients compared to Hispanic and non-Hispanic White patients pre-intervention. Interventions resulted in statistically significant overall improvement, with an OR of 2.9 (95% CI: 2.62 to 3.21). Though interventions did not target a specific population, pre-intervention differences based on race and ethnicity resolved post-intervention. Telephone calls serve as an important means of patient communication with care teams. General interventions to improve the timeliness of addressing telephone encounters can lead to sustainable improvement in a primary care academic clinic and may also alleviate disparities.

Contextual factors influencing the use of digital health by patients and physicians in primary care: a scoping review protocol

INTRODUCTION

Integrating digital health technologies to improve the overall performance of healthcare systems counts among the top priorities of the WHO. As evidenced in recent research, there are specific factors that may decisively determine the effective implementation and development of innovative digital health solutions. This review attempts to recognise and map the existing body of research and evidence to identify the determinants that either favour or hinder the deployment and use of digital health technologies by patients and physicians in primary care.

METHODS AND ANALYSIS

The scoping review will be conducted in accordance with the JBI Manual for Evidence Synthesis (2024 edition introducing nine stages) and with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. Search strategy will be conducted in PubMed, Embase, Cochrane Database of Systematic Reviews and Scopus in November 2024. The review will include quantitative, qualitative, mixed-methods studies, systematic, scoping or umbrella reviews, as well as text and opinion papers. The study selection process will be conducted by two researchers using Rayyan. The data will be analysed using MAXQDA and extracted into a tool prepared by the researchers. This review will summarise the existing data and will help create a list of potential and determinant barriers and facilitators that may be useful in conducting empirical research on embedding new digital health solutions and sustaining their use.

ETHICS AND DISSEMINATION

As no primary data will be collected for the purposes of this study, no formal ethical approval is required. Results will be published in a peer-reviewed journal. The findings will be used to conduct further research (HORIZON.2.1;grant:101095424) on the determinants of digital health implementation in primary care at the national level and to prepare recommendations for key stakeholders, as well as to develop recommendations on health policy in the European Union.

Experiences and Views of Older Adults of South Asian, Black African, and Caribbean Backgrounds About the Digitalization of Primary Care Services Since the COVID-19 Pandemic: Qualitative Focus Group Study

BACKGROUND

The COVID-19 pandemic from 2020 to 2022 prompted governments worldwide to enforce lockdowns and social restrictions, alongside the rapid adoption of digital health and care services. However, there are concerns about the potential exclusion of older adults, who face barriers to digital inclusion, such as age, socioeconomic status, literacy level, and ethnicity.

OBJECTIVE

This study aims to explore the experiences of older adults from the 3 largest minoritized ethnic groups in England and Wales-people of South Asian, Black African, and Caribbean backgrounds-in the use of digitalized primary care services since the beginning of the COVID-19 pandemic.

METHODS

In total, 27 individuals participated in 4 focus groups (April and May 2023) either in person or via online videoconferencing. Patient and public involvement and engagement were sought through collaboration with community organizations for focus group recruitment and feedback on the topic guide. Data were analyzed using framework analysis.

RESULTS

This paper summarizes the perspectives of 27 older adults from these 3 minoritized ethnic groups and identifies four key themes: (1) service accessibility through digital health (participants faced difficulties accessing digital health care services through online platforms, primarily due to language barriers and limited digital skills, with reliance on younger family members or community organizations for assistance; the lack of digital literacy among older community members was a prominent concern, and digital health care services were felt to be tailored for English speakers, with minimal consultation during the development phase), (2) importance of face-to-face (in-person) appointments for patient-clinician interactions (in-person appointments were strongly preferred, emphasizing the value of physical interaction and connection with health care professionals; video consultations were seen as an acceptable alternative), (3) stressors caused by the shift to remote access (the transition to remote digital access caused stress, fear, and anxiety; participants felt that digital health solutions were imposed without sufficient explanation or consent; and Black African and Caribbean participants reported experiences of racial discrimination within the health care system), and (4) digital solutions (evaluating technology acceptance; participants acknowledged the importance of digitalization but cautioned against viewing it as a one-size-fits-all solution; they advocated for offline alternatives and a hybrid approach, emphasizing the need for choice and a well-staffed clinical workforce).

CONCLUSIONS

Digital health initiatives should address the digital divide, health inequalities, and the specific challenges faced by older adults, particularly those from minoritized ethnic backgrounds, ensuring accessibility, choice, and privacy. Overcoming language barriers involves more than mere translation. Maintaining in-person options for consultations, addressing sensitive issues, and implementing support systems at the practice level to support those struggling to access services are vital. This study recommends that policy makers ensure the inclusivity of older adults from diverse backgrounds in the design and implementation of digital health and social care services.

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.

Remote Consultations in General Practice in Ireland: Who Is Missing Out?

Introduction: This research examines the characteristics associated with the use of remote consultations in general practice in Ireland during and after the COVID-19 pandemic. Methods: The analysis uses three waves of a nationally representative cross-sectional survey of health in Ireland ("Healthy Ireland" survey), relating to the years 2020/2021, 2021/2022, and 2022/2023. The sample includes people aged 15 and over who reported seeing a general practitioner (GP) in the 4 weeks prior to the survey. The outcome variable ("remote consultation") captures whether a respondent reported that their most recent GP consultation took place via telephone or video ("remote consultation"). Logistic regression analysis was used to assess the relationship between the likelihood of having a remote consultation and a range of potential explanatory variables including age, gender, insurance status, and socioeconomic status. Results: There was a significant decrease in the percentage of respondents reporting remote consultations over the period of analysis, from 39% in 2020/2021 to 10% in 2022/2023. In later periods, being female (odds ratio [OR] = 1.47 [1.04, 2.09]), having private health insurance (OR = 1.76 [1.13, 2.73]), and having a long-term health condition (OR = 1.53 [0.98, 2.39]) were positively associated with the probability of reporting a remote consultation, while being in an older age group (OR = 0.29 [0.13, 0.62]) was negatively associated with the likelihood of a remote consultation. Discussion: The high prevalence of remote consultations during the COVID-19 pandemic was not maintained in the postpandemic period. Policymakers should consider the reasons for this and consider the gendered, age-based, and insurance-based disparities in remote consultation utilization in the development and promotion of digital health care.

Experiences, impacts, and requirements of synchronous video consultations between nurses, allied health professionals, psychological therapists, and adult service-users: A review of the literature

BACKGROUND

Telemedicine is increasingly used within healthcare worldwide. More is known about its efficacy in treating different conditions and its application to different contexts than about service-users' and practitioners' experiences or how best to support implementation.

AIMS

To review adult service-users' experiences of synchronous video consultations with nurses, allied health professionals and psychological therapists, find out how consultations impact different groups of service-users and identify requirements for their conduct at individual, organisational, regional, and national levels.

METHOD

CINAHL, Embase, Medline, PsycINFO Scopus were searched for papers published between 01/01/2018 and 19/03/2021. One reviewer independently reviewed citations and a second reviewed those excluded by the first, in a liberal accelerated approach. Quality assessment was undertaken using the Mixed Methods Appraisal Tool and data were synthesised narratively.

RESULTS

65 papers were included. Service-users' experiences of video consultations ranged from feelings of connection to disconnection and ease of access to challenges to access. Many were excluded from video consultation services or research, for example because of lack of access to technology. Individual service-users required clear orientation and ongoing technical support, whereas staff needed support to develop technical and online-relational skills. At organisational levels, technology needed to be made available to users through equipment loan or service models such as hub-and-spoke; services required careful planning and integration within organisational systems; and security needed to be assured. Regional and national requirements related to interorganisational cooperation and developing functionality.

CONCLUSION

To support safe and equitable video consultation provision, we recommend: (1) providers and researchers consider how to maximise participation, for example through inclusive consent processes and eligibility criteria; (2) sharing video consultation user guides and technical support documentation; and (3) continuing professional development for practitioners, focusing on the technical and relational skills that service-users value, such as the ability to convey empathy online.

Optimising digital clinical consultations in maternity care: a realist review and implementation principles

OBJECTIVES

The COVID-19 pandemic has led to increased use of digital clinical consultations (phone or video calls) within UK maternity services. This project aimed to review the evidence on digital clinical consultations in maternity systems to illuminate how, for whom and in what contexts, they can be used to support safe, personalised and equitable care.

DESIGN

A realist synthesis, drawing on diverse sources of evidence (2010-present) from OECD countries, alongside insights from knowledge user groups (representing healthcare providers and service users).

METHODS

The review used three analytical processes (induction, abduction and retroduction) within three iterative stages (development of initial programme theories; evidence retrieval and synthesis; validation and refinement of the programme theories).

RESULTS

Ninety-three evidence sources were included in the final synthesis. Fifteen programme theories were developed showing that digital clinical consultations involve different mechanisms operating across five key contexts: the organisation, healthcare providers, the clinical relationship, the reason for consultation and women. The review suggests that digital clinical consultations can be effective and acceptable to stakeholders if there is access to appropriate infrastructure/digital resources and if implementation is able to ensure personalisation, informed choice, professional autonomy and relationship-focused connections. The review found relatively less evidence in relation to safety and equity.

CONCLUSIONS

Due to the complexity of maternity systems, there can be 'no one-size fits all' approach to digital clinical consultations. Nonetheless, the review distills four 'CORE' implementation principles: C-creating the right environment, infrastructure and support for staff; O-optimising consultations to be responsive, flexible and personalised to different needs and preferences; R-recognising the importance of access and inclusion; and E-enabling quality and safety through relationship-focused connections. Service innovation and research are needed to operationalise, explore and evaluate these principles, particularly in relation to safety and equity.

PROSPERO REGISTRATION NUMBER

CRD42021288702.

Gaining Insights Into Patients' Experiences of Remote Diagnostic Screening for Chronic Kidney Disease in Patients With Diabetes

Introduction: Chronic kidney disease (CKD) affects a significant portion of the UK population and is a pressing public health issue. Current screening methods have a low patient uptake rate. This retrospective study explores the patient experience of remote diagnostic screening. Objective: This article retrospectively analyses patient-reported experiences, focusing on at-home urinary screening to detect CKD. Intervention: Our primary care network commissioned a remote diagnostic service for adult patients with diabetes (Types I and II) who had not taken urinary albumin: creatinine ratio test within 12 months. Patients were provided with an at-home kit and guided by a smartphone application. Qualitative clinical data was collected during screening, with a questionnaire capturing patients' experiences. Impact: A total of 60% of eligible patients performed testing, and 35% were detected to have abnormal results. A total of 80% of patients preferred remote screening. Conclusions: This study provides evidence for remote CKD screening and opens avenues for innovation. Most patients reported a positive experience, underscoring the potential of this approach to improve health outcomes, especially in higher-risk populations.

Access to healthcare services during the COVID-19 pandemic: a cross-sectional analysis of income and user-access across 16 economically diverse countries

BACKGROUND

National health systems have different strengths and resilience levels. During the COVID-19 pandemic, resources often had to be reallocated and this impacted the availability of healthcare services in many countries. To date there have been few quantitative contemporary studies of inequalities in access to healthcare within and between countries. In this study, we aim to compare inequality within and between 16 economically diverse countries.

METHODS

Online surveys were conducted on 22 150 adults in 16 countries across six continents in 2022. Quota sampling and post-stratification weighting was used to obtain an age, gender, geographically, and educationally representative sample. The study assesses the differences in challenges in access to healthcare during the pandemic (for GP, surgical/clinical and digital GP services) using country-specific expanded health-needs-adjusted Erreygers' concentration indices and compares these values between countries using a Spearman's rank correlation coefficient.

RESULTS

Results show wide variation in income-related challenges in access within countries for different types of care. For example, Erreygers' concentration index for digital services in Colombia exhibited highly regressive inequality at 0·17, compared to Japan with an index of -0·15. Inequalities between countries were also evident, with Spearman rank coefficients of -0·69 and -0·65 (p-values of 0·003 and 0·006) for digital and surgical access, indicating that lower income countries had greater inequality in healthcare access challenges.

CONCLUSION

During the pandemic, inequalities in challenges to accessing healthcare were greatest in low and middle-income countries. Digital technologies offer a reasonable means to address some of this inequality if adequate support is provided and accessible digital infrastructure exists.

GP access for inclusion health groups: perspectives and recommendations

BACKGROUND

General practice has seen the widespread adoption of remote consulting and triage systems. There is a lack of evidence exploring how inclusion health populations have been impacted by this transformation.

AIM

This study aimed to explore the post-pandemic GP access for inclusion health populations, through the lens of those with lived experience, and identify practical recommendations for improving access for this population.

DESIGN & SETTING

A mixed-methods study exploring the direct experience of people from inclusion health groups trying to access GP care in 13 practices in east London.

METHOD

A mystery shopper exercise involving 39 in-person practice visits and 13 phone calls were undertaken. The findings were reflected on by a multidisciplinary stakeholder group, which identified recommendations for improvements.

RESULTS

Only 31% of the mystery shopper visits (n = 8) resulted in registration and the offer of an appointment to see a GP for an urgent problem. None of the mystery shoppers was able to book an appointment over the phone but n = 10/13 felt that they would be able to register and make an appointment if they followed the receptionist's instructions. Most mystery shoppers felt respected, listened to, and understood the information provided to them. Just under half of the practices (46%, n = 6) received positive comments on how accessible and supportive their spaces felt. Practice- and system-level recommendations were identified by the stakeholder group.

CONCLUSION

Ongoing GP access issues persist for inclusion health populations. We identified practice- and system-level recommendations for improving access for this vulnerable population.

Physician-Led Synchronous Telemedicine Compared to Face-To-Face Care in Primary Care: A Systematic Review

The COVID-19 crisis rapidly introduced telemedicine as the predominate modality to deliver healthcare however this change has not received attention in primary care settings and the health-related impacts are unknown. The study's objective was to explore the effects of physician-led synchronous telemedicine compared to face-to-face care delivered in the primary care setting on healthcare system use and attributes of primary care as reported in recent studies. We performed a comprehensive literature search in five databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PsycInfo) and critical appraisal using the Joanna Briggs Institute tools. Of 6,247 studies identified, 157 studies underwent full text review, and 19 studies were included. Most studies were conducted in the U.S. (78.9%) and used video and telephone telemedicine (57.9%). An outcome-based qualitative description and narrative synthesis showed similar or fewer emergency department visits, hospital visits, and prescribing, and fewer diagnostic tests and imaging for telemedicine visits compared to face-to-face care. Our systematic review fills a gap in the literature on telemedicine in primary care settings however our results need to be interpreted cautiously given studies' susceptibility to selection bias, confounding, and limited applicability to other health systems and time periods.

eVisits to primary care and subsequent health care contacts: a register-based study

BACKGROUND

Evidence concerning health care use related to virtual visits is conflicting. More research has been called for regarding the effectiveness of text-based virtual visits (eVisits). Therefore, we investigated patient characteristics, diagnoses, and subsequent health care contacts after eVisits to primary care.

METHODS

We conducted a register-based cohort study of eVisits to an all-virtual public primary care unit in Sweden and subsequent health care contacts within 14 days. Data for 2021 were acquired from the regional health care databases. Diagnoses were sorted into relevant diagnostic groups, such as skin diagnoses and respiratory tract diagnoses. Multiple logistic regression was performed with subsequent health care contact as the outcome variable and diagnostic group for the eVisit as the predictor variable. Analyses were adjusted for age, sex, and socioeconomic index.

RESULTS

There were 5817 eVisits to a nurse and 4267 eVisits to a general practitioner (N = 10 084). Most patients were 20 to 39 years of age (41.8%). Skin diagnoses were most frequent (47.3%), followed by respiratory tract diagnoses (19.9%). Approximately one-fourth (25.8%) of the patients who completed an eVisit with a nurse or a general practitioner had a subsequent face-to-face visit within 14 days, mostly in primary care. Subsequent contacts were more frequent after an eVisit to a nurse than to a general practitioner. After an eVisit to a general practitioner, patients with infections (especially respiratory tract but also urinary tract) and unspecified diagnoses (especially skin-related) were more likely to require further health care contact compared to a group with various other diagnoses.

CONCLUSIONS

eVisits to an all-virtual primary care unit may be appropriate for uncomplicated medical complaints. Nonetheless, the effectiveness of eVisits in terms of substitution of physical visits, and resource utilization in relation to the more complex care needs of a primary care population, should be further studied.

The Use of COVID-19 Mobile Apps in Connecting Patients with Primary Healthcare in 30 Countries: Eurodata Study

BACKGROUND

The COVID-19 pandemic has necessitated changes in European healthcare systems, with a significant proportion of COVID-19 cases being managed on an outpatient basis in primary healthcare (PHC). To alleviate the burden on healthcare facilities, many European countries developed contact-tracing apps and symptom checkers to identify potential cases. As the pandemic evolved, the European Union introduced the Digital COVID-19 Certificate for travel, which relies on vaccination, recent recovery, or negative test results. However, the integration between these apps and PHC has not been thoroughly explored in Europe.

OBJECTIVE

To describe if governmental COVID-19 apps allowed COVID-19 patients to connect with PHC through their apps in Europe and to examine how the Digital COVID-19 Certificate was obtained.

METHODOLOGY

Design and setting: Retrospective descriptive study in PHC in 30 European countries. An ad hoc, semi-structured questionnaire was developed to collect country-specific data on primary healthcare activity during the COVID-19 pandemic and the use of information technology tools to support medical care from 15 March 2020 to 31 August 2021. Key informants belong to the WONCA Europe network (World Organization of Family Doctors). The data were collected from relevant and reliable official sources, such as governmental websites and guidelines.

MAIN OUTCOME MEASURES

Patient's first contact with health system, governmental COVID-19 app (name and function), Digital COVID-19 Certification, COVID-19 app connection with PHC.

RESULTS

Primary care was the first point of care for suspected COVID-19 patients in 28 countries, and 24 countries developed apps to complement classical medical care. The most frequently developed app was for tracing COVID-19 cases (24 countries), followed by the Digital COVID-19 Certificate app (17 countries). Bulgaria, Italy, Serbia, North Macedonia, and Romania had interoperability between PHC and COVID-19 apps, and Poland and Romania's apps considered social needs.

CONCLUSIONS

COVID-19 apps were widely created during the first pandemic year. Contact tracing was the most frequent function found in the registered apps. Connection with PHC was scarcely developed. In future pandemics, connections between health system levels should be guaranteed to develop and implement effective strategies for managing diseases.

Video consultation in general practice during COVID-19: a register-based study in Denmark

BACKGROUND

During the COVID-19 pandemic, general practices in Denmark rapidly introduced video consultations (VCs) to prevent viral transmission.

AIM

To study the use of VCs in daytime general practice by describing the rate of VCs, and the patient characteristics associated with having VCs.

DESIGN & SETTING

Register-based study of consultations in daytime general practice in Denmark.

METHOD

We included all consultations in daytime general practice from 1 January 2019-30 November 2021. We calculated the rate of video use and categorised the general practices into no, low, and high use. Logistic regression was used to calculate adjusted odds ratios (aOR) for having a VC for different patient characteristics when contacting a video-using practice, stratified for low- and high-using practices.

RESULTS

A total of 30 148 478 eligible consultations were conducted during the pandemic period. VCs were used mostly during the early stage pandemic period, declining to about 2% of all clinic consultations in the late-stage period. Patients having more VCs were young, had a long education, were employed, and lived in big cities. In low-using practices, native Danes and 'western' immigrants had higher odds of receiving a VC than 'non-western' immigrants, and patients with ≥2 comorbidities had lower odds than those without comorbidities.

CONCLUSION

Patients of a younger age, with long education, or employment had higher odds of receiving a VC, while patients of an older age and patients who had retired had lower odds. This difference in the access to VCs warrants further attention.

The nexus of immigration regulation and health governance: a scoping review of the extent to which right to access healthcare by migrants, refugees and asylum seekers was upheld in the United Kingdom during COVID-19

OBJECTIVES

Complementing the well-established evidence base on health inequalities experienced by migrants, refugees and asylum seekers in the UK; we examined the extent to which their right to equal non-discriminatory access to health services (promotive, preventive, curative) was upheld during the COVID-19 pandemic.

STUDY DESIGN

Arksey and O'Malley's scoping review framework.

METHODS

A comprehensive search was conducted on Medline, PubMed, and CINAHL using detailed MESH terms, for literature published between 01 January 2020 and 01 January 2024. The process was supported by a ten-page Google search and hand searching of reference lists. 42 records meeting the inclusion criteria were charted, coded inductively and analysed thematically in an integrated team-based approach.

RESULTS

Dissonance between immigration regulation and health governance is illustrated in four themes: Health systems leveraged to (re)enforce the hostile environment; Dissonance between health rights on paper and in practice; Structural failures to overcome communication and digital exclusion; and COVID-19 vaccine (in)equity exacerbated fear, mistrust and exclusion. Migrants, refugees and asylum seekers encountered substantial individual, structural and policy-level barriers to accessing healthcare in the UK during COVID-19. Insecure immigration status, institutional mistrust, data-sharing and charging fears, communication challenges and digital exclusion impacted heavily on their ability to access healthcare in an equitable non-discriminatory manner.

CONCLUSIONS

An inclusive and innovative health equity and rights-based responses reaching all migrants, refugees and asylum seekers are warranted if the National Health Service is to live up to its promise of 'leaving no one behind' in post-pandemic and future responses.

Telephone consulting for 'Personalised Care and Support Planning' with people with long-term conditions: a qualitative study of healthcare professionals' experiences during COVID-19 restrictions and beyond

BACKGROUND

Personalised Care and Support Planning (PCSP) replaces conventional annual reviews for people with long-term conditions. It is designed to help healthcare professionals (HCPs) and patients engage in conversations as equals and collaboratively plan actions oriented to each patient's priorities, alongside biomedical concerns. Little is known about how the shift to remote consulting initiated with COVID-19 restrictions has impacted PCSP.

AIM

To investigate HCPs' experiences of conducting PCSP conversations remotely and consider implications for the fulfilment of PCSP ambitions as remote consulting continues beyond COVID-19 restrictions.

METHODS

19 semi-structured interviews with HCPs in England and Scotland; interpretive analysis.

RESULTS

HCPs' accounts made clear that COVID-19 restrictions impacted multiple aspects of PCSP delivery, not just the mode of conversation. Broader disruption to general practice systems for gathering and sharing information ahead of PCSP conversations, and moves to 'wide window' appointment times, made it harder for patients to be prepared for PCSP conversations. This constrained scope to achieve PCSP ambitions even with the best professional communication skills. Most remote PCSP conversations were conducted by telephone. In the absence of visual communication with patients, it was sometimes harder to achieve the ambitions of PCSP conversations, including to balance patient and professional agendas, fulfil key planning activities, and foster a relational ethos of equal, collaborative partnership. The challenges were particularly severe when working with new patients and people with complex clinical and social problems. Although options for telephone appointments now offer valued flexibility, sustained experience of struggling to achieve PCSP ambitions via remote consulting led some HCPs to lower their standards for judging a "good" PCSP conversation, and to diminished professional satisfaction.

CONCLUSIONS

There are significant challenges to fulfilling the ambitions of PCSP via telephone, especially when preparatory support is limited. This study provides grounds for scepticism about how compatible telephone appointments can be with this person-centred model of working, especially for people who are socially disadvantaged and live with complex health conditions. These threats to the provision of person-centred support for people with long-term conditions warrant careful attention going forward if the PCSP model and its benefits are to be sustained.

A corporeal conundrum: Challenges posed by remote consultation for postgraduate medical education

BACKGROUND

The COVID-19 pandemic accelerated the use of remote consultation in hospital outpatient clinics. Remote consultation alters the clinical environment and the learning environment in ways that are incompletely understood. This research sought to explore how trainees negotiate training and learning in such an environment when it is novel to them.

METHODS

Purposive sampling was used to recruit eight doctors from the gastroenterology department of an academic teaching hospital. Four consultants and four trainees participated in individual, semi-structured interviews. Interpretative phenomenological analysis of interview transcripts was employed and themes developed from the analysis, to characterise the experience of learning and teaching in remote consultation clinics, as described by participants.

RESULTS

Participants described how they try to create mental representations of each patient they review by remote consultation. Whilst consultants found this task relatively easy, trainee physicians found remote consultation more challenging and highlighted the importance of the physical presence of the patient to help them form a holistic sense of the patient's condition. Doctors in training also struggled to develop a workable mental model of the patient's condition when physical examination was precluded by remote consultation.

CONCLUSIONS

This study highlights the place of the patient's physical presence as an essential educational stimulus to facilitate teaching and learning. Further research is needed to characterise the processes clinicians use to formulate mental models of patients who are physically absent from the consultation room.

Developing user personas to capture intersecting dimensions of disadvantage in older patients who are marginalised: a qualitative study

BACKGROUND

Remote and digital services must be equitable, but some patients have difficulty using these services. Designing measures to overcome digital disparities can be challenging for practices. Personas (fictional cases) are a potentially useful tool in this regard.

AIM

To develop and test a set of personas to reflect the lived experiences and challenges that older people who are disadvantaged face when navigating remote and digital primary care services.

DESIGN AND SETTING

Qualitative study of digital disparities in NHS community health services offering video appointments.

METHOD

Following familiarisation visits and interviews with service providers, 17 older people with multiple markers of disadvantage (limited English, health conditions, and poverty) were recruited and interviewed using narrative prompts. Data were analysed using an intersectionality lens, underpinned by sociological theory. Combining data across all participant interviews, we produced personas and refined these following focus groups involving health professionals, patients, and advocates (n = 12).

RESULTS

Digital services create significant challenges for older patients with limited economic, social, and linguistic resources and low digital, health, or system literacy. Four contrasting personas were produced, capturing the variety and complexity of how dimensions of disadvantage intersected and influenced identity and actions. The personas illustrate important themes including experience of racism and discrimination, disorientation, discontinuity, limited presence, weak relationships, loss of agency, and mistrust of services and providers.

CONCLUSION

Personas can illuminate the multiple and intersecting dimensions of disadvantage in patient populations who are marginalised and may prove useful when designing or redesigning digital primary care services. Adopting an intersectional lens may help practices address digital disparities.

Reducing health inequalities through general practice: a realist review and action framework

Background

Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities.

Objectives

We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice.

Design

Realist review.

Main outcome measures

Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria.

Review methods

Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence.

Results

Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships.

Limitations

The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care.

Conclusions

Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred.

Future work

Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice.

Study registration

This trial is registered as PROSPERO CRD42020217871.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Satisfaction with remote consultations in primary care during COVID-19: a population survey of UK adults

BACKGROUND

Mode of access to primary care changed during the COVID-19 pandemic; remote consultations became more widespread. With remote consultations likely to continue in UK primary care, it is important to understand people's perceptions of remote consultations and identify potential resulting inequalities.

AIM

To assess satisfaction with remote GP consultations in the UK during the COVID-19 pandemic and identify demographic variation in satisfaction levels.

DESIGN AND SETTING

A cross-sectional survey from the second phase of a large UK-based study, which was conducted during the COVID-19 pandemic.

METHOD

In total, 1426 adults who self-reported having sought help from their doctor in the past 6 months completed an online questionnaire (February to March 2021). Items included satisfaction with remote consultations and demographic variables. Associations were analysed using multivariable regression.

RESULTS

A novel six-item scale of satisfaction with remote GP consultations had good psychometric properties. Participants with higher levels of education had significantly greater satisfaction with remote consultations than participants with mid-level qualifications (B = -0.82, 95% confidence interval [CI] = -1.41 to -0.23) or those with low or no qualifications (B = -1.65, 95% CI = -2.29 to -1.02). People living in Wales reported significantly higher satisfaction compared with those living in Scotland (B = -1.94, 95% CI = -3.11 to -0.78), although caution is warranted due to small group numbers.

CONCLUSION

These findings can inform the use and adaptation of remote consultations in primary care. Adults with lower educational levels may need additional support to improve their experience and ensure equitable care via remote consultations.

Medicare Benefits Schedule (MBS) Review Advisory Committee post-implementation review of MBS telehealth items: abolition of initial telehealth consultations for non-general practitioner specialists

In 2022, the Australian Federal Minister for Health and Aged Care commissioned the Medicare Benefits Schedule (MBS) Review Advisory Committee (MRAC) to conduct a post-implementation review of MBS telehealth services, including settings of video and telephone consultations. The MRAC has made a series of administrative recommendations for telehealth practice that appear at cross-purposes to the evidence-base on medical consultations and that would limit patient access to medical specialist assessment in Australia. These recommendations particularly underestimate the role of telehealth in rural and remote Australia and did not take into account high patient satisfaction with telehealth assessment and treatment during the ongoing coronavirus disease 2019 (COVID-19) pandemic. They also appear to contradict the Medical Board of Australia's guidance on telehealth. On this basis, the recommendations for telehealth principles and abolition of reimbursement for telehealth for all initial non-general practitioner medical specialist consultations should be withdrawn.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis

Background

Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care.

Objectives

Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services.

Methods

Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders.

Data sources

Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews.

Review methods

In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway.

Results

Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women's economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels.

Limitations

In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English.

Conclusions

The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services.

Recommendations for health policy and practice

These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Future work

Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries.

Trial registration

This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Changes in public health-seeking behaviours for self-limiting respiratory tract infections across England during the COVID-19 pandemic

BACKGROUND

National Health Service (NHS) guidance for acute respiratory tract infections (RTIs) advocates self-care, encourages utilization of local pharmacies and recommends consulting general practitioners (GPs) primarily for the vulnerable or those with persistent symptoms. Coronavirus disease 2019 exerted substantial strain on the English NHS, affecting public access to primary care services.

METHODS

For 3 years, public surveys assessed RTI incidences in the previous 12 months and associated health-seeking behaviours. Telephone surveys of 1676 respondents across England were conducted in March 2021 and 1663 respondents in March 2022. Findings were compared with a face-to-face baseline survey of 2022 respondents from March 2020. Key demographics were representative of the population.

RESULTS

In 2021, the proportion of respondents who reported an RTI (51%) significantly declined from 2020 (70%, P < 0.05), then returned to pre-pandemic rates in 2022 (67%). Respondents reported more proactive symptom management in both 2021 and 2022 from 2020: there were greater reports of seeking over-the-counter treatments (55%, 55% vs. 35%, P < 0.05) and use of alternative remedies (38%, 38% vs. 21%, P < 0.05). 2022 observed a reduction in those who reported consulting their GP for their most recent RTI (15%) compared to 2021 (25%, P < 0.05) and 2020 (23%), which was not accounted for through greater consultation rates with other healthcare services.

CONCLUSIONS

Public health bodies should consider how pandemic-related changes may have facilitated increased self-care for self-limiting infections such as RTIs. Resources and support must include safety-netting advice to safeguard against unintentional consequences of increased self-care.

Do critical illness survivors with multimorbidity need a different model of care?

There is currently a lack of evidence on the optimal strategy to support patient recovery after critical illness. Previous research has largely focussed on rehabilitation interventions which aimed to address physical, psychological, and cognitive functional sequelae, the majority of which have failed to demonstrate benefit for the selected outcomes in clinical trials. It is increasingly recognised that a person's existing health status, and in particular multimorbidity (usually defined as two or more medical conditions) and frailty, are strongly associated with their long-term outcomes after critical illness. Recent evidence indicates the existence of a distinct subgroup of critical illness survivors with multimorbidity and high healthcare utilisation, whose prior health trajectory is a better predictor of long-term outcomes than the severity of their acute illness. This review examines the complex relationships between multimorbidity and patient outcomes after critical illness, which are likely mediated by a range of factors including the number, severity, and modifiability of a person's medical conditions, as well as related factors including treatment burden, functional status, healthcare delivery, and social support. We explore potential strategies to optimise patient recovery after critical illness in the presence of multimorbidity. A comprehensive and individualized approach is likely necessary including close coordination among healthcare providers, medication reconciliation and management, and addressing the physical, psychological, and social aspects of recovery. Providing patient-centred care that proactively identifies critical illness survivors with multimorbidity and accounts for their unique challenges and needs is likely crucial to facilitate recovery and improve outcomes.

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.

Students' and tutors' experiences of remote 'student-patient' consultations

BACKGROUND

Remote consulting has become part of the medical student clinical experience in primary care, but little research exists regarding the impact on learning.

AIM

To describe the experiences of General Practitioner (GP) educators and medical students in using student-led remote consultations as an educational tool.

METHOD

A qualitative, explorative study conducted at four UK medical schools. GP educators and medical students were purposively sampled and interviewed.

RESULTS

Nine themes arose: practical application, autonomy, heuristics, safety, triage of undifferentiated patients, clinical reasoning, patient inclusion in student education, student-patient interaction, and student-doctor interaction.

DISCUSSION

Remote consulting has become part of the clinical placement experience. This has been found to expose students to a wider variety of clinical presentations. Verbal communication, history-taking, triage, and clinical reasoning skills were practised through remote consulting, but examination skills development was lacking. Students found building rapport more challenging, although this was mitigated by having more time with patients. Greater clinical risk was perceived in remote consulting, which had potential to negatively impact students' psychological safety. Frequent debriefs could ameliorate this risk and positively impact student-doctor relationships. Student autonomy and independence increased due to greater participation and responsibility. Pre-selection of patients could be helpful but had potential to expose students to lower complexity patients.[Box: see text].

The Impact of Virtual Consultations on the Quality of Primary Care: Systematic Review

BACKGROUND

The adoption of virtual consultations, catalyzed by the COVID-19 pandemic, has transformed the delivery of primary care services. Owing to their rapid global proliferation, there is a need to comprehensively evaluate the impact of virtual consultations on all aspects of care quality.

OBJECTIVE

This study aims to evaluate the impact of virtual consultations on the quality of primary care.

METHODS

A total of 6 databases were searched. Studies that evaluated the impact of virtual consultations, for any disease, were included. Title and abstract screening and full-text screening were performed by 2 pairs of investigators. Risk of bias was assessed using the Mixed Methods Appraisal Tool. A narrative synthesis of the results was performed.

RESULTS

In total, 30 studies (5,469,333 participants) were included in this review. Our findings suggest that virtual consultations are equally effective to or more effective than face-to-face care for the management of certain conditions, including mental illness, excessive smoking, and alcohol consumption. Overall, 4 studies indicated positive impacts on some aspects of patient-centeredness; however, a negative impact was noted on patients' perceived autonomy support (ie, the degree to which people perceive those in positions of authority to be autonomy supportive). Virtual consultations may reduce waiting times, lower patient costs, and reduce rates of follow-up in secondary and tertiary care settings. Evidence for the impact on clinical safety is extremely limited. Evidence regarding equity was considerably mixed. Overall, it appears that virtual care is more likely to be used by younger, female patients, with disparities among other subgroups depending on contextual factors.

CONCLUSIONS

Our systematic review demonstrated that virtual consultations may be as effective as face-to-face care and have a potentially positive impact on the efficiency and timeliness of care; however, there is a considerable lack of evidence on the impacts on patient safety, equity, and patient-centeredness, highlighting areas where future research efforts should be devoted. Capitalizing on real-world data, as well as clinical trials, is crucial to ensure that the use of virtual consultations is tailored according to patient needs and is inclusive of the intended end users. Data collection methods that are bespoke to the primary care context and account for patient characteristics are necessary to generate a stronger evidence base to inform future virtual care policies.

Virtual care use among older immigrant adults in Ontario, Canada during the COVID-19 pandemic: A repeated cross-sectional analysis

The critical role of virtual care during the COVID-19 pandemic has raised concerns about the widening disparities to access by vulnerable populations including older immigrants. This paper aims to describe virtual care use in older immigrant populations residing in Ontario, Canada. In this population-based, repeated cross-sectional study, we used linked administrative data to describe virtual care and healthcare utilization among immigrants aged 65 years and older before and during the COVID-19 pandemic. Visits were identified weekly from January 2018 to March 2021 among various older adult immigrant populations. Among older immigrants, over 75% were high users of virtual care (had two or more virtual visits) during the pandemic. Rates of virtual care use was low (weekly average <2 visits per 1000) prior to the pandemic, but increased for both older adult immigrant and non-immigrant populations. At the start of the pandemic, virtual care use was lower among immigrants compared to non-immigrants (weekly average of 77 vs 86 visits per 1000). As the pandemic progressed, the rates between these groups became similar (80 vs 79 visits per 1000). Virtual care use was consistently lower among immigrants in the family class (75 visits per 1000) compared to the economic (82 visits per 1000) or refugee (89 visits per 1000) classes, and was lower among those who only spoke French (69 visits per 1000) or neither French nor English (73 visits per 1000) compared to those who were fluent in English (81 visits per 1000). This study found that use of virtual care was comparable between older immigrants and non-immigrants overall, though there may have been barriers to access for older immigrants early on in the pandemic. However, within older immigrant populations, immigration category and language ability were consistent differentiators in the rates of virtual care use throughout the pandemic.

Faecal Immunochemical Testing to Detect Colorectal Cancer in Symptomatic Patients: A Diagnostic Accuracy Study

(1) Background: NHS England recommended faecal immunochemical testing (FIT) for symptomatic patients in June 2020 to rationalise limited diagnostic services during COVID-19. (2) Aim: to investigate the diagnostic performance of FIT, analysing the proportion of FIT-negative colorectal cancers (CRC) missed in symptomatic patients and how this risk could be mitigated. (3) Design and Setting: a retrospective study of biochemistry and cancer databases involving patients referred from primary healthcare with suspected CRC to a single secondary care trust in North East London. (4) Methods: a retrospective cohort diagnostic accuracy study was undertaken to determine the performance of FIT for detecting CRC at 10 µgHb/g. (5) Results: between January and December 2020, 7653 patients provided a stool sample for FIT analysis; 1679 (22%) samples were excluded due to inadequate or incorrect specimens; 48% of suspected CRC referrals completed FIT before evaluation; 86 FIT tested patients were diagnosed with histologically proven CRC. At 10 µgHb/g, FIT performance was comparable with the existing literature with a sensitivity of 0.8140 (95% CI 0.7189-0.8821), a specificity of 0.7704 (95% CI 0.7595-0.7809), a positive predictive value (PPV) of 0.04923 (95% CI 0.03915-0.06174), a negative predictive value (NPV) of 0.9965 (95% CI 0.9943-0.9978), and a likelihood ratio (LR) of 3.545; 16 patients with CRC had an FIT of ≤10 µgHb/g (18.6% 95% CI 11.0-28.4%). (6) Conclusions: this study raises concerns about compliance with FIT testing and the incidence of FIT-negative CRC at the NICE recommended threshold and how this risk can be mitigated without colonic imaging. Whilst FIT may have facilitated prioritisation during COVID-19, we must be cautious about using FIT alone to determine which patients are referred to secondary care or receive further investigation.

Consultation Rate and Mode by Deprivation in English General Practice From 2018 to 2022: Population-Based Study

BACKGROUND

The COVID-19 pandemic has had a significant impact on primary care service delivery with an increased use of remote consultations. With general practice delivering record numbers of appointments and rising concerns around access, funding, and staffing in the UK National Health Service, we assessed contemporary trends in consultation rate and modes (ie, face-to-face versus remote).

OBJECTIVE

This paper describes trends in consultation rates in general practice in England for key demographics before and during the COVID-19 pandemic. We explore the use of remote and face-to-face consultations with regard to socioeconomic deprivation to understand the possible effect of changes in consultation modes on health inequalities.

METHODS

We did a retrospective analysis of 9,429,919 consultations by general practitioners, nurses, or other health care professionals between March 2018 and February 2022 for patients registered at 397 general practices in England. We used routine electronic health records from Clinical Practice Research Datalink Aurum with linkage to national data sets. Negative binomial models were used to predict consultation rates and modes (ie, remote versus face-to-face) by age, sex, and socioeconomic deprivation over time.

RESULTS

Overall consultation rates increased by 15% from 4.92 in 2018-2019 to 5.66 in 2021-2022 with some fluctuation during the start of the COVID-19 pandemic. The breakdown into face-to-face and remote consultations shows that the pandemic precipitated a rapid increase in remote consultations across all groups, but the extent varies by age. Consultation rates increased with increasing levels of deprivation. Socioeconomic differences in consultation rates, adjusted for sex and age, halved during the pandemic (from 0.36 to 0.18, indicating more consultations in the most deprived), effectively narrowing relative differences between deprivation quintiles. This trend remains when stratified by sex, but the difference across deprivation quintiles is smaller for men. The most deprived saw a relatively larger increase in remote and decrease in face-to-face consultation rates compared to the least deprived.

CONCLUSIONS

The substantial increases in consultation rates observed in this study imply an increased pressure on general practice. The narrowing of consultation rates between deprivation quintiles is cause for concern, given ample evidence that health needs are greater in more deprived areas.

The impact of remote care approaches on continuity in primary care: a mixed-studies systematic review

BACKGROUND

The value of continuity in primary care has been demonstrated for multiple positive outcomes. However, little is known about how the expansion of remote and digital care models in primary care have impacted continuity.

AIM

To explore the impact of the expansion of remote and digital care models on continuity in primary care.

DESIGN AND SETTING

A systematic review of continuity in primary care.

METHOD

A keyword search of Embase, MEDLINE, and CINAHL databases was used along with snowball sampling to identify relevant English-language qualitative and quantitative studies from any country between 2000 and 2022, which explored remote or digital approaches in primary care and continuity. Relevant data were extracted, analysed using GRADE-CERQual, and narratively synthesised.

RESULTS

Fifteen studies were included in the review. The specific impact of remote approaches on continuity was rarely overtly addressed. Some patients expressed a preference for relational continuity depending on circumstance, problem, and context; others prioritised access. Clinicians valued continuity, with some viewing remote consultations more suitable where there was high episodic or relational continuity. With lower continuity, patients and clinicians considered remote consultations harder, higher risk, and poorer quality. Some evidence suggested that remote approaches and/or their implementation risked worsening inequalities and causing harm by reducing continuity where it was valuable. However, if deployed strategically and flexibly, remote approaches could improve continuity.

CONCLUSION

While the value of continuity in primary care has previously been well demonstrated, the dearth of evidence around continuity in a remote and digital context is troubling. Further research is, therefore, needed to explore the links between the shift to remote care, continuity and equity, using real-world evaluation frameworks to ascertain when and for whom continuity adds most value, and how this can be enabled or maintained.

Mapping Inequities in Digital Health Technology Within the World Health Organization's European Region Using PROGRESS PLUS: Scoping Review

BACKGROUND

The use of digital technologies within health care rapidly increased as services transferred to web-based platforms during the COVID-19 pandemic. Inequalities in digital health across the domains of equity are not routinely examined; yet, the long-term integration of digitally delivered services needs to consider such inequalities to ensure equitable benefits.

OBJECTIVE

This scoping review aimed to map inequities in access, use, and engagement with digital health technologies across equity domains.

METHODS

We searched 4 electronic databases (MEDLINE, ASSIA, PsycINFO, and Scopus) for quantitative and mixed methods reviews and meta-analyses published between January 2016 and May 2022. Reviews were limited to those that included studies from the World Health Organization's European region. Extracted data were mapped against Cochrane's PROGRESS PLUS (place of residence, race, ethnicity, culture, and language, occupation, gender and sex, religion, education, socioeconomic status, social capital, and other characteristics) dimensions of equity.

RESULTS

In total, 404 unique citations were identified from the searches, and 2 citations were identified from other sources. After eligibility assessment, 22 reviews were included. Consistent evidence was found showing higher access to digital health technologies among patients who were of White ethnicity, were English speaking, and had no disability. There were no reviews that explored differences in access to digital health care by age, gender and sex, occupation, education, or homeless or substance misuse. Higher use of digital health technologies was observed among populations that were White, English speaking, younger, with a higher level of education, of higher economic status, and residents in urban areas. No clear evidence of differences in the use of digital technologies by occupation, gender and sex, disability, or homeless or substance misuse was found, nor was clear evidence found in the included reviews on inequalities in the engagement with digital technologies. Finally, no reviews were identified that explored differences by place of residence.

CONCLUSIONS

Despite awareness of the potential impact of inequalities in digital health, there are important evidence gaps across multiple equity domains. The development of a common framework for evaluating digital health equity in new health initiatives and consistency in reporting findings is needed.

Rapid methods for identifying barriers and solutions to improve access to community health services: a scoping review protocol

OBJECTIVES

Low attendance rates for community health services reflect important barriers that prevent people from receiving the care they need. Services and health systems that seek to advance Universal Health Coverage need to understand and act on these factors. Formal qualitative research is the best way to elicit barriers and identify potential solutions, however traditional approaches take months to complete and can be very expensive. We aim to map the methods that have been used to rapidly elicit barriers to accessing community health services and identify potential solutions.

METHODS AND ANALYSIS

We will search MEDLINE, Embase, the Cochrane Library and Global Health for empirical studies that use rapid methods (<14 days) to elicit barriers and potential solutions from intended service beneficiaries. We will exclude hospital-based and 100% remotely delivered services. We will include studies conducted in any country from 1978 to present. We will not limit by language. Two reviewers will independently perform screening and data extraction, with disagreements resolved by a third reviewer. We will tabulate the different approaches used and present data on time, skills and financial requirements for each approach, as well as the governance framework and any strengths and weaknesses presented by the study authors. We will follow Joanna Briggs Institute (JBI) scoping review guidance and report the review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

ETHICS AND DISSEMINATION

Ethical approval is not required. We will share our findings in the peer-reviewed literature, at conferences, and with WHO policymakers working in this space.

REGISTRATION

Open Science Framework (https://osf.io/a6r2m).

A survey on the use of remote consultation for people with intellectual disability: The experience of community intellectual disability teams

BACKGROUND

Since COVID-19, remote consultation (by telephone and video) has become widespread. This study investigated the experience of using remote consultation in Specialist Intellectual Disability Community services.

METHOD

A total of 126 health staff working across eight Specialist Intellectual Disability Community teams in the NHS Health Board of Greater Glasgow and Clyde were asked to complete a short Likert-scale survey about remote consultation.

RESULTS

There were 61 (48%) respondents from a range of disciplines. Overall, respondents were positive about remote consultation but found it was often inadequate to complete a full patient assessment. Moving forwards, respondents wanted around 60% of all consultations to remain face-to-face. It was significantly more difficult to engage and communicate with patients with more severe levels of disability.

CONCLUSIONS

Remote consultation has been successful, but there is still a need for face-to-face assessment in intellectual disability services, particularly when working with people with more severe levels of disability.

Evaluating the Effectiveness of Remote Behavioral Interventions Facilitated by Health Care Providers at Improving Medication Adherence in Cardiometabolic Conditions: A Systematic Review and Meta-Analysis

BACKGROUND

Although cardiometabolic conditions account for over 32% of all global deaths, nearly half of the patients with cardiometabolic conditions do not take medication as prescribed. Remote behavioral interventions have been shown to potentially improve adherence in these patients and further support cost effective clinical practice.

PURPOSE

To evaluate the effectiveness of remote behavioral interventions at improving treatment adherence and to explore behavioral intervention components associated with it.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science in April 2021. Random-effects meta-analyses were utilized.

RESULTS

In total, 40 studies, including 24,672 participants, were included. The overall quality of evidence, assessed using the RoB2 tool, was low. The intervention had a small (odds ratios [OR] = 1.70, 95% CI: 1.47, 1.96, N = 4823 p < .001) to moderate effect (SMD = 0.57, 95% CI: 0.38, 0.76, N = 20,271, p < .001) on the dichotomous and continuous outcomes, respectively. Systolic blood pressure (SBP) was reduced by 3.71 mmHg (95% CI: 3.99, 3.43, N = 6,527, p < .001) and participants receiving the intervention were twice more likely to achieve blood pressure (BP) control (OR = 2.14, 95% CI: 1.61, 2.84, N = 1,172, p < .001). Generally, HBA1c decreased by 0.25% (95% CI: 0.33, 0.17, N = 6,734, p < .001), whereas low-density lipoprotein (LDL)-cholesterol dropped by 6.82 mg/dL (95% CI: 8.33, 5.30, N = 4,550, p < .001) in favor of the intervention. There was a trend suggesting a potential positive effects on reducing visits to emergency department (OR=0.76, 95% CI: 0.57, 1.01, N = 4,182) and mortality rates (OR=0.78, 95% CI: 0.42, 1.42, N = 1,971), and no risk for hospital readmission (OR=1.00, 95% CI: 0.83, 1.20, N = 5,402), favoring the intervention.

CONCLUSIONS

Despite low quality of evidence, remote consultations are effective at improving medication adherence and clinical indicators, and potentially cost-effective solution for health care services.

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.

The impact of the COVID-19 pandemic on cardiovascular disease prevention and management

How the Coronavirus Disease 2019 (COVID-19) pandemic has affected prevention and management of cardiovascular disease (CVD) is not fully understood. In this study, we used medication data as a proxy for CVD management using routinely collected, de-identified, individual-level data comprising 1.32 billion records of community-dispensed CVD medications from England, Scotland and Wales between April 2018 and July 2021. Here we describe monthly counts of prevalent and incident medications dispensed, as well as percentage changes compared to the previous year, for several CVD-related indications, focusing on hypertension, hypercholesterolemia and diabetes. We observed a decline in the dispensing of antihypertensive medications between March 2020 and July 2021, with 491,306 fewer individuals initiating treatment than expected. This decline was predicted to result in 13,662 additional CVD events, including 2,281 cases of myocardial infarction and 3,474 cases of stroke, should individuals remain untreated over their lifecourse. Incident use of lipid-lowering medications decreased by 16,744 patients per month during the first half of 2021 as compared to 2019. By contrast, incident use of medications to treat type 2 diabetes mellitus, other than insulin, increased by approximately 623 patients per month for the same time period. In light of these results, methods to identify and treat individuals who have missed treatment for CVD risk factors and remain undiagnosed are urgently required to avoid large numbers of excess future CVD events, an indirect impact of the COVID-19 pandemic.

Impact of Increased Patient-Clinician Virtual Visits During the COVID-19 Pandemic on Medical Student Enthusiasm for Future General Practice Careers

BACKGROUND

The COVID-19 pandemic restricted the availability of face-to-face primary care visits. This rapidly increased the proportion of primary care patient-clinician visits conducted virtually and asynchronously (remote consultations via video, telephone, and web-based text/email), altering the educational environment for medical students. Our study explored the impact of the increased proportion of primary care visits conducted virtually and asynchronously, on medical students' self-reported interest in pursuing a career in general (family) practice.

METHODS

We conducted a cross-sectional survey study of medical students at six universities within England and Wales to explore the impact of the increased proportion of primary care visits conducted virtually and asynchronously on medical students' interest in pursuing a career in general practice.

RESULTS

One hundred fifty-four medical students were recruited between December 2020 and May 2021; 79 (51%) of the participants reported being less interested in pursuing a career in general practice as a result of the increased proportion of virtual and asynchronous primary care visits during the COVID-19 pandemic. This increased to 104 (68%) of the participants reporting being less interested should primary care visits continue to be delivered virtually or asynchronously by default. Analysis of open-ended survey questions identified a poorer educational experience, concerns regarding the impact on patient care, an isolated working environment and technological challenges as key negative themes.

CONCLUSIONS

Sociable, supportive working and learning environments and offering equitable care are important motivators for the future workforce. There is a need to develop robust training and assessment in patient-clinician virtual visits and asynchronous communication and to integrate this into curricula.

Tackling climate change and health inequalities in primary care

The Climate Emergency is now widely accepted as the biggest public health crisis facing humanity. Previous research has highlighted how social and health inequalities shape the health impacts of climate change in the UK, but there has been little attention to the role of general practice in deprived areas. This Brief Report summarises a roundtable discussion of Scottish 'Deep End' GPs - family doctors working in the most socio-economically deprived areas - which took place weeks before the 26th UN Climate Change Conference (COP26), held in Glasgow in November 2021. The report highlights the need for urgent action to make general practice more sustainable, including recommendations for community engagement, (de)prescribing, medical education, digital inclusion, and investment in premises and capacity building.

Desperately Seeking Intersectionality in Digital Health Disparity Research: Narrative Review to Inform a Richer Theorization of Multiple Disadvantage

BACKGROUND

Digital consultations between patients and clinicians increased markedly during the COVID-19 pandemic, raising questions about equity.

OBJECTIVE

This study aimed to review the literature on how multiple disadvantage-specifically, older age, lower socioeconomic status, and limited English proficiency-has been conceptualized, theorized, and studied empirically in relation to digital consultations. We focused mainly on video consultations as they have wider disparities than telephone consultations and relevant data on e-consultations are sparse.

METHODS

Using keyword and snowball searching, we identified relevant papers published between 2012 and 2022 using Ovid MEDLINE, Web of Science, Google Scholar, and PubMed. The first search was completed in July 2022. Papers meeting the inclusion criteria were analyzed thematically and summarized, and their key findings were tabulated using the Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative Research criteria. Explanations for digital disparities were critically examined, and a search was undertaken in October 2022 to identify theoretical lenses on multiple disadvantage.

RESULTS

Of 663 articles from the initial search, 27 (4.1%) met our inclusion criteria. In total, 37% (10/27) were commentaries, and 63% (17/27) were peer-reviewed empirical studies (11/27, 41% quantitative; 5/27, 19% qualitative; 1/27, 4% mixed methods; 1/27, 4% systematic reviews; and 1/27, 4% narrative reviews). Empirical studies were mostly small, rapidly conducted, and briefly reported. Most studies (25/27, 93%) identified marked digital disparities but lacked a strong theoretical lens. Proposed solutions focused on identifying and removing barriers, but the authors generally overlooked the pervasive impact of multiple layers of disadvantage. The data set included no theoretically informed studies that examined how different dimensions of disadvantage combined to affect digital health disparities. In our subsequent search, we identified 3 theoretical approaches that might help account for these digital disparities. Fundamental cause theory by Link and Phelan addresses why the association between socioeconomic status and health is pervasive and persists over time. Digital capital theory by Ragnedda and Ruiu explains how people mobilize resources to participate in digitally mediated activities and services. Intersectionality theory by Crenshaw states that systems of oppression are inherently bound together, creating singular social experiences for people who bear the force of multiple adverse social structures.

CONCLUSIONS

A limitation of our initial sample was the sparse and undertheorized nature of the primary literature. The lack of attention to how digital health disparities emerge and play out both within and across categories of disadvantage means that solutions proposed to date may be oversimplistic and insufficient. Theories of multiple disadvantage have bearing on digital health, and there may be others of relevance besides those discussed in this paper. We call for greater interdisciplinary dialogue between theoretical research on multiple disadvantage and empirical studies on digital health disparities.

Opportunities and challenges in delivering remote primary care during the Coronavirus outbreak

Background

Social distancing and lockdowns were implemented during the first period of the COVID-19 pandemic. Primary care physicians needed to adapt quickly to deliver remote care/telemedicine.

Methods

A cross-sectional, 47-item online Google Survey was distributed through the Israel Association of Family Physicians (IAFP) mailing list between March 31-May 5, 2020. The questionnaire included demographics, physician characteristics, and information on usage and perceived telemedicine quality. Sampling weights by sex and age groups were applied.

Results

One hundred fifty-nine primary care physicians (10.6% of registered IAFP members; 63.5% women; mean age 53.4 ± 10.4 years and median professional experience 21.3 years) replied to the survey. The majority (59.7%) of the participants performed a mixture of in-person along with phone counseling. About 40% had no former telemedicine experience. The majority indicated that telephone and video formats were inferior to in-person consultation (68%, 57.1% online and phone, respectively). The overall counseling quality grade (on a 1–10 scale,)median (IQR)) was 6.2 (3) for telephone and 7(2) for video. While 66.9% reported experiencing no challenges, 10% had technical problems, 10% interpersonal problems, 5.6% scheduling difficulties, and 7.5% other difficulties. Majority of 56.6% physicians indicated they prescribed more antibiotics,16.4% sent more blood tests, 24.5% referred more to experts, and 49.7% referred more to imaging in comparison to usual counseling. Higher phone quality score was significantly associated with physicians who indicated not prescribing more antibiotics during the pandemic (OR = 0.30, 95%CI 0.134–0.688, p = 0.004).

Higher online quality score was associated with physicians who indicated not sending more blood tests during the pandemic (OR = 0.06 95%CI 0.008–0.378, P = 0.003).

Conclusions

Our findings suggest telehealth holds considerable promise for counseling in the primary care setting. However, interpersonal challenges raised by physicians should be understood in-depth to develop tailored training and further examine it in randomized trials while integrating patient-reported outcomes. Finally, further research on utility, cost, and cost-efficiency during remote counseling with follow-ups, medical prescribing, and additional referrals is needed.