Increase in Anxiety-Related Out-of-Hours Primary Care Consultations Since COVID-19: An Observational Study Using Routine Data in Flanders

Background: Survey studies suggest that COVID-19 has had a negative impact on the population's mental well-being. Routine registration data allow a more objective way for investigating such associations, complementary to self-report measures. This study investigates the level of out of hours (OOH) consultations for psychological problems since the start of the COVID-19 pandemic in Flanders, Belgium. Methods: The iCAREdata database is a clinical research database with routine data of OOH care, covering a large area in Flanders, Belgium. After defining the first wave and the second wave of COVID-19 in Flanders in time, we compared the number of consultations regarding psychological problems (in general, anxiety-related, depression-related, and sleep-related) between those periods, the period in between these waves, and the period before the start of COVID-19. Results: A significant rise in OOH consultations due to psychological—and more specifically, anxiety-related—problems is observed since the start of the COVID-19 pandemic in Flanders. Elevated levels are observed until the second wave. This finding is in sharp contrast with the general pattern of lower demand for primary healthcare during this period. The majority of these supplementary consultations happened by phone. Consultations regarding depression-related problems did not change over time. Sleep disturbances in the OOH setting were more common after the first wave. Conclusion: Despite some limitations, a large Flemish database with routine data on OOH care shows an increase in the number of consultations regarding psychological problems in general and anxiety-related problems since the start of the COVID-19-pandemic until the second wave.

Increase in Anxiety-Related Out-of-Hours Primary Care Consultations Since COVID-19: An Observational Study Using Routine Data in Flanders.

Background: Survey studies suggest that COVID-19 has had a negative impact on the population's mental well-being. Routine registration data allow a more objective way for investigating such associations, complementary to self-report measures. This study investigates the level of out of hours (OOH) consultations for psychological problems since the start of the COVID-19 pandemic in Flanders, Belgium. Methods: The iCAREdata database is a clinical research database with routine data of OOH care, covering a large area in Flanders, Belgium. After defining the first wave and the second wave of COVID-19 in Flanders in time, we compared the number of consultations regarding psychological problems (in general, anxiety-related, depression-related, and sleep-related) between those periods, the period in between these waves, and the period before the start of COVID-19. Results: A significant rise in OOH consultations due to psychological-and more specifically, anxiety-related-problems is observed since the start of the COVID-19 pandemic in Flanders. Elevated levels are observed until the second wave. This finding is in sharp contrast with the general pattern of lower demand for primary healthcare during this period. The majority of these supplementary consultations happened by phone. Consultations regarding depression-related problems did not change over time. Sleep disturbances in the OOH setting were more common after the first wave. Conclusion: Despite some limitations, a large Flemish database with routine data on OOH care shows an increase in the number of consultations regarding psychological problems in general and anxiety-related problems since the start of the COVID-19-pandemic until the second wave.

Burden of COVID-19 on primary care in Belgium: a prospective nationwide observational study from March to August 2020.

BACKGROUND: The COVID-19 outbreak had an important impact on general practice, for example the lack of personal protective equipment (PPE) and the switch to telephone consultations. We installed a monitoring instrument and reported the burden the COVID-19 pandemic placed on Belgian general practitioners (GPs) during the first wave of the pandemic. METHODS: We conducted an observational longitudinal prospective study from the 19th of March until the 17th of August 2020. Daily data were collected by using a structured electronic form integrated into the GPs' electronic medical records (EMRs). Data were collected on the GPs' need for support and workload, epidemiological indicators and the availability of PPE. Reports with graphical presentations were made for GP circles and primary care zones, and governments of different administrative levels had access to all data to guide their policy. RESULTS: A total of 3.769 different GP centres participated, which included more than 10.000 GPs. Throughout the first three weeks, 20% declared they had insufficient resources (personnel and material) for the following week. Approximately 10% continued to report this during the entire study. The majority reported being able to complete their daily tasks without loss of quality. During the first week, 30% indicated an increased workload. Afterwards, this number decreased and stabilized to an average of 10-20%. More than 70% of the consultations in March 2020 were conducted by telephone. This percentage declined in April and stabilized at approximately 30% in June 2020. Consultations due to respiratory symptoms peaked at 4000/100,000 inhabitants at the beginning of the outbreak, then decreased over time along with the COVID-19 incidence. We noticed a lack of disinfectant hand gel, surgical masks and FFP2 masks, the latter remaining problematic in the long term. CONCLUSION: We introduced an instrument in Belgian EMR systems to monitor the burden on GPs during the first wave of the COVID-19 pandemic. The lack of PPE and increased workload were considered to be the main obstacles. A large number of the GP offices switched to teleconsultations to provide healthcare. Our monitoring instrument provided information for policy makers to intervene on a local level.

Predicting COVID-19 Symptoms From Free Text in Medical Records Using Artificial Intelligence: Feasibility Study.

BACKGROUND: Electronic medical records have opened opportunities to analyze clinical practice at large scale. Structured registries and coding procedures such as the International Classification of Primary Care further improved these procedures. However, a large part of the information about the state of patient and the doctors' observations is still entered in free text fields. The main function of those fields is to report the doctor's line of thought, to remind oneself and his or her colleagues on follow-up actions, and to be accountable for clinical decisions. These fields contain rich information that can be complementary to that in coded fields, and until now, they have been hardly used for analysis. OBJECTIVE: This study aims to develop a prediction model to convert the free text information on COVID-19-related symptoms from out of hours care electronic medical records into usable symptom-based data that can be analyzed at large scale. METHODS: The design was a feasibility study in which we examined the content of the raw data, steps and methods for modelling, as well as the precision and accuracy of the models. A data prediction model for 27 preidentified COVID-19-relevant symptoms was developed for a data set derived from the database of primary-care out-of-hours consultations in Flanders. A multiclass, multilabel categorization classifier was developed. We tested two approaches, which were (1) a classical machine learning-based text categorization approach, Binary Relevance, and (2) a deep neural network learning approach with BERTje, including a domain-adapted version. Ethical approval was acquired through the Institutional Review Board of the Institute of Tropical Medicine and the ethics committee of the University Hospital of Antwerpen (ref 20/50/693). RESULTS: The sample set comprised 3957 fields. After cleaning, 2313 could be used for the experiments. Of the 2313 fields, 85% (n=1966) were used to train the model, and 15% (n=347) for testing. The normal BERTje model performed the best on the data. It reached a weighted F1 score of 0.70 and an exact match ratio or accuracy score of 0.38, indicating the instances for which the model has identified all correct codes. The other models achieved respectable results as well, ranging from 0.59 to 0.70 weighted F1. The Binary Relevance method performed the best on the data without a frequency threshold. As for the individual codes, the domain-adapted version of BERTje performs better on several of the less common objective codes, while BERTje reaches higher F1 scores for the least common labels especially, and for most other codes in general. CONCLUSIONS: The artificial intelligence model BERTje can reliably predict COVID-19-related information from medical records using text mining from the free text fields generated in primary care settings. This feasibility study invites researchers to examine further possibilities to use primary care routine data.

Overprescribing of Topical Ocular Corticosteroids and Antibiotics in Out-of-Hours Primary Care in Belgium.

Prescribing patterns by primary care physicians concerning ophthalmic problems were studied using the iCAREdata, a database containing information from the out-of-hours care setting in the Flanders region of Belgium. A very high percentage of prescribed ophthalmic medication was topical antibiotics (89.4%) with tobramycin as the most prevalent substance and in clear conflict with the prevailing guidelines. In addition, a very substantial fraction of prescribed medication contained corticosteroids (30.4%). This is a potentially unsafe option within the technical infrastructure of this setting, which limits the diagnostic possibilities concerning viral infections or preexisting glaucoma risk. We conclude that more efforts are required to limit unnecessary and inappropriate prescribing behavior to further promote patient safety.

Antibiotic Prescribing Trends in Belgian Out-of-Hours Primary Care during the COVID-19 Pandemic: Observational Study Using Routinely Collected Health Data.

Antibiotic overprescribing is one of the main drivers of the global and growing problem of antibiotic resistance, especially in primary care and for respiratory tract infections (RTIs). RTIs are the most common reason for patients to consult out-of-hours (OOH) primary care. The COVID-19 pandemic has changed the way general practitioners (GPs) work, both during office hours and OOH. In Belgian OOH primary care, remote consultations with the possibility of issuing prescriptions and telephone triage were implemented. We aimed to describe the impact of COVID-19 on GPs' antibiotic prescribing during OOH primary care. In an observational study, using routinely collected health data from GP cooperatives (GPCs) in Flanders, we analyzed GPs' antibiotic prescriptions in 2019 (10 GPCs) and 2020 (20 GPCs) during OOH consultations (telephone and face-to-face). We used autoregressive integrated moving average (ARIMA) modeling to identify any changes after lockdowns were implemented. In total, 388,293 contacts and 268,430 prescriptions were analyzed in detail. The number of antibiotic prescriptions per weekend, per 100,000 population was 11.47 (95% CI: 9.08-13.87) or 42.9% lower after compared to before the implementation of lockdown among all contacts. For antibiotic prescribing per contact, we found a decrease of 12.2 percentage points (95% CI: 10.6-13.7) or 56.5% among all contacts and of 5.3 percentage points (95% CI: 3.7-6.9) or 23.2% for face-to-face contacts only. The decrease in the number of prescriptions was more pronounced for cases with respiratory symptoms that corresponded with symptoms of COVID-19 and for antibiotics that are frequently prescribed for RTIs, such as amoxicillin (a decrease of 64.9%) and amoxicillin/clavulanate (a decrease of 38.1%) but did not appear for others such as nitrofurantoin. The implementation of COVID-19 lockdown measures coincided with an unprecedented drop in the number of antibiotic prescriptions, which can be explained by a decrease in face-to-face patient contacts, as well as a lower number of antibiotics prescriptions per face-to-face patient contact. The decrease was seen for antibiotics used for RTIs but not for nitrofurantoin, the first-choice antibiotic for urinary tract infections.

Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study.

BACKGROUND: During the COVID-19 pandemic, general practitioners worldwide re-organise care in very different ways because of the lack of evidence-based protocols. OBJECTIVE: This paper describes the organisation and the characteristics of consultations in Belgian out-of-hours primary care during five weekends at the peak of a COVID-19 outbreak and compares it to a similar period in 2019. METHODS: Real-time observational study using pseudonymised routine clinical data extracted out of reports from home visits, telephone- and physical consultations (iCAREdata). Nine general practice cooperatives (GPCs) participated covering a population of 1 513 523. RESULTS: All GPCs rapidly re-organised care in order to handle the outbreak and provide a safe working environment. The average consultation rate was 222 per 100 000 citizens per weekend. These consultations were handled by telephone alone in 40% (N = 6293). A diagnosis at risk of COVID-19 was registered in 6692 (43%) consultations,. Out of 5311 physical consultations, 1460 were at risk of COVID-19 of which 443 (30%) did not receive prior telephone consultation to estimate this risk. Compared to 2019, the workload initially increased due to telephone consultations but afterwards declined drastically. The physical consultation rate declined by 45% with a marked decline in diagnoses unrelated to COVID-19. CONCLUSIONS: General practitioners can rapidly re-organise out-of-hours care to handle patient flows during a COVID-19 outbreak. Forty percent of the out-of-hours primary care contacts are handled by telephone consultations alone. We recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care. The demand for physical consultations declined drastically provoking questions about patient's safety for care unrelated to COVID-19.

Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs.

OBJECTIVES: The current COVID-19 pandemic, as well as the measures taken to control it, have a profound impact on healthcare. This study was set up to gain insights into the consequences of the COVID-19 outbreak on the core competencies of general practice, as they are experienced by general practitioners (GPs) on the frontline. DESIGN, SETTING, PARTICIPANTS: We performed a descriptive study using semistructured interviews with 132 GPs in Flanders, using a topic list based on the WONCA definition of core competencies in general practice. Data were analysed qualitatively using framework analysis. RESULTS: Changes in practice management and in consultation strategies were quickly adopted. There was a major switch towards telephone triage and consults, for covid-related as well as for non-covid related problems. Patient-centred care is still a major objective. Clinical decision-making is largely focused on respiratory assessment and triage, and GPs feel that acute care is compromised, both by their own changed focus and by the fact that patients consult less frequently for non-covid problems. Chronic care is mostly postponed, and this will have consequences that will extend and become visible after the corona crisis. Through the holistic eyes of primary care, the current outbreak-as well as the measures taken to control it-will have a profound impact on psychological and socioeconomic well-being. This impact is already visible in vulnerable people and will continue to become clear in the medium and long terms. GPs think that they are at high risk of getting infected. Dropping out and being unable to contribute their part or becoming virus transmitters are reported to be greater concerns than getting ill themselves. CONCLUSIONS: The current times have a profound impact on the core competences of primary care. Although the vast increase in patients soliciting medical help and the necessary separate covid and non-covid flows have been dealt with, GPs are worried about the continuity of regular care and the consequences of the anticovid measures. These may become a threat for the general health of the population and for the provision of primary healthcare in the near and distant future.