The diagnostic and triage accuracy of digital and online symptom checker tools: a systematic review (preprint)

ABSTRACT Objective To evaluate the accuracy of digital and online symptom checkers in providing diagnoses and appropriate triage advice. Design Systematic review. Data sources Medline and Web of Science were searched up to 15 February 2021. Eligibility criteria for study selection Prospective and retrospective cohort, vignette, or audit studies that utilised an online or application-based service designed to input symptoms and biodata in order to generate diagnoses, health advice and direct patients to appropriate services were included. Main outcome measures The primary outcomes were (1) the accuracy of symptom checkers for providing the correct diagnosis and (2) the accuracy of subsequent triage advice given. Data extraction and synthesis Data extraction and quality assessment (using the QUADAS-2 tool) were performed by two independent reviewers. Owing to heterogeneity of the studies, meta-analysis was not possible. A narrative synthesis of the included studies and pre-specified outcomes was completed. Results Of the 177 studies retrieved, nine cohort studies and one cross-sectional study met the inclusion criteria. Symptom checkers evaluated a variety of medical conditions including ophthalmological conditions, inflammatory arthritides and HIV. 50% of the studies recruited real patients, while the remainder used simulated cases. The diagnostic accuracy of the primary diagnosis was low (range: 19% to 36%) and varied between individual symptom checkers, despite consistent symptom data input. Triage accuracy (range: 48.8% to 90.1%) was typically higher than diagnostic accuracy. Of note, one study found that 78.6% of emergency ophthalmic cases were under-triaged. Conclusions The diagnostic and triage accuracy of symptom checkers are variable and of low accuracy. Given the increasing push towards population-wide digital health technology adoption, reliance upon symptom checkers in lieu of traditional assessment models, poses the potential for clinical risk. Further primary studies, utilising improved study reporting, core outcome sets and subgroup analyses, are warranted to demonstrate equitable and non-inferior performance of these technologies to that of current best practice. PROSPERO registration number CRD42021271022. SUMMARY BOXES What is already known on this topic Chambers et al. (2019) have previously examined the evidence underpinning digital and online symptom checkers, including the accuracy of the diagnostic and triage information, for urgent health problems and found that diagnostic accuracy was generally low and varied depending on the symptom checker used. Given the increased reliance upon digital health technologies by health systems in light of the ongoing COVID-19 pandemic, in addition to the marked increase in availability of similarly themed digital health products since the last systematic review, a contemporary and comprehensive reassessment of this class of technologies to ascertain their diagnostic and triage accuracy is warranted. What this study adds Our systematic review demonstrates that the diagnostic accuracy of symptom checkers remains low and varies significantly depending on the pathology or symptom checker used. The findings of this systematic review suggests that this class of technologies, in their current state, poses significant risk for patient safety, particularly if utilised in isolation.

DETERMINANTS OF BURNOUT AND OTHER ASPECTS OF PSYCHOLOGICAL WELL-BEING IN HEALTHCARE WORKERS DURING THE COVID-19 PANDEMIC: A MULTINATIONAL CROSS-SECTIONAL STUDY (preprint)

BackgroundThe Covid-19 pandemic has placed unprecedented pressure on healthcare systems and workers around the world. Such pressures may impact on working conditions, psychological wellbeing and perception of safety. In spite of this, no study has assessed the relationship between safety attitudes and psychological outcomes. Moreover, only limited studies have examined the relationship between personal characteristics and psychological outcomes during Covid-19. MethodsFrom 22nd March 2020 to 18th June 2020, healthcare workers from the United Kingdom, Poland, and Singapore were invited to participate using a self-administered questionnaire comprising the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS) to evaluate safety culture, burnout and anxiety/depression. Multivariate logistic regression was used to determine predictors of burnout, anxiety and depression. ResultsOf 3,537 healthcare workers who participated in the study, 2,364 (67%) screened positive for burnout, 701 (20%) for anxiety, and 389 (11%) for depression. Significant predictors of burnout included patient-facing roles: doctor (OR 2.10; 95% CI 1.49-2.95), nurse (OR 1.38; 95% CI 1.04-1.84), and other clinical (OR 2.02; 95% CI 1.45-2.82); being redeployed (OR 1.27; 95% CI 1.02-1.58), bottom quartile SAQ score (OR 2.43; 95% CI 1.98-2.99), anxiety (OR 4.87; 95% CI 3.92-6.06) and depression (OR 4.06; 95% CI 3.04-5.42). Factors significantly protective for burnout included being tested for SARS-CoV-2 (OR 0.64; 95% CI 0.51-0.82) and top quartile SAQ score (OR 0.30; 95% CI 0.22-0.40). Significant factors associated with anxiety and depression, included burnout, gender, safety attitudes and job role. ConclusionOur findings demonstrate a significant burden of burnout, anxiety, and depression amongst healthcare workers. A strong association was seen between SARS-CoV-2 testing, safety attitudes, gender, job role, redeployment and psychological state. These findings highlight the importance of targeted support services for at risk groups and proactive SARS-CoV-2 testing of healthcare workers.

What Has Been the Impact of Covid-19 on Safety Culture? (preprint)

Introduction Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and in turn patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. Methods The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture during Covid-19 at a large UK teaching hospital. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. Results Significant increases were seen in SAQ score for doctors and AHPs (p value) from baseline (p value). A decrease in SAQ was found in the nursing group. Largely due to perception of management and safety climate subscales. During Covid-19, on univariate regression analysis, female gender (p<0.001), age 40-49 years (p<0.01), non-white ethnicity (p<0.001), nursing job role (p<0.001) were all associated with lower SAQ scores. Training (p<0.001) and support (p<0.001) for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13, -0.26-0.00), non-disclosed ethnicity (-0.11, -0.22-0.00), nursing role (-0.15, -0.24-0.06), and support (0.24, 0.07-0.4) persisted to significance. A significant decrease (p<0.003) was seen in error reporting after the onset of the Covid-19 pandemic. Discussion Differences in reported safety culture may reflect perception of risk due to: occupational exposure, job function, or access to support services. Reductions in incident reporting may be due to increased workload, change in nature of work, or changing safety attitudes. Targeted high-quality support for redeployed staff may help improve safety during future pandemics.

How should hospitals manage the backlog of patients awaiting surgery following the COVID-19 pandemic? A demand modelling simulation case study for carotid endarterectomy (preprint)

Background The COVID-19 pandemic presents unparalleled challenges for the delivery of safe and effective care. In response, many health systems have chosen to restrict access to surgery and reallocate resources; the impact on the provision of surgical services has been profound, with huge numbers of patient now awaiting surgery at the risk of avoidable harm. The challenge now is how do hospitals transition from the current pandemic mode of operation back to business as usual, and ensure that all patients receive equitable, timely and high-quality surgical care during all phases of the public health crisis. Aims and Methods This case study takes carotid endarterectomy as a time-sensitive surgical procedure and simulates 400 compartmental demand modelling scenarios for managing surgical capacity in the UK for two years following the pandemic. Results A total of 7,69 patients will require carotid endarterectomy. In the worst-case scenario, if no additional capacity is provided on resumption of normal service, the waiting list may never be cleared, and no patient will receive surgery within the 2-week target; potentially leading to >1000 avoidable strokes. If surgical capacity is doubled after 1-month of resuming normal service, it will still take more than 6-months to clear the backlog, and 30.8% of patients will not undergo surgery within 2-weeks, with an average wait of 20.3 days for the proceeding 2 years. Conclusions This case study for carotid endarterectomy has shown that every healthcare system is going to have to make difficult decisions for balancing human and capital resources against the needs of patients. It has demonstrated that the timing and size of this effort will critically influence the ability of these systems to return to their baseline and continue to provide the highest quality care for all. The failure to sustainably increase surgical capacity early in the post-COVID-19 period will have significant long-term negative impacts on patients and is likely to result in avoidable harm.

SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic.

The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.