Characterizing the use of virtual care in primary care settings during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: In March 2020, Canada implemented restrictions to curb viral transmission of COVID-19, which resulted in abrupt disruptions to conventional (in-person) clinical care. To retain continuity of care the delivery of primary care services shifted to virtual care. This study examined the nature of virtual visits, characterizing the use and users of virtual care in primary care settings from March 14/20 to June 30/20 of the COVID-19 pandemic.  METHODS: Retrospective cohort study of primary care providers in Manitoba, Canada that participate in the Manitoba Primary Care Research Network (MaPCReN) and offered ≥ 1 virtual care visit between 03/14/20 and 06/30/20 representing 142,616 patients. Tariff codes from billing records determined the visit type (clinic visit, virtual care). Between 03/14/20, and 06/30/20, we assessed each visit for a follow-up visit between the same patient and provider for the same diagnosis code. Patient (sex, age, comorbidities, visit frequency, prescriptions) and provider (sex, age, clinic location, provider type, remuneration, country of graduation, return visit rate) characteristics describe the study population by visit type. Generalized estimating equation models describe factors associated with virtual care.  RESULTS: There were 146,372 visits provided by 154 primary care providers between 03/14/20 and 06/30/20, of which 33.6% were virtual care. Female patients (OR 1.16, CI 1.09-1.22), patients with ≥ 3 comorbidities (OR 1.71, CI 1.44-2.02), and patients with ≥ 10 prescriptions (OR 2.71, 2.2-1.53) had higher odds of receiving at least one virtual care visit compared to male patients, patients with no comorbidities and patients with no prescriptions. There was no significant difference between the number of follow-up visits that were provided as a clinic visit compared to a virtual care visit (8.7% vs. 5.8%) (p = 0.6496). CONCLUSION: Early in the pandemic restrictions, approximately one-third of visits were virtual. Virtual care was utilized by patients with more comorbidities and prescriptions, suggesting that patients with chronic disease requiring ongoing care utilized virtual care. Virtual care as a primary care visit type continues to evolve. Ongoing provision of virtual care can enhance quality, patient-centered care moving forward.

Examining virtual visit use during a pandemic and perspectives of primary care providers, patients and caregivers: a mixed-methods research protocol

Introduction COVID-19 prompted rapid shifts to virtual primary care;however, the secondary implications and ideal applications of this change require further consideration. Patient and public stakeholder input has been bypassed. To integrate virtual care (VC) in what currently appears to be a lengthier battle against COVID-19 and related sequelae, further investigation is needed to support ideal implementation and use. This study aims to describe factors associated with the use of virtual visits in primary care practices, along with more in-depth description of users’ experiences and perspectives. Methods and analysis This study will be conducted in three phases, using a mixed-methods approach and in consultation with community advisors. Phase 1 will analyse data from electronic medical records (EMRs) to characterise the use and users of VC in primary care during the early phase of the COVID-19 pandemic. Analysis will be primarily descriptive;regression modelling will assess associations between patient and provider factors with a virtual visit. In phase 2, we will use an EMR-facilitated process to automate the distribution of patient surveys within an estimated 10 clinics. These surveys aim to describe care experiences, transactional use and perspectives of VC. In phase 3, focus groups with patients, caregivers and primary care clinicians will seek more in-depth exploration of VC regarding accessibility of care, acceptability and perceptions of quality care. Interpretive phenomenological analysis will be used for thematic analysis. The framework method will employ a matrix structure to organise the data and to facilitate comparison, integration and further interpretation. Ethics and dissemination This study has been approved by the University of Manitoba’s Health Research Ethics Board (HS24197). A co-designed dissemination strategy will include reports and infographics to policymakers and the public, manuscripts and presentations to academic and clinician audiences, and contributions to a learning plan for professional development.

Canadian Physiotherapists Integrate Virtual Care during the COVID-19 Pandemic

Purpose: To examine Canadian physiotherapists' experiences in adapting their delivery of patient care during the COVID-19 pandemic. We examine the level of strain on the profession and barriers and enablers to virtual care and provide strategies to support future virtual care implementation. Methods: From May-October 2020, a series of eight cross-sectional survey cycles were distributed every 2-4 weeks through branches and divisions of the Canadian Physiotherapy Association, social media, and personal networks. Descriptive statistics summarized the main findings. Open ended questions were first analyzed inductively using thematic analysis, then deductively mapped to the Capability-Opportunity-Motivation Behavioural (COM-B) Model. Results: Between 1,820 (cycle 1) and 334 (cycle 7) physiotherapists responded. Median strain level was 5/5 (cycle 1) and dropped to median 3/5 (cycles 5-8). In cycle 1, 55% of physiotherapists had ceased in-person care, while 41% were providing modified in-person care. Of these physiotherapists, 79% were offering virtual care. As modified in-person care increased, virtual care continued as a substantial aspect of practice. Physiotherapists identified barriers (e.g., lack of hands-on care) and enabling factors (e.g., greater accessibility to patients) for virtual care. In-depth examination of the barriers and enablers through the COM-B lens identified potential interventions to support future virtual care implementation, including education and training resources for physiotherapists and communication and advocacy to patients and the public on the value of virtual care. Conclusions: Canadian physiotherapists exhibited high adaptability in response to COVID-19 through the rapid and widespread use of virtual care. By creating an in-depth understanding of the barriers and enablers to virtual care, along with potential interventions, this work will facilitate future opportunities to support and enhance physiotherapists' delivery of virtual care.

Engaging nursing students in a COVID-19 Point-of-Care rapid screening clinic.

BACKGROUND: The COVID-19 pandemic has globally impacted nursing education, particularly clinical learning opportunities for undergraduate nursing students. PURPOSE: In this paper, we report on an educational activity wherein students participated in a COVID-19 Rapid Antigen Testing (RAT) clinic on a Canadian university campus. METHODS: Between February-April 2021, in the second term of a five-term accelerated program, nursing students (n = 60) participated in a nurse-led COVID-19 RAT clinic for students and staff living or working in congregate housing. Students participated in education activities which exposed nursing students to the full range of community health nursing roles in a pandemic. RESULTS: From clinical, research, policy, and public health, this educational activity acted as a microcosm of the critical roles that nurses employ in the health ecosystem. CONCLUSION: We offer lessons learned about implementing this activity, and how these lessons can be applied to routine and exceptional nursing curriculum.

Bedtime versus morning use of antihypertensives for cardiovascular risk reduction (BedMed): protocol for a prospective, randomised, open-label, blinded end-point pragmatic trial.

INTRODUCTION: Sleep-time blood pressure correlates more strongly with adverse cardiovascular events than does daytime blood pressure. The BedMed trial evaluates whether bedtime antihypertensive administration, as compared with conventional morning use, reduces major adverse cardiovascular events. METHODS AND ANALYSIS: DesignProspective randomised, open-label, blinded end-point trial.ParticipantsHypertensive primary care patients using blood pressure lowering medication and free from glaucoma.SettingCommunity primary care providers in 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba and Ontario) are mailing invitations to their eligible patients. Social media campaigns (Google, Facebook) are additionally running in the same provinces.InterventionConsenting participants are allocated via central randomisation to bedtime vs morning use of all antihypertensives.Follow-up(1) Telephone or email questionnaire at 1 week, 6 weeks, 6 months and every 6 months thereafter, and (2) accessing linked governmental healthcare databases tracking hospital and community medical services.Primary outcomeComposite of all-cause death, or hospitalisation for myocardial infarction/acute-coronary syndrome, stroke or congestive heart failure.Secondary outcomesEach primary outcome element on its own, all-cause hospitalisation or emergency department visit, long-term care admission, non-vertebral fracture, new glaucoma diagnosis, 18-month cognitive decline from baseline (via Short Blessed Test).Select other outcomesSelf-reported nocturia burden at 6 weeks and 6 months (no, minor or major burden), 1-year self-reported overall health score (EQ-5D-5L), self-reported falls, total cost of care (acute and community over study duration) and mean sleep-time systolic blood pressure after 6 months (via 24-hour monitor in a subset of 302 sequential participants).Primary outcome analysisCox proportional hazards survival analysis.Sample sizeThe trial will continue until a projected 254 primary outcome events have occurred.Current statusEnrolment ongoing (3227 randomised to date). ETHICS AND DISSEMINATION: BedMed has ethics approval from six research ethics review boards and will publish results in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02990663.