Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting. Method: 2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates. Results: Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote. Conclusion: Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

Mobile Health Interventions to Improve Health Behaviors and Healthcare Services among Vietnamese Individuals: A Systematic Review.

The purpose of this review is to summarize the feasibility, acceptability, and efficacy of interventions that utilize mobile health (mHealth) technology to promote health behavior changes or improve healthcare services among the Vietnamese population. Ovid MEDLINE, CINAHL, EMBASE, Scopus, and Web of Science were used to identify studies published from 2011-2022. Studies utilizing mHealth to promote behavior change and/or improve healthcare services among Vietnamese were included. Studies that included Vietnamese people among other Asians but did not analyze the Vietnamese group separately were excluded. Three independent researchers extracted data using Covidence following PRISMA guidelines. Measures of feasibility, acceptability, and efficacy were synthesized. The ROBINS-I and RoB2 tools were used to evaluate methodological quality. Fourteen articles met inclusion criteria and included 5660 participants. Participants rated high satisfaction, usefulness, and efficacy of mHealth interventions. Short message service was most frequently used to provide health education, support smoking cessation, monitor chronic diseases, provide follow-up, and manage vaccination. Measures of feasibility, acceptability, and efficacy varied across studies; overall findings indicated that mHealth is promising for promoting lifestyle behavior change and improving healthcare services. Cost effectiveness and long-term outcomes of mHealth interventions among the Vietnamese population are unknown and merit further research. Recommendations to integrate mHealth interventions are provided to promote the health of Vietnamese people.

The Indonesian Dentist Practice on The Coronavirus Disease-19 Pandemic: A Pilot Survey

Introduction: As a profession highly predisposed to coronavirus disease (COVID)-19, dentists should be aware of the possibility of cross-infection. The purpose of this study was to investigate descriptive statistics of dental practice during the covid-19 pandemic. Materials and Methods: This survey was conducted online using self-reported questionnaires created with Google Form®, among dentists in Indonesia. Descriptive statistics were used to summarize the survey results. Results: In total 102 participants completed the survey. The mean age was 42.71 (6.65) years. 19 males (18.8%) and 83 females (81.44%). Of all respondents, 80 (78 %) dentists provided dental services to patients during COVID-19 pandemic. Of those who had provided dental services, the most commonly indicated reasons were due to the emergency procedural 66 (82 %). We also found 51 (64%) dentists prefer online consultation. All of the provided temperature checking and will postpone the service with the symptomatic patient. Additionally, our survey found no significant difference between dentists who provided services to patients during COVID-19 pandemic or not based on gender, age, years in practice (all p> 0.05, respectively). The majority of research participants continued to give dental treatments during the COVID-19 pandemic. Conclusions: Personal protective equipment was essential, as well as a dental-care-safety environment. The small sample size of our survey limits its generalizability to the field of dentistry and needs further investigation. © 2023 UPM Press. All rights reserved.

Short- and long-term strategies for navigating research-ambivalent organizational cultures besetting embedded researchers.

Many health systems may host embedded researchers (ERs) and provide fiscal resources to encourage health service research. However, ERs may remain challenged to initiate research in these settings. This discussion examines how health system culture may impede research initiation, thereby exposing a paradox for embedded researchers immersed in research-ambivalent health systems. The discussion ultimately describes potential short-term and long-term strategies embedded researchers may employ to initiate scholarly inquiry in research-ambivalent health systems.

Effect of COVID-19 pandemic on utilisation of community-based mental health care in North-East of Italy: A psychiatric case register study.

AIMS: WHO declared that mental health care should be considered one essential health service to be maintained during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to describe the effect of lockdown and restrictions due to the COVID-19 pandemic in Italy on mental health services' utilisation, by considering psychiatric diagnoses and type of mental health contacts. METHODS: The study was conducted in the Verona catchment area, located in the Veneto region (northeastern Italy). For each patient, mental health contacts were grouped into: (1) outpatient care, (2) social and supportive interventions, (3) rehabilitation interventions, (4) multi-professional assessments, (5) day care. A 'difference in differences' approach was used: difference in the number of contacts between 2019 and 2020 on the weeks of lockdown and intermediate restrictions was compared with the same difference in weeks of no or reduced restrictions, and such difference was interpreted as the effect of restrictions. Both a global regression on all contacts and separate regressions for each type of service were performed and Incidence Rate Ratios (IRRs) were calculated. RESULTS: In 2020, a significant reduction in the number of patients who had mental health contacts was found, both overall and for most of the patients' characteristics considered (except for people aged 18-24 years for foreign-born population and for those with a diagnosis of schizophrenia. Moreover, in 2020 mental health contacts had a reduction of 57 096 (-33.9%) with respect to 2019; such difference remained significant across the various type of contacts considered, with rehabilitation interventions and day care showing the greatest reduction. Negative Binomial regressions displayed a statistically significant effect of lockdown, but not of intermediate restrictions, in terms of reduction in the number of contacts. The lockdown period was responsible of a 32.7% reduction (IRR 0.673; p-value <0.001) in the overall number of contacts. All type of mental health contacts showed a reduction ascribable to the lockdown, except social and supportive interventions. CONCLUSIONS: Despite the access to community mental health care during the pandemic was overall reduced, the mental health system in the Verona catchment area was able to maintain support for more vulnerable and severely ill patients, by providing continuity of care and day-by-day support through social and supportive interventions.

BSG cross-sectional survey on impact of COVID-19 recovery on workforce, workload and well-being.

Objective: The aim of this survey was to understand the impact of the COVID-19 pandemic and recovery phase on workload, well-being and workforce attrition in UK gastroenterology and hepatology. Design/method: A cross-sectional survey of British Society of Gastroenterology physician and trainee members was conducted between August and October 2021. Multivariable binary logistic regression and qualitative analyses were performed. Results: The response rate was 28.8% (180/624 of opened email invites). 38.2% (n=21/55) of those who contracted COVID-19 felt pressured to return to work before they felt ready. 43.8% (71/162) had a regular increase in out-of-hours working. This disproportionately affected newly appointed consultants (OR 5.8), those working full-time (OR 11.6), those who developed COVID-19 (OR 4.1) and those planning early retirement (OR 4.0). 92% (150/164) believe the workforce is inadequate to manage the service backlog with new consultants expressing the highest levels of anxiety over this. 49.1% (80/163) felt isolated due to remote working and 65.9% (108/164) felt reduced face-to-face patient contact made their job less fulfilling. 34.0% (55/162) planned to work more flexibly and 54.3% (75/138) of consultants planned to retire early in the aftermath of the pandemic. Early retirement was independently associated with male gender (OR 2.5), feeling isolated from the department (OR 2.3) and increased anxiety over service backlog (OR 1.02). Conclusion: The pandemic has placed an additional burden on work-life balance, well-being and workforce retention within gastroenterology and hepatology. Increased aspirations for early retirement and flexible working need to be explicitly addressed in future workforce planning.

UK endoscopy workload and workforce patterns: is there potential to increase capacity? A BSG analysis of the National Endoscopy Database.

Background: The lack of comprehensive national data on endoscopy activity and workforce hampers strategic planning. The National Endoscopy Database (NED) provides a unique opportunity to address this in the UK. We evaluated NED to inform service planning, exploring opportunities to expand capacity to meet service demands. Design: Data on all procedures between 1 March 2019 and 29 February 2020 were extracted from NED. Endoscopy activity and endoscopist workforce were analysed. Results: 1 639 640 procedures were analysed (oesophagogastroduodenoscopy (OGD) 693 663, colonoscopy 586 464, flexible sigmoidoscopy 335 439 and endoscopic retrograde cholangiopancreatography 23 074) from 407 sites by 4990 endoscopists. 89% of procedures were performed in NHS sites. 17% took place each weekday, 10% on Saturdays and 6% on Sundays. Training procedures accounted for 6% of total activity, over 99% of which took place in NHS sites. Median patient age was younger in the independent sector (IS) (51 vs 60 years, p<0.001). 74% of endoscopists were male. Gastroenterologists and surgeons each comprised one-third of the endoscopist workforce; non-medical endoscopists (NMEs) comprised 12% yet undertook 23% of procedures. Approximately half of endoscopists performing OGD (52%) or colonoscopies (48%) did not meet minimum annual procedure numbers. Conclusion: This comprehensive analysis reveals endoscopy workload and workforce patterns for the first time across both the NHS and the IS in all four UK nations. Half of all endoscopists perform fewer than the recommended minimum annual procedure numbers: a national strategy to address this, along with expansion of the NME workforce, would increase endoscopy capacity, which could be used to exploit latent weekend capacity.

Towards NHS Zero: greener gastroenterology and the impact of virtual clinics on carbon emissions and patient outcomes. A multisite, observational, cross-sectional study.

Objective: The National Health Service (NHS) produces more carbon emissions than any public sector organisation in England. In 2020, it became the first health service worldwide to commit to becoming carbon net zero, the same year as the COVID-19 pandemic forced healthcare systems globally to rapidly adapt service delivery. As part of this, outpatient appointments became largely remote. Although the environmental benefit of this change may seem intuitive the impact on patient outcomes must remain a priority. Previous studies have evaluated the impact of telemedicine on emission reduction and patient outcomes but never before in the gastroenterology outpatient setting. Method: 2140 appointments from general gastroenterology clinics across 11 Trusts were retrospectively analysed prior to and during the pandemic. 100 consecutive appointments during two periods of time, from 1 June 2019 (prepandemic) to 1 June 2020 (during the pandemic), were used. Patients were telephoned to confirm the mode of transport used to attend their appointment and electronic patient records reviewed to assess did-not-attend (DNA) rates, 90-day admission rates and 90-day mortality rates. Results: Remote consultations greatly reduced the carbon emissions associated with each appointment. Although more patients DNA their remote consultations and doctors more frequently requested follow-up blood tests when reviewing patients face-to-face, there was no significant difference in patient 90-day admissions or mortality when consultations were remote. Conclusion: Teleconsultations can provide patients with a flexible and safe means of being reviewed in outpatient clinics while simultaneously having a major impact on the reduction of carbon emissions created by the NHS.

Influences of COVID-19 pandemic on hospital-at-home functions in Finland - a questionnaire survey.

OBJECTIVE: To investigate functions of Finnish hospital-at-home (HAH) during the first year of COVID19-pandemic 2020 compared with the previous year 2019. DESIGN: Retrospective questionnaire survey. SETTING: Finnish HAHs from Northern, Eastern, Southern, Western and Central parts of Finland participated in a questionnaire web-based questionnaire survey. The numbers of patients, activities and staff in 2019 and 2020, participation in the care of COVID19 patients, availability of protective clothing, attitudes of patients towards home care and development of new practices in the corona era were asked using both predefined and free questions. SUBJECTS: questionnaire was sent to the nurses and physicians in charge of the HAHs (N = 13), 77% responded. The HAHs provided services to a total of 1,196,783 inhabitants in their municipalities. RESULTS: There were no significant changes in the numbers of patients, staff or activities between the years 2019 and 2020. Although nurses did viral tests, COVID19 patients were cared only in 40% of HAHs. Protective clothing was well available. New instructions for infection management were created. CONCLUSIONS: The COVID-19 pandemic did not largely influence the functions of the examined Finnish HAHs in 2020. Most activities and patients' characteristics remained unchanged from 2019. The role of HAHs should be further developed in Scandinavian countries, particularly during pandemics.Key PointsHospital-at-home (HAH) is a cost-effective model to provide hospital-like services.Data about the role of HAHs during COVID19 pandemics is lacking in the Nordic countries.This study shows that, the large Finnish municipal HAHs have been not influenced by pandemics.

Worries about inadequate medical treatment in case of a COVID-19 infection: the role of social inequalities, COVID-19 prevalence and healthcare infrastructure.

BACKGROUND: This study investigates individual and regional determinants of worries about inadequate medical treatment in case of a COVID-19 infection, an important indicator of mental wellbeing in pandemic times as it potentially affects the compliance with mitigation measures and the willingness to get vaccinated. The analyses shed light on the following questions: Are there social inequalities in worries about inadequate medical treatment in case of a COVID-19 infection? What is the role of the regional spread of COVID-19 infections and regional healthcare capacities? METHODS: Based on data derived from the German Socioeconomic Panel (SOEP), a representative sample of the German population aged 18 years and over, we estimated multilevel logistic regression models with individual-level (level 1) and regional-level (level 2) variables. The regional variables of interest were (a) the number of COVID-19 infections, (b) the number of hospital beds as an overall measure of the regional healthcare capacities, and (c) the number of free intensive care units as a measure of the actual capacities for treating patients with severe courses of COVID-19. RESULTS: Women, older respondents, persons with migrant background and those with a lower socioeconomic status were more likely to report worries about inadequate medical treatment in case of a COVID-19 infection. Moreover, respondents with chronic illness, lower subjective health and those who consider COVID-19 as a threat for their own health were more likely to report worries. In addition, also regional characteristics were relevant. Worries were more common in poorer regions with higher COVID-19 infections and worse health infrastructure as indicated by the number of hospital beds. CONCLUSIONS: The analysis not only indicates that several social groups are more concerned about inadequate medical treatment in case of a COVID-19 infection, but also highlights the need for considering regional-level influences, such as the spread of the virus, poverty rates and healthcare infrastructure, when analyzing the social and health-related consequences of the pandemic.

What complications have arisen after early medical abortion -’both pills by post’’ policy in the uk during Covid? Do these increase the risk of subsequent premature birth?

BackgroundDuring 2019 NICE and the RCOG introduced UK guidelines normalising the early medical abortion (EMA) protocol for pregnancies prior to 10 weeks gestation. Mifepristone is taken at the abortion clinic, and the second pill, Misoprostol may be taken unsupervised at home 36–48 hours later. In March 2020, UK EMA policy changed, and telemedicine with ‘both pills by post’(BPBP) was authorised by DHSC, during Covid-19.MethodsA worldwide systematic review and meta-analyses were conducted to compare risk of PTB after one or more abortions compared to none, and PB after medical versus surgical abortion. Systematic evidence on outcomes after medical abortion are recorded through the Finnish Abortion registry. Mannisto (2013) published a paper showing that when surgical abortion, or evacuation of retained products of conception (ERPC) is required after a medical abortion, it increases the risk of subsequent PB by 241%. Very little data has been collected on this subject in England. We examine data from FOI requests to CQC in Dec 2020 and to NHS Acute hospital trust A&E departments in England and Wales (E&W) to investigate the incidence of complications (haemorrhage and sepsis) and ERPC after EMA and BPBP since April 2020.ResultsOur meta-analysis showed adj OR of 1.52, 95% CI (1.43–1.62), for increased risk of PTB after Abortion, compared to none. Surgical abortion carried more risk (RR 1.23) than Medical Abortion. FOI (response rate 67%) showed a 5.9% EMA failure rate in E&W from data from NHS A&E depts between April 2020 and 2021. This is similar to EMA failure rate (5.48%) published in Marie Stopes Australia 2020 report. It means that more than 7,400 women per annum across England have had complications from EMA since the Covid approval for telemedicine and BPBP. 2.4% needed a subsequent ERPC, which increases further the risk of a PTB in a later pregnancy. Incidence of complications or ERPC after EMA is 0.75%, 5x higher than reported by DHSC (0.15%).ConclusionThese results suggest that this policy of BPBP during Covid-19, should revert to in-person consultation for EMA for the safety of women. The BPBP was a departure from Evidence Based Medicine. Abortion should be appropriately governanced, and outcomes fully evaluated with evidence collected using longitudinal data via the NHS number on HSA4 forms. This would inform a safer policy for the wellbeing of women and help to reduce the increasing rates of PTB for the future.

The effect of the COVID-19 lockdown on mental health care use in South Africa: an interrupted time-series analysis.

AIMS: The coronavirus disease 2019 (COVID-19) pandemic and ensuing restrictions have negatively affected the mental health and well-being of the general population, and there is increasing evidence suggesting that lockdowns have led to a disruption of health services. In March 2020, South Africa introduced a lockdown in response to the COVID-19 pandemic, entailing the suspension of all non-essential activities and a complete ban of tobacco and alcohol sales. We studied the effect of the lockdown on mental health care utilisation rates in private-sector care in South Africa. METHODS: We conducted an interrupted time-series analysis using insurance claims from 1 January 2017 to 1 June 2020 of beneficiaries 18 years or older from a large private sector medical insurance scheme. We calculated weekly outpatient consultation and hospital admission rates for organic mental disorders, substance use disorders, serious mental disorders, depression, anxiety, other mental disorders, any mental disorder and alcohol withdrawal syndrome. We calculated adjusted odds ratios (OR) for the effect of the lockdown on weekly outpatient consultation and hospital admission rates and the weekly change in rates during the lockdown until 1 June 2020. RESULTS: 710 367 persons were followed up for a median of 153 weeks. Hospital admission rates (OR 0.38; 95% confidence interval (CI) 0.33-0.44) and outpatient consultation rates (OR 0.74; 95% CI 0.63-0.87) for any mental disorder decreased substantially after the introduction of the lockdown and did not recover to pre-lockdown levels by 1 June 2020. Health care utilisation rates for alcohol withdrawal syndrome doubled after the introduction of the lockdown, but the statistical uncertainty around the estimates was large (OR 2.24; 95% CI 0.69-7.24). CONCLUSIONS: Mental health care utilisation rates for inpatient and outpatient services decreased substantially after the introduction of the lockdown. Hospital admissions and outpatient consultations for alcohol withdrawal syndrome increased after the introduction of the lockdown, but statistical uncertainty precludes strong conclusions about a potential unintended effect of the alcohol sales ban. Governments should integrate strategies for ensuring access and continuity of essential mental health services during lockdowns in pandemic preparedness planning.

The challenge of care coordination by midwives during the COVID-19 pandemic: a national descriptive survey.

BACKGROUND: As part of a decades-long process of restructuring primary care, independent (also known as community) healthcare workers are being encouraged to work in groups to facilitate their coordination and continuity of care in France. French independent midwives perform about half of the early prenatal interviews that identify mothers' needs during pregnancy and then refer them to the appropriate resources. The French government, however, structured the COVID-19 pandemic response around public health institutions and did not directly mobilise these community healthcare workers during the lockdown phase. These responses have raised questions about their role within the healthcare system in crises. This survey's main objectives were to estimate the proportion of independent midwives who experienced new difficulties in referring women to healthcare facilities or other caregivers and in collaborating with hospitals during the first stage of this pandemic. The secondary objective was to estimate the proportion, according to their mode of practice, of independent midwives who considered that all the women under their care had risked harm due to failed or delayed referral to care. METHODS: We conducted an online national survey addressed to independent midwives in France from 29 April to 15 May 2020, around the end of the first lockdown (17 March-11 May, 2020). RESULTS: Of the 5264 registered independent midwives in France, 1491 (28.3%) responded; 64.7% reported new or greater problems during the pandemic in referring women to health facilities or care-providers, social workers in particular, and 71.0% reported new difficulties collaborating with hospitals. Nearly half (46.2%) the respondents considered that all the women in their care had experienced, to varying degrees, a lack of or delay in care that could have affected their health. This proportion did not differ according to the midwives' form of practice: solo practice, group practice with other midwives only, or group practice with at least two types of healthcare professionals. CONCLUSIONS: The pandemic has degraded the quality of pregnant women's care in France and challenged the French model of care, which is highly compartmentalised between an almost exclusively independent primary care (community) sector and a predominantly salaried secondary care (hospital) sector.

Ambulatory care management of 69 patients with acute severe ulcerative colitis in comparison to 695 inpatients: insights from a multicentre UK cohort study.

INTRODUCTION: Acute severe ulcerative colitis (ASUC) traditionally requires inpatient hospital management for intravenous therapies and/or colectomy. Ambulatory ASUC care has not yet been evaluated in large cohorts. AIMS: We used data from PROTECT, a UK multicentre observational COVID-19 inflammatory bowel disease study, to report the extent, safety and effectiveness of ASUC ambulatory pathways. METHODS: Adults (≥18 years old) meeting Truelove and Witts criteria between 1 January 2019-1 June 2019 and 1 March 2020-30 June 2020 were recruited to PROTECT. We used demographic, disease phenotype, treatment outcomes and 3-month follow-up data. Primary outcome was rate of colectomy during the index ASUC episode. Secondary outcomes included corticosteroid response, time to and rate of rescue or primary induction therapy, response to rescue or primary induction therapy, time to colectomy, mortality, duration of inpatient treatment and hospital readmission and colectomy within 3 months of index flare. We compared outcomes in three cohorts: (1) patients treated entirely in inpatient setting; ambulatory patients subdivided into; (2) patients managed as ambulatory from diagnosis and (3) patients hospitalised and subsequently discharged to ambulatory care for continued intravenous steroids. RESULTS: 37% (22/60) participating hospitals used ambulatory pathways. Of 764 eligible patients, 695 (91%) patients received entirely inpatient care, 15 (2%) patients were managed as ambulatory from diagnosis and 54 (7%) patients were discharged to ambulatory pathways. Aside from younger age in patients treated as ambulatory from diagnosis, no significant differences in disease or patient phenotype were observed. The rate of colectomy (15.0% (104/695) vs 13.3% (2/15) vs 13.0% (7/54), respectively, p=0.96) and secondary outcomes were similar among all three cohorts. Stool culture and flexible sigmoidoscopy were less frequently performed in ambulatory cohorts. Forty per cent of patients treated as ambulatory from diagnosis required subsequent hospital admission. CONCLUSIONS: In a post hoc analysis of one of the largest ASUC cohorts collected to date, we report an emerging UK ambulatory practice which challenges treatment paradigms. However, our analysis remains underpowered to detect key outcome measures and further studies exploring clinical and cost-effectiveness as well as patient and physician acceptability are needed. TRIAL REGISTRATION NUMBER: NCT04411784.

Symptoms, complications and management of long COVID: a review.

Globally, there are now over 160 million confirmed cases of COVID-19 and more than 3 million deaths. While the majority of infected individuals recover, a significant proportion continue to experience symptoms and complications after their acute illness. Patients with 'long COVID' experience a wide range of physical and mental/psychological symptoms. Pooled prevalence data showed the 10 most prevalent reported symptoms were fatigue, shortness of breath, muscle pain, joint pain, headache, cough, chest pain, altered smell, altered taste and diarrhoea. Other common symptoms were cognitive impairment, memory loss, anxiety and sleep disorders. Beyond symptoms and complications, people with long COVID often reported impaired quality of life, mental health and employment issues. These individuals may require multidisciplinary care involving the long-term monitoring of symptoms, to identify potential complications, physical rehabilitation, mental health and social services support. Resilient healthcare systems are needed to ensure efficient and effective responses to future health challenges.

Evaluation of the Effects of the COVID-19 Pandemic on Electronic Consultation Use in Primary Care.

Background: Little is known about electronic consultation (e-consult) utilization during the COVID-19 pandemic when health systems rapidly implemented and scaled telehealth alternatives to in-person care. It is also unknown if e-consult utilization during the pandemic replaced or merely deferred the need for a specialty appointment. We evaluated if primary care providers' (PCPs) e-consult utilization and specialists' recommendations for specialty appointments changed after the transition to telemedicine during the COVID-19 pandemic. Methods: This cohort study used an interrupted time series analysis of e-consult utilization in a large, urban academic health care system between December 1, 2019, and June 27, 2020; the post-telemedicine time period began March 15, 2020. The primary outcome measure was the odds of an e-consult ordered during a PCP appointment; the secondary outcome measure was the odds of a specialist recommending a specialty appointment in an e-consult. Results: During 193,263 PCP appointments, 1,318 e-consults were placed to internal medicine subspecialties. Compared to the pre-telemedicine time period, the odds of a PCP ordering an e-consult increased (OR 1.04, 95% CI [1.02-1.07]) and the odds of specialists recommending specialty appointments increased (OR 1.11, 95% CI [1.06-1.15]). Conclusions: E-consult use increased following the transition to telemedicine in the context of the COVID-19 pandemic, suggesting that PCPs consider the e-consult a valuable tool for patient care when there is limited availability of specialty appointments. However, recommendations for specialty appointments following an e-consult also increased, suggesting that the e-consult may not replace the need for a specialty appointment.

Challenges and opportunities in health care and nursing management research in times of COVID-19 outbreak.

AIM: To reflect upon the concrete implications of the COVID-19 outbreak regarding ongoing health service and nursing management research (NMR) and to identify possible research priorities for the current and post-pandemic era. BACKGROUND: Health service research and the nursing management research debate have received little attention to date, despite their relevance in responding to the increased demand of care during the COVID-19 outbreak. METHODS: A critical analysis on experiences was performed while leading international-funded studies at different degrees of complexity and targets, involving nurse managers, nurses, care processes and health care services in the last year. RESULTS: Ongoing research projects have been profoundly affected by the COVID-19 outbreak in their aims, methods, management processes, feasibility and outcomes. CONCLUSIONS: The COVID-19 outbreak is an unprecedented stress test for the health care sector and for the nursing services. Its onset and persistence have rendered more easily to see what prevails in terms of effectiveness and what fails in our health care services. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers have lived and are still living through this crisis, given their omnipresence in the health care systems. Therefore, setting NMR priorities and working together to imagine and design the post-COVID-19 era is essential.