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2.
16th Annual International Conference on European Integration (AICEI) ; : 253-264, 2021.
Article in English | English Web of Science | ID: covidwho-1880156

ABSTRACT

During pandemic times, like the SARS-CoV-2 outbreak, the chance of spreading the virus in the community and the individual health risk of the population especially for chronic patients is imminent. The dramatic increase of Covid-19 cases and the various health measures issued by the governments as lockdowns, curfews, gathering limitations, etc. led to changes in the way of life and had a tremendous effect on the mental health of the population. Furthermore, it raised the awareness of the population concerning their health risk while visiting the physicians, which additionally had an impact on the general practice as the first line of defense. Aim: The aim of this study is to investigate the views and expectations of the population concerning some of these issues. Methodology: Questionnaires were distributed at the peak of the Coronavirus outbreak (June to August 2020) in R.N. Macedonia. One survey was emailed to 2200 individual general practitioners and one was distributed randomly via emails and social networks for the public, which included participants above 15 years of age. SPSS statistical software was used to analyze the gathered data. Findings: Findings indicate that participants showed increased concerns about their safety and health risks in comparison to the time before the pandemic when visiting the general practitioner. Additionally, the general practitioners revealed increased concerns about their own and the patients' safety in their medical facilities during the outbreak. Contribution: Governments and public health authorities should consider these findings, use them as a reference, and carefully see how all of this is influencing the population before issuing additional restrictions and regulations in which the general practice is affected during pandemics.

3.
Br J Gen Pract ; 2022 Apr 04.
Article in English | MEDLINE | ID: covidwho-1879499

ABSTRACT

BACKGROUND: The NHS response to COVID-19 altered provision and access to primary care. AIM: To examine the impact of COVID-19 on GP contacts with children and young people (CYP) in England. DESIGN AND SETTING: A longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum database. METHOD: All CYP aged <25 years registered with a GP in the CPRD Aurum database were included. The number of total, remote, and face-to-face contacts during the first UK lockdown (March to June 2020) were compared with the mean contacts for comparable weeks from 2015 to 2019. RESULTS: In total, 47 607 765 GP contacts with 4 307 120 CYP were included. GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1-14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15-24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1-14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%). CONCLUSION: During the COVID-19 pandemic, CYP's contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts and changing health-seeking behaviour. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.

4.
JMIR Form Res ; 6(6): e36289, 2022 Jun 14.
Article in English | MEDLINE | ID: covidwho-1875291

ABSTRACT

BACKGROUND: Uncertainties are omnipresent in health care, but little is known about general practitioners' (GPs) professional uncertainties concerning digital consultations. This is problematic, as many countries have undergone an extensive digital transformation. OBJECTIVE: The aim of this study was to explore the professional uncertainties that emerged among Danish GPs with the introduction of video consultations. METHODS: We conducted qualitative interviews with 15 Danish GPs during the beginning of the COVID-19 pandemic in 2020. The interviews were analyzed using an abductive approach. RESULTS: We identified 3 categories of uncertainty: integrity, setting, and interaction. Respectively, these 3 categories of uncertainty refer to (1) uncertainties related to how technology may impede the provision of health care; (2) uncertainties related to the potentials of video technology; and (3) uncertainties related to how the video consultation technology affects interactions with patients. CONCLUSIONS: The uncertainties experienced by Danish GPs appear to be a typical reaction to the introduction of new technology. Embedding video consultation technology into GPs' working routines will take time, and GPs do not necessarily feel intuitively capable of transferring their abilities, such as being good and socially present for video-mediated consultations. The heterogeneity of professional uncertainties experienced among the GPs suggests that they are the product of individual GP-technology relationships-not of the technology in itself. Consequently, we cannot expect that uncertainties can be remedied by changing or precluding new technology.

5.
BJGP Open ; 2022 May 31.
Article in English | MEDLINE | ID: covidwho-1875831

ABSTRACT

BACKGROUND: The Australian government introduced temporary government-subsidised telehealth service items (phone and video-conference) in mid-March 2020 in response to the COVID-19 pandemic. The uptake of telehealth by patients with type 2 diabetes (T2DM) for consulting with GPs is unknown. AIM: To evaluate the uptake of telehealth consultations and associated patient characteristics in Australian general practice, including the frequency of haemoglobin A1c (HbA1c) tests and change in HbA1c levels by telehealth use, compared with guideline recommendations. DESIGN & SETTING: This exploratory study used electronic patient data from approximately 800 general practices in Victoria and New South Wales (NSW), Australia. A pre-COVID-19 period from March 2019-February 2020 was compared with a pandemic period from March 2020-February 2021. Patients diagnosed with T2DM before March 2018 were included. METHOD: Telehealth uptake patterns were examined overall and by patient characteristics. Generalised estimating equation models were used to examine patient probability of 6-monthly HbA1c testing and change in HbA1c levels, comparing between patients who did and patients who did not use telehealth. RESULTS: Of 57 916 patients, 80.8% had telehealth consultations during the pandemic period. Telehealth consultations were positively associated with patients with T2DM who were older, female, had chronic kidney disease (CKD), prescribed antidiabetic medications, and living in remote areas. No significant difference was found in 6-monthly HbA1c testing and HbA1c levels between telehealth users and patients who had face-to-face consultations only. CONCLUSION: Telehealth GP consultations were well utilised by patients with T2DM. Diabetes monitoring care via telehealth is as effective as face-to-face consultations.

6.
Br J Gen Pract ; 2022 May 16.
Article in English | MEDLINE | ID: covidwho-1875827

ABSTRACT

BACKGROUND: Group consultations have been gaining ground as a novel approach to service delivery. When in-person care was restricted owing to COVID-19, general practice staff began delivering group consultations remotely over video. AIM: To examine how multiple interacting influences underpinned implementation and delivery of video group consultations (VGCs). DESIGN AND SETTING: Qualitative study in general practice in England. METHOD: a) 32 semi-structured interviews with patients, clinical, and non-clinical staff (from eight GP surgeries in total), NHS policymakers and programme managers, and other stakeholders; b) observation in relevant training and operational meetings; and c) three co-design workshops (21 participants). Thematic analysis was informed by the Planning and Evaluating Remote Consulting Services (PERCS) framework. RESULTS: In the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. Most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. However, not everyone agreed to engage in group-based care or was able to access IT equipment. At practice level, significant work was needed to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. Training provided nationally was seen as instrumental in capacity building for VGC implementation. CONCLUSION: Small scale VGC implementation addressed unmet need during the pandemic. However, embedding VGCs in routine care requires rethinking of operational, infrastructural, and clinical processes. Additional research on costs and benefits at service and patient level is needed.

7.
Diabetic Medicine ; 39(SUPPL 1):70, 2022.
Article in English | EMBASE | ID: covidwho-1868633

ABSTRACT

Aims: The National Institute for Health and Care Excellence recommend that all adult patients with diabetes should have a foot examination 'on any admission to hospital'. However, a 2013 Scotland-wide audit highlighted that this was not being done for over half of patients, with growing concern about hospital-acquired foot ulceration. A similar audit was conducted at a district general hospital in 2021, to assess for any improvement. Method: A 'snap shot' study was performed, identifying all inpatients with diabetes in the general medicine department at St John's Hospital, Livingston, on the 11th February 2021. Data were collected from patient notes including age, HbA1c, last documented foot risk, and any recorded inpatient diabetic foot examination up until the study date. 14 of these patients then underwent a diabetic foot examination. Results: 51 patients with diabetes were identified, 90% of whom had type 2 diabetes. The average age was 73.7 years (SD ± 13.9 years), and the average HbA1c was 65mmol/ mol (SD ± 18.7mmol/mol). 66% had low foot risk on last examination. Only 8% had a diabetic foot examination documented this admission. Of the 14 patients examined during this study, half had evidence of neuropathy, and two had active foot ulcers. Conclusions: This audit demonstrates that there is still much progress to be made in inpatient diabetic footcare. Furthermore, the covid-19 pandemic has likely had an impact both on foot screening and access to podiatry services, making it even more vital to be diligent with foot examinations.

8.
Diabetic Medicine ; 39(SUPPL 1):84, 2022.
Article in English | EMBASE | ID: covidwho-1868624

ABSTRACT

Aim: There are multifactorial reasons for obesity. Depression and obesity are linked bidirectionally. When providing a weight management service, food and activity play an important role. However, during this pandemic, we found a significant increase in number of people with depression and obesity. We reviewed patients referred to tier 3 weight management service during the pandemic to understand the prevalence of depression in people with obesity. We also looked into baseline prevalence of depression in people with obesity in a primary care setting. Methods and analysis: There has been a 100% increase in referrals to tier 3 weight management service from January 2021 to June 2021. The prevalence of depression in this group of patients is around 59%. The general prevalence of depression in patients with obesity based on a study published in the British Journal of General Practice was 23%. Prevalence of depression among 502 people with obesity in a nearby general practice was around 10%. Weight and depression demonstrated a U-shaped relationship, with higher prevalence of depression observed among underweight and obese general practice patients. There was however no correlation between depression and body weight in people with morbid obesity. Conclusion: Approach to weight management in tier 3 weight management service should now focus more on management of depression. This pandemic has clearly revealed the close relationship between obesity and depression.

9.
Diabetic Medicine ; 39(SUPPL 1):69-70, 2022.
Article in English | EMBASE | ID: covidwho-1868607

ABSTRACT

Introduction: Frequency of HbA1c testing links to outcome in terms of HbA1c control in diabetes. The influence of the variability of test-retest interval on HbA1c change needs to be determined. Methods: HbA1c results were collected from laboratory records on 3,872 people: HbA1c results at baseline and 5 years( ± 3 months) later with at least 6-tests during this period. We calculated the standard deviation (SD) of test interval for each individual. We then examined the link between deciles of SD of test interval/HbA1c level, stratified by baseline HbA1c. Results: In general, less variability in testing frequency = more consistent monitoring associated with better diabetes control over a 5-year period. This was most evident with moderately raised baseline HbA1c levels(54-75mmol/ mol[7.0-9.0%]). For example, in those with a starting HbA1c of 54-58mmol/ mol[7.0-7.5%], the lowest SDdecile associated with little change in HbA1c over 5 years, while for the highest SDdecile, HbA1c rose by 4-6mmol/ mol[0.4-0.6%], (p < 0.0001, standard beta 0.09-0.10). Multivariate analysis showed that the association was independent of age/sex/hospital site. Stratification by age suggested that the effect was most pronounced in those aged <65 years with baseline HbA1c 54-58mmol/ mol[7.0- 7.5%] (p < 0.0001, standard beta = 0.12). We also observed a 6.7-fold variation in the proportion of people in the top three SDdeciles across general practices. Conclusion/Interpretation: These findings indicate that consistency of testing interval, not just numbers of tests/year, is important in maintaining diabetes control, especially in those with moderately raised HbA1c. This suggests the need for developing systems to improve the regularity of HbA1c testing, especially given the recent impact of covid-19 on diabetes monitoring.

10.
J Adv Nurs ; 2022 May 27.
Article in English | MEDLINE | ID: covidwho-1868665

ABSTRACT

AIM: To explore how General Practice Nurses experience implementing change at pace and scale in delivering care during consecutive waves of the COVID-19 pandemic. To evaluate the impact of changes to general practice nurses' working practices on professional wellbeing. BACKGROUND: In response to the COVID-19 pandemic, general practice rapidly and extensively changed care delivery. There has been little exploration of the experiences of General Practice Nurses and care delivery, job satisfaction, workload, stress and professional support. DESIGN: A qualitative case study design of three to five general practice case sites will explore General Practice Nurses' experiences during the Covid-19 pandemic. The study was funded and approved by the General Nursing Council Trust in June 2021. University ethics approval was gained in July 2021. Health Research Authority approval has been obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. METHODS: Data will consist of focus groups and/or semi-structured interviews with General Practice Nurses, primary healthcare team members and other key informants. Business/strategy and nurse team meetings relating to workforce planning/review will be observed. Documents will be analysed and routinely collected general practice data will provide descriptive contextualisation at each site. The study will be theoretically underpinned by the Non-adoption, Abandonment, Scale-up, Spread and Sustainability Framework and data analysed using framework analysis. DISCUSSION: General Practice Nurses have a unique sphere of knowledge and undertake specific work in primary care. This workforce is challenged by recruitment, retention and retirement issues, leading to the loss of highly experienced and knowledgeable professionals. It is important to explore how working practices brought about by Covid-19 affect General Practice Nurses. IMPACT: This study will explore working practices brought about by the Covid-19 pandemic to inform care delivery, patient care and support General Practice Nursing workforce wellbeing and will highlight and mitigate negative aspects of novel and changing care delivery. Key factors in implementing and supporting future practice and change implementation will be developed. TRIAL REGISTRATION: CPMS: 51834.

11.
Rheumatology (United Kingdom) ; 61(SUPPL 1):i35, 2022.
Article in English | EMBASE | ID: covidwho-1868365

ABSTRACT

Background/Aims The COVID-19 pandemic has had a significant impact on emergency and scheduled care, affecting both inpatient and outpatient services for all specialities, including Rheumatology. During the first pandemic peak, rheumatology outpatient clinics all became virtual (i.e. telephone or video), except for a single emergency clinic per week. However, this face-to-face clinic, quickly became oversaturated resulting in a waiting list extending above 4 weeks for our patients. Methods In the lead-up to the second COVID-19 peak during the winter, we developed a novel, urgent, hot Rheumatology Clinic within our Ambulatory Emergency Care (AEC) department. This whole-day weekly clinic was delivered by a Rheumatology registrar, with consultant support. Its purpose was to provide a service for patients who did not require hospitalisation but required urgent face-to-face Rheumatology speciality review that could not wait for an outpatient appointment. Referrals came from General Practice, Urgent Care (i.e. Emergency Care, Acute Medicine and AEC) and from the Rheumatology department. Pathologies reviewed included vasculitides, inflammatory arthritis and inflammatory connective tissue diseases. The clinic facilitated for patients with suspected new diagnoses or flares of established rheumatological diseases. Furthermore, patients could also undergo urgent joint and soft tissue procedures. All referrals were directed to the Rheumatology registrar to triage. Because of the success of the clinic, it continued beyond the second peak with data gathered from its inception. Results Data was collected between November 2020 and June 2021, covering 23 hot clinics. A total of 118 patients were reviewed during this period. The highest number of referrals occurred during the second peak of the pandemic (38 patients over seven clinics compared to 48 patients over ten clinics post-peak). The majority of referrals were from Rheumatology directly (70%) compared with Urgent Care (14%) and General Practice (12%). Most (60%) were seen within 7-days of referral;a further 27% were seen within 7- 14 days. The main reasons for review delays beyond seven-days were lack of available clinic (46%) or lack of space (29%). The most common disease encountered was a chronic inflammatory arthropathy (48 patients). Conclusion The service has generated positive feedback from all patients. Furthermore, this clinic has benefited both Rheumatology and AEC. Firstly, it ensured timely face-to-face reviews of patients requiring urgent Rheumatology assessments. Secondly, it eased pressure on the Rheumatology department, particularly the outpatient emergency clinic. Thirdly, it ensured that the Rheumatology registrar continued to have Rheumatology training opportunities, particularly when redeployed during the Winter wave on other days of the week. Fourthly, the AEC department have had easier access to Rheumatology reviews. Finally, it has empowered the registrar to manage their own workload and organise the clinic enhancing management and leadership experience. The success of the clinic has resulted in its ongoing continuation.

12.
Rheumatology (United Kingdom) ; 61(SUPPL 1):i2, 2022.
Article in English | EMBASE | ID: covidwho-1868348

ABSTRACT

Background/Aims The COVID-19 pandemic has disrupted healthcare delivery and provision of medical education and training worldwide. We assessed the impact of the COVID-19 pandemic on rheumatology training experience in the Northwest and Merseyside deaneries of England. Methods Rheumatology trainees from the Northwest and Merseyside deaneries were issued links to an anonymous web-based survey on their training experience between August 2020 to April 2021, during the 2nd wave of the Covid-19 pandemic. Results 34 of 42 trainees completed the survey. 31 were in clinical training: 13 (42%) in a pure rheumatology post and 18 (58%) in a dual post with general medicine. Most trainees attended 3-4 clinics per week (58%), with 23% attending ≤2 clinics and 19% attending 5 clinics. The proportion of face-to-face clinics ranged from 20% to 100% (median 60%). The reduced face-to-face clinical experience was not due to trainees' needs to shield. The range of proportion of phone consultations was 0% to 80% (median 40%). Remote consultations were conducted by telephone only for 26 (84%) trainees and by video or phone for 3 (10%). The durations for both face-to-face and virtual consultations were ranged similarly at 15 to 45 minutes (median 30minutes) for new cases and 15 to 30 minutes (median 20 minutes) for follow-ups. Only 5 (16%) trainees felt confident with assessing new patients by remote consultation. 8 (26%) trainees had some form of formal training in a virtual consultation. However, only 4 (13%) reported being 'aware' of how to guide a patient through self-examination of the joints, 17 (55%) trainees were 'somewhat aware', and 10 (32%) were 'not aware'. 20 (65%) trainees reported reliance on radiological and serological investigations rather than clinical skills during remote consultations. Development of skills for patient communication, joint injections, time management, and prescribing immune-suppressive medications were mainly hampered. The majority of trainees agreed that virtual educational programs had improved opportunities for attendance at structured deanery teaching sessions. Conclusion The impact of the COVID-19 pandemic on rheumatology training has been significant both in terms of current rheumatology education programme delivery and training requirements. Our regional survey shows less than a third of trainees had formal training in conducting remote consultations resulting in low levels of confidence in assessing patients remotely. Less face-to-face patient contact negatively impacted clinical and procedural skills development. Restructuring the rheumatology curricula to include training in rheumatology-specific remote consultations and ensuring clinical and procedural competencies by including novel support modalities like simulation sessions may be options for consideration going forwards. Delivery of some structured teaching sessions through the virtual platform is here to stay.

13.
Irish Journal of Medical Science ; 191(SUPPL 1):S32, 2022.
Article in English | EMBASE | ID: covidwho-1866679

ABSTRACT

General practice is generally the first point of contact for patients presenting with COVID-19. Since the start of the COVID-19 pandemic general practitioners across Europe have had to adopt to using telemedicine consultations in order to minimise the number of social contacts made.(1). The aim of this study was to conduct a scoping review of the literature examining the use of telemedicine for delivering routine GP care since the start of the pandemic from the perspectives of patients and practitioners. We used the six-stage scoping review framework developed by Arksey and O'Malley (2). The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 19 studies across nine countries were included in the review. Thirteen studies explored the practitioner perspective of the use of telemedicine in general practice since the COVID-19 pandemic, while six studies looked at the patient perspective. The types of studies included in this review were: qualitative studies, literature reviews, a systematic review, observational studies, quantitative studies, Critical incident technique study, and surveys employing both closed and open styled questions. Key themes identified related to the patient/ practitioner experience and knowledge of using telemedicine, patient/ practitioner levels of satisfaction, GP collaboration, nature of workload, and suitability of consultations for telemedicine. Our findings suggest a level of acceptability and satisfaction of telemedicine by GPs and patients during the pandemic;however, further research is warranted in this area.

14.
Irish Journal of Medical Science ; 191(SUPPL 1):S34, 2022.
Article in English | EMBASE | ID: covidwho-1866670

ABSTRACT

Considerable literature has reported the COVID-19 pandemic's negative mental health sequelae. This surge in mental health problems will likely present to primary care in the coming months. The development of interventions to support GPs in the care of patients with mental health problems is a priority. The aim of this review was to examine interventions which could be implemented in general practice to enhance care of mental health disorders post COVID-19. PubMed, PsycINFO, Cochrane Library, Google Scholar and WHO Global Research on COVID-19 databases were searched following Arksey and O'Malley's scoping review process(1). Initial searches identified 148 articles. Twenty-nine studies were included in the review, mostly randomised control trials, qualitative interviews and surveys. Outcome measures to test feasibility of interventions included the 'Seven-item Generalised Anxiety Disorder Scale' and 'Nine-item Patient Health Questionnaire'. Results were divided into themes: Interventions to improve identification of mental health disorders;Interventions to support GPs;Therapeutic interventions;Telemedicine interventions, and barriers and facilitators to intervention implementation. Interventions requiring active involvement of patients in their own care may be effective. GPs should encourage participation in physical activity andmeditation, implement digitalmental health interventions and incorporate telemedicine into their practice. Our findings suggest a broad range of interventions may be implemented in primary care to tackle the mental health sequelae of COVID-19. Practitioners worldwide must stay informed of relevant research, and actively implement studied interventions to improve the mental health care they offer. Priority areas for future research include biological treatments for mental health sequelae of COVID-19.

15.
Irish Journal of Medical Science ; 191(SUPPL 1):S5, 2022.
Article in English | EMBASE | ID: covidwho-1866667

ABSTRACT

In 2017, the report on the National Wellbeing of Doctors proposed that there are ever-increasing burnout rates. [1] Reflective practice groups are used to explore a deep level of understanding of doctor-patient relationships, in order to combat burnout and increase satisfaction at work. This study aims to assess online reflective practice groups for interdisciplinary trainees in Paediatric hospitals during the Covid-19 pandemic. The Balint group methodology was adapted for an online format. Trainees from psychiatry, emergency and paediatric specialties answered two online questionnaires before and after six sessions of Balint group meetings. There were nine responses to the pre-Balint questionnaire and eight responses to the post-Balint questionnaire. The data was analysed using Microsoft Excel. 75% of participants were from Crumlin Children's Hospital. Most were women, aged 26-30 years and 3-11 years' experience. Six participants preferred online groups while four preferred face to face groups after the sessions were completed. Trainees indicated that they thought about patient cases afterward and their teams were disrupted which may cause mild burnout due to the struggles faced. There was a positive relation between burnout reduction and Balint sessions. Additionally, the sessions were positively reviewed by the trainees and there were no sessions cancelled which may indicate the trainees appreciation for the group. Reflective practice programs should be implemented for trainees in all institutions since there is a positive link between reducing the risk of burnout and reflective practice groups. It should be available for all specialties, not only psychiatry and general practice.

16.
Irish Journal of Medical Science ; 191(SUPPL 1):S48, 2022.
Article in English | EMBASE | ID: covidwho-1866662

ABSTRACT

Persistent symptomatic COVID-19 is a multi-system condition that affects approximately 10% of those with acute COVID-19 infection. Affected patients often have complex care needs requiring holistic and multidisciplinary care approaches, the kind routinely provided in general practice. However, there is a lack of evidence of appropriate general practice interventions for the condition. A scoping review was conducted using Arksey and O'Malley's 2005 five-stage framework[1], with later recommendations by Levac et al.[2] to examine the literature and identify knowledge gaps in general practice management of persistent COVID-19. Nineteen papers were selected for review. The studies spanned numerous geographical locations, encompassing several study designs, and a range of populations and sample sizes. The included studies used various definitions for persistent symptomatic COVID-19. The literature was analysed qualitatively, and six major themes were identified. These themes were (i) GP uncertainty, (ii) Listening and empathy, (iii) Assessment and monitoring of symptoms, (iv) Coordinating access to appropriate services, (v) Facilitating provision of continual and integratedmulti-disciplinary care and (vi) Need to facilitate psychological support. Overall, the findings show that general practitioners play a key role in the management of persistent COVID-19, but that more clinical guidance on appropriate interventions is necessary to enhance care. There is a need for scientifically accepted definitions for persistent COVID-19 to ensure that patients can be recognized, assessed and managed appropriately. Patient and public involvement should guide policy makers when developing future care models. Meanwhile, future research should evaluate the implementation and effectiveness of proposed management strategies and interventions.

17.
BMJ Open Qual ; 11(2)2022 May.
Article in English | MEDLINE | ID: covidwho-1865184

ABSTRACT

Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing '4 Key Instructions' and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.


Subject(s)
COVID-19 , General Practice , Remote Consultation , Humans , Pandemics/prevention & control , Quality Improvement , Remote Consultation/methods
18.
BMJ Evid Based Med ; 2021 Jun 07.
Article in English | MEDLINE | ID: covidwho-1865151

ABSTRACT

Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.

19.
JAMA Health Forum ; 2(10), 2021.
Article in English | ProQuest Central | ID: covidwho-1858105

ABSTRACT

Importance The importance of surveillance testing and quarantine on university campuses to limit SARS-CoV-2 transmission needs to be reevaluated in the context of a complex and rapidly changing environment that includes vaccines, variants, and waning immunity. Also, recent US Centers for Disease Control and Prevention guidelines suggest that vaccinated students do not need to participate in surveillance testing. Objective To evaluate the use of surveillance testing and quarantine in a fully vaccinated student population for whom vaccine effectiveness may be affected by the type of vaccination, presence of variants, and loss of vaccine-induced or natural immunity over time. Design, Setting, and Participants In this simulation study, an agent-based Susceptible, Exposed, Infected, Recovered model was developed with some parameters estimated using data from the 2020 to 2021 academic year at Duke University (Durham, North Carolina) that described a simulated population of 5000 undergraduate students residing on campus in residential dormitories. This study assumed that 100% of residential undergraduates are vaccinated. Under varying levels of vaccine effectiveness (90%, 75%, and 50%), the reductions in the numbers of positive cases under various mitigation strategies that involved surveillance testing and quarantine were estimated. Main Outcomes and Measures The percentage of students infected with SARS-CoV-2 each day for the course of the semester (100 days) and the total number of isolated or quarantined students were estimated. Results A total of 5000 undergraduates were simulated in the study. In simulations with 90% vaccine effectiveness, weekly surveillance testing was associated with only marginally reduced viral transmission. At 50% to 75% effectiveness, surveillance testing was estimated to reduce the number of infections by as much as 93.6%. A 10-day quarantine protocol for exposures was associated with only modest reduction in infections until vaccine effectiveness dropped to 50%. Increased testing of reported contacts was estimated to be at least as effective as quarantine at limiting infections. Conclusions and Relevance In this simulated modeling study of infection dynamics on a college campus where 100% of the student body is vaccinated, weekly surveillance testing was associated with a substantial reduction of campus infections with even a modest loss of vaccine effectiveness. Model simulations also suggested that an increased testing cadence can be as effective as a 10-day quarantine period at limiting infections. Together, these findings provide a potential foundation for universities to design appropriate mitigation protocols for the 2021 to 2022 academic year.

20.
BJGP Open ; 2022 May 17.
Article in English | MEDLINE | ID: covidwho-1855866

ABSTRACT

BACKGROUND: Among the manifestations of COVID-19 are taste and smell disorders (TSDs). AIM: To evaluate the sensitivity and specificity of TSDs and other associated symptoms to estimate predictive values for determining SARS-CoV-2 infection. DESIGN & SETTING: A retrospective observational study of healthcare professionals in Catalonia, Spain. METHOD: A study of the sensitivity and specificity of TSDs has been carried out using the polymerase chain reaction (PCR) test for the diagnosis of SARS-CoV-2 as the gold standard value. Logistic regressions adjusted for age and sex were performed to identify additional symptoms that might be associated with COVID-19. RESULTS: The results are based on 226 healthcare workers with clinical symptoms suggestive of COVID-19, 116 with positive PCR and 110 with negative PCR. TSDs had an odds ratio (OR) of 12.4 (95% confidence interval [CI] = 6.3 to 26.2), sensitivity 60.3% and specificity 89.1%. In the logistic regression model, the association of TSD, fever or low-grade fever, shivering, dyspnoea, arthralgia, and myalgia obtained an area under the curve (AUC) of 85.7% (95% CI = 80.7 % to 90.7 %), sensitivity 82.8 %, specificity 80.0%, and positive predictive values 81.4% and negative 81.5%. CONCLUSION: TSDs are a strong predictor of COVID-19. The association of TSD, fever, low-grade fever or shivering, dyspnoea, arthralgia, and myalgia correctly predicts 85.7% of the results of the COVID-19 test.

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