Initial characteristics and course of disease in patients with suspected COVID-19 managed in general practice: a prospective, multicentre cohort study.

OBJECTIVES: To describe and compare the initial clinical characteristics of a cohort of patients with suspected COVID-19 managed by general practitioners (GPs); to assess whether 3-month persistent symptoms were more frequent among confirmed cases than among no-COVID cases; and to identify factors predictive of persistent symptoms and adverse outcomes among confirmed cases. DESIGN AND SETTING: A comparative, prospective, multicentre cohort study in primary care in the Paris region of France. PARTICIPANTS: 521 patients aged ≥18 with suspected COVID-19 were enrolled between March and May 2020. OUTCOME MEASURES: Initial symptoms, COVID-19 status, persistent symptoms 3 months after inclusion and a composite criterion for potentially COVID-19-related events (hospitalisation, death, emergency department visits). The final COVID-19 status ('confirmed', 'no-COVID' and 'uncertain' cases) was determined by the GP after the receipt of the laboratory test results. RESULTS: 516 patients were analysed; 166 (32.2%) were classified into the 'confirmed COVID' group, 180 (34.9%) into the 'no-COVID' group and 170 (32.9%) in the 'uncertain COVID' group. Confirmed cases were more likely to have persistent symptoms than no-COVID cases (p=0.09); initial fever/feeling feverish and anosmia were independently associated with persistent symptoms. At 3 months, we observed 16 (9.8%) COVID-19-related hospital admissions, 3 (1.8%) intensive care unit admissions, 13 (37.1%) referrals to an emergency department and no death. Age >70 and/or at least one comorbidity (OR 6.53; 95% CI 1.13-37.84; p=0.036), abnormalities in a lung examination (15.39; 95% CI 1.61-146.77; p=0.057) and two or more systemic symptoms (38.61; 95% CI 2.30-647.40; p=0.011) were associated with the composite criterion. CONCLUSIONS: Although most patients with COVID-19 in primary care had mild disease with a benign course, almost one in six had persistent symptoms at 3 months. These symptoms were more frequent in the 'confirmed COVID' group. Our findings need to be confirmed in a prospective study with longer follow-up.

Adapting domestic abuse training to remote delivery during the COVID-19 pandemic: a qualitative study of views from general practice and support services.

BACKGROUND: Identifying and responding to patients affected by domestic violence and abuse (DVA) is vital in primary care. There may have been a rise in the reporting of DVA cases during the COVID-19 pandemic and associated lockdown measures. Concurrently general practice adopted remote working that extended to training and education. IRIS (Identification and Referral to Improve Safety) is an example of an evidence-based UK healthcare training support and referral programme, focusing on DVA. IRIS transitioned to remote delivery during the pandemic. AIM: To understand the adaptations and impact of remote DVA training in IRIS-trained general practices by exploring perspectives of those delivering and receiving training. DESIGN AND SETTING: Qualitative interviews and observation of remote training of general practice teams in England were undertaken. METHOD: Semi-structured interviews were conducted with 21 participants (three practice managers, three reception and administrative staff, eight general practice clinicians, and seven specialist DVA staff), alongside observation of eight remote training sessions. Analysis was conducted using a framework approach. RESULTS: Remote DVA training in UK general practice widened access to learners. However, it may have reduced learner engagement compared with face-to-face training and may challenge safeguarding of remote learners who are domestic abuse survivors. DVA training is integral to the partnership between general practice and specialist DVA services, and reduced engagement risks weakening this partnership. CONCLUSION: The authors recommend a hybrid DVA training model for general practice, including remote information delivery alongside a structured face-to-face element. This has broader relevance for other specialist services providing training and education in primary care.

Low Adoption of Video Consultations in Post-COVID-19 General Practice in Northern Europe: Barriers to Use and Potential Action Points.

In the wake of the COVID-19 pandemic, video consultation was introduced in general practice in many countries around the world as a solution to provide remote health care to patients. It was assumed that video consultation would find widespread adoption in post-COVID-19 general practice. However, adoption rates remain low across countries in Northern Europe, suggesting that barriers to its use exist among general practitioners and other practice staff. In this viewpoint, we take a comparative approach, reflecting on similarities and differences in implementation conditions of video consultations in 5 Northern European countries' general practice settings that might have created barriers to its use within general practice. We convened at a cross-disciplinary seminar in May 2022 with researchers and clinicians from 5 Northern European countries with expertise in digital care in general practice, and this viewpoint emerged out of dialogues from that seminar. We have reflected on barriers across general practice settings in our countries, such as lacking technological and financial support for general practitioners, that we feel are critical for adoption of video consultation in the coming years. Furthermore, there is a need to further investigate the contribution of cultural elements, such as professional norms and values, to adoption. This viewpoint may inform policy work to ensure that a sustainable level of video consultation use can be reached in the future, one that reflects the reality of general practice settings rather than policy optimism.

[Medical care in GP practices during the Covid-19 pandemic: A questionnaire-based survey among general practitioners and medical practice assistants asking for their opinion about changes, needs and burdens]. / Die hausärztliche Versorgung während der COVID-19-Pandemie: eine Fragebogenerhebung unter Hausärzt*innen und Medizinischen Fachangestellten zu ihrer Perspektive auf Veränderungen, Bedarfe und Belastungen.

INTRODUCTION: The coronavirus pandemic did not only result in changes in the provision and utilization of health care services in general practice but also in an increased workload for physicians and medical practice assistants. The VeCo practice study retrospectively explores the experiences of both professional groups two years after the start of the pandemic. METHODS: In March and April 2022, general practitioners and medical practice assistants in the three German federal states of Berlin, Brandenburg and Thuringia were asked to complete a paper-based questionnaire. RESULTS: 657 general practitioners and 762 medical practice assistants completed the questionnaire. Both professional groups agreed to statements indicating a reduction in regular health care provisions. Nevertheless, 74% of the physicians and 82.9% of the medical practice assistants considered the health care provided to their patients during the pandemic as good. This was only possible through considerable additional effort and stress. While more than half of both groups reported that work was still enjoyable, three quarters of both groups stated that the challenges arising from the pandemic outstripped their capacity. Both groups would like to receive more recognition from society (medical practice assistants 93.2%, general practitioners 85.3%) and from their patients (87.7% and 69.9%, respectively). DISCUSSION: General practitioners and medical practice assistants reduced regular health care provision but were still able to maintain a good quality of care for their patients during the pandemic. It became clear that more appreciation and adequate financial compensation are necessary to ensure long-term sustainability of GP care. CONCLUSION: The subjective view of general practitioners and medical practice assistants on their health care provision shows that appreciation and adequate financial renumeration, particularly when working under most difficult conditions, are necessary to increase the attractiveness of a career in general practice, for both physicians and medical practice assistants.

Validation of a rapid SARS-CoV-2 antibody test in general practice.

OBJECTIVES: To validate a rapid serological test (RST) for SARS-CoV-2 antibodies used in seroprevalence studies in healthcare providers, including primary healthcare providers (PHCPs) in Belgium. DESIGN: A phase III validation study of the RST (OrientGene) within a prospective cohort study. SETTING: Primary care in Belgium. PARTICIPANTS: Any general practitioner (GP) working in primary care in Belgium and any other PHCP from the same GP practice who physically manages patients were eligible in the seroprevalence study. For the validation study, all participants who tested positive (376) on the RST at the first testing timepoint (T1) and a random sample of those who tested negative (790) and unclear (24) were included. INTERVENTION: At T2, 4 weeks later, PHCPs performed the RST with fingerprick blood (index test) immediately after providing a serum sample to be analysed for the presence of SARS-CoV-2 immunoglobulin G antibodies using a two-out-of-three assay (reference test). PRIMARY AND SECONDARY OUTCOME MEASURES: The RST accuracy was estimated using inverse probability weighting to correct for missing reference test data, and considering unclear RST results as negative for the sensitivity and positive for the specificity. Using these conservative estimates, the true seroprevalence was estimated both for T2 and RST-based prevalence values found in a cohort study with PHCPs in Belgium. RESULTS: 1073 paired tests (403 positive on the reference test) were included. A sensitivity of 73% (a specificity of 92%) was found considering unclear RST results as negative (positive). For an RST-based prevalence at T1 (13.9), T2 (24.9) and T7 (70.21), the true prevalence was estimated to be 9.1%, 25.9% and 95.7%, respectively. CONCLUSION: The RST sensitivity (73%) and specificity (92%) make an RST-based seroprevalence below (above) 23% overestimate (underestimate) the true seroprevalence. TRIAL REGISTRATION NUMBER: NCT04779424.

Consultation Rate and Mode by Deprivation in English General Practice From 2018 to 2022: Population-Based Study.

BACKGROUND: The COVID-19 pandemic has had a significant impact on primary care service delivery with an increased use of remote consultations. With general practice delivering record numbers of appointments and rising concerns around access, funding, and staffing in the UK National Health Service, we assessed contemporary trends in consultation rate and modes (ie, face-to-face versus remote). OBJECTIVE: This paper describes trends in consultation rates in general practice in England for key demographics before and during the COVID-19 pandemic. We explore the use of remote and face-to-face consultations with regard to socioeconomic deprivation to understand the possible effect of changes in consultation modes on health inequalities. METHODS: We did a retrospective analysis of 9,429,919 consultations by general practitioners, nurses, or other health care professionals between March 2018 and February 2022 for patients registered at 397 general practices in England. We used routine electronic health records from Clinical Practice Research Datalink Aurum with linkage to national data sets. Negative binomial models were used to predict consultation rates and modes (ie, remote versus face-to-face) by age, sex, and socioeconomic deprivation over time. RESULTS: Overall consultation rates increased by 15% from 4.92 in 2018-2019 to 5.66 in 2021-2022 with some fluctuation during the start of the COVID-19 pandemic. The breakdown into face-to-face and remote consultations shows that the pandemic precipitated a rapid increase in remote consultations across all groups, but the extent varies by age. Consultation rates increased with increasing levels of deprivation. Socioeconomic differences in consultation rates, adjusted for sex and age, halved during the pandemic (from 0.36 to 0.18, indicating more consultations in the most deprived), effectively narrowing relative differences between deprivation quintiles. This trend remains when stratified by sex, but the difference across deprivation quintiles is smaller for men. The most deprived saw a relatively larger increase in remote and decrease in face-to-face consultation rates compared to the least deprived. CONCLUSIONS: The substantial increases in consultation rates observed in this study imply an increased pressure on general practice. The narrowing of consultation rates between deprivation quintiles is cause for concern, given ample evidence that health needs are greater in more deprived areas.

Implementation of ask-advise-connect for smoking cessation in Dutch general practice during the COVID-19 pandemic: a mixed-methods evaluation using the CFIR framework.

BACKGROUND: The Ask-Advise-Connect (AAC) approach can help primary care providers to increase the number of people who attempt to quit smoking and enrol into cessation counselling. We implemented AAC in Dutch general practice during the COVID-19 pandemic. In this study we describe how AAC was received in Dutch general practice and assess which factors played a role in the implementation. METHODS: A mixed-methods approach was used to evaluate the implementation of AAC. Implementation took place between late 2020 and early 2022 among 106 Dutch primary care providers (general practitioners (GPs), practice nurses and doctor's assistants). Quantitative and qualitative data were collected through four online questionnaires. A descriptive analysis was conducted on the quantitative data. The qualitative data (consisting of answers to open-ended questions) were inductively analysed using axial codes. The Consolidated Framework for Implementation Research was used to structure and interpret findings. RESULTS: During the study, most participants felt motivated (84-92%) and able (80-94%) to apply AAC. At the end of the study, most participants reported that the AAC approach is easy to apply (89%) and provides advantages (74%). Routine implementation of the approach was, however, experienced to be difficult. More GPs (30-48%) experienced barriers in the implementation compared to practice nurses and doctor's assistants (7-9%). The qualitative analysis showed that especially external factors, such as a lack of time or priority to discuss smoking due to the COVID-19 pandemic, negatively influenced implementation of AAC. CONCLUSIONS: Although AAC was mostly positively received in Dutch general practice, implementation turned out to be challenging, especially for GPs. Lack of time to discuss smoking was a major barrier in the implementation. Future efforts should focus on providing additional implementation support to GPs, for example with the use of e-health.

Free-text analysis of general practice out-of-hours (GPOOH) use by people with advanced cancer: an analysis of coded and uncoded free-text data.

BACKGROUND: People with advanced cancer frequently use the GP out-of-hours (GPOOH) service. Considerable amounts of routine GPOOH data are uncoded. Therefore, these data are omitted from existing healthcare datasets. AIM: To conduct a free-text analysis of a GPOOH dataset, to identify reasons for attendance and care delivered through GPOOH to people with advanced cancer. DESIGN AND SETTING: An analysis of a GPOOH healthcare dataset was undertaken. It contained all coded and free- text information for 5749 attendances from a cohort of 2443 people who died from cancer in Tayside, Scotland, from 2013-2015. METHOD: Random sampling methods selected 575 consultations for free-text analysis. Each consultation was analysed by two independent reviewers to determine the following: assigned presenting complaints; key and additional palliative care symptoms recorded in free text; evidence of anticipatory care planning; and free-text recording of dispensed medications. Inter-rater reliability concordance was established through Kappa testing. RESULTS: More than half of all coded reasons for attendance (n = 293; 51.0%) were 'other' or 'missing'. Free-text analysis demonstrated that nearly half (n = 284; 49.4%) of GPOOH attendances by people with advanced cancer were for pain or palliative care. More than half of GPOOH attendances (n = 325; 56.5%) recorded at least one key or additional palliative care symptom in free text, with the commonest being breathlessness, vomiting, cough, and nausea. Anticipatory care planning was poorly recorded in both coded and uncoded records. Uncoded medications were dispensed in more than one- quarter of GPOOH consultations. CONCLUSION: GPOOH delivers a substantial amount of pain management and palliative care, much of which is uncoded. Therefore, it is unrecognised and under-reported in existing large healthcare data analyses.

Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic.

OBJECTIVE: The new structured medication review (SMR) service was introduced into the National Health Service in England during the COVID-19 pandemic, following a major expansion of clinical pharmacists within new formations known as primary care networks (PCNs). The aim of the SMR is to tackle problematic polypharmacy through comprehensive, personalised medication reviews involving shared decision-making. Investigation of clinical pharmacists' perceptions of training needs and skills acquisition issues for person-centred consultation practice will help better understand their readiness for these new roles. DESIGN: A longitudinal interview and observational study in general practice. SETTING AND PARTICIPANTS: A longitudinal study of 10 newly recruited clinical pharmacists interviewed three times, plus a single interview with 10 pharmacists recruited earlier and already established in general practice, across 20 newly forming PCNs in England. Observation of a compulsory 2-day history taking and consultation skills workshop. ANALYSIS: A modified framework method supported a constructionist thematic analysis. RESULTS: Remote working during the pandemic limited opportunities for patient-facing contact. Pharmacists new to their role in general practice were predominantly concerned with improving clinical knowledge and competence. Most said they already practiced person-centred care, using this terminology to describe transactional medicines-focused practice. Pharmacists rarely received direct feedback on consultation practice to calibrate perceptions of their own competence in person-centred communication, including shared decision-making skills. Training thus provided knowledge delivery with limited opportunities for actual skills acquisition. Pharmacists had difficulty translating abstract consultation principles into specific consultation practices. CONCLUSION: SMRs were introduced when the dedicated workforce was largely new and being trained. Addressing problematic polypharmacy requires structural and organisational interventions to enhance the communication skills of clinical pharmacists (and other health professionals), and their use in practice. The development of person-centred consultation skills requires much more substantial support than has so far been provided for clinical pharmacists.

Changes to utilization and provision of health care in German GP practices during the COVID 19-pandemic: Protocol for a mixed methods study on the viewpoint of GPs, medical practice assistants, and patients.

INTRODUCTION: During the COVID-19 pandemic, general practitioners (GPs) continued to be a main point of contact for patients. For GP practices, it was and still is a challenge to meet constantly changing requirements due to the various phases of the pandemic. The aim of the study is to explore retrospectively the subjective experience with supply and utilization of health care services from the perspective of general practitioners, medical practice assistants and patients, in particular regarding instances of underutilization of services for non-Covid related conditions, adjustments due to the pandemic, and the appropriateness of care. METHODS: The study is carried out within the RESPoNsE research practice network in three of Germany's federal states: Berlin, Brandenburg, and Thuringia (RESPoNsE-Research practice network east). The study follows a convergent mixed method design, and consists of the following sections: a) two anonymous paper-based questionnaires filled out by GPs and medical practice assistants (MPAs), at an interval of 12 to 18 months; b) in-depth qualitative interviews conducted among a subgroup of GPs and MPAs; c) anonymous paper-based questionnaires among patients of participating practices. The idea for the study was derived from discussions with the practice advisory board of the RESPoNsE network. The themes and issues to be explored in the surveys and interviews are developed and discussed in the practice advisory board, the patient advisory board, and with interested MPAs. The questionnaires will be analyzed descriptively, exploring the effect of demographic variables. Qualitative content analysis is used to analyze the data from the interviews and focus groups. DISCUSSION: The study focuses on the conditions of GP care during the COVID-19 pandemic. A broad insight is provided as GPs and MPAs, as well as patients, are involved. It provides the opportunity to express needs and concerns. The results can support future discussions on lessons learned from the pandemic and necessary changes in health care delivery. TRIAL REGISTRATION: Trial registration at the German Clinical Trials Register: DRKS00028095.

The M-CHooSe pilot: the acceptability and utilisation of the nurse-led, general practice clinic co-located 'Mater CALD Healthcare Coordinator Service' for patients from multicultural backgrounds.

BACKGROUND: Patients from culturally and linguistically diverse (CALD) backgrounds often have unmet healthcare coordination needs. We aimed to evaluate the acceptability, utilisation and perceived benefits of the Mater CALD Health Coordinator Service (M-CHooSe), a pilot, nurse-led, general practice co-located, healthcare coordination service for patients from CALD backgrounds. METHODS: M-CHooSe began in March 2020 at five Brisbane (Queensland) sites. Process and service user data were collected over 12months at one site. A survey evaluated primary healthcare professionals' perceived benefits of the service. Another survey of M-CHooSe nurses examined indicators of service complexity. RESULTS: In total, 206 individuals accessed M-CHooSe over the 12-month period. Commonly delivered services included health service advocacy, chart reviews and health system navigation, including addressing social determinants. M-CHooSe nurses reported frequently performing tasks such as following up with external health services and performing health and social care system coordination. M-CHooSe benefits reported by primary healthcare professionals included better patient access to external health services and improved patient understanding of their conditions and treatments. CONCLUSION: Patients were accepting of referrals to M-CHooSE. Primary healthcare professionals also reported a variety of benefits to themselves and their patients because of M-CHooSe. M-ChooSe highlights the potential of a healthcare coordination service for multicultural patients to improve healthcare equity, accessibility, and system efficiency. This project demonstrates the potential value of coordination services to increase patient access and uptake of existing health and social care services for modern Australian communities, thus improving the efficiency and effectiveness of our health system. Further investigations, including user experience, opinions and cost analyses, will be required to confirm the promising benefits of embedding M-CHooSe into usual care.

A sustainable vision for general practice: Understanding the challenges.

BACKGROUND: The COVID-19 pandemic has revealed the full extent of the crisis in general practice, which has emerged as nothing more than the tip of the iceberg of a health system in crisis. OBJECTIVE: This article introduces the systems and complexity thinking that frame the problems affecting general practice and the systemic challenges inherent in redesigning it. DISCUSSION: The authors show how embedded general practice is in the overall complex adaptive organisation of the health system. They allude to some of the key concerns that need to be dissolved in its redesign to achieve an effective, efficient, equitable and sustainable general practice system within a redesigned overall health system to achieve the best possible desired health experiences for patients.

Educational change in a crisis: what has changed and what is here to stay in undergraduate teaching and learning in General Practice.

OBJECTIVES: The aim of the study was to explore the decisions and decision-making strategies employed by academic GPs tasked with adapting the delivery of undergraduate general practice education curricula to virtual platforms during the COVID-19 pandemic and to investigate how their experiences of this adaptation might influence the development of future curricula. METHODS: Approaching the study from a constructivist grounded theory (CGT) perspective, we recognised that experiences shape perception, and an individual's 'truths' are socially constructed. Nine academic GPs from three university GP departments participated in semistructured interviews conducted via Zoom©. Anonymised transcripts were iteratively analysed, generating codes, categories, and concepts using a constant comparative approach. The study was approved by the Royal College of Surgeons in Ireland (RCSI) Research Ethics Committee. RESULTS: Participants described the transition to online delivery of the curriculum as a 'response approach'. The elimination of in-person delivery necessitated the changes rather than any strategic development process. With varying levels of experience in eLearning, participants described the need for and engagement with collaboration both internally within institutions and externally between institutions. Virtual patients were developed to replicate learning in a clinical environment. How these adaptions were evaluated by learners differed across the institutions. The value and limitations of student feedback as a driver for change differed between participants. Two institutions plan to incorporate aspects of blended learning going forward. Participants recognised the impact of limited social engagement between peers on social determinants of learning. CONCLUSION AND IMPLICATIONS: Prior experience in eLearning appeared to colour participants' perceptions of its value; those experienced in online delivery were inclined to recommend some level of continuation post-pandemic. We now need to consider which elements of undergraduate education can be delivered effectively online into the future. Maintaining the socio-cultural learning environment is of critical importance but must be balanced by efficient, informed and strategic educational design.

Crisis, change and the future for teaching and learning in general practice.

OBJECTIVES: The aim of this study was to explore the decisions and decision-making strategies employed by academic GPs tasked with adapting the delivery of undergraduate general practice education curricula to virtual platforms during the Covid-19 pandemic. We sought to investigate how their experiences of this adaptation might influence the development of future curricula. METHODS: Recognising our 'insider' positions and constructivist paradigm preferences, we approached the study from a constructivist grounded theory (CGT) perspective and participants participated in semi-structured interviews. RESULTS: Nine participants from three university GP departments in Ireland described the transition to online delivery of the curriculum as a 'response approach'. Participants described seeking collaboration both within and between institutions. The value and limitations of student feedback as a driver for change differed between participants and recognised the impact of limited social engagement between peers on social determinants of learning. Participants with prior experience in e-learning were inclined to recommend some level of continuation. Two institutions plan to continue to incorporate aspects of blended learning. CONCLUSION AND IMPLICATIONS: All participants recognised a level of value (efficiency, social engagement and continuity) in online learning, they were less clear on the specific educational value and impact of this (e.g. on knowledge, skills and attributes). We need to consider which elements of undergraduate education can be delivered effectively online. Maintaining the socio-cultural learning environment is of critical importance but must be balanced by efficient, informed and strategic educational design.

Follow-up survey of general practitioners in Zhejiang Province post-completion of position transition training in 2017-2020.

BACKGROUND: Position transition training for general practitioners in Zhejiang Province started in 2017 and has since been held once a year. By the beginning of 2022, four training sessions were completed. The purpose of this survey was to establish the current situation of trainees after their graduation and provide reference for the evaluation of the training effect. METHODS: Of the 738 trainees who completed the training, 253 were contacted and followed up. A self-designed questionnaire was used to conduct the survey through online filling in. The content included questions to elucidate the following information: whereabouts after the training, registration as a general practitioner, undertaken general practice teaching and scientific research work, current occupational environment, improvement of post competence after receiving position transition training, willingness to complete survey, willingness to participate in future training programs, etc. RESULTS: A number of 253 valid questionnaires were collected with a recovery rate of 100%. Notably, 93.68% of the participants successfully completed their training and obtained the Training Certificate of General Practitioners. Further, 83.4% were registered as general practitioners, 82.94% of which added on the basis of the original registered scope of practice. Currently, most of them work in primary health care institutions, primarily occupied with medical treatment, chronic disease management, COVID-19 prevention and control, health education, and prevention and health care. Of them, 27.01% were currently undertaking teaching work, and only 3.32% of them were conducting scientific research work related to general practice. The overall satisfaction of the trainees in the three theoretical training bases was above 90%, with no statistically significant difference among them (P > 0.05). Importantly, 84.11% of the followed-up personnel hoped to continue to participate in similar training in the future to improve their general practitioner core competences. CONCLUSION: The position transition training in Zhejiang Province has achieved good results, but the details of training and the implementation of policies in individual regions need to be improved. Most of the graduates were willing to continue their education, especially in general practitioners with special interests.

General practice wide adaptations to support patients affected by DVA during the COVID-19 pandemic: a rapid qualitative study.

BACKGROUND: Reporting of domestic violence and abuse (DVA) increased globally during the pandemic. General Practice has a central role in identifying and supporting those affected by DVA. Pandemic associated changes in UK primary care included remote initial contacts with primary care and predominantly remote consulting. This paper explores general practice's adaptation to DVA care during the COVID-19 pandemic. METHODS: Remote semi-structured interviews were conducted by telephone with staff from six localities in England and Wales where the Identification and Referral to Improve Safety (IRIS) primary care DVA programme is commissioned.  We conducted interviews between April 2021 and February 2022 with three practice managers, three reception and administrative staff, eight general practice clinicians and seven specialist DVA staff. Patient and public involvement and engagement (PPI&E) advisers with lived experience of DVA guided the project. Together we developed recommendations for primary care teams based on our findings. RESULTS: We present our findings within four themes, representing primary care adaptations in delivering DVA care: 1. Making general practice accessible for DVA care: staff adapted telephone triaging processes for appointments and promoted availability of DVA support online. 2. General practice team-working to identify DVA: practices developed new approaches of collaboration, including whole team adaptations to information processing and communication 3. Adapting to remote consultations about DVA: teams were required to adapt to challenges including concerns about safety, privacy, and developing trust remotely. 4. Experiences of onward referrals for specialist DVA support: support from specialist services was effective and largely unchanged during the pandemic. CONCLUSIONS: Disruption caused by pandemic restrictions revealed how team dynamics and interactions before, during and after clinical consultations contribute to identifying and supporting patients experiencing DVA. Remote assessment complicates access to and delivery of DVA care. This has implications for all primary and secondary care settings, within the NHS and internationally, which are vital to consider in both practice and policy.

Opioid prescribing among aged care residents during the first year of the COVID-19 pandemic: an analysis using general practice health records in Australia.

BACKGROUND: Opioid use is common among adults 65 years and older, while long-term use of opioids remains controversial and poses risks of drug dependence and other adverse events. The acute disease caused by the SARS-CoV-2 (COVID-19) pandemic has created new challenges and barriers to healthcare access, particularly for long-term care residents. Australia had a relatively low incidence and deaths due to COVID-19 during the first year of the pandemic compared to most OECD countries. In this context, we examined opioid prescribing rates and their dosage in residential aged care facilities (RACFs) before (2019) and during the COVID-19 pandemic (2020) from March to December in Australia. METHODS: We conducted a retrospective cohort using general practice electronic health records. This includes 17,304 RACF residents aged 65 years and over from 361 general practices in New South Wales and Victoria. Number of opioid prescriptions and percentage of opioids over 50 mg/day of oral morphine equivalent (OME) were described. Multivariate generalized estimating equations were applied to estimate odds ratios [aORs (95% confidence intervals)] for 1) opioids prescribed per consultation and 2) prescription opioids over 50 mg/day OME. RESULTS: In 2020 among 11,154 residents, 22.8% of 90,897 total prescriptions were opioids, and of the opioids, 11.3% were over 50 mg/day OME. In 2019 among 10,506 residents, 18.8% of 71,829 total prescriptions were opioids, of which 10.3% were over 50 mg/day OME. Year [2020 vs. 2019: aOR (95% CI):1.50 (1.44, 1.56); 1.29 (1.15, 1.46)] and regionality [rural/regional vs. metropolitan: 1.37 (1.26, 1.49); 1.40 (1.14, 1.71)] were associated with higher odds of prescription opioids and OME > 50 mg/day, respectively. Similar results were found when limited to the same residents (n = 7,340) recorded in both years. CONCLUSIONS: Higher prescription rates of opioids were observed during the COVID-19 pandemic in 2020 than in 2019 in Australian RACFs. The higher odds of prescription opioids and higher dosing in rural/regional than metropolitan areas indicate a widening of the gap in the quality of pain management during the pandemic. Our findings contribute to the limited data that indicate increased opioid prescriptions in long-term care facilities, likely to continue while COVID-19 pandemic restrictions remain.