Patient, family member and caregiver engagement in shaping policy for primary health care teams in three Canadian Provinces.

INTRODUCTION: Improving health services integration through primary health care (PHC) teams for patients with chronic conditions is essential to address their complex health needs and facilitate better health outcomes. The objective of this study was to explore if and how patients, family members, and caregivers were engaged or wanted to be engaged in developing, implementing and evaluating health policies related to PHC teams. This patient-oriented research was carried out in three provinces across Canada: British Columbia, Alberta and Ontario. METHODS: A total of 29 semi-structured interviews with patients were conducted across the three provinces and data were analysed using thematic analysis. RESULTS: Three key themes were identified: motivation for policy engagement, experiences with policy engagement and barriers to engagement in policy. The majority of participants in the study wanted to be engaged in policy processes and advocate for integrated care through PHC teams. Barriers to patient engagement in policy, such as lack of opportunities for engagement, power imbalances, tokenism, lack of accessibility of engagement opportunities and experiences of racism and discrimination were also identified. CONCLUSION: This study increases the understanding of patient, family member, and caregiver engagement in policy related to PHC team integration and the barriers that currently exist in this engagement process. This information can be used to guide decision-makers on how to improve the delivery of integrated health services through PHC teams and enhance patient, family member, and caregiver engagement in PHC policy. PATIENT OR PUBLIC CONTRIBUTION: We would like to acknowledge the contributions of our patient partners, Brenda Jagroop and Judy Birdsell, who assisted with developing and pilot testing the interview guide. Judy Birdsell also assisted with the preparation of this manuscript. This study also engaged patients, family members, and caregivers to share their experiences with engagement in PHC policy.

OpenSAFELY: impact of national guidance on switching anticoagulant therapy during COVID-19 pandemic.

BACKGROUND: Early in the COVID-19 pandemic, the National Health Service (NHS) recommended that appropriate patients anticoagulated with warfarin should be switched to direct-acting oral anticoagulants (DOACs), requiring less frequent blood testing. Subsequently, a national safety alert was issued regarding patients being inappropriately coprescribed two anticoagulants following a medication change and associated monitoring. OBJECTIVE: To describe which people were switched from warfarin to DOACs; identify potentially unsafe coprescribing of anticoagulants; and assess whether abnormal clotting results have become more frequent during the pandemic. METHODS: With the approval of NHS England, we conducted a cohort study using routine clinical data from 24 million NHS patients in England. RESULTS: 20 000 of 164 000 warfarin patients (12.2%) switched to DOACs between March and May 2020, most commonly to edoxaban and apixaban. Factors associated with switching included: older age, recent renal function test, higher number of recent INR tests recorded, atrial fibrillation diagnosis and care home residency. There was a sharp rise in coprescribing of warfarin and DOACs from typically 50-100 per month to 246 in April 2020, 0.06% of all people receiving a DOAC or warfarin. International normalised ratio (INR) testing fell by 14% to 506.8 patients tested per 1000 warfarin patients each month. We observed a very small increase in elevated INRs (n=470) during April compared with January (n=420). CONCLUSIONS: Increased switching of anticoagulants from warfarin to DOACs was observed at the outset of the COVID-19 pandemic in England following national guidance. There was a small but substantial number of people coprescribed warfarin and DOACs during this period. Despite a national safety alert on the issue, a widespread rise in elevated INR test results was not found. Primary care has responded rapidly to changes in patient care during the COVID-19 pandemic.

Are We Reaching Everyone? A Cross-Sectional Study of Telehealth Inequity in the COVID-19 Pandemic in an Urban Academic Pediatric Primary Care Clinic.

The COVID-19 (coronavirus disease 2019) pandemic brought rapid expansion of pediatric telehealth to maintain patient access to care while decreasing COVID-19 community spread. We designed a retrospective, serial, cross-sectional study to investigate if telehealth implementation at an academic pediatric practice led to disparities in health care access. Significant differences were found in pre-COVID-19 versus during COVID-19 patient demographics. Patients seen during COVID-19 were more likely to be younger, White/Caucasian or Asian, English speaking, and have private insurance. They were less likely to be Black/African American or Latinx and request interpreters. Age was the only significant difference in patient demographics between in-person and telehealth visits during COVID-19. A multivariate regression showed older age as a significant positive predictor of having a video visit and public insurance as a significant negative predictor. Our study demonstrates telehealth disparities based on insurance existed at our clinic as did inequities in who was seen before versus during COVID-19.

[Telemedicine satisfaction of primary care patients during COVID-19 pandemics]. / Grado de satisfacción de los pacientes de la Unidad de Salud Familiar Vitrius con la teleconsulta durante la pandemia del COVID-19.

OBJECTIVES: To assess telemedicine satisfaction of patients from a primary health care center during COVID-19 pandemics. This work could bring information on its acceptance. MATERIALS AND METHODS: Transversal study with 253 individuals. A questionnaire was performed using Likert scale (1-very unsatisfied, 5-very satisfied) on patients with diabetes, hypertension and in subjects with other pathologies, whose consultations occurred between 01/04/2020 and 01/05/2020. Collected data included sociodemographics, previous telemedicine appointments, satisfaction levels of teleconsultation and doubt clarification, and interest in further telemedicine follow-up. In addition, a comparative analysis was performed between the periods January-February and April-May of 2020 in relation to age, sex, hypertension, diabetes and the type of contact (presential or remote). Statistics were performed using SPSS® and Excel®. RESULTS AND DISCUSSION: Diabetes follow-up appointments accounted for 34.4% of total consultations. Globally there was a high level of satisfaction and interest in future telemedicine follow-up. However, diabetic and older patients were less interested in this type of follow-up. Statistically significant differences about satisfaction were found in age, sex and presence/absence of diabetes. 70.6% of healthy patients preferred contact by e-mail over telephone. A selection bias is present because no randomization was made. The higher prevalence of diabetes consultations and the lack of adjustment for confounding factors can also affect results. Number of consults between January-February and April-May was compared and the main result was the significant reduction in the number of face-to-face consultations for diabetes (-50.1%) and hypertension (-94.1%). Presential consultations decreased by 72.6% and non-presential consultations increased by 61.9%. There was a selection bias because the sample was not random. The higher prevalence of diabetes consults and the lack of adjustment for confounders could affect results. CONCLUSIONS: This study allowed us to confirm the importance of telemedicine in primary health care, especially during pandemics. Participants recognized the usefulness of telemedicine and allowed future similar consultations.

Pregnancy-related anxiety and its associated factors during COVID-19 pandemic in Iranian pregnant women: a web-based cross-sectional study.

BACKGROUND: Pregnancy is a risk factor for coronavirus disease 2019 (COVID-19). Pregnant women suffer from varying levels of pregnancy-related anxiety (PRA) which can negatively affect pregnancy outcomes. The aim of this study was to assess PRA and its associated factors during the COVID-19 pandemic. METHODS: This web-based cross-sectional study was conducted in 2020 on 318 pregnant women purposively recruited from primary healthcare centers in Sari and Amol, Iran. Data were collected using questionnaires (PRAQ, Edinburg, KAP of COVID-19, CDA-Q and Demographic questionnaire), which were provided to participants through the social media or were completed for them over telephone. Data were analyzed with the linear regression and the logistic regression analysis, at the significance level of 0.05 using the SPSS software (v. 21). RESULTS: Around 21% of participants had PRA, 42.1% had depression, and 4.4% had COVID-19 anxiety. The significant predictors of PRA were number of pregnancies (P = 0.008), practice regarding COVID-19 (P < 0.001), COVID-19 anxiety (P < 0.001), depression (P < 0.001), and social support (P = 0.025) which explained 19% of the total variance. Depression and COVID-19 anxiety increased the odds of PRA by respectively four times and 13%, while good practice regarding COVID-19 decreased the odds by 62%. CONCLUSION: Around 21% of pregnant women suffer from PRA during the COVID-19 pandemic and the significant predictors of PRA during the pandemic include number of pregnancies, practice regarding COVID-19, COVID-19 anxiety, depression, and social support. These findings can be used to develop appropriate strategies for the management of mental health problems during pregnancy in the COVID-19 pandemic.

Disparities in Telemedicine Use for Subspecialty Diabetes Care During COVID-19 Shelter-In-Place Orders.

BACKGROUND: During the COVID-19 pandemic, telemedicine use rapidly and dramatically increased for management of diabetes mellitus. It is unknown whether access to telemedicine care has been equitable during this time. This study aimed to identify patient-level factors associated with adoption of telemedicine for subspecialty diabetes care during the pandemic. METHODS: We conducted an explanatory sequential mixed-methods study using data from a single academic medical center. We used multivariate logistic regression to explore associations between telemedicine use and demographic factors for patients receiving subspecialty diabetes care between March 19 and June 30, 2020. We then surveyed a sample of patients who received in-person care to understand why these patients did not use telemedicine. RESULTS: Among 1292 patients who received subspecialty diabetes care during the study period, those over age 65 were less likely to use telemedicine (OR: 0.34, 95% CI: 0.22-0.52, P < .001), as were patients with a primary language other than English (OR: 0.53, 95% CI: 0.31-0.91, P = .02), and patients with public insurance (OR: 0.64, 95% CI: 0.49-0.84, P = .001). Perceived quality of care and technological barriers were the most common reasons cited for choosing in-person care during the pandemic. CONCLUSIONS: Our findings suggest that, amidst the COVID-19 pandemic, there have been disparities in telemedicine use by age, language, and insurance for patients with diabetes mellitus. We anticipate telemedicine will continue to be an important care modality for chronic conditions in the years ahead. Significant work must therefore be done to ensure that telemedicine services do not introduce or widen population health disparities.

Uniting Public Health and Primary Care for Healthy Communities in the COVID-19 Era and Beyond.

The Coronavirus disease 2019 (COVID-19) pandemic has laid bare the dis-integrated health care system in the United States. Decades of inattention and dwindling support for public health, coupled with declining access to primary care medical services have left many vulnerable communities without adequate COVID-19 response and recovery capacity. "Health is a Community Affair" is a 1966 effort to build and deploy local communities of solution that align public health, primary care, and community organizations to identify health care problem sheds, and activate local asset sheds. After decades of independent effort, the COVID-19 pandemic offers an opportunity to reunite and align the shared goals of public health and primary care. Imagine how different things might look if we had widely implemented the recommendations from the 1966 report? The ideas and concepts laid out in "Health is a Community Affair" still offer a COVID-19 response and recovery approach. By bringing public health and primary care together in community now, a future that includes a shared vision and combined effort may emerge.

[Infectious Disease Prevention Group. Update on vaccines, 2020]. / Prevención de las enfermedades infecciosas. Actualización en vacunas, 2020.

Vaccine development is one of the fastest growing sectors in medicine now and in the future, as we are living with the emergency health care for the SARS-CoV-2 coronavirus. The semFYC PAPPS program biannually publishes the recommendations of the group and, in this edition, special emphasis is placed on the common vaccination proposed by the Ministry of Health, where, at last, it no longer discriminates between paediatrics and adults, and proposes a calendar throughout life. The main novelties in the field of vaccinology today are focused on the consolidation of the nonavalent vaccine against the human papilloma virus and in the change of the dose of monovalent meningitis vaccine C for the tetravalent one, ACWY, at age 12. The pandemic we are experiencing has led to the postponement of most preventive activities. On the return to «normality¼, the vaccination calendar must be examined, and completed if necessary.

Top POEMs of 2019 Consistent with the Principles of the Choosing Wisely Campaign.

In this article, we discuss the POEMs (patient-oriented evidence that matters) of 2019 judged to be most consistent with the principles of Choosing Wisely, an international campaign to reduce unnecessary testing and treatments. We selected these POEMs through a crowdsourcing strategy of the daily POEMs information service for the Canadian Medical Association's physician members. We present recommendations from these top POEMs of primary research or meta-analysis that identify interventions to encourage or consider avoiding in practice. The recommendations cover musculoskeletal conditions (e.g., do not recommend platelet-rich plasma injections for rotator cuff disease or knee osteoarthritis), respiratory disease (e.g., in clinically stable patients with community-acquired pneumonia, antibiotics can be stopped after five days), screening or preventive care (e.g., patients who take their blood pressure at home or in a pharmacy should know what to do when they have an elevated reading), and miscellaneous topics (e.g., in healthy adults treated for dermatophyte infection, do not obtain baseline or follow-up alanine transaminase level, aspartate transaminase level, or complete blood count). These POEMs describe interventions whose benefits are not superior to other options, are sometimes more expensive, or put patients at increased risk of harm. Knowing more about these POEMs and their connection with the Choosing Wisely campaign will help clinicians and patients engage in conversations better informed by high-quality evidence.

An Italian Guidance Model for the Management of Suspected or Confirmed COVID-19 Patients in the Primary Care Setting.

An outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 started in China's Hubei province at the end of 2019 has rapidly become a pandemic. In Italy, a great number of patients was managed in primary care setting and the role of general practitioners and physicians working in the first-aid emergency medical service has become of utmost importance to coordinate the network between the territory and hospitals during the pandemic. Aim of this manuscript is to provide a guidance model for the management of suspected, probable, or confirmed cases of SARS-CoV-2 infection in the primary care setting, from diagnosis to treatment, applying also the recommendations of the Italian Society of General Medicine. Moreover, this multidisciplinary contribution would analyze and synthetize the preventive measures to limit the spread of SARS-CoV-2 infection in the general population as well as the perspective for vaccines.

Improving primary care in Europe beyond COVID-19: from telemedicine to organizational reforms.

The COVID-19 pandemic has put under pressure all the health national systems in Europe and telemedicine (TM) has been an almost unavoidable answer for primary care (PC) services to constrain the contagion. PC includes all the healthcare services that are the first level of contact for individuals. General practitioners (GPs) are the pivotal providers of PC throughout Europe. Although GP costs are mainly covered by public services or social insurances in Europe, they are still self-employed physicians everywhere, differently from their colleagues in hospitals who are traditionally employees. TM is a very general term open to various interpretations and definitions. TM can now be practiced by means of modern audio-visual devices and is an alternative to the traditional face-to-face consultation in general practice. Although the adoption of TM seems to be compelling in our era, its practical dissemination in PC has been quite slow so far, and many different concerns have been raised on it. On the whole, TM widespread adoption in PC seems to be more a matter of labor organization and health care funding than of technology and ethics. Larger-scale organizations comprising a wide range of health professionals have become a pressing priority for a modern PC, because working together is crucial to provide high-quality care to patients, and co-location should boost teamwork and facilitate the management of information technology. A national network of large organizations in PC could be rationally managed through local budgets and should increase efficiency by adopting tools such as TM.

SARS-CoV-2 and the nose: Risks and implications for primary care.

BACKGROUND: General practitioners (GPs) have some of the highest rates of mortality from COVID-19 among healthcare workers. SARS-CoV-2 has unique properties that place GPs at particular risk. OBJECTIVE: The aim of this article is to discuss the nose-related features of SARS-CoV-2 that place GPs at risk, and to make recommendations pertinent to the safety and protection of primary healthcare physicians. DISCUSSION: The highest viral load of SARS-CoV-2 is in the nose and nasopharynx. It is often highest early in the illness, before the development of symptoms. Further, SARS-CoV-2 replicates and continues to shed in the nasopharynx long after the virus is no longer detectable in the lower respiratory tract. This places any physician performing examinations on, or procedures involving, the upper respiratory tract at risk for contracting COVID-19. New-onset hyposmia and dysgeusia are indicators for COVID-19 and should be included in screening protocols.