Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey.

BACKGROUND: Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload. OBJECTIVES: This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic. DESIGN: Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936). RESULTS: Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic. CONCLUSIONS: Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

Access to automated comparative feedback reports in primary care - a study of intensity of use and relationship with clinical performance among Swedish primary care practices.

BACKGROUND: Digital applications that automatically extract information from electronic medical records and provide comparative visualizations of the data in the form of quality indicators to primary care practices may facilitate local quality improvement (QI). A necessary condition for such QI to work is that practices actively access the data. The purpose of this study was to explore the use of an application that visualizes quality indicators in Swedish primary care, developed by a profession-led QI initiative ("Primärvårdskvalitet"). We also describe the characteristics of practices that used the application more or less extensively, and the relationships between the intensity of use and changes in selected performance indicators. METHODS: We studied longitudinal data on 122 primary care practices' visits to pages (page views) in the application over a period up to 5 years. We compared high and low users, classified by the average number of monthly page views, with respect to practice and patient characteristics as well as baseline measurements of a subset of the performance indicators. We estimated linear associations between visits to pages with diabetes-related indicators and the change in measurements of selected diabetes indicators over 1.5 years. RESULTS: Less than half of all practices accessed the data in a given month, although most practices accessed the data during at least one third of the observed months. High and low users were similar in terms of most studied characteristics. We found statistically significant positive associations between use of the diabetes indicators and changes in measurements of three diabetes indicators. CONCLUSIONS: Although most practices in this study indicated an interest in the automated feedback reports, the intensity of use can be described as varying and on average limited. The positive associations between the use and changes in performance suggest that policymakers should increase their support of practices' QI efforts. Such support may include providing a formalized structure for peer group discussions of data, facilitating both understanding of the data and possible action points to improve performance, while maintaining a profession-led use of applications.

Primary care utilisation, adherence to guideline-based pharmacotherapy and continuity of care in primary care patients with chronic diseases and multimorbidity - a cross-sectional study.

BACKGROUND: To understand how to improve care for patients with chronic diseases and multimorbidity we wanted to describe the prevalence of different chronic diseases and the pattern of multimorbidity and to analyse the associations between occurrence of diseases and primary care utilization, adherence to guideline-based pharmacotherapy, and continuity of care. METHODS: Retrospective cross-sectional study of routine care data of the general population in region Jönköping in Sweden (345 916 inhabitants using primary care services) covering 4.3 years. PARTICIPANTS: Patients fulfilling the inclusion criteria of having ≥ 1 of 10 common chronic diseases and ≥ 3 visits to primary care between 2011 and 2015. PRIMARY OUTCOME MEASURES: In order to determine diseases and multimorbidity, primary care utilisation, adherence to guideline-based pharmacotherapy, frequencies and percentages, interval and ratio scaled variables were described using means, standard deviations, and various percentiles in the population. Two continuity indices were used (MMCI, COC) to describe continuity. RESULTS: Of the general population, 25 829 patients fulfilled the inclusion criteria (7.5% of the population). Number of diseases increased with increasing age, and multimorbidity was much more common than single diseases (mean 2.0 per patient). There was a slight positive correlation (0.29) between number of diseases and visits, but visits did not increase proportionally to the number of diseases. Patients with physical diseases combined with anxiety and/or depression made more visits than others. The number of diseases per patient was negatively associated with the adherence to pharmacotherapy guidelines. There was no association between continuity and healthcare utilisation or adherence to pharmacotherapy guidelines. CONCLUSIONS: Multimorbid patients are common in primary care and for many chronic diseases it is more common to have other simultaneous diseases than having only one disease. This can make adherence to pharmacotherapy guidelines a questionable measure for aged multimorbid patients. Existing continuity indices also revealed limitations. Holistic and patient-centred measures should be used for quality assessment of care for multimorbid patients in primary care.

Virtual Follow up After Distal Radius Fracture Surgery-Patient Experiences During the COVID-19 Pandemic.

The majority of patients with a distal radius fracture (DRF) are elderly, a group known to experience difficulties with new technology, partly due to a low level of digital literacy. At the beginning of the coronavirus disease 2019 pandemic, during the spring 2020, patients that underwent DRF surgery had regular follow-ups replaced by video calls from their surgeon and physiotherapist. Afterward, patients answered questionnaires regarding health and digital literacy and took part in semistructured interviews regarding the experience of the virtual follow-up. By systemic text condensation, 2 major categories were identified: (1) The video call-new, but surprisingly simple: All but 1 found it easier than expected, and (2) Video calls-the patient's choice: All but 1 patient preferred video calls to physical visits for follow-up. This is the first mixed methods study to assess patients' experiences of digital follow-up after DRF surgery. This study indicates that digital follow-up was highly appreciated, even among patients with low levels of digital literacy. Digital technologies must be made suitable even for patients with inadequate levels of digital literacy.

Impact of the Covid-19 pandemic on primary care utilization: evidence from Sweden using national register data.

OBJECTIVE: To analyze changes in primary care utilization as a result of the Covid-19 pandemic. Swedish national register data from 2019 to 2020 on utilization of services were used to compare overall utilization levels and across types of contacts and patient groups. A specific objective was to assess the extent to which remote types of patient consultations were able to compensate for any observed fall in on-site visits. Data were stratified by sex and age to investigate any demographic pattern. RESULTS: Findings show significant reductions in overall utilization of services as the pandemic occurred in the first quarter of 2020. On-site visits fell during the first wave of the pandemic and rebounded thereafter. Patients over 65 years of age appear to have reduced utilization to a larger extent compared with younger groups. Simultaneously, remote contacts increased from around 12% before the pandemic to 17% of the total number of consultations. However, the net effect of changes in service utilization suggests an overall reduction of around 12 percent in the number of primary care consultations as a result of the pandemic. No differences between men and women were observed. Further research will continue to monitor changes in primary care utilization as the pandemic continues.

Conditions and barriers for quality improvement work: a qualitative study of how professionals and health centre managers experience audit and feedback practices in Swedish primary care.

BACKGROUND: High quality primary care is expected to be the basis of many health care systems. Expectations on primary care are rising as societies age and the burden of chronic disease grows. To stimulate adherence to guidelines and quality improvement, audit and feedback to professionals is often used, but the effects vary. Even with carefully designed audit and feedback practices, barriers related to contextual conditions may prevent quality improvement efforts. The purpose of this study was to explore how professionals and health centre managers in Swedish primary care experience existing forms of audit and feedback, and conditions and barriers for quality improvement, and to explore views on the future use of clinical performance data for quality improvement. METHODS: We used an explorative qualitative design. Focus groups were conducted with health centre managers, physicians and other health professionals at seven health centres. The interviews were audio recorded, transcribed and analysed using qualitative content analysis. RESULTS: Four different types of audit and feedback that regularly occurred at the health centres were identified. The main part of the audit and feedback was "external", from the regional purchasers and funders, and from the owners of the health centres. This audit and feedback focused on non-clinical measures such as revenues, utilisation of resources, and the volume of production. The participants in our study did not perceive that existing audit and feedback practices contributed to improved quality in general. This, along with lack of time for quality improvement, lack of autonomy and lack of quality improvement initiatives at the system (macro) level, were considered barriers to quality improvement at the health centres. CONCLUSIONS: Professionals and health centre managers did not experience audit and feedback practices and existing conditions in Swedish primary care as supportive of quality improvement work. From a professional perspective, audit and feedback with a focus on clinical measures, as well as autonomy for professionals, are necessary to create motivation and space for quality improvement work. Such initiatives also need to be supported by quality improvement efforts at the system (macro) level, which favour transformation to a primary care based system.

[How do we want to organize health centres? 838 Swedish general practitioners' attitudes to a personal patient list]. / Så vill vi organisera vårdcentraler.

In Swedish primary care patients are registered at health centres where different professions, such as general practitioners (GPs), nurses, assistant nurses, counsellors, physiotherapists, psychologists and biomedical analysts, work. In an international comparison personal physician continuity is low in Sweden. Several governmental inquiries propose that patients register with one GP or a care team. Do Swedish GPs want a personal patient list and how should this best be realised? A web survey was distributed to the members of the Swedish Union of General Practitioners and was answered by 838 GPs. 91% wanted a personal patient list if reasonably sized, the option to limit their list, and shared responsibility for the list with colleagues or a team. To be able to plan the working day themselves and designated time for collegial dialogue was considered essential for increased efficiency, well-being and reduced risk of patients harm due to their doctor's knowledge gaps.

Core Values of Family Medicine in Europe: Current State and Challenges.

Background: Values are deeply held views that act as guiding beliefs for individuals and organizations. They state what is important in a profession. The aims of this study were to determine whether European countries have already developed (or are developing) documents on core values in family medicine; to gather the lists of core values already developed in countries; and to gather the opinions of participants on what the core family values in their countries are. Methods: This was a qualitative study. The questionnaire was distributed as an e-survey via email to present and former members of the European Society for Quality and Safety in Family Practice (EQuiP), and other family medicine experts in Europe. The questionnaire included six items concerning core values in family medicine in the respondent's country: the process of defining core values, present core values, the respondents' suggestions for core values, and current challenges of core values. Results: Core values in family medicine were defined or in a process of being defined in several European countries. The most common core values already defined were the doctor-patient relationship, continuity, comprehensiveness and holistic care, community orientation, and professionalism. Some countries expressed the need for an update of the current core values' list. Most respondents felt the core values of their discipline were challenged in today's world. The main values challenged were continuity, patient-centered care/the doctor-patient relationship and comprehensive and holistic care, but also prioritization, equity, and community orientation and cooperation. These were challenged by digital health, workload/lack of family physicians, fragmentation of care, interdisciplinary care, and societal trends and commercial interests. Conclusion: We managed to identify suggestions for core values of family medicine at the European level. There is a clear need to adopt a definition of a value and tailor the discussion and actions on the family medicine core values accordingly. There is also a need to identify the core values of family medicine in European countries. This could strengthen the profession, promote its development and research, improve education, and help European countries to advocate for the profession.

Study protocol: effects, costs and distributional impact of digital primary care for infectious diseases-an observational, registry-based study in Sweden.

INTRODUCTION: The ability to provide primary care with the help of a digital platform raises both opportunities and risks. While access to primary care improves, overuse of services and medication may occur. The use of digital care technologies is likely to continue to increase and evidence of its effects, costs and distributional impacts is needed to support policy-making. Since 2016, the number of digital primary care consultations for a range of conditions has increased rapidly in Sweden. This research project aims to investigate health system effects of this development. The overall research question is to what extent such care is a cost-effective and equitable alternative to traditional, in-office primary care in the context of a publicly funded health system with universal access. Three specific areas of investigation are identified: clinical effect; cost and distributional impact. This protocol describes the investigative approach of the project in terms of aims, design, materials, methods and expected results. METHODS AND ANALYSIS: The research project adopts a retrospective study design and aims to apply statistical analyses of patient-level register data on key variables from seven regions of Sweden over the years 2017-2018. In addition to data on three common infectious conditions (upper respiratory tract infection; lower urinary tract infection; and skin and soft-tissue infection), information on other healthcare use, socioeconomic status and demography will be collected. ETHICS AND DISSEMINATION: This registry-based study has received ethical approval by the Swedish Ethical Review Authority. Use of data will follow the Swedish legislation and practice with regards to consent. The results will be disseminated both to the research community, healthcare decision makers and to the general public.

[Personal physician continuity in primary care associated with fewer emergency room visits]. / Hög personlig läkar­kontinuitet i primärvård förenad med färre besök på akutmottagning - En populationsbaserad studie i Jönköpings sjukvårdsregion.

Overloading of the emergency departments in hospitals is, in Sweden, a common problem that is often blamed on lack of access to primary care.  We have conducted a cross-sectional study comprising more than 40% of the 347 837  inhabitants of Region Jönköping with access to complete individual data on healthcare consumption, personal doctor continuity, socio-economics, and accessibility data for all of the region's health centres. Individuals with high personal continuity at their own health centre had significantly fewer emergency room visits compared to those with the lowest continuity: for younger adults 55% and for elderly 34% fewer emergency room visits. Access to doctor consultations or to counselling nurses in primary care was not associated with a lower number of emergency room visits. Our results show the importance of personal doctor continuity also for the group of younger adults.

Measuring Quality in Primary Healthcare - Opportunities and Weaknesses.

The easy access to data from electronic patient records has made using this type of data in pay-for-performance systems increasingly common. General practitioners (GPs) throughout Europe oppose this for several reasons. Not all data can be used to derive good quality indicators and quality indicators can't reflect the broad scope of primary care. Qualities like person-centred care and continuity are particularly difficult to measure. The indicators urge doctors and nurses to spend too much time on the registration and administration of required data. However, quality indicators can be very useful as starting points for discussions about quality in primary care, with the purpose being to initiate, stimulate and support local improvement work. This led to The European Society for Quality and Patient Safety in General Practice (EQuiP) feeling the urge to clarify the different aspects of quality indicators by updating their statement on measuring quality in Primary Care. The statement has been endorsed by the Wonca Europe Council in 2018.

Use of quality circles for primary care providers in 24 European countries: an online survey of European Society for Quality and Safety in family practice delegates.

Objective: To identify and describe the core characteristics and the spread of quality circles in primary healthcare in European countries. Design: An online survey was conducted among European Society for Quality and Safety in Family Practice (EQuiP) delegates. To allow comparison with earlier results, a similar survey as in a study from 2000 was used. Setting: Primary Health Care in European countries. Subjects: General practitioners, delegated experts of the European Society for Quality and Safety in Family Practice (EQuiP). Main outcome measures: (1) Attendance in quality circles (2) their objectives (3) methods of quality improvement quality circles use (4) facilitator's role and training (5) role of institutions (6) supporting material and data sources quality circles use. Results: 76% of the delegates responded, representing 24 of 25 countries. In 13 countries, more than 10% of general practitioners participated in quality circles, compared with eight countries in 2000. The focus of quality circles moved from continuous medical education to quality improvement. Currently, quality circles groups use case-based discussions, educational materials and local opinion leaders in addition to audit and feedback. Some national institutions provide training for facilitators and data support for quality circle groups. Conclusion: The use of quality circles has increased in European countries with a shift in focus from continuous medical education to quality improvement. Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools. Qualitative inquiry is necessary to examine why QCs thrive or fail in different countries and systems. KEY POINTS Countries with already established quality circle movements increased their participation rate and extended their range of quality circle activities The focus of quality circles has moved from CME/CPD to quality improvement Well-trained facilitators are important, as is the use of varying didactic methods and quality improvement tools Institutions should provide supporting material and training for facilitators.

Financial incentives linked to quality improvement projects in Swedish primary care: a model for improving quality of care.

Background: Quality improvement (QI) is necessary in all healthcare, but quality of healthcare is hard to measure. To use financial incentives to improve care is difficult and may even be harmful. However, conducting QI projects is a well-established way to increase quality in healthcare. Problem: In 2015, there were few QI projects conducted in primary care in the Stockholm Region, Sweden. There was no structured support or way to share the QI projects with other general practitioner (GP) practices. To use financial incentives could increase the number of projects performed and could possibly improve the quality of care. The aim was to increase the number of GP practices performing QI projects in the Stockholm Region through financial incentives. Method: To study QI projects performed during 2016 and 2017 in the Region Stockholm. This was compared with 2015 in Stockholm and with the Region Jönköping in Sweden during 2016 and 2017. Interventions: First, the healthcare administration started to reimburse GP practices for conducting and reporting QI projects in 2016. Second, a 4-hour course in QI was offered. Third, feedback on plans for QI projects was given. The year after the projects were prerformed, they were published online to stimulate sharing and inspiration between the GP practices. Results: For 2016, there were 166 (80%) of the GP practices that presented a QI project and in 2017, 164 (79%) did so. The number of projects in Stockholm increased almost by 100 per years compared with 2015. Conclusion: QI work has increased in Stockholm since 2016, probably because of the financial incentives from the Stockholm Region.

Utilization of digital primary care in Sweden: Descriptive analysis of claims data on demographics, socioeconomics, and diagnoses.

OBJECTIVE: As digital technologies for health continue to develop, the ability to provide primary care services to patients with new symptoms will grow. In Sweden, two providers of digital primary care have expanded rapidly over the past years giving rise to a heated debate with clear policy implications. The purpose of the study is to present a descriptive review of digital primary care as currently under development in Sweden. METHODS: Descriptive analysis of national coverage data on the utilization of digital care by sex, age, place of residence, socioeconomic status, and most common diagnoses. The data are compared with samples of corresponding data on traditional, office-based primary care, out-of-hours care, and on non-emergency telephone consultations to obtain a comparative analysis of digital care. RESULTS: Digital primary care in Sweden has increased rapidly over the past two years. Currently, more than 30,000 digital consultations are made per month, equivalent to around two percent of all physician-led primary care. Digital care differs in some ways to that of traditional care as users are generally younger and seek for different conditions compared with office-based primary care. Digital care is also similar to traditional care as utilization is higher in metropolitan areas compared with rural areas. Similar to general health care use, there is a negative correlation between use of digital care and socioeconomic status. User profiles by age and sex of digital care are also similar to those of out-of-hours care and non-emergency telephone medical consultations. CONCLUSIONS: By providing a detailed description of the development of digital primary care the study contributes to a growing understanding of the contributions that digital technologies can make to health care. Based on current trends digital primary care is likely to continue to increase in frequency over the coming years. As technologies develop and the public becomes more familiar to interacting with medical providers over the Internet also the scope of digital care is likely to expand. As the provision of digital primary care expands across Europe and beyond, policy makers will need to develop regulating capacities to ensure its safe, effective and equitable integration into existing health systems.

Setting priorities in primary health care--on whose conditions? A questionnaire study.

BACKGROUND: In Sweden three key criteria are used for priority setting: severity of the health condition; patient benefit; and cost-effectiveness. They are derived from the ethical principles established by the Swedish parliament 1997 but have been used only to a limited extent in primary care. The aim of this study was to describe and analyse: 1) GPs', nurses', and patients' prioritising in routine primary care 2) The association between the three key priority setting criteria and the overall priority assigned by the GPs and nurses to individual patients. METHODS: Paired questionnaires were distributed to all patients and the GPs or nurses they had contact with during a 2-week period at four health centres in Sweden. The staff registered the health conditions or health problem, and the planned intervention. Then they estimated the severity of the health condition, the expected patient benefit, and the cost-effectiveness of the planned intervention. Both the staff and the patients reported their overall prioritisation of the patient. In total, 1851 paired questionnaires were collected. RESULTS: Compared to the medical staff, the patients assigned relatively higher priority to acute/minor conditions than to preventive check-ups for chronic conditions. Severity of the health condition was the priority setting criterion that had the strongest association with the overall priority for the staff as a whole, but for the GPs it was cost-effectiveness. CONCLUSIONS: The challenge for primary care providers is to balance the patients' demands with medical needs and cost-effectiveness. Transparent priority setting in primary care might contribute to a greater consensus between GPs and nurses on how to use the key priority setting criteria.

Priority setting in primary health care - dilemmas and opportunities: a focus group study.

BACKGROUND: Swedish health care authorities use three key criteria to produce national guidelines for local priority setting: severity of the health condition, expected patient benefit, and cost-effectiveness of medical intervention. Priority setting in primary health care (PHC) has significant implications for health costs and outcomes in the health care system. Nevertheless, these guidelines have been implemented to a very limited degree in PHC. The objective of the study was to qualitatively assess how general practitioners (GPs) and nurses perceive the application of the three key priority-setting criteria. METHODS: Focus groups were held with GPs and nurses at primary health care centres, where the staff had a short period of experience in using the criteria for prioritising in their daily work. RESULTS: The staff found the three key priority-setting criteria (severity, patient benefit, and cost-effectiveness) to be valuable for priority setting in PHC. However, when the criteria were applied in PHC, three additional dimensions were identified: 1) viewpoint (medical or patient's), 2) timeframe (now or later), and 3) evidence level (group or individual). CONCLUSIONS: The three key priority-setting criteria were useful. Considering the three additional dimensions might enhance implementation of national guidelines in PHC and is probably a prerequisite for the criteria to be useful in priority setting for individual patients.

Premature chromosome condensation (PCC) assay for dose assessment in mass casualty accidents.

The study was undertaken to establish a dose calibration curve for a practical PCC ring assay and to apply it in a simulated mass casualty accident. The PCC assay was validated against the conventional dicentric assay. A linear relationship was established for PCC rings after (60)Co gamma irradiation with doses up to 20 Gy. In the simulated accident experiment, 62 blood samples were analyzed with both the PCC ring assay and the conventional dicentric assay, applying a triage approach. Samples received various uniform and non-uniform (10-40% partial-body) irradiations up to doses of 13 Gy. The results indicated that both assays yielded good dose estimates for the whole-body exposure scenario, although in the lower-dose range (0-6 Gy) dicentric scoring resulted in more accurate whole-body estimates, whereas PCC rings were better in the high-dose range (>6 Gy). Neither assay was successful in identifying partial-body exposures, most likely due to the low numbers of cells scored in the triage mode. In conclusion, the study confirmed that the PCC ring assay is suitable for use as a biodosimeter after whole-body exposure to high doses of radiation. However, there are limitations for its use in the triage of people exposed to high, partial-body doses.

Primary care patients' attitudes to priority setting in Sweden.

OBJECTIVE: To analyse attitudes to priority setting among patients in Swedish primary healthcare. DESIGN: A questionnaire was given to patients comprising statements on attitudes towards prioritizing, on the role of politicians and healthcare staff in prioritizing, and on patient satisfaction with the outcome of their contact with primary healthcare (PHC). SETTINGS: Four healthcare centres in Sweden, chosen through purposive sampling. PARTICIPANTS: All the patients in contact with the health centres during a two-week period in 2004 (2517 questionnaires, 72% returned). MAIN OUTCOMES: Patient attitudes to priority setting and satisfaction with the outcome of their contact. RESULTS: More than 75% of the patients agreed with statements like "Public health services should always provide the best possible care, irrespective of cost". Almost three-quarters of the patients wanted healthcare staff rather than politicians to make decisions on priority setting. Younger patients and males were more positive towards priority setting and they also had a more positive view of the role of politicians. Less than 10% of the patients experienced some kind of economic rationing but the majority of these patients were satisfied with their contact with primary care. CONCLUSIONS: Primary care patient opinions concerning priority setting are a challenge for both politicians and GPs. The fact that males and younger patients are less negative to prioritizing may pave the way for a future dialogue between politicians and the general public.