Quality and safety actions in primary care practices in COVID-19 pandemic: the PRICOV-19 study in Spain.

BACKGROUND: Primary Health Care (PHC) has been key element in detection, monitoring and treatment of COVID-19 cases in Spain. We describe how PHC practices (PCPs) organized healthcare to guarantee quality and safety and, if there were differences among the 17 Spanish regions according to the COVID-19 prevalence. METHODS: Cross-sectional study through the PRICOV-19 European Online Survey in PCPs in Spain. The questionnaire included structure and process items per PCP. Data collection was due from January to May 2021. A descriptive and comparative analysis and a logistic regression model were performed to identify differences among regions by COVID-19 prevalence (low < 5% or high ≥5%). RESULTS: Two hundred sixty-six PCPs answered. 83.8% of PCPs were in high prevalence regions. Over 70% PCPs were multi-professional teams. PCPs attended mainly elderly (60.9%) and chronic patients (53.0%). Regarding structure indicators, no differences by prevalence detected. In 77.1% of PCPs administrative staff were more involved in providing recommendations. Only 53% of PCPs had a phone protocol although 73% of administrative staff participated in phone triage. High prevalence regions offered remote assessment (20.4% vs 2.3%, p 0.004) and online platforms to download administrative documents more frequently than low prevalence (30% vs 4.7%, p < 0.001). More backup staff members were hired by health authorities in high prevalence regions, especially nurses (63.9% vs 37.8%, p < 0.001. OR:4.20 (1.01-8.71)). 63.5% of PCPs provided proactive care for chronic patients. 41.0% of PCPs recognized that patients with serious conditions did not know to get an appointment. Urgent conditions suffered delayed care in 79.1% of PCPs in low prevalence compared to 65.9% in high prevalence regions (p 0.240). A 68% of PCPs agreed on having inadequate support from the government to provide proper functioning. 61% of high prevalence PCPs and 69.5% of low ones (p: 0.036) perceived as positive the role of governmental guidelines for management of COVID-19. CONCLUSIONS: Spanish PCPs shared a basic standardized PCPs' structure and common clinical procedures due to the centralization of public health authority in the pandemic. Therefore, no relevant differences in safety and quality of care between regions with high and low prevalence were detected. Nurses and administrative staff were hired efficiently in response to the pandemic. Delay in care happened in patients with serious conditions and little follow-up for mental health and intimate partner violence affected patients was identified. Nevertheless, proactive care was offered for chronic patients in most of the PCPs.

Measures during the COVID-19 pandemic in public primary health care in Greece: is there still a missing link to universal health coverage?

BACKGROUND: The PRICOV-19 study aimed to assess the organization of primary health care (PHC) during the COVID-19 pandemic in 37 European countries and Israel; and its impact on different dimensions of quality of care. In this paper, we described measures taken by public PHC centers in Greece. Additionally, we explored potential differences between rural and non-rural settings. METHODS: The study population consisted of the 287 public PHC centers in Greece. A random sample of 100 PHC centers stratified by Health Region was created. The online questionnaire consisted of 53 items, covering six sections: general information on the PHC center, patient flow, infection prevention, information processing, communication to patients, collaboration, and collegiality. RESULTS: Seventy-eight PHC centers (78%) - 50 rural and 28 non-rural - responded to the survey. Certain measures were reported by few PHC centers. Specifically, the use of online messages about complaints that can be solved without a visit to the PHC center (21% rural; and 31% non-rural PHC centers), the use of video consultations with patients (12% rural; and 7% non-rural PHC centers), and the use of electronic medical records (EMRs) to systematically identify the list of patients with chronic conditions (5% rural; and 10% non-rural PHC centers) were scarcely reported. Very few PHC centers reported measures to support identifying and reaching out to vulnerable population, including patients that may have experienced domestic violence (8% rural; and 7% non-rural PHC centers), or financial problems (26% rural; and 7% non-rural PHC centers). Providing administrative documents to patients through postal mail (12% rural; and 21% non-rural PHC centers), or regular e-mail (11% rural; and 36% non-rural PHC centers), or through a secured server (8% rural; and 18% non-rural PHC centers) was rarely reported. Finally, providing information in multiple languages through a PHC website (12% rural PHC centers only), or an answering machine (6% rural PHC centers only), or leaflets (3% rural PHC centers only; and for leaflets specifically on COVID-19: 6% rural; and 8% non-rural PHC centers) were lacking in most PHC centers. CONCLUSION: Our study captured measures implemented by few PHC centers suggesting potential priority areas of future improvement.

General practitioners' well-being in Belgium: results from the cross-sectional PRICOV-19 study.

BACKGROUND: The mental health and well-being of GPs is a critical issue as they play a vital role in providing healthcare services to individuals and communities. Research has shown that GPs often face high levels of stress, burnout, and mental health problems due to their demanding work environment. During the COVID-19 pandemic, GPs faced additional challenges which further impacted their mental health and well-being. This study aims to investigate the impact of systemic work-related stressors on the level of well-being of GPs in Belgium during the pandemic, with a particular emphasis on identifying regional variations between Flanders, Wallonia, and Brussels-Capital. METHODS: Data were collected with a self-reported online questionnaire from 479 GPs Belgian practices between December 2020 and August 2021 as part of the international PRICOV-19 study that explored the organization of general practices during COVID-19 in 38 countries to guarantee safe, effective, patient-centered, and equitable care. Well-being was evaluated by the Mayo Clinic's expanded 9-item well-being index. RESULTS: The findings of this study reveal notable regional discrepancies in the degree of well-being experienced by Belgian GPs, with the Walloon region displaying the lowest level of well-being (37%) in a population highly susceptible to professional distress (57%). Among the key stressors contributing to such distress, financial difficulties among patients (p < 0.011), the fee-for-service payment system (p = 0.013), a lack of work-related purpose (p = 0.047), and inadequate work-life balance (p < 0.001) were identified as significant factors. When examining the influence of regional disparities, it was found that the sole significant interaction between work-related stressors and region regarding the probability of experiencing distress was related to the possibility of workload sharing among practice personnel. CONCLUSION: The findings from this study underscore the imperative for more comprehensive research aimed at scrutinizing the differences in well-being across the three regions in Belgium and identifying the systemic factors that influence the practice environment, as opposed to exclusively concentrating on enhancing individual resilience.

Characteristics of primary care practices associated with patient education during COVID-19: results of the cross-sectional PRICOV-19 study in 38 countries.

BACKGROUND: In response to the COVID-19 pandemic, the World Health Organization established a number of key recommendations such as educational activities especially within primary care practices (PCPs) which are a key component of this strategy. This paper aims to examine the educational activities of PCPs during COVID-19 pandemic and to identify the factors associated with these practices across 38 countries. METHODS: A "Patient Education (PE)" score was created based on responses to six items from the self-reported questionnaire among PCPs (n = 3638) compiled by the PRICOV-19 study. Statistical analyses were performed on 3638 cases, with PCPs with missing PE score values were excluded. RESULTS: The PE score features a mean of 2.55 (SD = 0.68) and a median of 2.50 (2.16 - 3.00), with a maximum of 4.00, and varies quite widely between countries. Among all PCPs characteristics, these factors significantly increase the PE score: the payment system type (with a capitation payment system or another system compared to the fee for service), the perception of average PCP with patients with chronic conditions and the perception of adequate governmental support. CONCLUSION: The model presented in this article is still incomplete and requires further investigation to identify other configuration elements favorable to educational activities. However, the results already highlight certain levers that will enable the development of this educational approach appropriate to primary care.

Outreach work in Belgian primary care practices during COVID-19: results from the cross-sectional PRICOV-19 study.

BACKGROUND: General practitioners (GPs) have a vital role in reaching out to vulnerable populations during and after the COVID-19 pandemic. Nonetheless, they experience many challenges to fulfill this role. This study aimed to examine associations between practice characteristics, patient population characteristics and the extent of deprivation of practice area on the one hand, and the level of outreach work performed by primary care practices (PCPs) during the COVID-19 pandemic on the other hand. METHODS: Belgian data from the international PRICOV-19 study were analyzed. Data were collected between December 2020 and August 2021 using an online survey in PCPs. Practices were recruited through randomized and convenience sampling. Descriptive statistics and ordinal logistic regression analyses were performed. Four survey questions related to outreach work constitute the outcome variable. The adjusted models included four practice characteristics (practice type, being a teaching practice for GP trainees; the presence of a nurse or a nurse assistant and the presence of a social worker or health promotor), two patient population characteristics (social vulnerability and medical complexity) and an area deprivation index. RESULTS: Data from 462 respondents were included. First, the factors significantly associated with outreach work in PCPs are the type of PCP (with GPs working in a group performing more outreach work), and the presence of a nurse (assistant), social worker or health promotor. Second, the extent of outreach work done by a PCP is significantly associated with the social vulnerability of the practice's patient population. This social vulnerability factor, affecting outreach work, differed with the level of medical complexity of the practice's patient population and with the level of deprivation of the municipality where the practice is situated. CONCLUSIONS: In this study, outreach work in PCPs during the COVID-19 pandemic is facilitated by the group-type cooperation of GPs and by the support of at least one staff member of the disciplines of nursing, social work, or health promotion. These findings suggest that improving the effectiveness of outreach efforts in PCPs requires addressing organizational factors at the practice level. This applies in particular to PCPs having a more socially vulnerable patient population.

Quality of care in Belgian general practices during the COVID-19 pandemic: results of the cross-sectional PRICOV-19 study.

BACKGROUND: The COVID-19 pandemic immensely impacted care provision, including quality of care in general practice. This paper aimed: (1) to assess how Belgian general practices acted upon the six dimensions of quality of care during COVID-19; (2) to study differences between the three Belgian regions; and (3) to benchmark the performance of the Belgian practices against the performance in other European countries. METHODS: The data collected from 479 Belgian practices during 2020-2021 using an online survey as part of the international cross-sectional PRICOV-19 study were analyzed.  Hereby, descriptive statistics, chi-squared tests, and binary logistic regression analyses were performed. Thirty-four survey questions related to the six dimensions of quality of care were selected as outcome variables. The adjusted regression models included four practice characteristics as covariates: practice type, being a teaching practice for GP trainees, multidisciplinarity of the team, and payment system. RESULTS: Belgian practices made important organizational changes to deliver high-quality care during COVID-19. Most practices (n = 259; 56.1%) actively reached out to vulnerable patients. Limitations to the practice building or infrastructure threatened high-quality care in 266 practices (55.5%). Infection prevention measures could not always be implemented during COVID-19, such as using a cleaning protocol (n = 265; 57.2%) and providing a separate doctor bag for infection-related home visits (n = 130; 27.9%). Three hundred and sixty practices (82.0%) reported at least one safety incident related to a delayed care process in patients with an urgent condition. The adjusted regression analysis showed limited significant differences between the Belgian regions regarding the quality of care delivered. Belgian practices demonstrated varied performance compared to other European countries. For example, they excelled in always checking the feasibility of isolation at home but reported more patient safety incidents related to timely care than at least three-quarters of the other European countries. CONCLUSIONS: Future studies using different design methods are crucial to investigate which country and practice characteristics are associated with delivering high-quality care.

Preventing smoking initiation in adolescents living in vulnerable socioeconomic conditions: Study protocol of the KickAsh!-intervention.

AIMS: Adolescents living in vulnerable socioeconomic conditions are confronted with tobacco-related health disparities. As school-based interventions appear to be less effective among these youngsters, other approaches are necessary. One promising avenue is youth social work settings that offer sport and recreational activities (SR-settings). SR-settings have been examined as a levering context for health promotion, but evidence regarding smoking prevention is currently lacking. METHODS: This study describes the protocol of a non-randomised cluster controlled trial evaluating a smoking prevention intervention for adolescents. At least 24 SR-settings are needed for the intervention and control group. A mixed-method design will be used. Quantitative measures will be used to assess effectiveness, involving validated questionnaires on smoking initiation behaviour and influencing factors (i.e. attitude, self-efficacy, social influence and risk perception). In addition, feasibility will be assessed with regard to intervention fidelity, dose and reach. Data will be collected at baseline, three and nine months following the intervention. To gain deeper understanding on the impact and underlying processes of the intervention, we will conduct qualitative interviews with users (adolescents) and implementers (youth workers within the SR-settings) of the intervention. CONCLUSIONS: Conducting this trial will offer novel insights into the effectiveness of a smoking prevention intervention designed for adolescents living in vulnerable socioeconomic conditions. A mixed-method design will enable to measure impact, implementation and underlying processes of the intervention. Overall, this design will enhance our understanding on the suitability of SR-settings as contexts for smoking prevention initiatives targeting hard-to-reach youth. This trial is registered on Clinicaltrials.gov: NCT05920772.

Moving forward after the COVID-19 pandemic: Lessons learned in primary care from the multi-country PRICOV-19 study.

BACKGROUND: The COVID-19 pandemic has accentuated the indispensable role of primary care. Objectives: Recognising this, the PRICOV-19 study investigated how 5,489 GP practices across 38 countries (Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kosovo*, Latvia, Lithuania, Luxembourg, Malta, Republic of Moldova, Netherlands, North Macedonia, Norway, Poland, Portugal, Romania, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine, and United Kingdom) adapted their care delivery during the pandemic. METHODS: Based on a series of discussions on the results of the PRICOV-19 study group, eight recommendations to enhance primary care's preparedness for future crises were formulated and endorsed by EQuiP and WONCA Europe. RESULTS: The recommendations underscore the importance of recognising and sustaining the substantial strides made in patient safety within GP practices during the pandemic in current daily practices; acknowledging and supporting the pivotal role of GP practices in addressing health inequalities during crises; adopting interprofessional care models to enhance practices' resilience and adaptability to change; supporting training practices; creating healthy working environments; investing in infrastructure that supports adequate and safe care; and increasing funding for research on patient safety and primary care quality to inform evidence-based health policies and fostering international knowledge exchange among healthcare professionals and policymakers. CONCLUSION: Policymakers, primary care associations, and the broader healthcare system are urged to collaboratively take responsibility and increase support for GP practices to enhance their resilience, adaptability, and capacity to deliver safe and equitable healthcare during future crises.

Governments should recognise the critical role of family medicine in addressing inequity and prioritise carers' wellbeing to maintain quality care during crises.Associations for practitioners should lead in crisis management developments and advocate for primary care.PC facilities should participate in health system design to answer challenges posed by crises.

Intercultural effectiveness in GPs' communication and clinical assessment: An experimental study.

OBJECTIVE: This study aimed to investigate potential disparities in general practitioners' overall communication and clinical assessments based on patient ethnicity, while examining the influence of intercultural effectiveness. METHODS: Employing a 2 × 2 experimental study design, online video recorded consultations with simulated patients were conducted and analyzed using OSCEs. Each GP (N = 100) completed a consultation with both an ethnic majority and an ethnic minority patient. Additionally, a follow-up survey was administered to gather supplementary data. Paired sample t-tests explored ethnic disparities, correlation and regression analyses determined associations with intercultural attitudes, traits and capabilities. RESULTS: No statistically significant differences in GPs' communication or clinical assessment were found based on patients' ethnic background. Positive associations were observed between all aspects of intercultural effectiveness and GPs' consultation behavior. Intercultural traits emerged as a strong and robust predictor of clinical assessment of ethnic minority patients. CONCLUSION: Intercultural traits, such as ethnocultural empathy, may play a critical role in GPs' clinical assessment skills during intercultural consultations. PRACTICE IMPLICATIONS: Findings provide valuable insights into the determinants of intercultural effectiveness in healthcare, fostering promising targets for interventions and training programs aiming to ensure higher-quality and more equitable care delivery.

Triage of patients and remote consultations in primary care facilities during the COVID-19 pandemic in France (PRICOV-19 study) / Triage des patients et consultations à distance dans les structures de soins primaires pendant la pandémie de Covid-19 en France (étude PRICOV-19)

Introduction: PRICOV-19 is a European cross-sectional study based on an online questionnaire, describing the impact of the pandemic on primary care structures (PCS). In France, PCS are solo practices (SP), single or multi-professional group practices (GP), coordinated practice structures (CPS): health houses and health centers. Triage, whether it is digital (TD), by telephone (TT) or at the reception (TR), is essential to reduce the risk of infection, and is part of recommended organizational practices. Purpose of research: Based on French data from the PRICOV-19 study, the objective is to describe the frequency and factors associated with triage in PCSs during the COVID 19 pandemic. Results: 1100 structures responded to the survey. The TD was implemented in 64% of PCSs (53.3% of SPs, 64.9% of GPs, 73.2% of CPSs). The TT was implemented in 76% of structures (72.7% of SPs, 75.4% of GPs and 81% of CPSs). Finally, TR was implemented in 52% of structures (37.7% of SPs, 52% of GPs and 67% of CPSs). The other positively associated factors are the urban territory and the lower workload for the TD, and the presence of a receptionist for the TR. Conclusions: Triage practices seem to be clearly associated with the organization and working conditions in the PCSs, and first and foremost with the type of structure.

Introduction: PRICOV-19 est une étude transversale européenne basée sur un questionnaire en ligne, décrivant l'impact de la pandémie sur les structures de soins primaires (SSP). En France, les SSP sont les cabinets solo (CS), les cabinets de groupe mono ou pluriprofessionnels (CG), les structures d'exercice coordonné (SEC) : maisons de santé et centres de santé. Le triage, qu'il soit numérique (TN), téléphonique (TT) ou à l'arrivée (TA) est indispensable pour réduire le risque infectieux, et fait partie des pratiques d'organisation recommandées. But de l'étude: En s'appuyant sur les données françaises de l'étude PRICOV-19, l'objectif est de décrire la fréquence et les facteurs associés au triage dans les SSP pendant la pandémie de COVID 19. Résultats: 1 100 structures ont répondu au questionnaire. Le TN a été mis en œuvre dans 64 % des SSP (53,3 % des CS, 64,9 % des CG, 73,2 % des SEC). Le TT a été mis en œuvre dans 76 % des structures (72,7 % des CS, 75,4 % des CG et 81 % des SEC). Enfin, le TA a été mis en œuvre dans 52 % des structures (37,7 % des CS, 52 % des CG et 67 % des SEC). Les autres facteurs positivement associés sont le territoire urbain et la charge de travail moins importante pour le TN, et la présence d'une réceptionniste pour le TA. Conclusion: Les pratiques de triage semblent clairement associés à l'organisation et aux conditions d'exercice dans les SSP, et en premier lieu au type de structure.

Barriers and Enablers Experienced by General Practitioners in Delivering Safe and Equitable Care during COVID-19: A Qualitative Investigation in Two Countries.

Addressing equity in healthcare is fundamental for delivering safe care to vulnerable patients, especially during COVID-19. This paper aims to identify barriers and enabling factors for general practitioners (GPs) in delivering safe and equitable care during the COVID-19 pandemic. Semi-structured interviews took place during May-July 2020 among 18 Flemish and 16 Dutch GPs. Thematic analysis of the interviews demonstrated that while GPs acknowledged a smooth information flow by governments and professional organizations on care guidelines, the fast-changing information challenged them to stay up to date. Media communication facilitated information dissemination but also fueled misinformation and miscommunication, creating unrealistic patient expectations. Certain guidelines and patient reluctance delayed necessary care. A shortage of personal protective equipment made GPs concerned about patient safety during face-to-face contacts. Teleconsultations became a popular alternative, but posed increased patient safety risks. GPs struggled to identify and reach vulnerable patients. Equitable care was hindered by time constraints; thus, having the appropriate materials facilitated such care. An interprofessional collaboration involving paramedical, social, and city services benefited patient safety and equity in healthcare. However, limitations in this collaboration pressured GPs. The unprecedented and resource-constrained environment challenged GPs' capacity to provide the healthcare quality they aspired to deliver. A well-structured collaborative network involving all stakeholders could benefit safe and equitable care in future pandemics.

First steps of learning analytics in a blended learning general practice curriculum at Saarland University - a quantitative approach.

Objectives: Medical education has been revolutionized by the growing importance of digital learning. Little is known about students' online study behaviour and its relationship with exam performance. This quantitative study analyses and describes students' digital learning behaviours in a blended learning curriculum for General practice at Saarland University, Germany. It also examines the relationship between digital learning behaviour and exam performance. Methods: Cohort and individualized AMBOSS® user data from 195 students at Saarland University was analysed quantitatively. Performance in course-specific multiple-choice question sessions and user data of the integrated online learning activities were correlated with each other and with General practice exam grades. Anonymized data from 10,534 students from 35 other German universities served as the reference cohort. Differences in digital learning behaviour between the groups were calculated using Mann-Whitney-U-Test for non-normally distributed data. Results: Students in the blended learning course used integrated content more frequently than the reference cohort (U=48777, p<0.001). The number of digital learning cards read correlated moderately with digital formative assessment performance (ρ=0.331, p=0.005 and ρ=0.217, p=0.034). Formative assessment scores and exam results correlated strongly in the summer semester cohort (ρ=0.505, p<0.001), and moderately in the winter semester cohort (ρ=0.381, p<0.001). Conclusion: There is a difference in the usage of online learning activities when they are purposefully integrated into a curriculum. Digital learning activities including formative assessment may serve as valuable, constructively aligned exam preparation. This is relevant for medical educators when planning future blended learning curricula and portfolio systems, as it may save financial and human resources.

The safety of patient management in family medicine in Slovenia during Covid-19: a cross-sectional study.

BACKGROUND: During the Covid-19 pandemic, family medicine practices (FMPs) changed to improve safety against new coronavirus infections for both patients and employees. Protocols for treating patients with suspected Sars-Cov-2 infections were established to protect medical staff and other patients from being infected. However, these protocols also led to increased safety risks, such as delays in treating patients with other medical conditions. This exploratory study aimed to investigate safety risks in treating patients in FMPs during the Covid-19 pandemic and to suggest improvements to prevent Covid-19 in FMPs in Slovenia. METHODS: A cross-sectional study was rolled out in FMPs in Slovenia as part of the international Pricov-19 study. Data collection on safety management during the Covid-19 pandemic in FMPs in Slovenia took place from November 2020 until January 2021 using a self-administered online survey for FP working in Slovenia. A chi-square test, ANOVA, independent samples t-test or bivariate correlation test was performed to explore associations regarding the safety of patients' management variables. RESULTS: From the 191 participating family physicians (FPs) (15.2% response rate), 54.8% reported having treated patients with fever (not Covid-19) late due to the new protocols at least once, and 54.8% reported patients with urgent conditions having been seen late at least once due to not coming. In the suburbs and rural environments FPs more often reported that at least once patient with a fever (not Covid-19) was seen late due to the protocol (p = 0.017) and more often reported that at least once patient with an urgent condition was seen late due to not coming to their FP (p = 0.017). The larger the practice, the more they reported that at least once a patient with fever (not Covid-19) was seen late due to the protocol (p = 0.012) and the more they reported at least once a patient with an urgent condition was seen late due to not coming to their FP (p = 0.012). CONCLUSION: Covid-19 affected the safety of patient management in FMP in Slovenia. The most common problem was foregone care. Therefor, protocols for chronic patient management in the event of epidemics need to be established.

From disease- to people-centred pandemic management: organized communities, community-oriented primary care and health information systems.

BACKGROUND: The COVID-19 pandemic exposed the health equity gap between and within countries. Western countries were the first to receive vaccines and mortality was higher among socially deprived, minority and indigenous populations. Surprisingly, many sub-Saharan countries reported low excess mortalities. These countries share experiences with community organization and participation in health. The aim of this article was to analyse if and how this central role of people can promote a successful pandemic response. METHODS: This analysis was partly based on local and national experiences shared during an international and Latin American conference on person-and people-centred care in 2021. Additionally, excess mortality data and pandemic control-relevant data, as well as literature on the pandemic response of countries with an unexpected low excess mortality were consulted. RESULTS: Togo, Mongolia, Thailand and Kenya had a seven times lower mean excess mortality for 2020 and 2021 than the United States of America. More successful pandemic responses were observed in settings with experience in managing epidemics like Ebola and HIV, well-established community networks, a national philosophy of mutual aid, financial government assistance, more human resources for primary care and paid community health workers. DISCUSSION: Since trust in authorities and health needs vary greatly, local strategies are needed to complement national and international pandemic responses. Three key levers were identified to promote locally-tailored pandemic management: well-organized communities, community-oriented primary care, and health information systems. An organized community structure stems from a shared ethical understanding of humanity as being interconnected with each other and the environment. This structure facilitates mutual aid and participation in decision making. Community-oriented primary care includes attention for collective community health and ways to improve health from its roots. A health information system supports collective health and health equity analysis by presenting health needs stratified for social deprivation, ethnicity, and community circumstances. CONCLUSIONS: The difference in excess mortality between countries during the COVID-19 pandemic and various country experiences demonstrate the potential of the levers in promoting a more just and effective health emergency response. These same levers and strategies can promote more inclusive and socially just health systems.

RESUMEN: ANTECEDENTES: La pandemia de COVID-19 expuso la brecha de equidad en salud dentro y entre países. Los países occidentales fueron los primeros en recibir vacunas y la mortalidad fue mayor entre las poblaciones indígenas, minoritarias y socialmente desfavorecidas dentro de los países. Sorprendentemente, muchos países subsaharianos reportaron un exceso de mortalidad bajo. Estos países comparten experiencias de organización y participación comunitaria en salud. El objetivo es analizar si y cómo este papel central de las personas puede promover una respuesta exitosa a la pandemia. MéTODOS: Este análisis se basa en parte en las experiencias locales y nacionales compartidas durante una conferencia internacional y latinoamericana sobre la atención centrada en las personas y comunidades en 2021. Además, se consultó los datos de exceso de mortalidad y los datos relevantes para el control de la pandemia, así como la literatura sobre la respuesta a la pandemia de países con un exceso de mortalidad inesperadamente bajo. RESULTADOS: Togo, Mongolia, Tailandia y Kenia tuvieron un exceso de mortalidad promedio por 2020 y 2021 siete veces menor que los Estados Unidos de América. Se observaron respuestas pandémicas más exitosas en entornos con experiencia en el manejo de epidemias como el ébola y el VIH, redes comunitarias bien establecidas, una filosofía nacional de ayuda mutua, asistencia financiera del gobierno, más recursos humanos para atención primaria y trabajadores de salud comunitarios remunerados. DISCUSIóN: Dado que la confianza en autoridades y las necesidades en salud varían mucho, se necesitan estrategias locales para complementar las respuestas nacionales e internacionales a la pandemia. Se identificaron tres palancas clave para promover la gestión de pandemias adaptada localmente: comunidades bien organizadas, atención primaria orientada a la comunidad y sistemas de información de salud. Una estructura comunitaria organizada surge de una comprensión ética compartida que concibe a la humanidad interconectada entre sí y con el medio ambiente. Esta estructura facilita la ayuda mutua y la participación en la toma de decisiones. La atención primaria orientada a la comunidad incluye la atención a la salud comunitaria colectiva y las formas de mejorar la salud desde sus raíces. Un sistema de información de salud puede apoyar el análisis de la salud colectiva y la equidad en salud al presentar las necesidades de salud estratificadas por privación social, etnicidad y circunstancias de la comunidad. CONCLUSIONES: La diferencia en el exceso de mortalidad entre países durante la pandemia de COVID-19 y las experiencias de varios países, demuestran el potencial de las palancas para promover una respuesta de emergencia sanitaria más justa y eficaz. Estas mismas palancas y estrategias pueden promover sistemas de salud más inclusivos y socialmente justos.

Insights into the use of telemedicine in primary care in times of the SARS-CoV-2 pandemic - a cross-sectional analysis based on the international PRICOV-19 study in Austria.

BACKGROUND: The SARS-CoV2 pandemic as well as the implementation of public health measures to decrease the spread of the virus re-sparked the call for "virtual" health or "distance" treatments. This paper aimed to assess the use of video consultations, the up-to-dateness of practice websites, and the views of GPs on whether eHealth is a positive aspect for the future of their practices in publicly -funded primary healthcare facilities in Austria. METHODS: The cross-sectional online questionnaire, part of the PRICOV-19 study, was conducted from December 2020 until July 2021. We randomly recruited 176 GP practices across Austria. Descriptive statistics as well as binary logistic regression models were applied to examine the associations between telemedicine use and practice factors. RESULTS: Compared with before the pandemic (3.8%), 7.6% of publicly funded GP practices have been using video consultations since the pandemic. In line with this, 93.9% of the practices had no increase in video consultation use. Fewer than half (44.3%) had an up-to-date webpage, and 27.8% assumed that the pandemic might have been a positive driver for eHealth in their practices. Positive associations with video consultation use could be found in practices with fewer patients aged 70 years and over than the average and more patients with chronic diseases than the average. CONCLUSION: The use of video consultations in general practice and the readiness for other telemedicine approaches are both very low in Austria. Austria has to urgently follow the example of countries with a transparent and comprehensive national digital health strategy that includes video consultation. Without a proper payment system, patient inclusion, and support with regard to administrative and organizational aspects, no substantial change will occur in spite of an increase in need due to the pandemic and changes in the patient population.

The impact of the COVID-19 pandemic on primary health care practices and patient management in the Republic of Moldova - results from the PRICOV-19 survey.

BACKGROUND: The COVID-19 pandemic has had an enormous impact on health systems in Europe and has generated unprecedented challenges for tertiary care. Less is known about the effects on the activities of local family doctors (FDs), who have shifted tasks and adapted their practice to accommodate the new services brought by the pandemic. The PRICOV-19 study was a multi-country survey aiming to understand the challenges posed by the pandemic in primary health care (PHC) practices around Europe. Within the framework of this study, we assessed the impact of the pandemic on PHC facilities in urban, rural, and mixed urban/rural areas in the Republic of Moldova. METHODS: We present the results from the PRICOV-19 questionnaire designed at Ghent University (Belgium) and distributed between January and March 2021 to PHC facilities from the 35 districts of the Republic of Moldova. This analysis presents descriptive data on limitations to service delivery, staff role changes, implementation and acceptance of COVID-19 guidelines, and incidents reported on staff and patient safety during the pandemic. RESULTS: Results highlighted the differences between facilities located in urban, rural, and mixed areas in several dimensions of PHC. Nearly half of the surveyed facilities experienced limitations in the building or infrastructure when delivering services during the pandemic. 95% of respondents reported an increase in time spent giving information to patients by phone, and 88% reported an increase in responsibilities. Few practices reported errors in clinical assessments, though a slightly higher number of incidents were reported in urban areas. Half of the respondents reported difficulties delivering routine care to patients with chronic conditions and a delay in treatment-seeking. CONCLUSIONS: During the pandemic, the workload of PHC staff saw a significant increase, and practices met important structural and organizational limitations. Consequently, these limitations may have also affected care delivery for vulnerable patients with chronic conditions. Adjustments and bottlenecks need to be addressed, considering the different needs of PHC facilities in urban, rural, and mixed areas.

"The measures taken by the government overburdened the daily practice" - insights of the PRICOV-19 study on German general practitioners in times of COVID-19.

BACKGROUND: The international study PRICOV-19 aims to assess the impact of the COVID-19 pandemic on the organisation of primary health care. The German part focuses on German general practitioners during the second wave of the COVID-19 pandemic. This paper addresses the following research questions: (1) How were changes in tasks on primary care and patient treatment perceived by GPs?, (2) What was the role of GPs during the pandemic, and how was their wellbeing?, (3) How did GPs perceive health policy measures?, and, (4) What influenced the attitudes of GPs on health policy measures? METHODS: This study pursues a multi-country cross-sectional design. Data collection took place throughout Germany from 01.02. to 28.02.2021 with a quantitative online questionnaire consisting of 53 items. The questionnaire was analysed through descriptive and inferential analyses using correlation and multiple regression models. RESULTS: The response rate was 20.4% (n = 349). The respondents were mainly GPs (59.6%) in single practices (62.5%) with a mean work experience of 15 to 20 years. GPs experienced a change in their work and practice organisation (80.3%). They felt a high responsibility (70.6%) and found their work has become more meaningful to them (76%). They also saw a lack of political support (75.2%) and that the measures taken by the government overburdened the daily practice (66.4%). Not many GPs were at risk of being distressed (53.4%) but rated the health policies rather negatively (60%). The multiple regression showed, the more GPs were exposed to risk of distress, the worse they assessed the government's measures. CONCLUSION: GPs perceived their work as relevant and felt confident they could fulfil their tasks, but noticed that health policy initially hardly supported the outpatient sector. Health policies should increase their competence in relation to primary care, ensure its needs and consider an active inclusion of GPs in preparedness plans.

Changes in work tasks and organization of general practice in Norway during the COVID-19 pandemic: results from a comparative international study.

BACKGROUND: The COVID-19 pandemic led to huge and rapid changes in general practice in Norway as in the rest of Europe. This paper aims to explore to what extent the COVID-19 pandemic changed the work tasks and organization of Norwegian general practice. MATERIAL AND METHOD: We analysed data from the Norwegian part of the international, cross-sectional PRICOV-19 study, collecting data from general practice via an online self-reported questionnaire. We included 130 Norwegian general practices, representing an estimated 520 Norwegian general practitioners (GPs). All Norwegian GPs were invited to participate. In the analyses, we focused on items related to the use of alternatives to face-to-face consultations, changes in the workload, tasks and delegated responsibilities of both the GPs and other personnel in the GP offices, adaptations in routines related to hygiene measures, triage of patients, and how the official rules and recommendations affected the practices. RESULTS: There was a large and significant increase in the use of all forms of alternative consultation forms (digital text-based, video- and telephone consultations). The use of several different infection prevention measures were significantly increased, and the provision of hand sanitizer to patients increased from 29.6% pre-pandemic to 95.1% since the pandemic. More than half of the GPs (59.5%) reported that their responsibilities in the practice had increased, and 41% were happy with the task shift. 27% felt that they received adequate support from the government; however, 20% reported that guidelines from the government posed a threat to the well-being of the practice staff. We found no associations with the rurality of the practice location or size of the municipalities. CONCLUSION: Norwegian GPs adapted well to the need for increased use of alternatives to face-to-face consultations, and reported a high acceptance of their increased responsibilities. However, only one in four received adequate support from the government, which is an important learning point for similar situations in the future.

GWAS of random glucose in 476,326 individuals provide insights into diabetes pathophysiology, complications and treatment stratification.

Conventional measurements of fasting and postprandial blood glucose levels investigated in genome-wide association studies (GWAS) cannot capture the effects of DNA variability on 'around the clock' glucoregulatory processes. Here we show that GWAS meta-analysis of glucose measurements under nonstandardized conditions (random glucose (RG)) in 476,326 individuals of diverse ancestries and without diabetes enables locus discovery and innovative pathophysiological observations. We discovered 120 RG loci represented by 150 distinct signals, including 13 with sex-dimorphic effects, two cross-ancestry and seven rare frequency signals. Of these, 44 loci are new for glycemic traits. Regulatory, glycosylation and metagenomic annotations highlight ileum and colon tissues, indicating an underappreciated role of the gastrointestinal tract in controlling blood glucose. Functional follow-up and molecular dynamics simulations of lower frequency coding variants in glucagon-like peptide-1 receptor (GLP1R), a type 2 diabetes treatment target, reveal that optimal selection of GLP-1R agonist therapy will benefit from tailored genetic stratification. We also provide evidence from Mendelian randomization that lung function is modulated by blood glucose and that pulmonary dysfunction is a diabetes complication. Our investigation yields new insights into the biology of glucose regulation, diabetes complications and pathways for treatment stratification.

Quick adaptation of the organisation of general practices during the COVID-19 pandemic in the Netherlands.

BACKGROUND: General practices have adapted the practice organisation to the circumstances of the COVID-19 pandemic. In this article we describe several adjustments in general practices in the field of patient flow management, appointments, triage, referral and infection prevention. We also examined how practices relate to the policy of the government and of the professional organisations during the pandemic. METHODS: A cross-sectional online survey was conducted among a sample of 893 general practitioners (GPs) during February and March 2021. The response rate was 17%. Because the questionnaire concerns practices and not individual GPs, one practice owner per practice received an invitation with a link to the online questionnaire. One reminder has been sent. RESULTS: General practices adapted their organisation during the corona pandemic, partly based on information and advice from their professional organisations. The adjustments were necessary to ensure that patient care continued as much and as safely as possible, often remotely. The use of video consultations quickly increased from 6% to 65% of the practices. The cooperation with neighbouring practices improved and practices felt supported by the professional organisations. CONCLUSIONS: The pandemic itself, remote care and stricter patient flow management have put pressure on the quality of care and patient safety. The accessibility of the practices was sometimes limited. In the perception of patients, this was stronger than in reality.