Visit Experience and Fulfillment of Care Needs in Primary Care Differs for Video Visits Compared to In-person and Chat Visits.

BACKGROUND: There is a lack of research comparing patient experience and to what extent patients' care needs are fulfilled in telemedicine compared to in-person care. OBJECTIVE: To investigate if patient experience and fulfillment of care needs differ between video and chat visits with direct to consumer telemedicine providers compared to in-person visits. DESIGN: Cross-sectional study. PARTICIPANTS: Adults visiting a primary care physician in person or via chat or video in Region Stockholm, Sweden, October 2020-May 2021. MAIN MEASURES: Patient-reported visit experience and fulfillment of care needs. KEY RESULTS: The sample included 3315 patients who had an in-person (1950), video (844), or chat (521) visit. Response rates were 42% for in-person visitors and 41% for telemedicine visitors. Patients were 18-97 years old, mean age of 51 years, and 66% were female. In-person visitors reported the most positive patient experience ("To a very high degree" or "Yes, completely") for being listened to (64%), being treated with care (64%), and feeling trust and confidence in the health care professional (76%). Chat visitors reported the most positive patient experience for being given enough time (61%) and having care needs fulfilled during the care visit (76%). Video visitors had the largest proportion of respondents choosing "To a very low degree" or "No, not at all" for all visit experience measures. There were statistically significant differences in the distribution of visit experiences between in-person, video, and chat visits for all visit experience measures (P < 0.001). CONCLUSIONS: Video visits were associated with a more negative visit experience and lower fulfillment of care needs than in-person visits. Chat visits were associated with a similar patient experience and fulfillment of care needs as in-person visits. Chat visits may be a viable alternative to in-person visits for selected patients.

Individual Patient Factors Associated with the Use of Physical or Digital Primary Care in Sweden.

Introduction: Little is known about factors that influence patients' choice to use physical or digital primary care. This study aimed to compare self-rated health, internet habits, and what patients deem important when choosing health care between users of physical and digital primary health care. Methods: We recruited 2,716 adults visiting one of six physical or four digital primary health care providers in Stockholm, Sweden, October 2020 to May 2021. Participants answered a questionnaire with questions about sociodemography, self-rated health, internet habits, and what they considered important when seeking care. We used logistic regression and estimated odds ratios (ORs) for choosing digital care. Results: Digital users considered themselves healthier and used the internet more, compared with physical users (p < 0.001). Competence of health care staff was the most important factor when seeking care to both physical and digital users (90% and 78%, respectively). Patients considering it important to avoid leaving home were more likely to seek digital care (OR 29.55, 95% confidence interval [CI] 12.65-69.06), while patients valuing continuity were more likely to seek physical care (OR 0.25, 95% CI 0.19-0.32). These factors were significant also when adjusting for self-rated health and sociodemographic characteristics. Conclusion: What patients considered important when seeking health care was associated with what type of care they sought. Patient preferences should be considered when planning health care to optimize resource allocation.

Socioeconomic, medical and demographic characteristics of early adopters of digital primary care.

AIMS: In this paper, we investigated which socioeconomic and demographic groups first adopted digital primary care video consultations when they became accessible to the entire population in Sweden. METHODS: We analysed data on all patients (378,000) who had a consultation with the largest provider of digital healthcare in Sweden - Kry - in the first years of national availability of the service, 2016-2018. We studied their income, education, demographics, and diagnosis backgrounds using matched registry data. Moreover, to compare users and non-users of digital primary care, we used data on all physical primary care users in one Swedish region: Skåne. RESULTS: We found that this digital primary care was first used by young and higher-income adults, but not far from half of adult users had incomes below the national median. Digital care patients were more educated than the general population, reflecting that urban inhabitants were more likely than rural inhabitants to be users. First-generation immigrants were less represented among digital care users than in the population. However, second-generation immigrants with two foreign parents were slightly over-represented. The prevalence of some chronic diseases in pre-digital secondary (specialist and hospital) healthcare data among digital care users was similar to the population adjusted for age. Studying all physical primary care users in Skåne region, young digital care users had more primary care diagnoses and previous in-person primary care appointments than non-users, while the pattern was reversed for older users. CONCLUSIONS: When digital primary care became nationally available, younger, urban and more educated patients were the first to adopt the new technology. Regarding medical history, young users of digital care had a higher previous disease burden than young non-users, suggesting that these digital services were first adopted by young people with high primary care needs.

Escape to the future - a qualitative study of physicians' views on the work environment, education, and support in a digital context.

BACKGROUND: The use of remote services such as video consultations (VCs) has increased significantly in the wake of the COVID-19 pandemic. In Sweden, private healthcare providers offering VCs have grown substantially since 2016 and have been controversial. Few studies have focused on physicians' experiences providing care in this context. Our aim was to study physicians' experiences of VCs, focusing on the work environment, quality of care, and educational needs. METHODS: Twenty-two semi-structured interviews were performed with physicians working with VCs in Sweden, and analyzed through inductive content analysis. RESULTS: We identified five categories; flexibility, social work environment, impact on care and society, continuous learning and career development, and organizational support. Flexibility and accessibility were considered positive features of working digitally by giving physicians control over their time and workplace and increasing patients' timely access to healthcare. Regarding collegial contact and social activities in a digital context, the majority of the participants did not experience any significant difference compared to the physical context. Access to technical support services, educational support, and collegial support in decision-making, guidance, and consultations were described as well-functioning. Satisfied patients positively impacted the work environment, and participants felt that VCs have a positive socio-economic effect. Continuity of care was considered supported, but patients did not always prioritize this. Privacy risks were considered a challenge, as were poor development of clinical skills due to the low variation of patient cases. Working for an online healthcare provider was contributing to career advancements for junior clinicians. CONCLUSIONS: Physicians appreciate the flexibility of the digital context and seem satisfied with a work environment where they have a high level of control, but few consider this a full-time career option. The pandemic year 2020 has led to a significant increase in the implementation of VCs in traditional care systems. How this affects the work environment and continuous education needs and career development remains to be seen.

Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study.

BACKGROUND: Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. METHODS: An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. RESULTS: We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. CONCLUSIONS: An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.

Evaluation of interprofessional teamwork modules implementation in an emergency department - A mixed-methods case study of implementation fidelity.

BACKGROUND: The need for interprofessional collaboration has been emphasized by health organizations. This study was part of a mixed-methods evaluation of interprofessional teamwork modules implementation in an emergency department (ED), where a major intervention was didactic training of team roles and behaviours in combination with practice scenarios. The aim of the study was to evaluate the implementation of interprofessional teamwork modules from a staff perspective and focus on how implementation fidelity may be sustained. METHODS: In this mixed-methods case study we triangulated staff data from structured observations, semi-structured interviews, and a questionnaire repeated at intervals over 5 years. A protocol of key team behaviours was used for the observations conducted in June 2016 and June 2018, 1½ and 3½ years after the initial implementation. A purposeful sample of central informants, including nursing and medical professionals and section managers, was interviewed from May to June 2018. The interview guide consisted of open-ended questions about the experiences of interprofessional teamwork modules and the implementation process. The questionnaire consisted of five statements about the perceived workload, interprofessional collaboration and patient satisfaction, where each was rated on a Likert scale. RESULTS: Good fidelity to four out of five key team behaviours was observed during the first year. However, fidelity was sustained only for one key team behaviour after 3 years. We conducted a qualitative content analysis of 18 individual interviews. The theme Enjoying working together, but feeling less efficient emerged of the interprofessional teamwork modules, despite shorter ED stays for the patients. Negative experiences of the staff included passive team leaders and slow care teams. The theme Stimulating to create, but challenging to sustain emerged of the implementation process, where barriers were not adressed and implementation fidelity not sustained. The staff questionnaire showed that the perceived work conditions was improved in periods of high fidelity, but deteriorated to pre-implementation levels as fidelity to the key team behaviours decayed in 2018. CONCLUSIONS: Extensive planning and successful initial implementation were not enough to sustain the key behaviour changes in the study. The use of implementation frameworks can be helpful in future projects.

Forecasting emergency department visits using internet data.

STUDY OBJECTIVE: Using Internet data to forecast emergency department (ED) visits might enable a model that reflects behavioral trends and thereby be a valid tool for health care providers with which to allocate resources and prevent crowding. The aim of this study is to investigate whether Web site visits to a regional medical Web site, the Stockholm Health Care Guide, a proxy for the general public's concern of their health, could be used to predict the ED attendance for the coming day. METHODS: In a retrospective, observational, cross-sectional study, a model for forecasting the daily number of ED visits was derived and validated. The model was derived through regression analysis, using visits to the Stockholm Health Care Guide Web site between 6 pm and midnight and day of the week as independent variables. Web site visits were measured with Google Analytics. The number of visits to the ED within the region was retrieved from the Stockholm County Council administrative database. All types of ED visits (including adult, pediatric, and gynecologic) were included. The period of August 13, 2011, to August 12, 2012, was used as a training set for the model. The hourly variation of visits was analyzed for both Web site and the ED visits to determine the interval of hours to be used for the prediction. The model was validated with mean absolute percentage error for August 13, 2012, to October 31, 2012. RESULTS: The correlation between the number of Web site visits between 6 pm and midnight and ED visits the coming day was significant (r=0.77; P<.001). The best forecasting results for ED visits were achieved for the entire county, with a mean absolute percentage error of 4.8%. The result for the individual hospitals ranged between mean absolute percentage error 5.2% and 13.1%. CONCLUSION: Web site visits may be used in this fashion to predict attendance to the ED. The model works both for the entire region and for individual hospitals. The possibility of using Internet data to predict ED visits is promising.

To read or not to read - A cross-sectional study of Swedish primary care patients' adoption of patient accessible electronic health records.

Objective: Patient-accessible electronic health records (PAEHR) were implemented in the Stockholm region of Sweden seven years ago. This study examines socio-demographic and psychographic factors associated with reading/not reading these records, as well as the common reasons for such behaviours. Methods: Patients or guardians of minors seeking face-to-face or digital primary healthcare in the Stockholm region responded to a questionnaire about whether they were aware that they could read their PAEHR, and if so, if they had read it and reasons for reading or not reading. We conducted a comparative analysis of readers and non-readers and a stepwise multiple logistic regression. Results: The majority of participants were aware that they could read the PAEHR (86%) and among those aware, 77% had read it. The odds of reading decreased with increased age, unfavourable opinion of PAEHR, low information literacy and being single. Access to a smartphone increased the probability of reading. Participants who had read their PAEHR had commonly read it to get an overview of their health and care (65%) and to follow up on a healthcare visit (55%). Participants who had not read their PAEHR stated generally that they did not need to (63%) and/or had received sufficient information from their providers (38%). Conclusions: While most people were aware they could read the PAEHR and many had read it, a digital divide and several barriers to reading the PAEHR were identified. Efforts to increase PAEHR reading may be targeted at older people, people needing more informal support, those who may be excluded due to limited information literacy, and towards improving the patient portals' usability.

The Future of Online Video Consultations in Primary Care: A Qualitative Study.

The COVID-19 pandemic has significantly increased the use of remote services such as video consultations (VCs). In Sweden, private healthcare providers offering VCs have grown substantially since 2016 and have been controversial. Few studies have focused on physicians' experiences of providing care in this context. Our overall aim was to study physicians' experiences of VCs, here focusing on their suggestions for future improvements. Twenty-two semi-structured interviews were performed with physicians working for an online healthcare provider in Sweden, and analyzed through inductive content analysis. Two themes emerged related to desired future improvements of VCs; blended care and technical innovation.

Nurses' experience of using video consultation in a digital care setting and its impact on their workflow and communication.

Sweden as many other countries uses video consultation to increase patients' access to primary healthcare services particularly during the COVID-19 pandemic. Working in digital care settings and using new technologies, in this case video consultations, require learning new skills and adoption to new workflow. The aim of this study is to explore nurses' experience of using video consultation in a digital care setting and its impact on their workflow and communication. Fifteen semi-structured interviews were carried out with registered nurses recruited from a private digital healthcare provider. Interviews were recorded, transcribed, and analysed using an abductive approach. Nurses' workflow was modeled, and several categories and subcategories were identified: nurses' workflow (efficiency, flexibility, and information accessibility); communication (interaction with patients and interprofessional communication); user experience (change and development of the platform, challenges, and combining digital and physical care). Even though providing online care has its limitations, the nurses were positive towards using video consultations.

Interprofessional teamwork versus fast track streaming in an emergency department-An observational cohort study of two strategies for enhancing the throughput of orthopedic patients presenting limb injuries or back pain.

OBJECTIVE: To compare two strategies, interprofessional teams versus fast track streaming, for orthopedic patients with limb injuries or back pain, the most frequent orthopedic complaints in an emergency department. METHODS: An observational before-and-after study at an adult emergency department from May 2012 to Nov 2015. Patients who arrived on weekdays from 8 am to 9 pm and presented limb injury or back pain during one year of each process were included, so that 11,573 orthopedic presentations were included in the fast track period and 10,978 in the teamwork period. Similarly, another 11,020 and 10,760 arrivals presenting the six most frequent non-orthopedic complaints were included in the respective periods, altogether 44,331 arrivals. The outcome measures were the time to physician (TTP) and length of stay (LOS). The LOS was adjusted for predictors, including imaging times, by using linear regression analysis. RESULTS: The overall median TTP was shorter in the teamwork period, 76.3 min versus 121.0 min in the fast track period (-44.7 min, 95% confidence interval (CI): -47.3 to -42.6). The crude median LOS for orthopedic presentations was also shorter in the teamwork period, 217.0 min versus 230.0 min (-13.0 min, 95% CI: -18.0 to -8.0), and the adjusted LOS was 22.8 min shorter (95% CI: -26.9 to -18.7). For non-orthopedic presentations, the crude median LOS did not differ significantly between the periods (2.0 min, 95% CI: -3.0 to 7.0). However, the adjusted LOS was shorter in the teamwork period (-20.1 min, 95% CI: -24.6 to -15.7). CONCLUSIONS: The median TTP and LOS for orthopedic presentations were shorter in the teamwork period. For non-orthopedic presentations, the TTP and adjusted LOS were also shorter in the teamwork period. Therefore, interprofessional teamwork may be an alternative approach to improve the patient flow in emergency departments.

Can interprofessional teamwork reduce patient throughput times? A longitudinal single-centre study of three different triage processes at a Swedish emergency department.

OBJECTIVE: To determine the impact on emergency department (ED) throughput times and proportion of patients who leave without being seen by a physician (LWBS) of two triage interventions, where comprehensive nurse-led triage was first replaced by senior physician-led triage and then by interprofessional teamwork. DESIGN: Single-centre before-and-after study. SETTING: Adult ED of a Swedish urban hospital. PARTICIPANTS: Patients arriving on weekdays 08:00 to 21:00 during three 1-year periods in the interval May 2012 to November 2015. A total of 185 806 arrivals were included. INTERVENTIONS: Senior physicians replaced triage nurses May 2013 to May 2014. Interprofessional teamwork replaced the triage process on weekdays 08:00 to 21:00 November 2014 to November 2015. MAIN OUTCOME MEASURES: Primary outcomes were the median time to physician (TTP) and the median length of stay (LOS). Secondary outcome was the LWBS rate. RESULTS: The crude median LOS was shortest for teamwork, 228 min (95% CI 226.4 to 230.5) compared with 232 min (95% CI 230.8 to 233.9) for nurse-led and 250 min (95% CI 248.5 to 252.6) for physician-led triage. The adjusted LOS for the teamwork period was 16 min shorter than for nurse-led triage and 23 min shorter than for physician-led triage. The median TTP was shortest for physician-led triage, 56 min (95% CI 54.5 to 56.6) compared with 116 min (95% CI 114.4 to 117.5) for nurse-led triage and 74 min (95% CI 72.7 to 74.8) for teamwork. The LWBS rate was 1.9% for nurse-led triage, 1.2% for physician-led triage and 3.2% for teamwork. All outcome measure differences had two-tailed p values<0.01. CONCLUSIONS: Interprofessional teamwork had the shortest length of stay, a shorter time to physician than nurse-led triage, but a higher LWBS rate. Interprofessional teamwork may be a useful approach to reducing ED throughput times.

Swedish emergency department triage and interventions for improved patient flows: a national update.

BACKGROUND: In Scandinavia, emergency department triage and patient flow processes, are under development. In Sweden, the triage development has resulted in two new triage scales, the Adaptive Process Triage and the Medical Emergency Triage and Treatment System. Both these scales have logistic components, aiming to improve patient flows. The aim of this study was to report the development and current status of emergency department triage and patient flow processes in Sweden. METHODS: In 2009 and 2010 the Swedish Council on Health Technology Assessment sent out a questionnaire to the ED managers in all (74) Swedish hospital emergency departments. The questionnaire comprised questions about triage and interventions to improve patient flows. RESULTS: Nearly all (97%) EDs in Sweden employed a triage scale in 2010, which was an increase from 2009 (73%). Further, the Medical Emergency Triage and Treatment System was the triage scale most commonly implemented across the country. The implementation of flow-related interventions was not as common, but more than half (59%) of the EDs have implemented or plan to implement nurse requested X-ray. CONCLUSIONS: There has been an increase in the use of triage scales in Swedish EDs during the last few years, with acceleration for the past two years. Most EDs have come to use the Medical Emergency Triage and Treatment System, which also indicates regional co-operation. The implementation of different interventions for improved patient flows in EDs most likely is explained by the problem of crowding. Generally, more studies are needed to investigate the economical aspects of these interventions.

Experimental treatment for focal hyperglycemic ischemic brain injury in the rat.

Hyperglycemia aggravates ischemic brain injury, possibly due to the activation of signaling pathways involving reactive oxygen species, Src and mitogen-activated protein kinases. The aim of this study was to investigate the effects of the spin trap agent alpha-phenyl-N-tert-butyl nitrone (PBN), the Src family kinase inhibitor PP2 and the MEK1-inhibitor U0126 on focal hyperglycemic ischemic brain injury. Temporary middle cerebral artery occlusion (90 min) was induced in four groups of rats (PBN, PP2, and U0126 vs. control). Neurological testing and tetrazolium red staining were performed after 1 day. PBN decreased the infarct volume by 70% compared with the control (P<0.05) and a tendency towards reduced infarcts was seen in the PP2 or U0126 groups. Furthermore, neurological testing was consistent with the volumetric analysis. In conclusion, PBN appears to be a potential neuroprotective agent in hyperglycemic, focal ischemic brain injury, while the efficacy of PP2 and U0126 could not be confirmed by the present data.