The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review.

BACKGROUND: In recent years, eHealth has received much attention as an opportunity to increase efficiency within healthcare organizations. Adoption of eHealth might consequently help to solve perceived health workforce challenges, including labor shortages and increasing workloads among primary care professionals, who serve as the first point of contact for healthcare in many countries. The purpose of this systematic review was to investigate the impact of general eHealth use and specific eHealth services use on general practice workload in the pre-COVID-19 era. METHODS: The databases of CINAHL, Cochrane, Embase, IEEE Xplore, Medline ALL, PsycINFO, Web of Science, and Google Scholar were searched, using combinations of keywords including 'eHealth', 'workload', and 'general practice'. Data extraction and quality assessment of the included studies were independently performed by at least two reviewers. Publications were included for the period 2010 - 2020, before the start of the COVID-19 pandemic. RESULTS: In total, 208 studies describing the impact of eHealth services use on general practice workload were identified. We found that two eHealth services were mainly investigated within this context, namely electronic health records and digital communication services, and that the largest share of the included studies used a qualitative study design. Overall, a small majority of the studies found that eHealth led to an increase in general practice workload. However, results differed between the various types of eHealth services, as a large share of the studies also reported a reduction or no change in workload. CONCLUSIONS: The impact of eHealth services use on general practice workload is ambiguous. While a small majority of the effects indicated that eHealth increased workload in general practice, a large share of the effects also showed that eHealth use reduced workload or had no impact. These results do not imply a definitive conclusion, which underscores the need for further explanatory research. Various factors, including the study setting, system design, and the phase of implementation, may influence this impact and should be taken into account when general practices adopt new eHealth services. STUDY REGISTRATION NUMBER: PROSPERO (International Prospective Register of Systematic Reviews) CRD42020199897; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199897 .

Dutch GP healthcare consumption in COVID-19 heterogeneous regions: an interregional time-series approach in 2020-2021.

BACKGROUND: Many countries observed a sharp decline in the use of general practice services after the outbreak of the COVID-19 pandemic. However, research has not yet considered how changes in healthcare consumption varied among regions with the same restrictive measures but different COVID-19 prevalence. AIM: To investigate how the COVID-19 pandemic affected healthcare consumption in Dutch general practice during 2020 and 2021, among regions with known heterogeneity in COVID-19 prevalence, from a pre-pandemic baseline in 2019. DESIGN & SETTING: Population-based cohort study using electronic health records. The study was undertaken in Dutch general practices involved in regional research networks. METHOD: An interrupted time-series analysis of changes in healthcare consumption from before to during the pandemic was performed. Descriptive statistics were used on the number of potential COVID-19-related contacts, reason for contact, and type of contact. RESULTS: The study covered 3 595 802 contacts (425 639 patients), 3 506 637 contacts (433 340 patients), and 4 105 413 contacts (434 872 patients) in 2019, 2020, and 2021, respectively. Time-series analysis revealed a significant decrease in healthcare consumption after the outbreak of the pandemic. Despite interregional heterogeneity in COVID-19 prevalence, healthcare consumption decreased comparably over time in the three regions, before rebounding to a level significantly higher than baseline in 2021. Physical consultations transitioned to phone or digital over time. CONCLUSION: Healthcare consumption decreased irrespective of the regional prevalence of COVID-19 from the start of the pandemic, with the Delta variant triggering a further decrease. Overall, changes in care consumption appeared to reflect contextual factors and societal restrictions rather than infection rates.

What can we learn from experiences in general practice during the COVID-19 pandemic? A qualitative study.

BACKGROUND: Experiences with organizational changes in daytime general practices and out-of-hours (OOH) services during the COVID-19 pandemic may help to address the challenges in general practice care that were already a concern before the crisis. This study aimed to describe these experiences and the potential usefulness of the organizational changes for future general practice care and any future pandemics. METHODS: Semi-structured interviews were performed among 11 directors of OOH services, and 19 (locum) general practitioners (GPs) or practice managers, who were purposively sampled. Video or telephone interviews were performed in two rounds: between November 2020 and January 2021 and between May 2021 and August 2021. The data were analyzed using thematic analysis methods. RESULTS: Three themes emerged from the data: (1) Changes in the triage procedures; in GP practices and OOH services, stricter triage criteria were implemented, and GPs were more actively involved in the triage process. These measures helped to reduce the number of 'low urgency' face-to-face consultations. (2) Changes in GP care; there was a shift towards video and telephone consultations, allowing GPs to spend more time with patients during the remaining face-to-face consultations. For chronic patients, the shift towards telemonitoring appeared to encourage self-care, and postponing face-to-face consultations for regular checkups appeared to be unproblematic for stable patients. (3) Coordination of GP care and information communication flow during the COVID-19 pandemic; OOH directors perceived a lack of consistency in the information from various governmental and non-governmental parties on containment measures and guidelines related to COVID-19, making it difficult to act on them. The COVID-19 pandemic intensified collaboration between GPs, OOH services, and other healthcare professionals. CONCLUSIONS: The results of this study indicate that some of the organizational changes, such as stricter triage, remote consultations, and changes in managed care of chronic patients, may help in tackling the pre-existing challenges in GP care from before the COVID-19 pandemic. However, more extensive research and continuous monitoring are necessary to establish the effects on patients and their health outcomes. To navigate future pandemics, the intensified collaboration between health professionals should be maintained, while there is considerable room for improvement in the provision of unambiguous information.

Care by general practitioners for patients with asthma or COPD during the COVID-19 pandemic.

The impact of the COVID-19 pandemic on general practitioners' (GP) care for patients with asthma and/or COPD is largely unknown. To describe the impact of the pandemic on asthma or COPD-related GP care, we analysed routinely recorded electronic health records data from Dutch general practices and out-of-hours (OOH) services. During the COVID-19 pandemic (2020), the contact rates for asthma and/or COPD were significantly lower in GP practices and OOH services compared with the pre-pandemic period (2019) (respectively, 15% lower and 28% lower). The proportion of telephone contacts increased significantly with 13%-point in GP practices and 12%-point at OOH services, while the proportion of face-to-face contacts decreased. Furthermore, the proportion of high urgent contacts with OOH services decreased by 8.5%-point. To conclude, the overall contact rates in GP practices and OOH services decreased, while more contacts were remote. Lower contact rates have, after a short follow-up, not resulted in more patients with exacerbations in OOH care. However, this might still be expected after a longer follow-up.

Patient experiences during the COVID-19 pandemic: a qualitative study in Dutch primary care.

BACKGROUND: Changes in primary care provision during the COVID-19 pandemic could have affected patient experience of primary care both positively and negatively. AIM: To assess the experiences of patients in primary care during the COVID-19 pandemic. DESIGN & SETTING: A qualitative study of patients from regions with high and low COVID-19 prevalence in the Netherlands. METHOD: A qualitative study using a phenomenological framework was performed among purposively sampled patients. Individual semi-structured interviews were performed and transcribed. Data were thematically analysed by means of an inductive approach. RESULTS: Twenty-eight patients were interviewed (13 men and 15 women, aged 27-91 years). After thematic analysis, two main themes emerged: accessibility and continuity of primary care. Changes considered positive during the pandemic regarding accessibility and continuity of primary care included having a quieter practice, having more time for consultations, and the use of remote care for problems with low complexity. However, patients also experienced decreases in both care accessibility and continuity, such as feeling unwelcome, the GP postponing chronic care, seeing unfamiliar doctors, and care being segregated. CONCLUSION: Despite bringing several benefits, patients indicated that the changes to primary care provision during the COVID-19 pandemic could have threatened care accessibility and continuity, which are core values of primary care. These insights can guide primary care provision not only in this and future pandemics, but also when implementing permanent changes to care provision in primary care.

The use of out-of-hours primary care during the first year of the COVID-19 pandemic.

BACKGROUND: In the Netherlands, General Practitioners (GP) are usually the first point of contact with a health professional for most health problems. Out-of-hours (OOH) primary care is provided by regional OOH services. Changes in consultation rates at OOH services may be regarded as a warning system for failures elsewhere in the healthcare system. Therefore in this study, we investigated how the COVID-19 pandemic changed the use of primary care OOH services during the first year of the pandemic. METHODS: Routine electronic health records data were used from 60% of OOH services in the Netherlands, collected by the Nivel Primary Care Database. We compared consultation rates per week (2020) for COVID-19-like symptoms and other health problems (e.g. small traumas, urinary tract infections), for different age groups, the proportion of remote consultations, and different levels of urgency during the pandemic compared to the same period in 2019. RESULTS: The number of consultations for COVID-19-like symptoms peaked at the start of the COVID-19 pandemic, while consultations for other health problems decreased. These changes in consultation rates differed between age groups. Remote consultations took place more frequently for all health problems, while the proportion of non-urgent health problems increased. CONCLUSION: There were significant changes in the number of consultations and the proportion that were remote for COVID-19-like symptoms and other health problems. Especially care for babies and young children decreased, while the number of consultations for older adults remained stable. The continued use of OOH services by older adults suggests there were unmet care needs elsewhere in our healthcare system.

Prediction models for hospital readmissions in patients with heart disease: a systematic review and meta-analysis.

OBJECTIVE: To describe the discrimination and calibration of clinical prediction models, identify characteristics that contribute to better predictions and investigate predictors that are associated with unplanned hospital readmissions. DESIGN: Systematic review and meta-analysis. DATA SOURCE: Medline, EMBASE, ICTPR (for study protocols) and Web of Science (for conference proceedings) were searched up to 25 August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were eligible if they reported on (1) hospitalised adult patients with acute heart disease; (2) a clinical presentation of prediction models with c-statistic; (3) unplanned hospital readmission within 6 months. PRIMARY AND SECONDARY OUTCOME MEASURES: Model discrimination for unplanned hospital readmission within 6 months measured using concordance (c) statistics and model calibration. Meta-regression and subgroup analyses were performed to investigate predefined sources of heterogeneity. Outcome measures from models reported in multiple independent cohorts and similarly defined risk predictors were pooled. RESULTS: Sixty studies describing 81 models were included: 43 models were newly developed, and 38 were externally validated. Included populations were mainly patients with heart failure (HF) (n=29). The average age ranged between 56.5 and 84 years. The incidence of readmission ranged from 3% to 43%. Risk of bias (RoB) was high in almost all studies. The c-statistic was <0.7 in 72 models, between 0.7 and 0.8 in 16 models and >0.8 in 5 models. The study population, data source and number of predictors were significant moderators for the discrimination. Calibration was reported for 27 models. Only the GRACE (Global Registration of Acute Coronary Events) score had adequate discrimination in independent cohorts (0.78, 95% CI 0.63 to 0.86). Eighteen predictors were pooled. CONCLUSION: Some promising models require updating and validation before use in clinical practice. The lack of independent validation studies, high RoB and low consistency in measured predictors limit their applicability. PROSPERO REGISTRATION NUMBER: CRD42020159839.

The course of readmission in frail older cardiac patients.

AIM: The aim of this study is to explore patients' and (in)formal caregivers' perspectives on their role(s) and contributing factors in the course of unplanned hospital readmission of older cardiac patients in the Cardiac Care Bridge (CCB) program. DESIGN: This study is a qualitative multiple case study alongside the CCB randomized trial, based on grounded theory principles. METHODS: Five cases within the intervention group, with an unplanned hospital readmission within six months after randomization, were selected. In each case, semi-structured interviews were held with patients (n = 4), informal caregivers (n = 5), physical therapists (n = 4), and community nurses (n = 5) between April and June 2019. Patients' medical records were collected to reconstruct care processes before the readmission. Thematic analysis and the six-step analysis of Strauss & Corbin have been used. RESULTS: Three main themes emerged. Patients experienced acute episodes of physical deterioration before unplanned hospital readmission. The involvement of (in)formal caregivers in adequate observation of patients' health status is vital to prevent rehospitalization (theme 1). Patients and (in)formal caregivers' perception of care needs did not always match, which resulted in hampering care support (theme 2). CCB caregivers experienced difficulties in providing care in some cases, resulting in limited care provision in addition to the existing care services (theme 3). CONCLUSION: Early detection of deteriorating health status that leads to readmission was often lacking, due to the acuteness of the deterioration. Empowerment of patients and their informal caregivers in the recognition of early signs of deterioration and adequate collaboration between caregivers could support early detection. Patients' care needs and expectations should be prioritized to stimulate participation. IMPACT: (In)formal caregivers may be able to prevent unplanned hospital readmission of older cardiac patients by ensuring: (1) early detection of health deterioration, (2) empowerment of patient and informal caregivers, and (3) clear understanding of patients' care needs and expectations.