Vickybot, a Chatbot for Anxiety-Depressive Symptoms and Work-Related Burnout in Primary Care and Health Care Professionals: Development, Feasibility, and Potential Effectiveness Studies.

BACKGROUND: Many people attending primary care (PC) have anxiety-depressive symptoms and work-related burnout compounded by a lack of resources to meet their needs. The COVID-19 pandemic has exacerbated this problem, and digital tools have been proposed as a solution. OBJECTIVE: We aimed to present the development, feasibility, and potential effectiveness of Vickybot, a chatbot aimed at screening, monitoring, and reducing anxiety-depressive symptoms and work-related burnout, and detecting suicide risk in patients from PC and health care workers. METHODS: Healthy controls (HCs) tested Vickybot for reliability. For the simulation study, HCs used Vickybot for 2 weeks to simulate different clinical situations. For feasibility and effectiveness study, people consulting PC or health care workers with mental health problems used Vickybot for 1 month. Self-assessments for anxiety (Generalized Anxiety Disorder 7-item) and depression (Patient Health Questionnaire-9) symptoms and work-related burnout (based on the Maslach Burnout Inventory) were administered at baseline and every 2 weeks. Feasibility was determined from both subjective and objective user-engagement indicators (UEIs). Potential effectiveness was measured using paired 2-tailed t tests or Wilcoxon signed-rank test for changes in self-assessment scores. RESULTS: Overall, 40 HCs tested Vickybot simultaneously, and the data were reliably transmitted and registered. For simulation, 17 HCs (n=13, 76% female; mean age 36.5, SD 9.7 years) received 98.8% of the expected modules. Suicidal alerts were received correctly. For the feasibility and potential effectiveness study, 34 patients (15 from PC and 19 health care workers; 76% [26/34] female; mean age 35.3, SD 10.1 years) completed the first self-assessments, with 100% (34/34) presenting anxiety symptoms, 94% (32/34) depressive symptoms, and 65% (22/34) work-related burnout. In addition, 27% (9/34) of patients completed the second self-assessment after 2 weeks of use. No significant differences were found between the first and second self-assessments for anxiety (t8=1.000; P=.34) or depressive (t8=0.40; P=.70) symptoms. However, work-related burnout scores were moderately reduced (z=-2.07, P=.04, r=0.32). There was a nonsignificant trend toward a greater reduction in anxiety-depressive symptoms and work-related burnout with greater use of the chatbot. Furthermore, 9% (3/34) of patients activated the suicide alert, and the research team promptly intervened with successful outcomes. Vickybot showed high subjective UEI (acceptability, usability, and satisfaction), but low objective UEI (completion, adherence, compliance, and engagement). Vickybot was moderately feasible. CONCLUSIONS: The chatbot was useful in screening for the presence and severity of anxiety and depressive symptoms, and for detecting suicidal risk. Potential effectiveness was shown to reduce work-related burnout but not anxiety or depressive symptoms. Subjective perceptions of use contrasted with low objective-use metrics. Our results are promising but suggest the need to adapt and enhance the smartphone-based solution to improve engagement. A consensus on how to report UEIs and validate digital solutions, particularly for chatbots, is required.

Antidepressants overuse in primary care: Prescription trends between 2010 and 2019 in Catalonia.

INTRODUCTION: There has been an increase in the prescription of antidepressants (AD) in primary care (PC). However, it is unclear whether this was explained by a rise in diagnoses with an indication for AD. We investigated the changes in frequency and the variables associated with AD prescription in Catalonia, Spain. METHODS: We retrieved AD prescription, sociodemographic, and health-related data using individual electronic health records from a population-representative sample (N=947.698) attending PC between 2010 and 2019. Prescription of AD was calculated using DHD (Defined Daily Doses per 1000 inhabitants/day). We compared cumulative changes in DHD with cumulative changes in diagnoses with an indication for AD during the study period. We used Poisson regression to examine sociodemographic and health-related variables associated with AD prescription. RESULTS: Both AD prescription and mental health diagnoses with an indication for AD gradually increased. At the end of the study period, DHD of AD prescriptions and mental health diagnoses with an indication for AD reached cumulative increases of 404% and 49% respectively. Female sex (incidence rate ratio (IRR)=2.83), older age (IRR=25.43), and lower socio-economic status (IRR=1.35) were significantly associated with increased risk of being prescribed an AD. CONCLUSIONS: Our results from a large and representative cohort of patients confirm a steady increase of AD prescriptions that is not explained by a parallel increase in mental health diagnoses with an indication for AD. A trend on AD off-label and over-prescriptions in the PC system in Catalonia can be inferred from this dissociation.

PRimary carE digital Support ToOl in mental health (PRESTO): Design, development and study protocols.

BACKGROUND: About 30-50% of Primary Care (PC) users in Spain suffer mental health problems, mostly mild to moderate anxious and depressive symptoms, which account for 2% of Spain's total Gross domestic product and 50% of the costs associated to all mental disorders. Mobile health tools have demonstrated to cost-effectively reduce anxious and depressive symptoms while machine learning (ML) techniques have shown to accurately detect severe cases. The main aim of this project is to develop a comprehensive ML digital support platform (PRESTO) to cost-effectively screen, assess, triage, and provide personalized treatments for anxious and depressive symptoms in PC. METHODS: The project will be carried out in 3 complementary phases: First, a ML predictive severity model will be built based on all the cases referred to the PC mental health support programme during the last 5 years in Catalonia. Simultaneously, a smartphone app to monitor and deliver psychological interventions for anxiety and depressive symptoms will be developed and tested in a clinical trial. Finally, the ML models and the app will be integrated in a comprehensive decision-support platform (PRESTO) which will triage and assign to each patient a specific intervention based on individual personal and clinical characteristics. The effectiveness of PRESTO to reduce waiting times in receiving mental healthcare will be tested in a stepped-wedge cluster randomized controlled trial in 5 PC centres. DISCUSSION: PRESTO will offer timely and personalized cost-effective mental health treatment to people with mild to moderate anxious and depressive symptoms. This will result in a reduction of the burden of mental health problems in PC and on society as a whole. TRIAL REGISTRATION: The project and their clinical trials were registered in Clinical Trials.gov: NCT04559360 (September 2020).

Prognostic factors in Spanish COVID-19 patients: A case series from Barcelona.

BACKGROUND: In addition to the lack of COVID-19 diagnostic tests for the whole Spanish population, the current strategy is to identify the disease early to limit contagion in the community. AIM: To determine clinical factors of a poor prognosis in patients with COVID-19 infection. DESIGN AND SETTING: Descriptive, observational, retrospective study in three primary healthcare centres with an assigned population of 100,000. METHOD: Examination of the medical records of patients with COVID-19 infections confirmed by polymerase chain reaction. Logistic multivariate regression models adjusted for age and sex were constructed to analyse independent predictive factors associated with death, ICU admission and hospitalization. RESULTS: We included 322 patients (mean age 56.7 years, 50% female, 115 (35.7%) aged ≥ 65 years): 123 (38.2) were health workers (doctors, nurses, auxiliaries). Predictors of ICU admission or death were greater age (OR = 1.05; 95%CI = 1.03 to 1.07), male sex (OR = 2.94; 95%CI = 1.55 to 5.82), autoimmune disease (OR = 2.82; 95%CI = 1.00 to 7.84), bilateral pulmonary infiltrates (OR = 2.86; 95%CI = 1.41 to 6.13), elevated lactate-dehydrogenase (OR = 2.85; 95%CI = 1.28 to 6.90), elevated D-dimer (OR = 2.85; 95%CI = 1.22 to 6.98) and elevated C-reactive protein (OR = 2.38; 95%CI = 1.22 to 4.68). Myalgia or arthralgia (OR = 0.31; 95%CI = 0.12 to 0.70) was protective factor against ICU admission and death. Predictors of hospitalization were chills (OR = 5.66; 95%CI = 1.68 to 23.49), fever (OR = 3.33; 95%CI = 1.89 to 5.96), dyspnoea (OR = 2.92; 95%CI = 1.62 to 5.42), depression (OR = 6.06; 95%CI = 1.54 to 40.42), lymphopenia (OR = 3.48; 95%CI = 1.67 to 7.40) and elevated C-reactive protein (OR = 3.27; 95%CI = 1.59 to 7.18). Anosmia (OR = 0.42; 95%CI = 0.19 to 0.90) was the only significant protective factor for hospitalization after adjusting for age and sex. CONCLUSION: Determining the clinical, biological and radiological characteristics of patients with suspected COVID-19 infection will be key to early treatment and isolation and the tracing of contacts.

Proceso de Bolonia (VI): aprendiendo comunicación para la salud en el Grado de Medicina / Bologna Process (VI): learning health communication in medical undergraduate

La comunicación forma parte de la actividad clínica y en ocasiones determina el éxito o fracaso del proceso asistencial. Sin embargo, no ha sido reconocida en los planes de estudio del Estado español hasta muy recientemente, sobre todo con el impulso del llamado 'Plan Bolonia'. En el año 2009 se aprobó en la Facultad de Medicina de la Universitat de Barcelona un nuevo plan docente que proponía incorporar la enseñanza de la comunicación en las materias clínicas y preclínicas, contabilizando entre 3 y 6 créditos europeos (ECTS), como competencia transversal. El presente artículo aborda el diseño de esta competencia, los pros y contras, cómo se inserta en diferentes asignaturas y cómo puede evaluarse (AU)

Communication is part of the clinical activity and sometimes determines the healthcare success or failure. However it has not been recognized in the Spanish curricula until recently, in the context of the so called Plan Bologna. In 2009 a new teaching plan was approved at Medical School of Barcelona University which intended to incorporate communication in clinical and preclinical areas (3-6 ECTS). In this article we explain pros and cons to introduce communication not as a subject, but as a competency, how can be integrated in different subjects and how can be evaluated (AU)

Personalised care, access, quality and team coordination are the main dimensions of family medicine output

BACKGROUND: Health organisations continually seek good output indicators of family medicine health care provision because they are accountable to society, they need to compare services, and need to evaluate the impact of organisational reforms. OBJECTIVES: Using the sources of information routinely available in health-service management, we sought to assess the groups of components of primary health care output that best serve to define the outcome of family medicine services. DESIGN: Cross-sectional descriptive study. SITE: Primary health care in Catalunya. PARTICIPANTS: 213 primary health care teams. MEASUREMENTS: Information was collected on team structure, user satisfaction, quality-of-professional-life of the health care professionals, and physicians' drug prescription. Confirmatory Factor Analysis was used to assess the number of dimensions that best explained the family medicine outcome. RESULTS: The model that best fits the structure of the data (AGFI=0.778) is that which consists of three dimensions i.e. (1) the individual accessibility to the services and professional-patient relationship; (2) the coordination within the health care team; (3) the scientific-technical quality of the service. The first two of these dimensions were correlated between themselves, but the third was totally independent of the other two. CONCLUSIONS: Using sources of information that are routinely employed in primary health care services management, the model enables the measurement of the output of family medicine by considering the dimensions such as inter-personnel relationships, internal coordination of the team and the scientific-technical quality of the service. Despite its simplicity, this measure of the output incorporates the views not only of the users but of the health care professionals, as well. (AU)

Personalised care, access, quality and team coordination are the main dimensions of family medicine output.

BACKGROUND: Health organisations continually seek good output indicators of family medicine health care provision because they are accountable to society, they need to compare services, and need to evaluate the impact of organisational reforms. OBJECTIVES: Using the sources of information routinely available in health-service management, we sought to assess the groups of components of primary health care output that best serve to define the outcome of family medicine services. DESIGN: Cross-sectional descriptive study. SITE: Primary health care in Catalunya. PARTICIPANTS: 213 primary health care teams. MEASUREMENTS: Information was collected on team structure, user satisfaction, quality-of-professional-life of the health care professionals, and physicians' drug prescription. Confirmatory Factor Analysis was used to assess the number of dimensions that best explained the family medicine outcome. RESULTS: The model that best fits the structure of the data (AGFI=0.778) is that which consists of three dimensions i.e. (1) the individual accessibility to the services and professional-patient relationship; (2) the coordination within the health care team; (3) the scientific-technical quality of the service. The first two of these dimensions were correlated between themselves, but the third was totally independent of the other two. CONCLUSIONS: Using sources of information that are routinely employed in primary health care services management, the model enables the measurement of the output of family medicine by considering the dimensions such as inter-personnel relationships, internal coordination of the team and the scientific-technical quality of the service. Despite its simplicity, this measure of the output incorporates the views not only of the users but of the health care professionals, as well.

Impact of economic incentives on quality of professional life and on end-user satisfaction in primary care.

BACKGROUND: A new economic incentive scheme based on (i) quality of care objectives for physicians, and (ii) professional development for both physicians and nurses, was introduced in primary care teams. OBJECTIVE: To assess weather the implementation of these economic incentive schemes has had an impact on the quality of professional life (QPL) of both physicians and nurses and on end-user satisfaction. METHODS: Before-after study. Participants are 257 primary care teams in Catalonia, Spain, in the period 2002-2003. QPL and end-user satisfaction were used as outcome measures. RESULTS: QPL was improved in terms of the dimension "perception of support from the management structure" among physicians (4.897 versus 5.220; p<0.001) as well as nurses (5.272 versus 5.638; p<0.001). Further, physicians perceived an increase in the dimension "demands made upon them" (6.124 versus 6.364; p<0.001), differently from the nurses group (5.8191 versus 5.929; p=0.063). Overall, user satisfaction did not vary significantly, although a positive relationship was found between "perception of support from the management structure" and user satisfaction among nurses (beta=0.078, p=0.007), and a negative relationship between "demands made upon them" and user satisfaction in the case of physicians (beta=-0.057, p=0.011). CONCLUSIONS: Incentives related to quality of care annual targets may increase physicians' perception of burden and it may have a negative impact on consumer satisfaction. Incentives on long-term professional development seem to be related to an increase in professionals' perception of support from the management structure. Among nurses, this increase is related to an improvement of user satisfaction.

[Primary health care product defined by health professionals and users]. / El producto de la atención primaria definido por profesionales y usuarios.

OBJECTIVE: To identify the components of the primary health care (PHC) product defined by health professionals and users in order to establish indicators for evaluation. METHODS: Qualitative methodology was used with group techniques: a nominal group (health professionals) and focus groups (users). The study was performed in PHC centers in Catalonia (Spain). There were 7 groups: a) family physicians and pediatricians; b) nurses and social workers; c) staff from admissions units and customer services; d) other medical specialists; e) users; f) managers, pharmacists, pharmacologists, and technicians. Participants responded to the question: "Which features should be evaluated in the services that should be provided by PHC?". A content analysis was performed. Textual data were broken down into units and then grouped into categories, following analogy criteria. The interpretative context of the research team was taken into account. RESULTS: Health professionals and users identified 4 dimensions of the PHC product, coinciding with its basic attributes: a) access to services; b) coordination and continuity of the PHC teams with other levels of healthcare; c) relationship between health professionals and users, and d) scientific-technical quality of the PHC teams and the portfolio of services. Equity, satisfaction and efficiency appeared as keystones in all the components of the product identified. CONCLUSION: There was broad agreement in the product definition among health professionals and users. The relationship between health professionals and patients was a key element in all groups. The four dimensions should be included in the evaluation of PHC teams.

El producto de la atención primaria definido por profesionales y usuarios / Primary health care product defined by health professionals and users

Objetivo: Definir los componentes del producto de la atención primaria de salud (APS) a partir de las opiniones de profesionales y usuarios, para establecer indicadores de evaluación. Métodos: Estudio con metodología cualitativa, con técnicas grupales: grupo nominal (profesionales) y grupos focales (usuarios). Ámbito de realización: APS de Catalunya. Se realizaron 7 grupos: a) médicos de familia y pediatras; b) enfermeras y trabajadoras sociales; c) personal de la unidad de admisión y atención al usuario; d) otros médicos especialistas; e) usuarios, y f) gestores, farmacéuticos y farmacólogos y técnicos de salud. Los participantes respondieron a la pregunta: «Respecto a los servicios que debería ofrecer la APS, ¿cuáles son los aspectos que se deberían valorar?». Se realizó un análisis de contenido. Los datos textuales se descompusieron en unidades, posteriormente agrupadas en categorías, siguiendo el criterio de analogía. Se tuvo en cuenta el contexto de interpretación del equipo investigador. Resultados: Profesionales y usuarios identifican 4 dimensiones del producto de la APS, coincidentes con sus atributos básicos: a) accesibilidad a los servicios; b) coordinación y continuidad del equipo de APS con otros niveles asistenciales; c) relación entre profesionales y usuarios, y d) calidad científico-técnica de los equipos de atención primaria y cartera de servicios. Equidad, satisfacción y eficiencia aparecen en los discursos como ejes transversales de todos los componentes del producto identificados. Conclusión: Hay una gran coincidencia en la definición del producto entre profesionales y usuarios. La relación profesional-paciente aparece como un elemento clave en todos los grupos. Estas 4 dimensiones deberían formar parte de la evaluación de los equipos de APS

Objective: To identify the components of the primary health care (PHC) product defined by health professionals and users in order to establish indicators for evaluation. Methods: Qualitative methodology was used with group techniques: a nominal group (health professionals) and focus groups (users). The study was performed in PHC centers in Catalonia (Spain). There were 7 groups: a) family physicians and pediatricians; b) nurses and social workers; c) staff from admissions units and customer services; d) other medical specialists; e) users; f) managers, pharmacists, pharmacologists, and technicians. Participants responded to the question: «Which features should be evaluated in the services that should be provided by PHC?». A content analysis was performed. Textual data were broken down into units and then grouped into categories, following analogy criteria. The interpretative context of the research team was taken into account. Results: Health professionals and users identified 4 dimensions of the PHC product, coinciding with its basic attributes: a) access to services; b) coordination and continuity of the PHC teams with other levels of healthcare; c) relationship between health professionals and users, and d) scientific-technical quality of the PHC teams and the portfolio of services. Equity, satisfaction and efficiency appeared as keystones in all the components of the product identified. Conclusion: There was broad agreement in the product definition among health professionals and users. The relationship between health professionals and patients was a key element in all groups. The four dimensions should be included in the evaluation of PHC teams

Family medicine attributes related to satisfaction, health and costs.

OBJECTIVE: To identify, from a systematic review of the literature, the attributes of Family Medicine (FM) that influence the primary health care outcome as measured by users' satisfaction, improvement in patient health and in costs. DATA SOURCES: Literature search of Medline and the Cochrane library using MeSH terms 'Primary Health' or 'Family Practice' or 'Family Physicians' and 'Outcome Assessment' or 'Process Assessment'. Papers were excluded if they lacked a based on primary data, if no single component of FM was assessed; if indicators of evaluation were not related to health, satisfaction or costs. RESULTS: A total of 356 articles were initially identified and 19 finally met the inclusion criteria. Study methods were a systematic review of randomized control trials, a double-blind randomized trial, 4 systematic reviews of observational studies, 2 cohort studies and 12 descriptive cross-sectional studies. CONCLUSIONS: There was evidence of relationships between the attributes of FM and the service outcomes measured by indicators of satisfaction, health and cost. User satisfaction was associated with accessibility, continuity of care, consultation time and the doctor-patient relationship. Improvement in patient's health was related to continuity, consultation time, doctor-patient relationship and the implementation of preventive activities. Coordination of care showed mixed results with health outcomes. Continuity, consultation time, doctor-patient communication and prevention were cost-effective in the primary care setting.