Telehealth use by walk-in patients who subsequently visited an academic emergency department: a repeated cross-sectional study during the COVID-19 summer 2021.

AIM OF THE STUDY: During the COVID-19 pandemic, telehealth use increased worldwide in a variety of medical specialities and reached new population groups. A baseline survey of telehealth use prior to admission to the emergency department (ED) conducted before COVID-19 concluded that predominantly well-educated men used telehealth. It is unclear how COVID-19 changed the use of telehealth in Swiss emergency patients. We therefore aimed to investigate (i) the frequency of telehealth use during the pandemic, and (ii) how the pandemic has influenced telehealth use and users. MATERIALS AND METHODS: A repeated cross-sectional study was conducted among ED walk-in patients at a tertiary university hospital in Switzerland. The study took place one and a half years after the first confirmed COVID-19 case, during 30 shifts from 8 to 29 July 2021 and compared with the baseline survey conducted in 2019. Eligible patients were questioned about their use of, and attitudes to telehealth. RESULTS: A total of 1020 patients were screened for the COVID survey and 443 complete questionnaires were evaluated. A trend towards a general increase (+6.4%) in telehealth use was demonstrated (50.3%, n = 223 COVID survey vs 43.9%, n = 183 baseline survey; p = 0.058), with a shift to more female patients using telehealth in the COVID survey (female 54.9%, n = 124 vs 45.1%, n = 102; p = 0.052). During the pandemic, first use of telehealth was reported by 12.2% (n = 54) of patients, with a significant increase among patients with low educational status, and the latter patients often indicated that they did not plan to use telehealth after the pandemic. The perceived usefulness of telehealth and adherence to recommendations increased in the COVID survey compared with the baseline survey (adherence 90.3%, n = 149, vs 78.0%, n = 131; p = 0.002). CONCLUSION: We found a trend towards increased use of telehealth among Swiss ED patients. First-time users of telehealth were predominantly less educated and inclusion of these user groups may not be sustainable, as was indicated by the patients. COVID-19 led to greater adherence to telehealth recommendations and higher perceived usefulness. This could be due to the limited access to healthcare providers due to pandemic precautions. When offering telehealth, the needs of all patient groups must be considered, in order to ensure that telehealth provides the greatest benefit with lower barriers to use.

Did the pandemic influence telehealth use among Swiss emergency department patients? A sequential explanatory study.

OBJECTIVE: The aim of this study was to explore pandemic telehealth use among walk-in emergency department (ED) patients at Bern University Hospital. DESIGN: As in sequential explanatory designs, quantitative data were collected first. To explain the quantitative results, telehealth use was explored qualitatively using an interview guide informed by the quantitative results. SETTING: The University Hospital of Bern ED designed a follow-up cross-sectional study (baseline done in 2019) to assess telehealth use among ED walk-in patients during the pandemic (2021). PARTICIPANTS: We included participants of all age groups that had consented to a follow-up qualitative study and also ensured a gender and age balance. We aimed for data saturation that was achieved by the seventh key informant. A total of 11 key informants took part in the study. RESULTS: Three main themes emerged, namely: (1) telehealth use means the use of a telephone for many; (2) telehealth has both remits and limits; and (3) perceived future telehealth opportunities and threats. CONCLUSION: The pandemic seems not to have increased telehealth use among walk-in ED patients. The slight increase observed in telehealth use among women seems related to the use of the COVID-19 app from trusted sites like the Federal Office of Public Health. Telehealth emerged as having remits, limits, opportunities and threats. The human factor preference emerged as very important to all key informants. The fear that telehealth threatens the human factor cannot be over emphasised. The telephone remains the biggest telehealth modality among Swiss ED walk-in patients.

Public health communication: Attitudes, experiences, and lessons learned from users of a COVID-19 digital triage tool for children.

Background: The pandemic has made public health communication even more daunting because acceptance and implementation of official guidelines and recommendations hinge on this. The situation becomes even more precarious when children are involved. Our child-specific COVID-19 online forward triage tool (OFTT) revealed some of the public health communication challenges. We aimed to explore attitudes, experiences, and challenges faced by OFTT users and their families, in regard to public health recommendations. Methods: We selected key informants (n = 20) from a population of parents, teachers, guardians, as well as doctors who had used the child-specific COVID-19 OFTT and had consented to a further study. Videos rather than face-face interviews were held. Convenience and quota sampling were performed to include a variety of key informants. Interviews were recorded, transcribed verbatim, and analyzed for themes. Results: Several themes emerged, namely; (1) definition and expectations of high-risk persons, (2) quarantine instructions and challenges, (3) blurred division of responsibility between authorities and parents, (4) a novel condition and the evolution of knowledge, (5) definition and implications of socioeconomic status, (6) new normal and societal divisions, and (7) the interconnectedness of these factors-systems thinking. Conclusion: As the virus is evolving and circumstances are changing rapidly, the communication of public health to the different interest groups becomes, both an art and science, even more so when using a new technological communication channel: an OFTT. A myriad of interconnected factors seems to influence attitudes toward public health recommendations, which calls for systems thinking in public health communication.

The Utility of a Pediatric COVID-19 Online Forward Triage Tool in Switzerland.

Background: To offset the burden on the health system, hospitals set up telehealth interventions, such as online forward triage tools (OFTT). The website www.coronabambini.ch was developed to specifically address the needs of children and their families in Switzerland and to facilitate the decision to test, isolate, attend school, or access the health care system. Methods: Video interviews were held with key informants (n = 20) from a population of parents, teachers, guardians, as well as doctors who had used the child-specific COVID-19 OFTT and had consented to a further study. Convenience and quota sampling were done to include a variety of key informants. Interviews were recorded, transcribed verbatim, and analyzed for themes. Results: Three main themes emerged: i) the usefulness of the OFTT to the users, ii) expectation management and importance of stakeholder involvement in OFTT development, and iii) OFTT limitations. Conclusion: Our study highlights opportunities, limitations, and lessons to consider when developing a pediatric COVID-19 OFTT. The involvement of stakeholders, parents, teachers, and health care providers in the design, set up, implementation, and evaluation of telehealth interventions is critical as this can help with expectation management and enhance OFTT utility.

The Utility of an Online Forward Triage Tool During the SARS-CoV-2 Pandemic: Health Care Provider and Health Authority Perspectives.

Introduction: The SARS CoV-2 pandemic poses major challenges not only to patients but also to health care professionals and policy-makers, with rapidly changing, sometimes complex, recommendations, and guidelines to the population. Online forward triage tools (OFTT) got a major boost from the pandemic as they helped with the implementation and monitoring of recommendations. Methods: A multiphase mixed method sequential explanatory study design was employed. Quantitative data were collected first and informed the qualitative interview guides. Video interviews were held with key informants (health care providers and health authorities) between 2 September and 10 December 2020. Audio-recordings were transcribed verbatim, coded thematically and compared with patient perspectives (framework). Objectives: To explore the perspectives of health care providers and authorities in Canton Bern on the utility of a COVID-19 OFTT, as well as elicit recommendations for telehealth in future. Results: The following themes emerged; (i) accessibility (ii) health system burden reduction (iii) utility in preventing onward transmission (iv) utility in allaying fear and anxiety (v) medical decision-making utility (vi) utility as information source (vii) utility in planning and systems thinking. The health care providers and health authorities further provided insights on potential barriers and facilitators of telehealth in future. Conclusion: Similar to patients, health care providers acknowledge the potential and utility of the COVID-19 OFTT particularly as an information source and in reducing the health system burden. Data privacy, doctor-patient relationship, resistance to change, regulatory, and mandate issues, and lack of systems thinking were revealed as barriers to COVID-19 OFTT utility.

Effects and utility of an online forward triage tool during the SARS-CoV-2 pandemic: a mixed method study and patient perspectives, Switzerland.

OBJECTIVE: To assess the effects (quantitatively) and the utility (qualitatively) of a COVID-19 online forward triage tool (OFTT) in a pandemic context. DESIGN: A mixed method sequential explanatory study was employed. Quantitative data of all OFTT users, between 2 March 2020 and 12 May 2020, were collected. Second, qualitative data were collected through key informant interviews (n=19) to explain the quantitative findings, explore tool utility, user experience and elicit recommendations. SETTING: The working group e-emergency medicine at the emergency department developed an OFTT, which was made available online. PARTICIPANTS: Participants included all users above the age of 18 that used the OFTT between 2 March 2020 and 12 May 2020. INTERVENTION: An OFTT that displayed the current test recommendations of the Federal Office of Public Health on whether someone needed testing for COVID-19 or not. No diagnosis was provided. RESULTS: In the study period, 6272 users consulted our OFTT; 40.2% (1626/4049) would have contacted a healthcare provider had the tool not existed. 560 participants consented to a follow-up survey and provided a valid email address. 31.4% (176/560) participants returned a complete follow-up questionnaire. 84.7% (149/176) followed the recommendations given. 41.5% (73/176) reported that their fear was allayed after using the tool. Qualitatively, seven overarching themes emerged namely (1) accessibility of tool, (2) user-friendliness of tool, (3) utility of tool as an information source, (4) utility of tool in allaying fear and anxiety, (5) utility of tool in medical decision-making (6) utility of tool in reducing the potential for onward transmissions and (7) utility of tool in reducing health system burden. CONCLUSION: Our findings demonstrated that a COVID-19 OFTT does not only reduce the health system burden but can also serve as an information source, reduce anxiety and fear, reduce potential for cross infections and facilitate medical decision-making.

A Utility Framework for COVID-19 Online Forward Triage Tools: A Swiss Telehealth Case Study.

The SARS-CoV-2 pandemic caused a surge in online tools commonly known as symptom checkers. The purpose of these symptom checkers was mostly to reduce the health system burden by providing worried people with testing criteria, where to test and how to self-care. Technical, usability and organizational challenges with regard to online forward triage tools have also been reported. Very few of these online forward triage tools have been evaluated. Evidence for decision frameworks may be of particular value in a pandemic setting where time frames are restricted, uncertainties are ubiquitous and the evidence base is changing rapidly. The objective was to develop a framework to evaluate the utility of COVID-19 online forward triage tools. The development of the online forward triage tool utility framework was conducted in three phases. The process was guided by the socio-ecological framework for adherence that states that patient (individual), societal and broader structural factors affect adherence to the tool. In a further step, pragmatic incorporation of themes on the utility of online forward triage tools that emerged from our study as well as from the literature was performed. Seven criteria emerged; tool accessibility, reliability as an information source, medical decision-making aid, allaying fear and anxiety, health system burden reduction, onward forward transmission reduction and systems thinking (usefulness in capacity building, planning and resource allocation, e.g., tests and personal protective equipment). This framework is intended to be a starting point and a generic tool that can be adapted to other online forward triage tools beyond COVID-19. A COVID-19 online forward triage tool meeting all seven criteria can be regarded as fit for purpose. How useful an OFTT is depends on its context and purpose.

Testing the contextual Interaction theory in a UHC pilot district in South Africa.

BACKGROUND: World-wide, there is growing universal health coverage (UHC) enthusiasm. The South African government began piloting policies aimed at achieving UHC in 2012. These UHC policies have been and are being rolled out in the ten selected pilot districts. Our study explored policy implementation experiences of 71 actors involved in UHC policy implementation, in one South African pilot district using the Contextual Interaction Theory (CIT) lens. METHOD: Our study applied a two-actor deductive theory of implementation, Contextual Interaction Theory (CIT) to analyse 71 key informant interviews from one National Health Insurance (NHI) pilot district in South Africa. The theory uses motivation, information, power, resources and the interaction of these to explain implementation experiences and outcomes. The research question centred on the utility of CIT tenets in explaining the observed implementation experiences of actors and outcomes particularly policy- practice gaps. RESULTS: All CIT central tenets (information, motivation, power, resources and interactions) were alluded to by actors in their policy implementation experiences, a lack or presence of these tenets were explained as either a facilitator or barrier to policy implementation. This theory was found as very useful in explaining policy implementation experiences of both policy makers and facilitators. CONCLUSION: A central tenet that was present in this context but not fully captured by CIT was leadership. Leadership interactions were revealed as critical for policy implementation, hence we propose the inclusion of leadership interactions to the current CIT central tenets, to become motivation, information, power, resources, leadership and interactions of all these.

Use of telehealth and outcomes before a visit to the emergency department: a cross-sectional study on walk-in patients in Switzerland.

AIMS OF THE STUDY: An increasing number of patients are using telehealth before contacting the healthcare system. If we are to optimise future telehealth strategies and adequately respond to patient needs, we need to know more about the frequency and characteristics of telehealth use. Our objectives were (i) to investigate whether patients use telehealth before consulting the emergency department (ED), (ii) to compare patients with and without use of telehealth, and (iii) to investigate adherence, confidence and satisfaction. MATERIALS AND METHODS: A survey was conducted among ED walk-in patients at a tertiary university hospital in Switzerland. Eligible patients were questioned about their use of telehealth before current presentation, during 30 shifts from 23 October to 15 December 2019. RESULTS: A total of 183 (43.9%) of 417 surveyed patients used telehealth, with the telephone being the most commonly used modality, especially among elderly patients. Patients using telehealth were more likely to be male (53.5%, p = 0.001) and were similar in age to non-users. Telehealth users tended to be better educated. Telehealth was predominantly used for semi-urgent non-traumatic diseases that did not lead to hospitalisation. All age groups expressed satisfaction with telehealth, trusted the recommendations and adhered to them. The main reason for "non-use" of telehealth was lack of knowledge. CONCLUSIONS: Lack of knowledge about telehealth opportunities and barriers in specific patient groups should be addressed to include all patients, and thus to exploit telehealth’s many advantages.

What does a pandemic proof health system look like?

Switzerland is currently in a lockdown and other lockdowns are looming world-wide. Many countries in the West are now experiencing a third COVID-19 wave. While some scientists are aiming for Zero Covid, calls to learn to live with the virus are becoming prominent as anti-lockdown protests spread across Europe. A health system is defined as all organizations, institutions and resources that produce actions whose primary purpose is to improve health. A health care system on the other hand, is defined as institutions, people and resources involved in delivering health care to individuals. Many countries that have health systems previously thought to be world class, have also been tested, pushed to the edge and in some ways found wanting. The pandemic took all countries by some surprise and the discussion on appropriate national and global strategies is very diverse. Lessons from similar earlier outbreaks seem to suggest, that living and learning to live with the virus could be the way forward. Others argue that the virus is new, not like any other we have fought before, calling for novel ways of containing the virus. Irrespective of standpoint, being a high-, middle- or low-income country, pandemic fatigue is setting in, while new variants are being discovered. It is urgent and unprecedented. The pandemic is here and more pandemics are expected to follow. What does, 'living with the virus,' mean in practical terms? The purpose of this viewpoint is to stimulate debate on how we can move towards pandemic proof health care systems.

What we need is health system transformation and not health system strengthening for universal health coverage to work: Perspectives from a National Health Insurance pilot site in South Africa.

BACKGROUND: Globally, universal health coverage (UHC) has gained traction as a major health priority. In 2011, South Africa embarked on a UHC journey to ensure that everyone has access to quality healthcare services without suffering financial impoverishment. National Health Insurance (NHI) and primary healthcare (PHC) re-engineering were two vehicles chosen to reach UHC over a 14-year period (2012-2026). The first phase of health system strengthening (HSS) initiatives to improve the quality of health services in the public sector began in 2012. These HSS initiatives are still being carried out by the Department of Health in conjunction with other partners. METHODS: A qualitative case study design utilising a theory of change (TOC) approach was employed. Data were collected from key informants (n = 71) during three phases: 2011-2012 (contextual mapping), 2013-2014 (Phase 1) and 2015 (Phase 2). In-depth face-to-face interviews were conducted with participants using a TOC interview guide, adapted for each phase. All interviews were audio-recorded and transcribed verbatim. An iterative, inductive and deductive data analysis approach was utilised. Transcripts were coded with the aid of MAXQDA 2018. RESULTS: Six broad themes emerged: make PHC work, transform policy development, transform policy implementation, establish public-private partnerships, transform systems and processes and adopt a systems lens. CONCLUSION: A third great transition seems to be sweeping the globe, changing how health systems are organised. Actors in our study have identified this need also. Health system transformation rather than strengthening, they say, is needed to make UHC a reality. Who is listening?

The Impact of Rehabilitation-oriented Virtual Reality Device in Patients With Ischemic Stroke in the Early Subacute Recovery Phase: Study Protocol for a Phase III, Single-Blinded, Randomized, Controlled Clinical Trial.

BACKGROUND AND RATIONALE: Stroke is considered the most common cause of adult disability. Intensive rehabilitation protocols outperform nonintensive counterparts. The subacute stroke phase represents a potential window to recovery. Virtual reality (VR) has been shown to provide a more stimulating environment, allowing for increased patient compliance. However, the quality of current literature comparing VR with standard therapies is limited. Our aim is to measure the impact of VR versus standard therapy on the recovery of the upper limb motor function in patients with stroke in the early subacute recovery phase. METHOD: This is a randomized, controlled trial that will assign 262 patients to tailor-made standard rehabilitation (TMSR) or TMSR plus immersive VR device. The trial will be conducted in an urban rehabilitation clinic in the United States with expertise in the management of poststroke patients. Patients will be 18 to 70 years of age and in the early subacute period (30-90 days post ischemic stroke). The primary outcome will be the change of Fugl-Meyer Assessment-Upper Extremity (FMA-UE) score, measured at baseline and 13 weeks after randomization. The secondary outcome will be the change in the UK Functional Independence Measure and Functional Assessment Measure (UK FIM-FAM) score at the same time points. DISCUSSION: If the use of VR in the rehabilitation of patients with stroke proves to have a significant impact on their motor recovery, it will constitute an extremely important step into decreasing the functional impairment associated with stroke and the related health care expense burden.

A qualitative study of the dissemination and diffusion of innovations: bottom up experiences of senior managers in three health districts in South Africa.

BACKGROUND: In 2012 the South African National Department of Health (SA NDoH) set out, using a top down process, to implement several innovations in eleven health districts in order to test reforms to strengthen the district health system. The process of disseminating innovations began in 2012 and senior health managers in districts were expected to drive implementation. The research explored, from a bottom up perspective, how efforts by the National government to disseminate and diffuse innovations were experienced by district level senior managers and why some dissemination efforts were more enabling than others. METHODS: A multiple case study design comprising three cases was conducted. Data collection in 2012 - early 2014 included 38 interviews with provincial and district level managers as well as non- participant observation of meetings. The Greenhalgh et al. (Milbank Q 82(4):581-629, 2004) diffusion of innovations model was used to interpret dissemination and diffusion in the districts. RESULTS: Managers valued the national Minister of Health's role as a champion in disseminating innovations via a road show and his personal participation in an induction programme for new hospital managers. The identification of a site coordinator in each pilot site was valued as this coordinator served as a central point of connection between networks up the hierarchy and horizontally in the district. Managers leveraged their own existing social networks in the districts and created synergies between new ideas and existing working practices to enable adoption by their staff. Managers also wanted to be part of processes that decide what should be strengthened in their districts and want clarity on: (1) the benefits of new innovations (2) total funding they will receive (3) their specific role in implementation and (4) the range of stakeholders involved. CONCLUSION: Those driving reform processes from 'the top' must remember to develop well planned dissemination strategies that give lower-level managers relevant information and, as part of those strategies, provide ongoing opportunities for bottom up input into key decisions and processes. Managers in districts must be recognised as leaders of change, not only as implementers who are at the receiving end of dissemination strategies from those at the top. They are integral intermediaries between those at the at the coal face and national policies, managing long chains of dissemination and natural (often unpredictable) diffusion.

Identifying gaps in HIV service delivery across the diagnosis-to-treatment cascade: findings from health facility surveys in six sub-Saharan countries.

INTRODUCTION: Despite the rollout of antiretroviral therapy (ART), challenges remain in ensuring timely access to care and treatment for people living with HIV. As part of a multi-country study to investigate HIV mortality, we conducted health facility surveys within 10 health and demographic surveillance system sites across six countries in Eastern and Southern Africa to investigate clinic-level factors influencing (i) use of HIV testing services, (ii) use of HIV care and treatment and (iii) patient retention on ART. METHODS: Health facilities (n = 156) were sampled within 10 surveillance sites: Nairobi and Kisumu (Kenya), Karonga (Malawi), Agincourt and uMkhanyakude (South Africa), Ifakara and Kisesa (Tanzania), Kyamulibwa and Rakai (Uganda) and Manicaland (Zimbabwe). Structured questionnaires were administered to in-charge staff members of HIV testing, prevention of mother-to-child transmission (PMTCT) and ART units within the facilities. Forty-one indicators influencing uptake and patient retention along the continuum of HIV care were compared across sites using descriptive statistics. RESULTS: The number of facilities surveyed ranged from six in Malawi to 36 in Zimbabwe. Eighty percent were government-run; 73% were lower-level facilities and 17% were district/referral hospitals. Client load varied widely, from less than one up to 65 HIV testing clients per provider per week. Most facilities (>80%) delivered services or interventions that would support patient retention in care such as delivering free services, offering PMTCT within antenatal care, pre-ART monitoring and adherence counselling. Many facilities under-delivered in several areas, however, such as targeted testing for high-risk groups (21%) and mobile testing (36%). There were also intra-site and inter-site differences, including in the delivery of Option B+ (ranging from 6% in Kisumu to 93% in Kyamulibwa), and nurse-led ART initiation (ranging from 50% in Kisesa to 100% in Karonga and Agincourt). Only facilities in Malawi did not require additional lab tests for ART initiation. Stock-outs of HIV test kits and antiretroviral drugs were particularly common in Tanzania. CONCLUSION: We identified a high standard of health facility performance in delivering strategies that may support progression through the continuum of HIV care. HIV testing policy and practice was particularly weak. Inter- and intra-country differences in quality and coverage represent opportunities to improve the delivery of comprehensive services to people living with HIV.

Collective patient behaviours derailing ART roll-out in KwaZulu-Natal: perspectives of health care providers.

BACKGROUND: Antiretroviral therapy (ART) roll-out is fraught with challenges, many with serious repercussions. We explored and described patient behaviour-related challenges from the perspective of health care providers from non-governmental organisations involved in ART programmes in KwaZulu-Natal, South Africa. METHODS: A descriptive case study design using qualitative approach was applied during this study. Data was collected from nine key informants from the three biggest NGOs involved in ART roll-out using in-depth semi-structured interviews. Transcribing and coding for emergent themes was done by two independent reviewers. Ethical approval for the study was granted by the UNISA research ethics committee of The Faculty of Health Sciences. Written consent was obtained from directors of the three NGOs involved and individual audio taped informed consent was obtained from all study participants prior to data collection. RESULTS: Findings revealed six broad areas of patient behaviour challenges. These were patient behaviour related to socio-economic situation of patient (skipping of medication due to lack of food, or due to lack of transport fees), belief systems (traditional and religious), stigma (non- disclosure), sexual practices (non-acceptability of condoms, teenage pregnancies), escapism (drug and alcohol abuse) and opportunism (skipping medication in order to access disability grant, teenage pregnancies in order to access child grant). CONCLUSION: New programmes need to address patient behaviour as a complex phenomenon requiring a multi-pronged approach that also addresses social norms and institutions. In the face of continued ART scale up, this is further evidence for the need for multi-sectoral collaboration to ensure successful and sustainable ART roll-out.