Improving antibiotic prescribing quality in out-of-hours primary care: a mixed-methods study using participatory action research.

Background: During out-of-hours (OOH) primary care, GPs overprescribe antibiotics for respiratory tract infections (RTIs). Many interventions have been shown to improve antibiotic prescribing quality, but their implementation in practice remains difficult. Participatory action research (PAR) aims to explore, implement and evaluate change in practice with an active involvement of local stakeholders, while generating knowledge through experience. Objectives: To evaluate whether PAR improves antibiotic prescribing quality for RTIs during OOH primary care and simultaneously identify the pivotal lessons learned. Methods: A mixed-methods study with a PAR approach in three OOH GP cooperatives (GPCs). Each GPC co-created a multifaceted intervention focusing on improving antibiotic use for RTIs through plan-do-study-act cycles. We quantified antibiotic prescribing quality indicators and formulated the lessons learned from a qualitative process analysis. Results: Interventions were chosen with the GPs and adapted to be context-relevant. The willingness to work on quality and engagement of local stakeholders led to ownership of the project, but was time-consuming. In one GPC, antibiotic prescribing significantly decreased for tonsillitis, bronchitis, otitis media and acute upper RTI. In all three GPCs, use of guideline-recommended antibiotics for otitis media significantly increased. Conclusions: Implementing multifaceted interventions through PAR can lower total and increase guideline-recommended antibiotic prescribing for RTIs in OOH primary care. Co-creating interventions with GPs to suit local needs is feasible, but reaching all GPs targeted is challenging.

Differences in antibiotic prescribing quality in Belgian out-of-hours primary care services.

OBJECTIVES: This study aims to compare trends in antibiotic prescribing behaviour for lower urinary tract infections among different out-of-hours primary care services. METHODS: Cross-sectional study using routine prescription data extracted from electronic health records from six out-of-hours services. The study population included 5888 cases diagnosed with an uncomplicated lower urinary tract infection from 2016 to 2020. Prescriptions were assessed based on the national guidelines. RESULTS: Considering the total study period, an antibiotic was prescribed in 98.9% of cases. Among these cases, 55.0% was prescribed a guideline recommended antibiotic, 21.0% was prescribed fosfomycin, 17.4% was prescribed a quinolone and 1.8% was prescribed more than one antibiotic. Guideline recommended prescribing improved substantially over time. However, there were significant differences among out-of-hours services in terms of proportion over the total study period (between 49.0% and 66.7%) as well as in terms of time-trend pattern. CONCLUSION: Substantial differences among out-of-hours services suggest a potential for further improvement in the quality of antibiotic prescribing. Monitoring prescribing behaviour per out-of-hours primary care service can guide focused interventions.

Burden of COVID-19 on primary care in Belgium: a prospective nationwide observational study from March to August 2020.

BACKGROUND: The COVID-19 outbreak had an important impact on general practice, for example the lack of personal protective equipment (PPE) and the switch to telephone consultations. We installed a monitoring instrument and reported the burden the COVID-19 pandemic placed on Belgian general practitioners (GPs) during the first wave of the pandemic. METHODS: We conducted an observational longitudinal prospective study from the 19th of March until the 17th of August 2020. Daily data were collected by using a structured electronic form integrated into the GPs' electronic medical records (EMRs). Data were collected on the GPs' need for support and workload, epidemiological indicators and the availability of PPE. Reports with graphical presentations were made for GP circles and primary care zones, and governments of different administrative levels had access to all data to guide their policy. RESULTS: A total of 3.769 different GP centres participated, which included more than 10.000 GPs. Throughout the first three weeks, 20% declared they had insufficient resources (personnel and material) for the following week. Approximately 10% continued to report this during the entire study. The majority reported being able to complete their daily tasks without loss of quality. During the first week, 30% indicated an increased workload. Afterwards, this number decreased and stabilized to an average of 10-20%. More than 70% of the consultations in March 2020 were conducted by telephone. This percentage declined in April and stabilized at approximately 30% in June 2020. Consultations due to respiratory symptoms peaked at 4000/100,000 inhabitants at the beginning of the outbreak, then decreased over time along with the COVID-19 incidence. We noticed a lack of disinfectant hand gel, surgical masks and FFP2 masks, the latter remaining problematic in the long term. CONCLUSION: We introduced an instrument in Belgian EMR systems to monitor the burden on GPs during the first wave of the COVID-19 pandemic. The lack of PPE and increased workload were considered to be the main obstacles. A large number of the GP offices switched to teleconsultations to provide healthcare. Our monitoring instrument provided information for policy makers to intervene on a local level.

Cost effects of nurse led triage at an emergency department with the advice to consult the adjacent general practice cooperative for low-risk patients, a cluster randomised trial.

BACKGROUND: During the TRIAGE trial, emergency nurses diverted 13.3% of patients with low-risk complaints from a Belgian emergency department (ED) to the adjacent general practitioner cooperative (GPC). We examined the effects of this diversion on the total cost, insurance costs and patient costs, as charged on the invoice. Changes in the cost composition and the direct impact on revenues of both locations were examined as a secondary objective. METHODS: The differences in costs between intervention and control weekends were tested with two-sample t-tests and Kolmogorov-Smirnov (KS) tests. For the main outcomes an additional generalised linear model was created. Proportions of patients charged with certain costs were examined using Pearson's chi-square tests. Average revenues per weekend were compared using pooled t-tests. RESULTS: During intervention weekends, total costs increased by 3% (€3.3). The costs decreased by 8% (€2.2) for patients and increased by 6% (€5.5) for insurance, mainly driven by differences in physician fees. More patients were charged a consultation fee only (25% vs. 19%, p-value<0.01). The GPC's revenues increased by 13% (p-value=0.06); no change was found for the ED's revenues. CONCLUSION: The intervention reduced costs slightly for patients, while total costs and insurance costs slightly increased. When implementing triage systems with primary care involvement, the effects on the costs and revenues of the stakeholders should be monitored.

Differences in emergency nurse triage between a simulated setting and the real world, post hoc analysis of a cluster randomised trial.

OBJECTIVES: In the TRIAGE trial, a cluster randomised trial about diverting emergency department (ED) patients to a general practice cooperative (GPC) using a new extension to the Manchester Triage System, the difference in the proportion of patients assigned to the GPC was striking: 13.3% in the intervention group (patients were encouraged to comply to an ED or GPC assignment, real-world setting) and 24.7% in the control group (the assignment was not communicated, all remained at the ED, simulated setting). In this secondary analysis, we assess the differences in the use of the triage tool between intervention and control group and differences in costs and hospitalisations for patients assigned to the GPC. SETTING: ED of a general hospital and the adjacent GPC. PARTICIPANTS: 8038 patients (6294 intervention and 1744 control).Primary and secondary outcome measures proportion of patients with triage parameters (reason for encounter, discriminator and urgency category) leading to an assignment to the ED, proportion of patients for which the computer-generated GPC assignment was overruled, motivations for choosing certain parameters, costs (invoices) and hospitalisations. RESULTS: An additional 3.1% (p<0.01) of the patients in the intervention group were classified as urgent. Discriminators leading to the ED were registered for an additional 16.2% (p<0.01), mainly because of a perceived need for imaging. Nurses equally chose flow charts leading to the ED (p=0.41) and equally overruled the protocol (p=0.91). In the intervention group, the mean cost for patients assigned to the GPC was €23 (p<0.01) lower and less patients with an assignment to the GPC were hospitalised (1.0% vs 1.6%, p<0.01). CONCLUSION: Nurses used a triage tool more risk averse when it was used to divert patients to primary care as compared with a theoretical assignment to primary care. Outcomes from a simulated setting should not be extrapolated to real patients. TRIAL REGISTRATION NUMBER: NCT03793972.

Triaging and referring in adjacent general and emergency departments (the TRIAGE-trial): A process evaluation of medical staff experiences in a nurse-led triage system.

AIMS: This process evaluation aims at identifying the facilitators and inhibitors that influenced the successful uptake of a nurse-led triage system streaming low-risk patients from an emergency department (ED) to the general practitioner (GP). DESIGN & METHODS: Semi-structured interviews with ED nurses (n = 12), ED doctors (n = 6) from the ED of a Belgian general hospital and GPs (n = 5) affiliated with the adjacent GP cooperative (GPC). The process evaluation ran in parallel with the TRIAGE trial that started in March 2019 and ended 31st of December 2019. The first set of interviews was conducted in June 2019 and the second set in January 2020. Data were analysed based on grounded theory. RESULTS: Through a deductive framework, facilitators and inhibitors could be identified on three levels: the organisational, group and individual level. Main inhibitors are the degree of risk aversion of individual nurses, possible language barriers during delivery of the triage advice and the non-adapted ED infrastructure. Training on both the use of the triage protocol and effective delivery of the triage advice, in combination with periodical feedback from the GPC were the most important facilitators. CONCLUSION: Based on the process evaluation we can conclude that a consensus exists among stakeholders that the ED Nurses are considered ideally positioned to perform the triage of walk-in patients, although a certain degree of experience is necessary. Although the extended triage protocol and GPC referral increases the complexity and duration of triage and entails a higher workload for the triage nurses, ED nurses found it did lead to a lower (perceived) workload for the ED in general.

Safety netting advice for respiratory tract infections in out-of-hours primary care: A qualitative analysis of consultation videos.

BACKGROUND: General practitioners (GPs) use safety netting advice to communicate with patients when and how to seek further help when their condition fails to improve or deteriorate. Although many respiratory tract infections (RTI) during out-of-hours (OOH) care are self-limiting, often antibiotics are prescribed. Providing safety netting advice could enable GPs to safely withhold an antibiotic prescription by dealing both with their uncertainty and the patients' concerns. OBJECTIVES: To explore how GPs use safety netting advice during consultations on RTIs in OOH primary care and how this advice is documented in the electronic health record. METHODS: We analysed video observations of 77 consultations on RTIs from 19 GPs during OOH care using qualitative framework analysis and reviewed the medical records. Videos were collected from August until November 2018 at the Antwerp city GP cooperative, Belgium. RESULTS: Safety netting advice on alarm symptoms, expected duration of illness and/or how and when to seek help is often lacking or vague. Communication of safety netting elements is scattered throughout the end phase of the consultation. The advice is seldom recorded in the medical health record. GPs give more safety netting advice when prescribing an antibiotic than when they do not prescribe an antibiotic. CONCLUSION: We provided a better understanding of how safety netting is currently carried out in OOH primary care for RTIs. Safety netting advice during OOH primary care is limited, unspecific and not documented in the medical record.

Non-compliance with a nurse's advice to visit the primary care provider: an exploratory secondary analysis of the TRIAGE-trial.

BACKGROUND: During the cluster randomised TRIAGE-trial, a nurse advised 13% of low-risk patients presenting at an emergency department in Belgium to visit the adjacent general practitioner cooperative. Patients had the right to refuse this advice. This exploratory study examines the characteristics of refusers by uncovering the determinants of non-compliance and its impact on costs, as charged on the patient's invoice. METHODS: Bivariate analyses with logistic regressions and T-tests were used to test the differences in patient characteristics, patient status, timing characteristics, and costs between refusers and non-refusers. A chi-square automatic interaction detection analysis was used to find the predictors of non-compliance. RESULTS: 23.50% of the patients refused the advice to visit the general practitioner cooperative. This proportion was mainly influenced by the nurse on duty (non-compliance rates per nurse ranging from 2.9% to 52.8%) and the patients' socio-economic status (receiving increased reimbursement versus not OR 1.37, 95%CI: 0.96 to 1.95). Additionally, non-compliance was associated (at the 0.10 significance level) with being male, not living nearby and certain reasons for encounter. Fewer patients refused when the nurse perceived crowding level as quiet relative to normal, and more patients refused during the evening. The mean cost was significantly higher for patients who refused, which was a result of more extensive examination and higher out-of-pocket expenses at the ED. CONCLUSIONS: The nurse providing the advice to visit the general practitioner cooperative has a central role in the likelihood of patients' refusal. Interventions to reduce non-compliance should aim at improving nurse-patient communication. Special attention may be required when managing patients with a lower socio-economic status. The overall mean cost was higher for refusers, illustrating the importance of compliance. TRIAL REGISTRATION: The trial was registered on registration number NCT03793972 on 04/01/2019.

Opioid prescribing in out-of-hours primary care in Flanders and the Netherlands: A retrospective cross-sectional study.

BACKGROUND: Increased opioid prescribing has raised concern, as the benefits of pain relief not always outweigh the risks. Acute and chronic pain is often treated in a primary care out-of-hours (OOH) setting. This setting may be a driver of opioid use but the extent to which opioids are prescribed OOH is unknown. We aimed to investigate weak and strong opioid prescribing at OOH primary care services (PCS) in Flanders (Northern, Dutch-speaking part of Belgium) and the Netherlands between 2015 and 2019. METHODS: We performed a retrospective cross sectional study using data from routine electronic health records of OOH-PCSs in Flanders and the Netherlands (2015-2019). Our primary outcome was the opioid prescribing rate per 1000 OOH-contacts per year, in total and for strong (morphine, hydromorphone, oxycodone, oxycodone and naloxone, fentanyl, tapentadol, and buprenorphine and weak opioids (codeine combinations and tramadol and combinations) and type of opioids separately. RESULTS: Opioids were prescriped in approximately 2.5% of OOH-contacts in both Flanders and the Netherlands. In Flanders, OOH opioid prescribing went from 2.4% in 2015 to 2.1% in 2017 and then increased to 2.3% in 2019. In the Netherlands, opioid prescribing increased from 1.9% of OOH-contacts in 2015 to 2.4% in 2017 and slightly decreased thereafter to 2.1% of OOH-contacts. In 2019, in Flanders, strong opioids were prescribed in 8% of the OOH-contacts with an opioid prescription. In the Netherlands a strong opioid was prescribed in 57% of these OOH-contacts. Two thirds of strong opioids prescriptions in Flanders OOH were issued for patients over 75, in the Netherlands one third was prescribed to this age group. CONCLUSION: We observed large differences in strong opioid prescribing at OOH-PCSs between Flanders and the Netherlands that are likely to be caused by differences in accessibility of secondary care, and possibly existing opioid prescribing habits. Measures to ensure judicious and evidence-based opioid prescribing need to be tailored to the organisation of the healthcare system.

Predicting COVID-19 Symptoms From Free Text in Medical Records Using Artificial Intelligence: Feasibility Study.

BACKGROUND: Electronic medical records have opened opportunities to analyze clinical practice at large scale. Structured registries and coding procedures such as the International Classification of Primary Care further improved these procedures. However, a large part of the information about the state of patient and the doctors' observations is still entered in free text fields. The main function of those fields is to report the doctor's line of thought, to remind oneself and his or her colleagues on follow-up actions, and to be accountable for clinical decisions. These fields contain rich information that can be complementary to that in coded fields, and until now, they have been hardly used for analysis. OBJECTIVE: This study aims to develop a prediction model to convert the free text information on COVID-19-related symptoms from out of hours care electronic medical records into usable symptom-based data that can be analyzed at large scale. METHODS: The design was a feasibility study in which we examined the content of the raw data, steps and methods for modelling, as well as the precision and accuracy of the models. A data prediction model for 27 preidentified COVID-19-relevant symptoms was developed for a data set derived from the database of primary-care out-of-hours consultations in Flanders. A multiclass, multilabel categorization classifier was developed. We tested two approaches, which were (1) a classical machine learning-based text categorization approach, Binary Relevance, and (2) a deep neural network learning approach with BERTje, including a domain-adapted version. Ethical approval was acquired through the Institutional Review Board of the Institute of Tropical Medicine and the ethics committee of the University Hospital of Antwerpen (ref 20/50/693). RESULTS: The sample set comprised 3957 fields. After cleaning, 2313 could be used for the experiments. Of the 2313 fields, 85% (n=1966) were used to train the model, and 15% (n=347) for testing. The normal BERTje model performed the best on the data. It reached a weighted F1 score of 0.70 and an exact match ratio or accuracy score of 0.38, indicating the instances for which the model has identified all correct codes. The other models achieved respectable results as well, ranging from 0.59 to 0.70 weighted F1. The Binary Relevance method performed the best on the data without a frequency threshold. As for the individual codes, the domain-adapted version of BERTje performs better on several of the less common objective codes, while BERTje reaches higher F1 scores for the least common labels especially, and for most other codes in general. CONCLUSIONS: The artificial intelligence model BERTje can reliably predict COVID-19-related information from medical records using text mining from the free text fields generated in primary care settings. This feasibility study invites researchers to examine further possibilities to use primary care routine data.

How accurate is telephone triage in out-of-hours care? An observational trial in real patients.

OBJECTIVES: Patients in Belgium needing out-of-hours medical care have two options: the emergency department (ED) or a general practitioner (GP) on call. Currently, there is no triage system in Belgium, so patients do not know where they should go. However, patients who could be managed by a GP frequently present themselves at an ED without referral. GPs often organise themselves in a General Practitioners Cooperative (GPC). This study assesses the accuracy of a newly developed telephone triage guideline. METHODS: Observational real-time simulation: all walk-in patients at two GPCs and three EDs were asked to call a triage telephone number with their current medical problem. The operator handling this call registered an urgency level and a resource (ED, GP or ambulance) to deploy. The treating physician's opinion was used a the gold standard for correct triage. Patients were not informed about the outcome of the triage and continued the standard care path they had chosen. RESULTS: The overall sensitivity of the telephone triage for detecting patients who could be managed by a GP was 82% with a specificity of 53%. The correctness of the advice given by the operator according to the physicians was 71%, with 12% underestimation of urgency and 17% overestimation. At the GPC, the sensitivity for detecting patients requiring GP management/care was 91% with a specificity of 36%. At the ED, the sensitivity for detecting GP patients was 67% with a specificity of 48%. CONCLUSION: This study evaluates a new guideline for telephone triage, showing potential overtriage for patients wanting to attend the GPC, with possible inefficiency, and potential undertriage for patients wanting to attend the ED, with possible safety issues.

A scoping review on the use and usefulness of online symptom checkers and triage systems: How to proceed?

Background: Patients are increasingly turning to the Internet for health information. Numerous online symptom checkers and digital triage tools are currently available to the general public in an effort to meet this need, simultaneously acting as a demand management strategy to aid the overburdened health care system. The implementation of these services requires an evidence-based approach, warranting a review of the available literature on this rapidly evolving topic. Objective: This scoping review aims to provide an overview of the current state of the art and identify research gaps through an analysis of the strengths and weaknesses of the presently available literature. Methods: A systematic search strategy was formed and applied to six databases: Cochrane library, NICE, DARE, NIHR, Pubmed, and Web of Science. Data extraction was performed by two researchers according to a pre-established data charting methodology allowing for a thematic analysis of the results. Results: A total of 10,250 articles were identified, and 28 publications were found eligible for inclusion. Users of these tools are often younger, female, more highly educated and technologically literate, potentially impacting digital divide and health equity. Triage algorithms remain risk-averse, which causes challenges for their accuracy. Recent evolutions in algorithms have varying degrees of success. Results on impact are highly variable, with potential effects on demand, accessibility of care, health literacy and syndromic surveillance. Both patients and healthcare providers are generally positive about the technology and seem amenable to the advice given, but there are still improvements to be made toward a more patient-centered approach. The significant heterogeneity across studies and triage systems remains the primary challenge for the field, limiting transferability of findings. Conclusion: Current evidence included in this review is characterized by significant variability in study design and outcomes, highlighting the significant challenges for future research.An evolution toward more homogeneous methodologies, studies tailored to the intended setting, regulation and standardization of evaluations, and a patient-centered approach could benefit the field.

Antibiotic Prescribing Trends in Belgian Out-of-Hours Primary Care during the COVID-19 Pandemic: Observational Study Using Routinely Collected Health Data.

Antibiotic overprescribing is one of the main drivers of the global and growing problem of antibiotic resistance, especially in primary care and for respiratory tract infections (RTIs). RTIs are the most common reason for patients to consult out-of-hours (OOH) primary care. The COVID-19 pandemic has changed the way general practitioners (GPs) work, both during office hours and OOH. In Belgian OOH primary care, remote consultations with the possibility of issuing prescriptions and telephone triage were implemented. We aimed to describe the impact of COVID-19 on GPs' antibiotic prescribing during OOH primary care. In an observational study, using routinely collected health data from GP cooperatives (GPCs) in Flanders, we analyzed GPs' antibiotic prescriptions in 2019 (10 GPCs) and 2020 (20 GPCs) during OOH consultations (telephone and face-to-face). We used autoregressive integrated moving average (ARIMA) modeling to identify any changes after lockdowns were implemented. In total, 388,293 contacts and 268,430 prescriptions were analyzed in detail. The number of antibiotic prescriptions per weekend, per 100,000 population was 11.47 (95% CI: 9.08-13.87) or 42.9% lower after compared to before the implementation of lockdown among all contacts. For antibiotic prescribing per contact, we found a decrease of 12.2 percentage points (95% CI: 10.6-13.7) or 56.5% among all contacts and of 5.3 percentage points (95% CI: 3.7-6.9) or 23.2% for face-to-face contacts only. The decrease in the number of prescriptions was more pronounced for cases with respiratory symptoms that corresponded with symptoms of COVID-19 and for antibiotics that are frequently prescribed for RTIs, such as amoxicillin (a decrease of 64.9%) and amoxicillin/clavulanate (a decrease of 38.1%) but did not appear for others such as nitrofurantoin. The implementation of COVID-19 lockdown measures coincided with an unprecedented drop in the number of antibiotic prescriptions, which can be explained by a decrease in face-to-face patient contacts, as well as a lower number of antibiotics prescriptions per face-to-face patient contact. The decrease was seen for antibiotics used for RTIs but not for nitrofurantoin, the first-choice antibiotic for urinary tract infections.

Antibiotic Prescribing and Doctor-Patient Communication During Consultations for Respiratory Tract Infections: A Video Observation Study in Out-of-Hours Primary Care.

Objective: Communication skills can reduce inappropriate antibiotic prescribing, which could help to tackle antibiotic resistance. General practitioners often overestimate patient expectations for an antibiotic. In this study, we describe how general practitioners and patients with respiratory tract infections (RTI) communicate about their problem, including the reason for encounter and ideas, concerns, and expectations (ICE), and how this relates to (non-)antibiotic prescribing in out-of-hours (OOH) primary care. Methods: A qualitative descriptive framework analysis of video-recorded consultations during OOH primary care focusing on doctor-patient communication. Results: We analyzed 77 videos from 19 general practitioners. General practitioners using patient-centered communication skills received more information on the perspective of the patients on the illness period. For some patients, the reason for the encounter was motivated by their belief that a general practitioner (GP) visit will alter the course of their illness. The ideas, concerns, and expectations often remained implicit, but the concerns were expressed by the choice of words, tone of voice, repetition of words, etc. Delayed prescribing was sometimes used to respond to implicit patient expectations for an antibiotic. Patients accepted a non-antibiotic management plan well. Conclusion: Not addressing the ICE of patients, or their reason to consult the GP OOH, could drive assumptions about patient expectations for antibiotics early on and antibiotic prescribing later in the consultation.

Overprescribing of Topical Ocular Corticosteroids and Antibiotics in Out-of-Hours Primary Care in Belgium.

Prescribing patterns by primary care physicians concerning ophthalmic problems were studied using the iCAREdata, a database containing information from the out-of-hours care setting in the Flanders region of Belgium. A very high percentage of prescribed ophthalmic medication was topical antibiotics (89.4%) with tobramycin as the most prevalent substance and in clear conflict with the prevailing guidelines. In addition, a very substantial fraction of prescribed medication contained corticosteroids (30.4%). This is a potentially unsafe option within the technical infrastructure of this setting, which limits the diagnostic possibilities concerning viral infections or preexisting glaucoma risk. We conclude that more efforts are required to limit unnecessary and inappropriate prescribing behavior to further promote patient safety.

Triaging and referring in adjacent general and emergency departments (the TRIAGE trial): A cluster randomised controlled trial.

OBJECTIVES: To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC). METHODS: Unblinded randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard). RESULTS: In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised. CONCLUSIONS: ED nurses using a new tool safely diverted 9.5% of the included patients to primary care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03793972.

Increase in Anxiety-Related Out-of-Hours Primary Care Consultations Since COVID-19: An Observational Study Using Routine Data in Flanders.

Background: Survey studies suggest that COVID-19 has had a negative impact on the population's mental well-being. Routine registration data allow a more objective way for investigating such associations, complementary to self-report measures. This study investigates the level of out of hours (OOH) consultations for psychological problems since the start of the COVID-19 pandemic in Flanders, Belgium. Methods: The iCAREdata database is a clinical research database with routine data of OOH care, covering a large area in Flanders, Belgium. After defining the first wave and the second wave of COVID-19 in Flanders in time, we compared the number of consultations regarding psychological problems (in general, anxiety-related, depression-related, and sleep-related) between those periods, the period in between these waves, and the period before the start of COVID-19. Results: A significant rise in OOH consultations due to psychological-and more specifically, anxiety-related-problems is observed since the start of the COVID-19 pandemic in Flanders. Elevated levels are observed until the second wave. This finding is in sharp contrast with the general pattern of lower demand for primary healthcare during this period. The majority of these supplementary consultations happened by phone. Consultations regarding depression-related problems did not change over time. Sleep disturbances in the OOH setting were more common after the first wave. Conclusion: Despite some limitations, a large Flemish database with routine data on OOH care shows an increase in the number of consultations regarding psychological problems in general and anxiety-related problems since the start of the COVID-19-pandemic until the second wave.

Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study.

BACKGROUND: During the COVID-19 pandemic, general practitioners worldwide re-organise care in very different ways because of the lack of evidence-based protocols. OBJECTIVE: This paper describes the organisation and the characteristics of consultations in Belgian out-of-hours primary care during five weekends at the peak of a COVID-19 outbreak and compares it to a similar period in 2019. METHODS: Real-time observational study using pseudonymised routine clinical data extracted out of reports from home visits, telephone- and physical consultations (iCAREdata). Nine general practice cooperatives (GPCs) participated covering a population of 1 513 523. RESULTS: All GPCs rapidly re-organised care in order to handle the outbreak and provide a safe working environment. The average consultation rate was 222 per 100 000 citizens per weekend. These consultations were handled by telephone alone in 40% (N = 6293). A diagnosis at risk of COVID-19 was registered in 6692 (43%) consultations,. Out of 5311 physical consultations, 1460 were at risk of COVID-19 of which 443 (30%) did not receive prior telephone consultation to estimate this risk. Compared to 2019, the workload initially increased due to telephone consultations but afterwards declined drastically. The physical consultation rate declined by 45% with a marked decline in diagnoses unrelated to COVID-19. CONCLUSIONS: General practitioners can rapidly re-organise out-of-hours care to handle patient flows during a COVID-19 outbreak. Forty percent of the out-of-hours primary care contacts are handled by telephone consultations alone. We recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care. The demand for physical consultations declined drastically provoking questions about patient's safety for care unrelated to COVID-19.

Impact of the COVID-19 pandemic on the core functions of primary care: will the cure be worse than the disease? A qualitative interview study in Flemish GPs.

OBJECTIVES: The current COVID-19 pandemic, as well as the measures taken to control it, have a profound impact on healthcare. This study was set up to gain insights into the consequences of the COVID-19 outbreak on the core competencies of general practice, as they are experienced by general practitioners (GPs) on the frontline. DESIGN, SETTING, PARTICIPANTS: We performed a descriptive study using semistructured interviews with 132 GPs in Flanders, using a topic list based on the WONCA definition of core competencies in general practice. Data were analysed qualitatively using framework analysis. RESULTS: Changes in practice management and in consultation strategies were quickly adopted. There was a major switch towards telephone triage and consults, for covid-related as well as for non-covid related problems. Patient-centred care is still a major objective. Clinical decision-making is largely focused on respiratory assessment and triage, and GPs feel that acute care is compromised, both by their own changed focus and by the fact that patients consult less frequently for non-covid problems. Chronic care is mostly postponed, and this will have consequences that will extend and become visible after the corona crisis. Through the holistic eyes of primary care, the current outbreak-as well as the measures taken to control it-will have a profound impact on psychological and socioeconomic well-being. This impact is already visible in vulnerable people and will continue to become clear in the medium and long terms. GPs think that they are at high risk of getting infected. Dropping out and being unable to contribute their part or becoming virus transmitters are reported to be greater concerns than getting ill themselves. CONCLUSIONS: The current times have a profound impact on the core competences of primary care. Although the vast increase in patients soliciting medical help and the necessary separate covid and non-covid flows have been dealt with, GPs are worried about the continuity of regular care and the consequences of the anticovid measures. These may become a threat for the general health of the population and for the provision of primary healthcare in the near and distant future.

Performance of a new guideline for telephone triage in out-of-hours services in Belgium: A pilot study using simulated patients.

BACKGROUND: Patients in Belgium needing out-of-hours care have two options: the emergency department or the general practitioner on call often organised in a general practitioner cooperative. Currently, there is no triage system in Belgium so patients do not know where to go. METHODS: Our primary objective was to examine the ability of a newly developed telephone guideline, called 1733, to adequately estimate the urgency of health problems presented by simulated patients. Ten clinical vignettes were presented to 12 operators in a simulated phone call. The operators had to assign a protocol, urgency level and resource to dispatch (ambulance, general practitioner house visit, etc.) to each case. RESULTS: A total of 120 phone calls were analysed. The operators chose the right protocol in 69% and the correct urgency level in 35% of the cases. The proportion of under- and over-triage was 26% and 39%, respectively. There was important variation in between the operators. The sensitivity for detecting highly urgent cases was 0.42, the specificity 0.92. CONCLUSION: Using the new Belgian 1733 guideline for telephone triage, operators mostly chose the appropriate protocol but only chose the correct urgency in one out of three cases. In this phase of development, the studied telephone guideline is not ready for implementation.