Did the organization of primary care practices during the COVID-19 pandemic influence quality and safety? - an international survey.

BACKGROUND: Changes in demographics with an older population, the illness panorama with increasing prevalence of non-communicable diseases, and the shift from hospital care to home-based care place demand on primary health care, which requires multiprofessional collaboration and team-based organization of work. The COVID-19 pandemic affected health care in various ways, such as heightened infection control measures, changing work practices, and increased workload. OBJECTIVES: This study aimed to investigate the association between primary care practices' organization, and quality and safety changes during the COVID-19 pandemic. DESIGN: Data were collected from 38 countries in a large online survey, the PRICOV-19 study. For this paper, the participating practices were categorized as "Only GPs", comprising practices with solely general practitioners (GPs) and/or GP trainees, without any other health care professionals (n = 1,544), and "Multiprofessional," comprising practices with at least one GP or GP trainee and one or more other health professionals (n = 3,936). RESULTS: Both categories of practices improved in infection control routines when compared before and during the COVID-19 pandemic. A larger proportion of the multiprofessional practices changed their routines to protect vulnerable patients. Telephone triage was used in more "Multiprofessional" practices, whereas "Only GPs" were more likely to perform video consultations as an alternative to physical visits. Both types of practices reported that the time to review new guidelines and scientific literature decreased during the pandemic. However, both had more meetings to discuss directives than before the pandemic. CONCLUSIONS: Multiprofessional teams were keener to introduce changes to the care organization to protect vulnerable patients. However, practices with only GPs were found to be more aligned with video consultations, perhaps reflecting the close patient-doctor relationship. In contrast, telephone triage was used more in multiprofessional teams.

Medical deserts in Spain-Insights from an international project.

INTRODUCTION: Medical deserts are a growing phenomenon across many European countries. They are usually defined as (i) rural areas, (ii) underserved areas or (iii) by applying a measure of distance/time to a facility or a combination of the three characteristics. The objective was to define medical deserts in Spain as well as map their driving factors and approaches to mitigate them. METHODS: A mixed methods approach was applied following the project "A Roadmap out of medical deserts into supportive health workforce initiatives and policies" work plan. It included the following elements: (i) a scoping literature review; (ii) a questionnaire survey; (iii) national stakeholders' workshop; (iv) a descriptive case study on medical deserts in Spain. RESULTS: Medical deserts in Spain exist in the form of mostly rural areas with limited access to health care. The main challenge in their identification and monitoring is local data availability. Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be identified in Spain. They can be related to demand for or supply of health care services. More national data, analyses and/or initiatives seem to be focused on the health care supply dimension. CONCLUSIONS: Addressing medical deserts in Spain requires a comprehensive and multidimensional approach. Effective policies are needed to address both the medical staff education and planning system, working conditions, as well as more intersectoral approach to the population health management.

[Why is it increasingly difficult to "do the right thing" and to "stop doing the wrong thing"? Strategies for reversing low-value practices]. / ¿Por qué resulta cada vez más complicado "hacer lo que hay que hacer" y "dejar de hacer lo que no hay que hacer"? Estrategias para revertir las prácticas de bajo valor.

This manuscript describes the factors that have led to the spread of low-value practices (LVP) and the main initiatives to reverse them. The paper highlights the strategies that have proven to be most useful over the years, from the alignment of clinical practice with "do not do" recommendations, to quaternary prevention and the risks associated with interventionism. Reversing LVP requires a planned process with a multifactorial approach engaging the different actors involved. It considers the barriers to de-implementation of low-value interventions and incorporates tools that facilitate adherence to "do not do" recommendations. Family doctor has an especially relevant role in LVP prevention, detection and de-implementation, due to their coordinating and integrating nature in the patients' healthcare, and because most of the citizens' healthcare demands are managed and resolved at the first level of care.

[Open data for monitoring COVID-19 in Spain: descriptive study]. / Datos abiertos de monitorización de la COVID-19 en España: estudio descriptivo.

BACKGROUND: The indicators of the pandemic have been based on the total number of diagnosed cases of COVID-19, the number of people hospitalized or in intensive care units, and deaths from the infection. The aim of this study is to describe the available data on diagnostic tests, health service used for the diagnosis of COVID-19, case detection and monitoring. METHOD: Descriptive study with review of official data available on the websites of the Spanish health councils corresponding to 17 Autonomous Communities, 2 Autonomous cities and the Ministry of Health. The variables collected refer to contact tracing, technics for diagnosis, use of health services and follow-up. RESULTS: all regions of Spain show data on diagnosed cases of COVID-19 and deaths. Hospitalized cases and intensive care admissions are shown in all regions except the Balearic Islands. Diagnostic tests for COVID-19 have been registered in all regions except Madrid region and Extremadura, with scarcely information on what type of test has been performed (present in 7 CCAA), requesting service and study of contacts. CONCLUSIONS: The information available on the official websites of the Health Departments of the different regions of Spain are heterogeneous. Data from the use of health service or workload in Primary Care, Emergency department or Out of hours services are almost non-existent.

Primary health care response in the management of pandemics: Learnings from the COVID-19 pandemic.

Primary care is an essential foundation for the global response to COVID-19 pandemic. It plays a significant role in the health care response: identifying and triaging potential COVID-19 cases, making an early diagnosis, helping vulnerable people cope with their anxiety about the virus, strengthening compliance with prevention and protection measures, and reducing the demand for hospital services. Primary care teams have continued to address citizens' health problems during the pandemic, adapting to strict social control measures imposed by governments such as closing of borders, lockdowns and self-isolation of cases and contacts. We describe the COVID-19 response from primary care in Hong Kong and China, based on their recent pandemic experiences. We also present that of a European country, United Kingdom, less experienced in pandemic management, but with universal and highly developed primary care with great social recognition. Finally, we point out some crucial learning for future pandemic management, highlighting the crucial need to improve the relationship between primary care and public health to improve pandemics response.

[Diagnostic error and overdiagnosis in Primary Care. Proposals for the improvement of clinical practice family medicine]. / El error diagnóstico y sobrediagnóstico en Atención Primaria. Propuestas para la mejora de la práctica clínica en medicina de familia.

Family doctors see a wide range of patients, with a wide range of complexity, in a short time and with few diagnostic resources. This situation makes primary care professionals more vulnerable to diagnostic errors. For this reason, an adequate clinical reasoning process is the most powerful tool family doctors have to safely guide the patient care process. Considering these errors as missed opportunities for a correct diagnosis, which may cause harm to the patient, leads us as professionals to review how to improve this process. The review includes, among other aspects, identifying cognitive biases, analysing the ways in which work is organised in primary care teams, and situations in the care context that may contribute to such errors. In this article we describe the most frequent diagnostic errors and their causal factors in primary care, the impact of cognitive process failures, situations of overdiagnosis and the diagnostic and therapeutic cascades associated with them. Finally, we propose a set of tools to improve decision-making in the diagnostic process in primary care.

[Patient safety training and a safe teaching in primary care]. / La formación en seguridad del paciente y una docencia segura en atención primaria.

This narrative review manuscript aims to raise the difficulties and opportunities for patient safety in specialised healthcare training considering undergraduate, postgraduate, specialist and continuing education, even during the COVID-19 pandemic. It also suggests some proposals for carrying it out. It very briefly discusses this specific training and its current situation in primary care. Highlighting that patient safety is a need, an area of competence and a training opportunity for residents. It establishes the general framework of patient safety in primary care in the document "7 steps for Patient Safety in Primary Care", stating the need for a systemic approach. It highlights the elaboration and presentation of cases on clinical errors as the most frequent training strategy. The real-life clinical scenarios relate to difficult patients, critical incidents and bioethics issues in professional practice. These scenarios have as common characteristics, the fact to produce difficulties and suffering for all the actors involved. Several instruments for training in patient safety are also included. The medium-term goal is to consolidate clinical safety in specialised healthcare training. Finally, an analysis is made of the impact of the pandemic on patient safety training, particularly on specialised healthcare training and some proposals are recommended on how to carry out safe teaching in the times of the COVID-19 pandemic.

[Health worker safety as an essential condition for patient safety]. / La seguridad de los profesionales como condición indispensable para la seguridad de los pacientes.

The greatest asset of any health system is its professionals, and they must be cared for in order to take care. It is necessary to emphasize that they are key for the resilience of our health systems. This is particularly important in crisis times and especially important for primary health care.During the COVID-19 pandemic, working conditions have been the main common latent factor for patient safety incidents. Primary Care professionals have worked in unsafe working conditions, with lack of means of protection, great uncertainty, lack of scientific knowledge and rapidly changing work protocols for dealing with cases and contacts of COVID-19 infection, with a high care pressure, long working hours, suspension of vacations, and even changes in their jobs. All of this has contributed to their becoming, not only the first victims of the pandemic, but also the second victims of the adverse events that occurred during it.Therefore, in this article we analyze the main risks and damages suffered by professionals in Primary Care and provide keys to contribute to their protection in future similar situations.

[Human resource management and vaccination strategies in primary care in Europe during COVID-19 pandemic]. / Gestión de los recursos humanos y estrategias de vacunación en atención primaria en Europa en la pandemia COVID-19.

This article describes the management of human resource and the vaccination strategies in primary care in twelve European countries in relation to the COVID-19 pandemic. All the countries have found solutions to increase their workforce in primary care. Other healthcare professionals were incorporated to support family doctors assuming their tasks, under their supervision and coordination. The European Commission had a crucial role in the production, purchase and distribution of the vaccines. The engagement of primary care in the vaccination campaign has had an unequal participation in the different countries, although the greatest burden has been managed from the government's public health departments.

[The role of primary care during COVID-19 pandemic: A European overview]. / El papel de la atención primaria en la pandemia COVID-19: Una mirada hacia Europa.

We describe the role of primary care (PC) in 12 European countries in relation to the COVID-19 pandemic. There is no official information at European level on the activity of PC. The findings were: All countries provided COVID-19 information through telephone lines and websites to their citizens. Contact tracing was mainly carried out by Public Health except for Ireland, Portugal and Spain. The epidemiological surveillance task has overlapped with the PC assistance. Active Infection Diagnostic Tests (AIDT) were performed in PC exclusively in Spain. The other countries performed them in external laboratories. Patients were followed-up in PC mostly by remote assessment. Health coverage for vulnerable populations and nursing homes has been regulated in all countries. There is a need for a strategic plan for PC in Europe that responds to the challenges posed.

[The Global Patient Safety Action Plan 2021-2030: Identifying actions for safer primary health care]. / El Plan de acción mundial para la seguridad del paciente 2021-2030: identificando acciones para una atención primaria más segura.

The 74th World Health Assembly adopted in May 2021 the "Global Patient Safety Action Plan: 2021-2030" to enhance patient safety as an essential component in the design, procedures and performance evaluation of health systems worldwide. It is a strategic plan that guides country governments, health sector entities, health organisations and the World Health Organisation secretariat on how to implement the assembly's patient safety resolution. Deployment of the plan will strengthen the quality and safety of health systems worldwide by spanning the entire continuum of people's health care from diagnosis to treatment and care, reducing the likelihood of harm in the course of care. The Declaration on Primary Health Care during the Global Conference on Primary Health Care in Astana, 2018, urged countries to strengthen their primary health care systems as an essential step towards achieving universal health coverage and providing access to safe, quality care without financial loss. The deployment of the Global Patient Safety Action Plan in primary care is therefore a high-priority health policy action. The Action Plan is structured into 6 strategic objectives with 35 strategic actions. We present an analysis of the strategic actions regarding healthcare organizations and the challenges ahead for their particular deployment in primary health care settings.

Resident Physicians as Patients: Perceptions of Residents and Their Teaching Physicians.

OBJECTIVE: This study aims to broaden understanding into the process by which resident physicians deal with illness and to identify areas for improvement regarding healthcare of residents and teaching physicians training to support them adequately. METHODS: A qualitative study of ten semi-structured interviews with residents who had suffered a serious illness and a focus group of teaching physicians were conducted. Analysis of the interview transcripts was performed using the grounded theory approach, with information divided into five categories: Differences between residents as patients and general patients; confidentiality; feelings and attitudes; learning from illness; and impact on work and training. RESULTS: There are differences between residents and the general population: In the initial stage, diagnosis is made promptly with preferential treatment shown by colleagues. Subsequently, the lack of clear guidelines can lead to poor follow-up. They accept a loss of confidentiality in the process. One of the most serious concerns felt by residents is the impact of their illness on their training as specialists, meaning that teaching physicians are charged with the important role of guaranteeing the resident's proper recovery, return to work, and readaptation to the training program. Teaching physicians demand their own training be reinforced in these aspects. CONCLUSION: There is a need to assess the great diversity observed in training-related decisions made by teaching physicians when residents fall ill. Given the differences observed, more research is required to improve the care provided to sick residents and particularly the teaching physicians training to handle them.

[Conflicts of interest in the medical profession]. / Conflictos de interés en la profesión médica.

In the last decades the world of medicine has become familiar with the disclosure of conflicts of interest (CDI). The requirement for authors to declare their CDIs concerning their publications is a common issue. Another topic for CDI is related to the medical decision making on prescription. Finally, professionals being in positions of responsibility in professional societies or associations and healthcare institutions are asked to show their disclosure of CDI. These debates show up the interest of democratic societies for justice and social ethics that demand fair play in making decisions that may affect third parties, particularly patients. In the present work, the concept and types of CDIs are analyzed, and authors make proposals for the management of CDI in the medical profession.

[Impact of overdiagnosis and overtreatment on the patient, the health system and society]. / Impacto del sobrediagnóstico y sobretratamiento en el paciente, el sistema sanitario y la sociedad.

The medical activity displays a set of skills aimed at improving the health status of people. In this way, diagnoses are made, choices of tests and treatments are made, and decisions are made about what to do and what not to do that affect the lives of patients. In this article, we propose a reflection on overdiagnosis and overtreatment in relation to the factors that promote it and the impact they have on society, on the functioning of the health system and also directly on patients. Finally, we make some proposals on how to address this overuse considering that primary care is a privileged place to adapt and minimize the impact of the actions of the health system on the health of citizens and reduce the incidents of patient safety linked to the overdiagnosis and inappropriate use of tests and treatments that do not add value to the health of patients.

Are Spanish primary care professionals aware of patient safety?

BACKGROUND: Knowledge about safety culture improves patient safety (PS) in health-care organizations. The first contact a patient has with health care occurs at the primary level. We conducted a survey to measure patient safety culture (PSC) among primary care professionals (PCPs) of health centres (HCs) in Spain and analyzed PS dimensions that influence PSC. METHODS: We used Agency for Healthcare Research and Quality (AHRQ) Medical Office Survey on Patient Safety Culture translated and validated into Spanish to conduct a cross-sectional anonymous postal survey. We randomly selected a sample of 8378 PCPs at 289 HCs operated by 17 Regional Health Services. Statistical analysis was performed on sociodemographic variables, survey items, PS dimensions and a patient safety synthetic index (PSSI), calculated as average score of the items per dimension, to identify potential predictors of PSC. We used AHRQ data to conduct international comparison. RESULTS: A total of 4344 PCPs completed the questionnaire. The response rate was 55.69%. Forty-two percent were general practitioners, 34.9% nurses, 18% administrative staff and 4.9% other professionals. The highest scoring dimension was 'PS and quality issues' 4.18 (4.1-4.20) 'Work pressure and pace' was the lowest scored dimension with 2.76 (2.74-2.79). Professionals over 55 years, with managerial responsibilities, women, nurses and administrative staff, had better PSSI scores. Professionals with more than 1500 patients and working for more than 11 years at primary care had lower PSSI scores. CONCLUSIONS: This is the first national study to measure PSC in primary care in Spain. Results may reflect on-going efforts to build a strong PSC. Further research into its association with safety outcomes and patients' perceptions is required.

Open data for monitoring COVID-19 in Spain: Descriptive study.

BACKGROUND: The indicators of the pandemic have been based on the total number of diagnosed cases of COVID-19, the number of people hospitalized or in intensive care units, and deaths from the infection. The aim of this study is to describe the available data on diagnostic tests, health service used for the diagnosis of COVID-19, case detection and monitoring. METHOD: Descriptive study with review of official data available on the websites of the Spanish health councils corresponding to 17 Autonomous Communities, 2 Autonomous cities and the Ministry of Health. The variables collected refer to contact tracing, technics for diagnosis, use of health services and follow-up. RESULTS: All regions of Spain show data on diagnosed cases of COVID-19 and deaths. Hospitalized cases and intensive care admissions are shown in all regions except the Balearic Islands. Diagnostic tests for COVID-19 have been registered in all regions except Madrid region and Extremadura, with scarcely information on what type of test has been performed (present in 7 CCAA), requesting service and study of contacts. CONCLUSIONS: The information available on the official websites of the Health Departments of the different regions of Spain are heterogeneous. Data from the use of health service or workload in Primary Care, Emergency department or Out of hours services are almost non-existent.

How different countries respond to adverse events whilst patients' rights are protected.

Patient safety is high on the policy agenda internationally. Learning from safety incidents is a core component in achieving the important goal of increasing patient safety. This study explores the legal frameworks in the countries to promote reporting, disclosure, and supporting healthcare professionals (HCPs) involved in safety incidents. A cross-sectional online survey was conducted to ascertain an overview of the legal frameworks at national level, as well as relevant policies. ERNST (The European Researchers' Network Working on Second Victims) group peer-reviewed data collected from countries was performed to validate information. Information from 27 countries was collected and analyzed, giving a response rate of 60%. A reporting system for patient safety incidents was in place in 85.2% (N = 23) of countries surveyed, though few (37%, N = 10) were focused on systems-learning. In about half of the countries (48.1%, N = 13) open disclosure depends on the initiative of HCPs. The tort liability system was common in most countries. No-fault compensation schemes and alternative forms of redress were less common. Support for HCPs involved in patient safety incidents was extremely limited, with just 11.1% (N = 3) of participating countries reporting that supports were available in all healthcare institutions. Despite progress in the patient safety movement worldwide, the findings suggest that there are considerable differences in the approach to the reporting and disclosure of patient safety incidents. Additionally, models of compensation vary limiting patients' access to redress. Finally, the results highlight the need for comprehensive support for HCPs involved in safety incidents.

Patient Safety Incidents in Primary Care: Comparing APEAS-2007 (Spanish Patient Safety Adverse Events Study in Primary Care) with Data from a Health Area in Catalonia (Spain) in 2019.

The initial APEAS study, conducted in June 2007, examined adverse events (AEs) in Spanish Primary Healthcare (PHC). Since then, significant changes have occurred in healthcare systems. To evaluate these changes, a study was conducted in the Camp de Tarragona PHC region (CTPHC) in June 2019. This cross-sectional study aimed to identify AEs in 20 PHC centres in Camp de Tarragona. Data collection used an online questionnaire adapted from APEAS-2007, and a comparative statistical analysis between APEAS-2007 and CTPHC-2019 was performed. The results revealed an increase in nursing notifications and a decrease in notifications from family doctors. Furthermore, fewer AEs were reported overall, particularly in medication-related incidents and healthcare-associated infections, with an increase noted in no-harm incidents. However, AEs related to worsened clinical outcomes, communication issues, care management, and administrative errors increased. Concerning severity, there was a decrease in severe AEs, coupled with an increase in moderate AEs. Despite family doctors perceiving a reduction in medication-related incidents, the overall preventability of AEs remained unchanged. In conclusion, the reporting patterns, nature, and causal factors of AEs in Spanish PHC have evolved over time. While there has been a decrease in medication-related incidents and severe AEs, challenges persist in communication, care management, and clinical outcomes. Although professionals reported reduced severity, the perception of preventability remains an area that requires attention.