Transitions in Atrial Fibrillation Care: A Systematic Review.

BACKGROUND: Patients with atrial fibrillation (AF) commonly transition between care settings and providers. These transitions are often points in the health care system where errors and clinical deterioration can occur. Anticoagulation interruption or discontinuation and sub-optimal follow-up post-emergency department (ED) discharge are considered major transitional issues. OBJECTIVE: The purpose of this study was to synthesise the evidence examining the impact of transitional care interventions on patient, provider, and health care utilisation outcomes. METHODS: This systematic mixed studies review examined citations from four databases Medline, CINAHL, EMBASE, and Cochrane Central Controlled Register of Trials (CENTRAL) using relevant search terms. Fourteen (14) moderate to high quality articles were selected. RESULTS: The available evidence reporting impacts of transitional interventions on health care utilisation, provider, and patient outcomes in AF patients is mixed and of variable quality. The stronger evidence revealed improvements in patient outcomes including knowledge, quality of life, and medication adherence and increased provider anticoagulant prescriptions resulting from transitional interventions. Hospital admissions and ED visits were not significantly affected by any interventions. CONCLUSIONS: Apps and educational toolkits improved patient knowledge. Pathways increased patient quality of life and provider prescription rates. There is a need for more research to determine the AF transition interventions which maximise patient, provider and health care outcomes.

Atrial fibrillation care in rural communities: a mixed methods study of physician and patient perspectives.

BACKGROUND: Atrial fibrillation (AF) is a serious heart arrhythmia associated with devastating outcomes such as stroke. Inequitable rural AF care may put patients at risk. Virtually delivered specialty AF care offers a viable option, but stakeholder perceptions of this option within the context of rural AF care is unknown. The study purpose was to obtain patient and primary care physician perspectives of rural AF care and virtually delivered AF care as a potential option. METHODS: Using a mixed methods design, AF patients (n = 101) and physicians (n = 15) from three rural communities participated in focus groups and/or surveys. Focus group data were thematically analyzed, survey data were descriptively analyzed, and data were triangulated. RESULTS: Findings captured patients' and physicians' perceptions of prioritized, needs, concerns and problems in AF management, available/unavailable services, and their ideas about virtual AF care. Patients and physicians identified eclectic problems in managing AF. Overall, patients felt ill informed about managing their AF and their most salient problems related to fatigue, exercise intolerance, weight maintenance, sleep apnea, and worry about stroke and bleeding. Physicians found treating patients with co-morbidities and cognitive decline problematic and balancing risks related to anticoagulation challenging. Patients and physicians identified education as a pressing need, which physicians lacked time and resources to meet. Despite available rural services, access to primary and cardiology care was a recurring challenge, and emergency department (ED) use highly contentious but often the only option for accessing care. Physicians' managed AF care and varied in the referrals they made, often reserving them for complex situations to avoid patient travel. Patients and providers supported a broad approach to virtual AF care, tailored to an inclusive rural patient demographic. CONCLUSIONS: The study offered valuable physician and patient perspectives on AF care in rural communities including diverse management challenges, gaps in access to primary and specialty services that made ED an often used but contentious option. Findings point to the potential value of virtual care designed to reach patients with AF across the spectrum and geared to local contexts that preserve the vital role of primary care physicians in AF care in their communities.

Physical activity patterns in urban neighbourhood parks: insights from a multiple case study.

BACKGROUND: Many characteristics of urban parks and neighbourhoods have been linked to patterns of physical activity, yet untangling these relationships to promote increased levels of physical activity presents methodological challenges. Based on qualitative and quantitative data, this article describes patterns of activity within urban parks and the socio-demographic characteristics of park visitors. It also accounts for these patterns in relation to the attributes of parks and their surrounding neighbourhoods. METHODS: A multiple case study was undertaken that incorporated quantitative and qualitative data derived from first-hand observation in a purposive sample of four urban parks. Quantitative data, based on direct observation of visitors' patterns of use and socio-demographic characteristics, were collected using a structured instrument. Differences in frequencies of observed activities and socio-demographic characteristics of visitors were compared between the four parks. Qualitative data, based on direct observation of park characteristics and patterns of use, were generated through digital photography and analyzed through captioning. Quantitative data on patterns in activity and socio-demographic characteristics were synthesized with the qualitative data on park and usage characteristics. RESULTS: A comprehensive portrait of each park in the study was generated. Activity types (sedentary, walking, dog-related, cycling, and play), patterns of park use (time of day, day of week), and socio-demographic characteristics (age group, social group) differed between the four parks. Patterns in park use and activity appeared to be associated with socio-demographic characteristics of the surrounding neighbourhoods as well as the physical and social environmental characteristics specific to each park. CONCLUSIONS: Both park and neighbourhood characteristics influence patterns of use and physical activity within parks. The study findings suggest that socio-demographic characteristics of neighbourhoods surrounding parks need be considered in planning, development and management. Engaging local communities could help planners to develop and update urban parks in ways that reflect the needs and characteristics of community residents and, in turn, encourage visits and more physical activity amongst visitors.

The Landscape of Health Technology for Equity Deserving Groups in Rural Communities: A Systematic Review.

BACKGROUND: Equity-deserving groups face well-known health disparities that are exacerbated by rural residence. Health technologies have shown promise in reducing disparities among these groups, but there has been no comprehensive evidence synthesis of outcomes. PURPOSE: The purpose of this systematic review was to examine the patient, healthcare, and economic outcomes of health technology applications with rural living equity-deserving groups. RESEARCH DESIGN: The databases searched included Medline and Embase. Articles were assessed for bias using the McGill mixed methods appraisal tool. ANALYSIS: Data were synthesized narratively using a convergent integrated approach for qualitative and quantitative findings. RESULTS: This evidence synthesis includes papers (n = 21) that reported on health technologies targeting rural equity-deserving groups. Overall, patient outcomes - knowledge, self-efficacy, weight loss, and clinical indicators - improved. Healthcare access improved with greater convenience, flexibility, time and travel savings, though travel was still occasionally necessary. All studies reported satisfaction with health technologies. Technology challenges reported related to connectivity and infrastructure issues influencing appointment quality and modality options. While some studies reported additional costs, overall, studies indicated cost savings for patients. CONCLUSIONS: There is a paucity of research on health technologies targeting rural equity-deserving groups, and the available research has primarily focused on women. While current evidence was primarily of high quality, research is needed inclusive of equity-deserving groups and interventions co-designed with users that integrate culturally sensitive approaches. Review registered with Prospero ID = CRD42021285994.

Personal Health Record implementation in rural primary care: A descriptive exploratory study using RE-AIM framework.

Demand is emerging for personal health records (PHRs), a patient-centric digital tool for engaging in shared decision-making and healthcare data management. This study uses a RE-AIM framework to explore rural patients and providers' perceptions prior to and following implementation of a PHR. Health care providers and their patients were recruited from early-adopter patient medical home clinics and a local patient advisory group. Focus groups were used to explore patient and provider pre-implementation perceptions of PHRs and post-implementation provider perspectives. Patients were invited through participating clinics to use the PHR. An implementation process evaluation was conducted. Multiple methods and data sources were used and included pre-/post-intervention patient surveys, provider interviews, and PHR/EHR administrative data. Both patient and provider focus groups described PHRs as providing a comprehensive health story and enhanced communication. Patients prioritized collection of health promotion data while providers endorsed health-related, clinical data. Both groups expressed the need for managing expectations and setting boundaries on PHR use. The evaluation indicated Reach: 16% of targeted patients participated and an additional 127 patients used the PHR as a tool during the COVID-19 pandemic. Effectiveness: Patient satisfaction with use was neutral, with no significant changes to quality of life, self-efficacy, or patients' activation. Adoption: 44% of eligible clinics participated, primarily those operated publicly versus privately, in smaller communities, and farther from a regional hospital. Implementation: Despite system interoperability expectations, at time of roll out, information exchange standards had not been reached. Additional implementation complications arose from the onset of the pandemic. One clinic on-boarded additional patients resulting in a rapid spike in PHR use. Maintenance: All clinics discontinued PHR within the study period, citing several key barriers to use. RE-AIM offers a valuable process evaluation framework for a comprehensive depiction of impact, and how to drive future success. Interoperability, patient agency and control, and provider training and support are critical obstacles to overcome in PHR implementation.

Generating user-driven patient personas to support preventive health care activities of rural-living unattached patients.

Objective: This study created personas using quantitative segmentation and knowledge user enhancement to inform intervention and service design for rural patients to encourage preventive care uptake. Methods: This study comprised a cross-sectional survey of rural unattached patients and a co-design workshop for persona development. Cross-sectional survey data were analyzed for meaningful subgroups based on quartiles of preventive care completion. These quartiles informed "relevant user segments" grouped according to demographics (age, sex), length of unattachment, percentage of up-to-date preventive activities, health care visit frequency, preventive priorities, communication confidence with providers, and chronic health conditions, which were then used in the workshop to build the final personas. Results: 207 responses informed persona user segments, and five health care providers and 13 patients attended the workshop. The resulting four personas, included John (not up-to-date on preventive care activities), Terrance (few up-to-date preventive care activities), George (moderately up-to-date preventive care activities), and Anne (mostly up-to-date preventive care activities). Conclusion: Quantitative persona development with integrated knowledge user co-design/enhancement elevated and enriched final personas that achieved robust profiles for intervention design. Innovation: This project's use of a progressive methodology to build robust personas coupled with participant feedback on the co-design process offers a replicable approach for health researchers.

Assessing the impact of atrial fibrillation self-care interventions: A systematic review.

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population.

Patients' Experiences With the Fit of Virtual Atrial Fibrillation Care During the Pandemic: Qualitative Descriptive Study.

BACKGROUND: In-person health care has been the standard model of care delivery for patients with atrial fibrillation (AF). Despite the growing use of remote technology, virtual health care has received limited formal study in populations with AF. Understanding the virtual care experiences of patients in specialized AF clinics is essential to inform future planning of AF clinic care. OBJECTIVE: This qualitative descriptive study aimed to understand patients' virtual AF clinic care experiences during the COVID-19 pandemic. METHODS: Participants were recruited from a pool of patients who were receiving care from an AF clinic and who were enrolled in a larger survey study. A total of 8 virtual focus groups (n=30) were conducted in 2 waves between March 2021 and May 2021. Facilitators used a semistructured discussion guide to ask participants questions about their experiences of virtual care and the perceived quality of virtual care and technology support. Three team members initially open coded group data to create a preliminary coding framework. As the analysis progressed, with subsequent focus groups, the code clusters were refined. RESULTS: The participants were primarily male (21/30, 70%), aged ≥65 years (20/30, 67%), and college graduates (22/30, 73%). Patients found virtual care to be highly beneficial. Central to their experiences of virtual care was its fit or lack of fit with their health needs, which was integrally connected to communication effectiveness and their preferred virtual care future. Practical benefits included flexibility, convenience, and time and cost savings of virtual care. Virtual care fit occurred for small, quick, and mundane issues (eg, medication refills) but was suboptimal for new and more complex issues that patients thought warranted an in-person visit. Fit often reflected the effectiveness of communication between patient and provider and that of in-clinic follow-up. There was near-complete agreement among participants on the acceptability of virtual communication with their providers in addressing their needs, but this depended on adequate reciprocal communication. Without the benefit of in-person physical assessments, patients were uncertain and lacked confidence in communicating the needed, correct, and comprehensive information. Finally, participants described concerns related to ongoing virtual care with recommendations for their preferred future using a hybrid model of care and integrating patient-reported data (ie, blood pressure measurements) in virtual care delivery. CONCLUSIONS: Virtual care from a specialty AF clinic provides practical benefits for patients, but they must be weighed against the need for virtual care's fit with patients' needs and problems. The stability and complexity of patients' health needs, their management, and their perceptions of communication effectiveness with providers and clinics must be considered in decisions about appointment modality. Patients' recommendations for future virtual care through use of hybrid models together with systems for data sharing have the potential to optimize fit.

Telehealth Satisfaction in Patients Receiving Virtual Atrial Fibrillation Care: Quantitative Exploratory Study.

BACKGROUND: Telehealth can optimize access to specialty care for patients with atrial fibrillation (AF). Virtual AF care, however, may not fit with the complex needs of patients with AF. OBJECTIVE: This study aims to explore the correlation among attitudes toward health care technologies, self-efficacy, and telehealth satisfaction as part of the future planning of virtual AF clinic care. METHODS: Patients with AF older than 18 years from an urban-based, highly specialized AF clinic who had an upcoming telehealth visit were invited to participate in a web-based survey. The survey asked about demographic characteristics; use of technology; general, computer, and health care technology self-efficacy (HTSE) and health care technology attitudes, using a validated 30-item tool; and telehealth satisfaction questionnaire using a validated 14-item questionnaire. Data were analyzed with descriptive statistics, correlational analyses, and linear regression modeling. RESULTS: Participants (n=195 of 579 invited, for a 34% response rate) were primarily older, male, and White, had postsecondary schooling or more, and had high self-reported overall and mental health ratings. A variety of technologies were used in their daily lives and for health care, with the majority of technologies comprising desktop and laptop computers, smartphones, and tablets. Self-efficacy and telehealth satisfaction questionnaire scores were high overall, with male participants having higher general self-efficacy, computer self-efficacy, HTSE, and technology attitude scores. After controlling for age and sex, only HTSE was significantly related to individuals' attitudes toward health care technology. Both general self-efficacy and attitude toward health care technology were positively related to telehealth satisfaction. CONCLUSIONS: Consistent with a previous study, only HTSE significantly influenced attitudes toward health care technology. This finding confirms that, in this regard, self-efficacy is not a general perception but is domain specific. Considering participants' predominant use of the telephone for virtual care, it follows that general self-efficacy and attitude toward health care technology were significant contributors to telehealth satisfaction. Given our patients' frequent use of technology and high computer self-efficacy and HTSE scores, the use of video for telehealth appointments could be supported.

Quality of life among patients with atrial fibrillation: A theoretically-guided cross-sectional study.

BACKGROUND: Patients with atrial fibrillation (AF) have significantly lower health-related quality of life (HRQoL) compared to the general population and patients with other heart diseases. The research emphasis on the influence of AF symptoms on HRQoL overshadows the role of individual characteristics. To address this gap, this study's purpose was to test an incremental predictive model for AF-related HRQoL following an adapted HRQoL conceptual model that incorporates both symptoms and individual characteristics. METHODS: Patients attending an AF specialty clinic were invited to complete an online survey. Hierarchical regression analyses were conducted to examine whether individual characteristics (overall mental health, perceived stress, sex, age, AF knowledge, household and recreational physical activity) incremented prediction of HRQoL and AF treatment satisfaction beyond AF symptom recency and overall health. RESULTS: Of 196 participants (mean age 65.3 years), 63% were male and 90% were Caucasian. Most reported 'excellent' or 'good' overall and mental health, had high overall AF knowledge scores, had low perceived stress scores, and had high household and recreation physical activity. The mean overall AF Effect On Quality-Of-Life Questionnaire (AFEQT) and AF treatment satisfaction scores were 70.62 and 73.84, respectively. Recency of AF symptoms and overall health accounted for 29.6% of the variance in overall HRQoL and 20.2% of the variance in AF treatment satisfaction. Individual characteristics explained an additional 13.6% of the variance in overall HRQoL and 7.6% of the variance in AF treatment satisfaction. Perceived stress and household physical activity were the largest contributors to overall HRQoL, whereas age and AF knowledge made significant contributions to AF treatment satisfaction. CONCLUSIONS: Along with AF symptoms and overall health, individual characteristics are important predictors of HRQoL and AF treatment satisfaction in AF patients. In particular, perceived stress and household physical activity could further be targeted as potential areas to improve HRQoL.

Managing With Atrial Fibrillation: An Exploratory Model-Based Cluster Analysis of Clinical and Personal Patient Characteristics.

Background: Examining characteristics of patients with atrial fibrillation (AF) has the potential to help in identifying groups of patients who might benefit from different management approaches. Methods: Secondary analysis of online survey data was combined with clinic referral data abstraction from 196 patients with AF attending an AF specialty clinic. Cluster analyses were performed to identify distinct, homogeneous clusters of AF patients defined by 11 relevant variables: CHA2DS2-VASc score, age, AF symptoms, overall health, mental health, AF knowledge, perceived stress, household and recreation activity, overall AF quality of life, and AF symptom treatment satisfaction. Follow-up analyses examined differences between the cluster groups in additional clinical variables. Results: Evidence emerged for both 2- and 4-cluster solutions. The 2-cluster solution involved a contrast between patients who were doing well on all variables (n = 129; 66%) vs those doing less well (n = 67; 34%). The 4-cluster solution provided a closer-up view of the data, showing that the group doing less well was split into 3 meaningfully different subgroups of patients who were managing in different ways. The final 4 clusters produced were as follows: (i) doing well; (ii) stressed and discontented; (iii) struggling and dissatisfied; and (iv) satisfied and complacent. Conclusions: Patients with AF can be accurately classified into distinct, natural groupings that vary in clinically important ways. Among the patients who were not managing well with AF, we found 3 distinct subgroups of patients who may benefit from tailored approaches to AF management and support. The tailoring of treatment approaches to specific personal and/or behavioural patterns, alongside clinical patterns, holds potential to improve patient outcomes (eg, treatment satisfaction).

Contexte: L'examen des caractéristiques des patients atteints de fibrillation auriculaire (FA) pourrait permettre de mieux cerner les groupes qui pourraient bénéficier de différentes approches de prise en charge. Méthodologie: Nous avons combiné une analyse secondaire de données issues d'un sondage en ligne et les données issues de l'orientation clinique de 196 patients atteints de FA d'une clinique spécialisée en FA. Des analyses par grappes ont été réalisées pour cerner des groupes homogènes et distincts de patients atteints de FA, définis grâce à 11 variables pertinentes : score CHA2DS2-VASc, âge, symptômes de FA, état de santé général, état de santé mentale, niveau de connaissances sur la FA, niveau de stress perçu, activités récréatives et domestiques, qualité de vie générale avec la FA, et satisfaction concernant le traitement des symptômes de FA. Des ana-lyses ultérieures ont permis de se pencher sur les différences entre les groupes pour d'autres variables cliniques. Résultats: Deux solutions de regroupement des patients sont apparues possibles à l'analyse : en 2 groupes ou en 4 groupes. Le regroupement en 2 groupes mettait en relief le contraste entre les patients qui avaient des résultats favorables pour tous les paramètres (n = 129; 66 %) et ceux qui avaient des résultats moins favorables (n = 67; 34 %). Le regroupement en 4 groupes permettait d'observer les données plus en détail, et démontrait que le groupe avec des résultats moins favorables se subdivisait en 3 sous-groupes avec des distinctions pertinentes, qui vivaient leur maladie de façon différente. Les 4 groupes finaux étaient les suivants : (i) patients avec une expérience positive; (ii) patients vivant du stress et du mécontentement; (iii) patients vivant des difficultés et une insatisfaction; et (iv) patients vivant une satisfaction complaisante. Conclusions: Les patients atteints de FA peuvent être classés avec exactitude dans des groupes naturels distincts dont les différences sont d'intérêt clinique. Parmi les patients chez qui la prise en charge de la FA n'est pas optimale, il existe 3 sous-groupes différents qui pourraient tirer profit d'une approche de soutien et de prise en charge adaptée à leur profil. La personnalisation des approches thérapeutiques selon le type de comportements et de traits de personnalité, en plus du tableau clinique, pourrait permettre d'améliorer les résultats des patients (p. ex. la satisfaction par rapport au traitement).

Usability and Feasibility Testing of an Atrial Fibrillation Educational Website with Patients Referred to an Atrial Fibrillation Specialty Clinic.

BACKGROUND: The purpose of this study was to design, usability test, and explore the feasibility of a web-based educational platform/intervention for patients with atrial fibrillation (AF) as part of their virtual AF care. METHODS: Participants were patients attending a specialized AF clinic. The multiple mixed-methods design included website design, think-aloud usability test, 1-month unstructured pre-testing analysis using Google Analytics, follow-up interviews, and a non-randomized one-group feasibility test using pre/post online surveys and Google Analytics. RESULTS: Usability testing participants (n = 2) guided adjustments for improving navigation. Pre-testing participants' (n = 9) website activity averaged four sessions (SD = 2.6) at 10 (SD 8) minutes per session during a 1-month study period. In the feasibility test, 30 patients referred to AF specialty clinic care completed the baseline survey, and 20 of these completed the 6-month follow-up survey. A total of 19 patients accessed the website over the 6 months, and all 30 participants were sent email prompts containing information from the website. Health-related quality of life, treatment satisfaction, household activity, and AF knowledge scores were higher at follow-up than baseline. There was an overall downward trend in self-reported healthcare utilization at follow-up. CONCLUSIONS: Access to a credible education website for patients with AF has great potential to complement virtual and hybrid models of care.

Has Virtual Care Arrived? A Survey of Rural Canadian Providers During the Early Stages of the COVID-19 Pandemic.

We investigated the uptake and perceptions of virtual care solutions by rural Canadian primary and specialist providers during the early phase (May-June 2020) of the COVID-19 pandemic. A web-based, cross-sectional survey of rural primary and specialty care providers examined types of virtual care platforms used (eg, phone, video), appointment length, experience and satisfaction with the solution used, plans for future use of virtual care, and patients' use of virtual care services. Targeted participants were actively-practicing providers in rural Western Canada who were emailed an invitation for the study and its survey link. Fifty-nine providers (26% response rate) completed the survey. During the pandemic, 78% of providers reported using virtual care for more than 60% of their appointments, while only 3% did so frequently pre-pandemic. Most providers used phone consultations, despite believing that video provided a better virtual visit. Key barriers included workflow interruptions, unique concerns about quality of care, remuneration and sustainability, or poor internet access and bandwidth for both providers and patients. The key opportunity noted was improved access to care. While most virtual care visits were not conducted using video technologies, overall virtual care resulted in high provider satisfaction, while not increasing workload. Virtual care will continue to play an important role in future rural care practice; however, sustainability will require both provider-level and system-level changes.

Empowering Patients Through Virtual Care Delivery: Qualitative Study With Micropractice Clinic Patients and Health Care Providers.

BACKGROUND: Prior to the wider adoption of digital health technologies during the COVID-19 pandemic, applications of virtual care were largely limited to specialist visits and remote care using telehealth (phone or video) applications. Data sharing approaches using tethered patient portals were mostly built around hospitals and larger care systems. These portals offer opportunities for improved communication, but despite a belief that care has improved, they have so far shown few outcome improvements beyond medication adherence. Less is known about use of virtual care and related tools in the outpatient context and particularly in rural community contexts. OBJECTIVE: This study aims to reflect on the opportunities and barriers for sustainable virtual care through an example of a digitally enabled rural micropractice, which has provided 10%-15% virtual care since 2016 and 70% virtual care since March 2020. METHODS: Three focus groups, 1 with providers (physician and medical office manager) and 2 with a total of 8 patients from a rural micropractice in British Columbia, were conducted in November 2020 and December 2020. Virtual care delivery was explored through the topics of communication approach, mixing virtual and in-person care, the practice team's journey in developing these approaches, and provider and patient satisfaction with the care model. Interviews were transcribed, checked for accuracy against recordings, and thematically analyzed. RESULTS: Both patients and providers reported ease of communication and high satisfaction. Either could initiate communication, and patients found the ability to share health information asynchronously through the portal allowed time to reflect and prepare their thoughts. Patients were highly engaged and reported feeling empowered and true partners in their health care, although they noted limited care coordination with specialists. The mix of virtual and in-person visits was highly regarded by patients and providers, and patients reported feeling safe and cared for 24/7, although both expressed concern about work spilling into the provider's home life. The physician worried about missed diagnoses with virtual care. With respect to establishing the micropractice, solutions took about 5 years to optimize, with providers noting a learning curve requiring technical support for both themselves and their patients and a willingness to respond to patient feedback to identify the best solutions. Despite a mature virtual practice, patients reported deferred care due to COVID-19. CONCLUSIONS: The micropractice's hybrid care model encouraged patients to be true partners in their care and resulted in high patient engagement and satisfaction; yet, success may rely on the patient population being willing to engage and being comfortable with technology. Barriers lie in gaps in care coordination and provider fear that signs or symptoms more evident with an in-person exam could be missed. Even in this setting, deferral of care in light of COVID-19 was present, and opportunities to address care gaps should be sought.

Telehealth Use for Enhancing the Health of Rural Older Adults: A Systematic Mixed Studies Review.

BACKGROUND AND OBJECTIVES: Telehealth holds potential for inclusive and cost-saving health care; however, a better understanding of the use and acceptance of telehealth for health promotion among rural older adults is needed. This systematic review aimed to synthesize evidence for telehealth use among rural-living older adults and to explore cost-effectiveness for health systems and patients. RESEARCH DESIGN AND METHODS: This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study designs reporting health promotion telehealth interventions with rural-living adults aged 55 and older were eligible for review. Following screening and inclusion, articles were quality-rated and ranked by level of evidence. Data extraction was guided by the Technology Acceptance Model and organized into outcomes related to ease of use, usefulness, intention to use, and usage behavior along with cost-effectiveness. RESULTS: Of 2,247 articles screened, 42 were included. Positive findings for the usefulness of telehealth for promoting rural older adults' health were reported in 37 studies. Evidence for ease of use and usage behavior was mixed. Five studies examined intention to continue to use telehealth and in 4 of these, patients preferred telehealth. Telehealth was cost-effective for health care delivery (as a process) compared to face to face. However, findings were mixed for cost-effectiveness with both reports of savings (e.g., reduced travel) and increased costs (e.g., insurance). DISCUSSION AND IMPLICATIONS: Telehealth was useful for promoting health among rural-living older adults. Technological supports are needed to improve telehealth ease of use and adherence. Cost-effectiveness of telehealth needs more study, particularly targeting older adults.

A cross-sectional study of the preventive health care activities of western Canadian rural-living patients unattached to primary care providers.

Prevention services, such as screening tests and vaccination, are underutilized, especially by rural populations and patients without a usual primary care provider. Little is known about the compounding impacts on preventive care of being unattached and living in a rural area and there has been no comprehensive exploration of this highly vulnerable population's prevention activities. The twofold purpose of this research was to examine rural unattached patients' prevention activity self-efficacy and completion and to explore their experiences accessing healthcare, including COVID-19 impacts. Two thirds of patients had been unattached for over one year, and over 20 % had been unattached for over 5 years; males experienced longer unattachment compared to females. Completion rates of prevention activities were relatively low, ranging from 5.9 % (alcohol screening) to 59 % (vision test). Most participants did not complete their prevention care activities in line with the Lifetime Prevention Schedule timeline: 65 % of participants had less than half of their activities up-to-date and only 6.7 % of participants were up to date on 75 % or more of their prevention activities. Participants with higher prevention self-efficacy scores were more likely to be up-to-date on associated prevention activities but the longer patients had been unattached, the fewer their up-to-date prevention activities. Patients expressed negative impacts of COVID-19 including walk-in clinics shutting down limiting access to care. These results suggest serious gaps in rural unattached patients' preventive care and highlight the need for support when they are without a usual primary care provider, which can be lengthy.

Perceptions of Personal Health Records in Rural Primary Health Clinics in Canada - Patient Perspectives.

Personal health records are increasingly being deployed in healthcare settings. In this study we explored patients' perceptions of personal health records in a rural community in Canada where a primary health network is being deployed. A focus group was held and data were thematically analysed. All patients used technology on a regular basis. Themes included communication and information sharing, issues with access to prior health records, data content and data control and features and functions for continuity of care. Participants expressed desire to be owners of their own record, but described instances where they might be too ill to do so. Participants were hopeful that the functions of a personal health record might help to overcome frustrations with current fragmented information and open to using technologies as part of their care process. Personal health records are promising technologies to overcome fragmented care in rural communities.

Preferred Functions of Personal Health Records in Rural Primary Health Clinics in Canada: Health Care Team Perspectives.

BACKGROUND: Personal health records (PHR) provide opportunities for improved patient engagement, collection of patient-generated data, and overcome health-system inefficiencies. While PHR use is increasing, uptake in rural populations is lower than in urban areas. OBJECTIVES: The study aimed to identify priorities for PHR functionality and gain insights into meaning, value, and use of patient-generated data for rural primary care providers. METHODS: We performed PHR preimplementation focus groups with rural providers and their health care teams from five primary care clinics in a sparsely populated mountainous region of British Columbia, Canada to obtain their understanding of PHR functionality, needs, and perceived challenges. RESULTS: Eight general practitioners (GP), five medical office assistants, two nurse practitioners (NP), and two registered nurses (14 females and 3 males) participated in focus groups held at their respective clinics. Providers (GPs, NPs, and RNs) had been practicing for a median of 9.5 (range = 1-38) years and had used an electronic medical record for 7.0 (1-20) years. Participants expressed interest in incorporating functionality around two-way communication and appointment scheduling, previsit data gathering, patient and provider data sharing, virtual care including visits using videoconferencing tools, and postvisit sharing of educational materials. Three further themes emerged from the focus groups: (1) the context in which the providers' practice matters, (2) the need for providing patients and providers with choice (e.g., which data to share, who gets to initiate/respond in communications, and processes around virtual care visits), and (3) perceived risks of system use (e.g., increased complexity for older patients and workload barriers for the health care team). CONCLUSION: Rural primary care teams perceived PHR opportunities for increased patient engagement and access to patient-generated data, while worries about changes in workflow were the biggest perceived risk. Recommendations for PHR adoption in a rural primary health network include setting provider-patient expectations about response times, ability to share notes selectively, and automatically augmented note-taking from virtual-care visits.

News Article Portrayal of Virtual Care for Health Care Delivery in the First 7 Months of the COVID-19 Pandemic.

Objectives: The onset of the 2020 coronavirus pandemic resulted in rapid implementation of virtual care solutions at an unprecedented pace. The news media, as a trusted source for many Canadians, plays a vital role during emergencies by reporting on changes in health care protocols, policies, and technologies. This article presents the results of a qualitative analysis of Canadian news articles between February and August of 2020 to identify critical themes with respect to virtual care. Methods: A full-text search of the database Canadian Newsstream resulted in 1542 articles (708 duplicates), of which 294 articles were included in the final analysis. Inductive analysis was used to generate themes and identify voices, contradictions, and tensions in the articles. Results: Analysis generated four themes: coronavirus disease (COVID-19) as a catalyst for virtual care, safety and protection, economic impacts, and telehealth as a model of care. Media portrayals represented some voices (e.g., physicians) while limiting others (e.g., patients), reflected some contradictory messaging with respect to safety and protection, and raised key issues and concerns about virtual health care delivery during the first 7 months of COVID-19. Conclusions: Our findings of successful and rapid uptake, uses and concerns around funding, and privacy and virtual care adoption reported in the news media can be used to inform longer term implementation and sustainability. Policy makers could benefit from crafting messages that balance information and reassurance. Public/patient perspectives, which were largely missing from news media, are needed to gauge receptivity and sustainability.

The impact of nurse-led atrial fibrillation clinics on patient and healthcare outcomes: a systematic mixed studies review.

BACKGROUND: Atrial fibrillation, the most common arrhythmia worldwide, continues to increase as the population ages. Patients with atrial fibrillation, particularly those newly diagnosed or who have multiple comorbidities, have high healthcare utilisation rates. Nurse-led atrial fibrillation clinics have developed to improve care and guidance for atrial fibrillation patients, with the potential to reduce hospital presentations and healthcare utilisation. Atrial fibrillation clinics that provide specialised and patient-centred care have improved patient symptom management, quality of life and reduced healthcare utilisation and costs. AIMS: The aim of this study was to provide the first synthesis of evidence for the impact of nurse-led atrial fibrillation clinics on patient, healthcare utilisation, and quality of care outcomes. METHODS: This systematic mixed studies review examined citations from three databases: Medline, CINAHL and Embase, using the search terms 'atrial fibrillation' and 'clinic', and related concepts. Seventeen moderate to high quality articles were selected. RESULTS: Overall, atrial fibrillation clinics were more cost effective, had shorter wait times and reduced hospitalisation and emergency department visits. Symptoms and sinus rhythm restoration were comparable in the nurse-led compared to physician-led cardioversion clinics. Findings related to patient knowledge and patient satisfaction were mixed, while mortality rates were lower, and patient medication adherence was higher in nurse-led atrial fibrillation compared to usual care. Quality of life and guideline adherence was increased in patients receiving nurse-led atrial fibrillation care compared to usual care. CONCLUSION: Nurse-led clinics improved healthcare, patient and quality care outcomes. Future research might examine the role of technology in delivery of nurse-led clinics in rural/remote areas as well as patient experiences with nurse-led clinics.