Determinants for use of direct-to-consumer telemedicine consultations in primary healthcare-a registry based total population study from Stockholm, Sweden

Differences in use of telemedicine integrated into traditional primary health care - a comparative observational study

Telemedicine in primary health care is expected to address many of the issues currently challenging service delivery. However, the impact and effect will depend on who will use the new technology.

OBJECTIVE

The objective of the study was to investigate differences between users and non-users of telemedicine integrated into traditional office-based primary health care.

METHODS

Quantitative registry-based population study in two regions in the southeast part of Sweden (n = 73,486), comparing users with non-users of telemedicine across the variables sex, age, socioeconomic status (SES), morbidity and health care seeking behaviour (HSB). Two study periods of six months were used (September 2019-February 2020 for Region Östergötland, and September 2021-February 2022 for Region Kalmar County) to collect user data. A reference period of 36 months (September 2016-August 2019) was used, to collect data on HSB.

RESULTS

Users were more often women under the age of 60 and had higher morbidity (measured as resource utilisation) than non-users (p < .001). In contrast, no statistically significant differences were seen between the two groups regarding SES, measured as Care Need Index (CNI). Regarding HSB, a proxy measure (health record entries) showed more entries for users than non-users.

CONCLUSIONS

Our findings suggest that users are more likely to be women and below the age of 60. Likewise, users also tend to have a greater need for health care services compared to non-users, and they seek health care more often compared to non-users. No differences regarding SES were found.

To connect or not connect: long-term adoption of video consultations, and reasons for discontinuing use

IntroductionThis study investigates factors related to long-term and short-term adoption of video consultations (VCs) and reasons for discontinuing use among primary care patients.MethodsA sample of primary care patients using VCs with healthcare providers were invited to take a survey in a cross-sectional study. Participants were asked about their intention to continue to have video consultations in the future, and those indicating no intention to use VCs in the future (short-term adopters) were asked about their reasons for this. Prevalence and statistical differences between long-term and short-term adopters were investigated.ResultsThere were several statistically significant differences between long-term and short-term adopters (76% vs. 24%). Long-term adopters consisted of more middle-aged individuals (35-54 years) and the majority worked full-time (56%). They had more positive opinions of VCs and used VCs and video meetings for other purposes to a larger extent. They chose VCs because of the lack of time to go to the healthcare centre and because their provider offered them. The most common reason for discontinuing use was a preference for face-to-face consultations, with the youngest age group (16-34 years) reporting this to a larger extent.DiscussionYounger and older age groups may be less likely to continue the use of VCs, potentially preserving the digital divide. Additionally, disparities in using similar technologies might contribute to the digital divide. Moreover, convenience, positive opinions of VCs, and experience with VCs were related to long-term adoption. Further studies are needed to explore non-use, age's influence, and address usability issues.

A new normal in primary care: the rapid normalization of a major eHealth program in public health centers

BACKGROUND

This study aimed to contribute to a better understanding of the context, mechanisms and outcomes in the implementation process of an eHealth video consultation program in primary care. The study focused on how the program is normalized in the primary care setting. The primary research question for this study is "in what ways is the implementation of video consultation normalized in primary care?".

METHODS

The qualitative design and content analysis of primary data from the transcripts were based on in-depth interviews, complemented with free-text answers to open-ended survey questions and various documents. The study focuses on the large-scale implementation of the public eHealth program Närhälsan Online, which represents more than 100 health centers in Sweden's largest region of Västra Götaland. Multiagent perspectives on how the program is normalized were drawn from expressed perceptions by professions directly linked to both strategic and functional implementation, as well as administration and clinical operation.

RESULTS

This study both confirms and enhances the field with a theoretical contribution in six ways to the reviewed previous research, as well as showing practical implications. It also provides multi-agent perspectives on the rapid normalization of the implementation program studied.

CONCLUSIONS

In relation to the rapid progression of different initiatives in eHealth, this study contributes to perspectives on specific challenges as expressed by professions directly linked to both strategic and functional implementation as well as administration and clinical operation.

Behavioural intentions towards use of digital video consultations in primary care: a survey study on physicians', nurses' and psychologists' perceptions in Swedish primary care

OBJECTIVES

The study aimed to describe the experiences of physicians, nurses and psychologists employed in primary care in using digital video consultations. The second objective was to study the association between the predictors of behaviour and behavioural intentions to use digital consultations and to relate underlying behavioural beliefs to experiences of digital consultations in primary care. Overall, the research questions focused on the association between previous training, profession or theory-based behavioural predictors and behavioural intentions to use digital video consultations.

DESIGN

A web survey based on the theory of planned behaviour was sent to primary care professionals in western Sweden who had implemented digital video consultations. The questionnaire contained both closed and open-ended questions focusing on theory-based predictors of behavioural intentions, such as as attitudes, subjective norms and perceived behavioural control. Data were analysed with a mixed-methods approach using quantitative and qualitative analyses.

PARTICIPANTS

The questionnaire was distributed between June and October 2022 to 140 primary healthcare centres in western Sweden, of which 47 agreed to participate. Overall, the questionnaire was sent out to 969 clinicians, representing physicians, nurses and psychologists.

RESULTS

Physicians and nurses had lower experience and less positive attitudes towards digital video consultations compared with psychologists. No statistically significant differences were seen among the groups in behavioural intentions to use digital video consultations. The regression analysis showed that attitude was the strongest predictor of behavioural intentions among primary care physicians, while attitude and perceived behavioural control were associated with behavioural intentions among nurses. No associations between predictors and intentions were found among psychologists.

CONCLUSIONS

The medical professionals reported high behavioural intentions to use digital video consultation despite different levels of experience. Attitude and perceived behavioural control were predictors of behavioural intentions among physicians and nurses, indicating that future implementation should consider the professions' participation in the process.

eVisits to primary care and subsequent health care contacts: a register-based study

BACKGROUND

Evidence concerning health care use related to virtual visits is conflicting. More research has been called for regarding the effectiveness of text-based virtual visits (eVisits). Therefore, we investigated patient characteristics, diagnoses, and subsequent health care contacts after eVisits to primary care.

METHODS

We conducted a register-based cohort study of eVisits to an all-virtual public primary care unit in Sweden and subsequent health care contacts within 14 days. Data for 2021 were acquired from the regional health care databases. Diagnoses were sorted into relevant diagnostic groups, such as skin diagnoses and respiratory tract diagnoses. Multiple logistic regression was performed with subsequent health care contact as the outcome variable and diagnostic group for the eVisit as the predictor variable. Analyses were adjusted for age, sex, and socioeconomic index.

RESULTS

There were 5817 eVisits to a nurse and 4267 eVisits to a general practitioner (N = 10 084). Most patients were 20 to 39 years of age (41.8%). Skin diagnoses were most frequent (47.3%), followed by respiratory tract diagnoses (19.9%). Approximately one-fourth (25.8%) of the patients who completed an eVisit with a nurse or a general practitioner had a subsequent face-to-face visit within 14 days, mostly in primary care. Subsequent contacts were more frequent after an eVisit to a nurse than to a general practitioner. After an eVisit to a general practitioner, patients with infections (especially respiratory tract but also urinary tract) and unspecified diagnoses (especially skin-related) were more likely to require further health care contact compared to a group with various other diagnoses.

CONCLUSIONS

eVisits to an all-virtual primary care unit may be appropriate for uncomplicated medical complaints. Nonetheless, the effectiveness of eVisits in terms of substitution of physical visits, and resource utilization in relation to the more complex care needs of a primary care population, should be further studied.

Analysis of Demographic and Socioeconomic Factors Influencing Adherence to a Web-Based Intervention Among Patients After Acute Coronary Syndrome: Prospective Observational Cohort Study

BACKGROUND

Although telemedicine has been proven to have significant potential for improving care for patients with cardiac problems, there remains a substantial risk of introducing disparities linked to the use of digital technology, especially for older or socially vulnerable subgroups.

OBJECTIVE

We investigated factors influencing adherence to a telemedicine-delivered health education intervention in patients with ischemia, emphasizing demographic and socioeconomic considerations.

METHODS

We conducted a descriptive, observational, prospective cohort study in consecutive patients referred to our cardiology center for acute coronary syndrome, from February 2022 to January 2023. Patients were invited to join a web-based health educational meeting (WHEM) after hospital discharge, as part of a secondary prevention program. The WHEM sessions were scheduled monthly and used a teleconference software program for remote synchronous videoconferencing, accessible through a standard computer, tablet, or smartphone based on patient preference or availability.

RESULTS

Out of the 252 patients (median age 70, IQR 61.0-77.3 years; n=189, 75% male), 98 (38.8%) declined the invitation to participate in the WHEM. The reasons for nonacceptance were mainly challenges in handling digital technology (70/98, 71.4%), followed by a lack of confidence in telemedicine as an integrative tool for managing their medical condition (45/98, 45.9%), and a lack of internet-connected devices (43/98, 43.8%). Out of the 154 patients who agreed to participate in the WHEM, 40 (25.9%) were unable to attend. Univariable logistic regression analysis showed that the presence of a caregiver with digital proficiency and a higher education level was associated with an increased likelihood of attendance to the WHEM, while the converse was true for increasing age and female sex. After multivariable adjustment, higher education level (odds ratio [OR] 2.26, 95% CI 1.53-3.32; P<.001) and caregiver with digital proficiency (OR 12.83, 95% CI 5.93-27.75; P<.001) remained independently associated with the outcome. The model discrimination was good even when corrected for optimism (optimism-corrected C-index=0.812), as was the agreement between observed and predicted probability of participation (optimism-corrected calibration intercept=0.010 and slope=0.948).

CONCLUSIONS

This study identifies a notable lack of suitability for a specific cohort of patients with ischemia to participate in our telemedicine intervention, emphasizing the risk of digital marginalization for a significant portion of the population. Addressing low digital literacy rates among patients or their informal caregivers and overcoming cultural bias against remote care were identified as critical issues in our study findings to facilitate the broader adoption of telemedicine as an inclusive tool in health care.

Benchmarking Sweden's Digitalization Transformation Strategy-Is It a Good Fit for the UAE?

Background: The ongoing revolution in health care, driven by wearable technology, virtual reality, and the Internet of Things, is reshaping both health care operations and our daily lives. This digital transformation ensures broader access to health care options, fosters patient-centered care and affects both health care institutions and individuals. In Sweden, health care is undergoing a digital shift, with initiatives like personal health management, remote monitoring, and virtual care enhancing patient involvement. This article reviews Sweden's health care digital transformation and compares it with the United Arab Emirates (UAE's) initiatives to assess viability. Methods: Using systematic literature review methods, databases from 2011 to 2023 were searched, supplemented by reference lists. Results: Database searches identified 761 records. A total of 480 articles were screened on basis of title and abstract, yielding 184 that were assessed for eligibility, leading to 40 academic studies to be included and 12 grey literature. Conclusions: The findings highlight Sweden's success in empowering patients through enhanced connectivity with clinical teams, knowledge sharing, and care management. However, due to contextual differences, the UAE should not blindly replicate Sweden's strategy. In conclusion, Sweden's efforts have positively engaged patients in health care, but challenges such as emerging technologies, demographic shifts, and budget constraints persist. Proactive planning and adaptation are crucial, with lessons applicable to the UAE market. Establishing a clear regulatory framework for digital care is imperative for future resilience.

Measuring competition in primary care-Evidence from Sweden

INTRODUCTION

In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system.

AIM

The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care.

METHODS

A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape-our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market.

RESULTS

Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition.

CONCLUSIONS

While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.

Video consultation in general practice during COVID-19: a register-based study in Denmark

BACKGROUND

During the COVID-19 pandemic, general practices in Denmark rapidly introduced video consultations (VCs) to prevent viral transmission.

AIM

To study the use of VCs in daytime general practice by describing the rate of VCs, and the patient characteristics associated with having VCs.

DESIGN & SETTING

Register-based study of consultations in daytime general practice in Denmark.

METHOD

We included all consultations in daytime general practice from 1 January 2019-30 November 2021. We calculated the rate of video use and categorised the general practices into no, low, and high use. Logistic regression was used to calculate adjusted odds ratios (aOR) for having a VC for different patient characteristics when contacting a video-using practice, stratified for low- and high-using practices.

RESULTS

A total of 30 148 478 eligible consultations were conducted during the pandemic period. VCs were used mostly during the early stage pandemic period, declining to about 2% of all clinic consultations in the late-stage period. Patients having more VCs were young, had a long education, were employed, and lived in big cities. In low-using practices, native Danes and 'western' immigrants had higher odds of receiving a VC than 'non-western' immigrants, and patients with ≥2 comorbidities had lower odds than those without comorbidities.

CONCLUSION

Patients of a younger age, with long education, or employment had higher odds of receiving a VC, while patients of an older age and patients who had retired had lower odds. This difference in the access to VCs warrants further attention.

Individual Patient Factors Associated with the Use of Physical or Digital Primary Care in Sweden

Introduction: Little is known about factors that influence patients' choice to use physical or digital primary care. This study aimed to compare self-rated health, internet habits, and what patients deem important when choosing health care between users of physical and digital primary health care. Methods: We recruited 2,716 adults visiting one of six physical or four digital primary health care providers in Stockholm, Sweden, October 2020 to May 2021. Participants answered a questionnaire with questions about sociodemography, self-rated health, internet habits, and what they considered important when seeking care. We used logistic regression and estimated odds ratios (ORs) for choosing digital care. Results: Digital users considered themselves healthier and used the internet more, compared with physical users (p < 0.001). Competence of health care staff was the most important factor when seeking care to both physical and digital users (90% and 78%, respectively). Patients considering it important to avoid leaving home were more likely to seek digital care (OR 29.55, 95% confidence interval [CI] 12.65-69.06), while patients valuing continuity were more likely to seek physical care (OR 0.25, 95% CI 0.19-0.32). These factors were significant also when adjusting for self-rated health and sociodemographic characteristics. Conclusion: What patients considered important when seeking health care was associated with what type of care they sought. Patient preferences should be considered when planning health care to optimize resource allocation.

From office to digital primary care services: analysing income-related inequalities in utilization

The use of digital technologies to deliver primary health care has increased over the past decade. While some technologies have been shown to be medically effective and efficient, the effects of digital primary care on the policy goal of equality in the use of such types of care have not been studied using large register data. The aim of this study was to analyse how digital contacts differ from officebased visits by income as an indicator of socioeconomic status. Specifically, we estimated differences in primary care utilization across income, factors of contribution to these inequalities, and applied a needs-based standardisation of utilization to estimate differences in equity.We used a purposively built consultation level dataset with 726 000 Swedish adult patients diagnosed with an infection, including clinical and sociodemographic variables. Applying concentration indexes (CI) and graphical illustrations we measured how the two types of services are distributed relative to income. We estimated how much of the inequalities were attributed to different sociodemographic factors by decomposing the concentration indexes. Standardised utilization for sex, age and comorbidity allowed for the estimation of horizontal inequity indexes for both types of services.Utilization by the two types of care showed large income inequalities. Office-based visits were propoor (CI -0.116), meaning lowincome patients utilized relatively more of these services, while digital contacts were prorich (CI 0.205). However, within the patient group who had at least one digital contact, the utilization was also propoor (CI -0,101), although these patients had higher incomes on average. The standardised utilization showed a smaller prorich digital utilization (CI 0.143), although large differences remained. Decomposing the concentration indexes showed that education level and being born in Sweden were strong attributes of prorich digital service utilization.The prorich utilization effects of digital primary care may risk undermining the policy goals of access and utilization to services regardless of socioeconomic status. As digital health technologies continue to expand, policy makers need to be aware of the risk.

Inequity in access to digital public primary healthcare in Sweden: a cross-sectional study of the effects of urbanicity and socioeconomic status on utilization

BACKGROUND

Social and geographical inequity in access to primary healthcare is an ongoing concern in Sweden. Digital care can potentially decrease geographical inequity. This study aimed to evaluate how urbanicity affects the utilization of a public digital primary healthcare service - PHC Online.

METHODS

We performed an ecological cross-sectional study of 4,482 PHC Online visits grouped by 83 public primary healthcare centers. Multiple linear regression analysis was performed with PHC Online visits per 1,000 registered patients as the dependent variable and urbanicity (municipalities grouped by number of inhabitants), socioeconomic status (Care Need Index), and morbidity (Adjusted Clinical Groups) per primary healthcare center as independent variables.

RESULTS

Utilization of PHC Online was more common among those of a younger age (median 32 years) and among women (65%). Urbanicity did not affect utilization. Lower socioeconomic status and higher morbidity had negative effects on utilization (B -3.289, p = 0.001, B -7.728, p = 0.045).

CONCLUSIONS

Geographical differences based on urbanicity do not seem to affect the utilization of PHC Online. Further studies are needed to clarify a possible association to geographical barriers in access to primary healthcare, specifically accounting for factors associated with urbanicity and distance to physical clinics, and how age and sex affect such an association. Lower utilization of PHC Online in low socioeconomic status and high morbidity populations raises questions on the effect of digital primary care on equitable access to primary healthcare.

Short- and intermediate-term impact of DTC telemedicine consultations on subsequent healthcare consumption

AIM

The use of direct-to-consumer (DTC) telemedicine consultations in primary healthcare has increased rapidly, in Sweden and internationally. Such consultations may be a low-cost alternative to face-to-face visits, but there is limited evidence on their effects on overall healthcare consumption. The aim of this study was to assess the short- and intermediate-term impact of DTC telemedicine consultations on subsequent primary healthcare consumption, by comparing DTC telemedicine users to matched controls in a Swedish setting.

METHODS

We constructed a database with individual-level data on healthcare consumption, for all residents of Region Stockholm in 2018, by linking national and regional registries. The study population included all individuals who had ≥ 1 physician consultation (telemedicine or face-to-face) during the first half of 2018. DTC telemedicine users were matched 1:2 to controls who were non-users of DTC telemedicine but who had a traditional face-to-face consultation during the study period. The matching criteria were diagnosis and demographic and socioeconomic variables. An interrupted time series analysis was performed to compare the healthcare consumption of DTC telemedicine users to that of the control group.

RESULTS

DTC telemedicine users increased their healthcare consumption more than controls. The effect seemed to be mostly short term (within a month), but was also present at the intermediate term (2-6 months after the initial consultation). The results were robust across age and disease groups.

CONCLUSION

The results indicate that DTC telemedicine consultations increase the total number of physician consultations in primary healthcare. From a policy perspective, it is therefore important to further investigate for which diagnoses and treatments DTC telemedicine is suitable so that its use can be encouraged when it is most cost-efficient and limited when it is not. Given the fundamentally different models for reimbursement, there are reasons to review and possibly harmonise the incentive structures for DTC telemedicine and traditional primary healthcare.

Evaluating the Impact of Teleconsultations on Access to Ambulatory Primary Care in Medically Underserved Areas: A National Observational Cross-Sectional Multicenter Study

Introduction: Access to care is a major public health concern particularly in medically underserved areas (MUAs) (Zones d'Interventions Prioritaires). Teleconsultations were legalized in France in 2010, however, have been reimbursed by the national health insurance since 2018. Large-scale studies assessing the impact of teleconsultations on access to care are limited. The objective of this study was to evaluate the impact of teleconsultations in MUAs at a national scale. Methods: An observational, multicenter cross-sectional study was conducted in seven teleconsultation centers. Teleconsultations were included if they were with patients living in France and received ambulatory care at primary ambulatory care settings by registered medical doctors between August 1 and November 30, 2021. Each center provided a randomized sample of 3,000 case data per month, yielding a total of 84,000 patients. Teleconsultation incidence was measured in MUAs and non-MUAs as the primary outcome. Results: In total, 25.1% of French patients lived in MUAs, with a mean age of 30.1 ± 0.08 years. Incidence of teleconsultations was 1,964 per 100,000 compared with 787 per 100,000 in non-MUAs (p < 0.0001). Teleconsultations were mostly performed during the day (88.6%), on weekdays (90.6%), were booked (88.3%), involved a general practitioner (GP) (89.0%), and were carried out as a video consultation (96.5%). The median delay to access was 60 min for GPs. Discussion: This was the largest study of teleconsultations in France and the first in the world to pool data from competing telemedicine companies. The incidence of teleconsultations was higher in MUAs, which may show that teleconsultations improve access to care. Clinical Trial Registration number: NCT05311241.

Make My Day: primary prevention of stroke using engaging everyday activities as a mediator of sustainable health - a randomised controlled trial and process evaluation protocol

INTRODUCTION

The individual, societal and economic benefits of stroke prevention are high. Even though most risk factors can be reduced by changes to lifestyle habits, maintaining new and healthy activity patterns has been shown to be challenging.The aim of the study is to evaluate the impact of an interdisciplinary team-based, mHealth-supported prevention intervention on persons at risk for stroke. The intervention is mediated by engaging everyday activities that promote health. An additional aim is to describe a process evaluation that serves to increase knowledge about how the programme leads to potential change by studying the implementation process and mechanisms of impact.

METHODS AND ANALYSIS

The study will be a randomised controlled trial including 104 persons at risk for stroke. Persons at risk of stroke (n=52) will be randomised to an mHealth-supported stroke prevention programme. Controls will have ordinary primary healthcare (PHC) services. The 10-week programme will be conducted at PHC clinics, combining group meetings and online resources to support self-management of lifestyle change using engaging everyday activities as a mediator. Primary outcomes are stroke risk, lifestyle habits and participation in health-promoting activities. Assessments will be performed at baseline and at follow-up (11 weeks and 12 months). The effects of the programme will be analysed using inferential statistics. Implementation will be analysed using qualitative and quantitative methods.

ETHICS AND DISSEMINATION

The study has been approved by the Swedish Ethical Review Authority. Study results will be disseminated in peer-reviewed journals and at regional and international conferences targeting mixed audiences.

TRIAL REGISTRATION NUMBER

NCT05279508.

Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use

Importance

Virtual visits became more common after the COVID-19 pandemic, but it is unclear in what context they are best used.

Objective

To investigate whether there was a difference in subsequent emergency department use between patients who had a virtual visit with their own family physician vs those who had virtual visits with an outside physician.

Design, Setting, and Participants

This propensity score-matched cohort study was conducted among all Ontario residents attached to a family physician as of April 1, 2021, who had a virtual family physician visit in the subsequent year (to March 31, 2022).

Exposure

The type of virtual family physician visit, with own or outside physician, was determined. In a secondary analysis, own physician visits were compared with visits with a physician working in direct-to-consumer telemedicine.

Main Outcome and Measure

The primary outcome was an emergency department visit within 7 days after the virtual visit.

Results

Among 5 229 240 Ontario residents with a family physician and virtual visit, 4 173 869 patients (79.8%) had a virtual encounter with their own physician (mean [SD] age, 49.3 [21.5] years; 2 420 712 females [58.0%]) and 1 055 371 patients (20.2%) had an encounter with an outside physician (mean [SD] age, 41.8 [20.9] years; 605 614 females [57.4%]). In the matched cohort of 1 885 966 patients, those who saw an outside physician were 66% more likely to visit an emergency department within 7 days than those who had a virtual visit with their own physician (30 748 of 942 983 patients [3.3%] vs 18 519 of 942 983 patients [2.0%]; risk difference, 1.3% [95% CI, 1.2%-1.3%]; relative risk, 1.66 [95% CI, 1.63-1.69]). The increase in the risk of emergency department visits was greater when comparing 30 216 patients with definite direct-to-consumer telemedicine visits with 30 216 patients with own physician visits (risk difference, 4.1% [95% CI, 3.8%-4.5%]; relative risk, 2.99 [95% CI, 2.74-3.27]).

Conclusions and Relevance

In this study, patients whose virtual visit was with an outside physician were more likely to visit an emergency department in the next 7 days than those whose virtual visit was with their own family physician. These findings suggest that primary care virtual visits may be best used within an existing clinical relationship.

Professionals Evaluating Clients' Suitability for Digital Health and Social Care: Scoping Review of Assessment Instruments

BACKGROUND

Increased digital health and social care services are generally considered to improve people's access to services. However, not everyone can equally access and use these resources. Health and social care professionals should assess clients' suitability for digital solutions, but to succeed, they need information about what to evaluate and how.

OBJECTIVE

This scoping review aimed to identify evaluation tools that professionals can use when assessing clients' suitability for digital health and social care. We summarized the dimensions and the practical usefulness of the instruments.

METHODS

The MEDLINE (Ovid), CINAHL, Web of Science, and ASSIA databases were searched in February 2023 following the Joanna Briggs Institute's Manual for Evidence Synthesis. Studies were included if they focused on health and social care clients and professionals, examined clients' suitability for using digital health or social care, and applied related assessment methods in the direct client work of professionals. Studies focusing primarily on instruments intended for research use without clear applicability to professionals' practical contexts were excluded. Details of the eligible studies were extracted, and qualitative content analysis according to the research objectives was performed.

RESULTS

A total of 19 articles introducing 12 different assessment instruments intended for the health care context were included in the review. No instruments were found for evaluating the suitability for digital social care. The instruments contained 60 dimensions of the client's suitability for digital health, which reflected four perspectives: (1) skill-based suitability, (2) suitability based on general ability to maintain health, (3) suitability based on attitude and experience, and (4) suitability based on practical matters. The described practical usefulness of the instruments included professionals' possibility to (1) identify clients most in need of education and support, (2) direct and recommend the right clients for the right digital services, (3) ensure that clients can use digital health, (4) improve effectiveness and maximize the provision of digital health, (5) develop and redesign services, and (6) empower clients.

CONCLUSIONS

Based on the diverse assessment instruments available and the dimensions they measure, there seems to be no comprehensive evaluation tool for assessing clients' prerequisites to use digital solutions. It is important to further develop comprehensive screening tools applicable to professionals' busy work (both in health and social care) with defined threshold values for suitability.

Digital Health Interventions to Improve Access to and Quality of Primary Health Care Services: A Scoping Review

Global digital technology advances offer the potential to enhance primary health care (PHC) quality, reach, and efficiency, driving toward universal health coverage (UHC). This scoping review explored how digital health solutions aid PHC delivery and UHC realization by examining the context, mechanisms, and outcomes of eHealth interventions. A comprehensive literature search was conducted, capturing qualitative and quantitative studies, process evaluations, and systematic or scoping reviews. Our analysis of 65 articles revealed that a well-functioning digital ecosystem-featuring adaptable, interoperable digital tools, robust Information and Communications Technology foundations, and enabling environments-is pivotal for eHealth interventions' success. Facilities with better digital literacy, motivated staff, and adequate funding demonstrated a higher adoption of eHealth technologies, leading to improved, coordinated service delivery and higher patient satisfaction. However, eHealth's potential is often restricted by existing socio-cultural norms, geographical inequities in technology access, and digital literacy disparities. Our review underscores the importance of considering the digital ecosystem's readiness, user behavior, broader health system requirements, and PHC capacity for adopting digital solutions while assessing digital health interventions' impact.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review

BACKGROUND

This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness.

METHODS

Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE.

RESULTS

Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment.

DISCUSSION

Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access.

TRIAL REGISTRATION

The review was registered in the PROSPERO database, CRD42021277624.

Assessment of Consumer Attitudes Following Recent Changes in the US Hearing Health Care Market

Importance

The addition of over-the-counter hearing aid (HA) options has transformed the way individuals can access hearing health care (HHC). However, although critical to their adoption and use, consumer attitudes and opinions about direct-to-consumer (DTC) models of health care are often understudied.

Objective

To assess how recent DTC market changes in HHC delivery may be associated with consumer choice and attitudes towards specific HHC models.

Design, Setting, and Participants

A mixed-methods survey, distributed online between March 22 and 25, 2022, using Qualtrics Survey Panels. Participants were US residents older than 50 years with no previous hearing aid experience, enrolled using consecutive sampling. A minimum of 1000 completed responses was set; once the 70% threshold was met, any future respondent who identified as White would not be given the survey.

Main Outcomes and Measures

Respondents were asked to report their level of comfort with using different variations of DTC-HHC and asked about their previous experience with other DTC health care models. Respondents then reported which model (in-person vs online) of HHC they would most likely pursue.

Results

Of 1377 respondents, 1037 were included in the survey study (mean [SD] age, 61.4 [7.84] years; 714 [69.0%] were female; 674 [65.0%] were White). Most respondents reported discomfort with pursuing hearing aids via DTC pathways, with 84% (874 of 1037) indicating they would pursue HHC via an in-person model. Individuals who were older (odds ratio [OR], 0.95; 95% CI, 0.92-0.98), reported an income greater than $150 000 (OR, 0.29; 95% CI, 0.08-0.91), and were not interested in HA (OR, 0.42; 95% CI, 0.23-0.79) were less likely to pursue HHC online. Those who had previous experience with DTC health care (OR, 1.97; 95% CI, 1.27-3.02), and did not have (OR, 2.61; 95% CI, 1.59-4.31) or were uncertain (OR, 2.05; 95% CI, 1.13-3.70) about their insurance coverage for HA were more likely to pursue HHC online.

Conclusions and Relevance

Current consumer attitudes and opinions found in this survey study suggest that DTC-HHC may not find immediate acceptance by most potential HA seekers in the US.

Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis

BACKGROUND

Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use.

OBJECTIVE

The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit.

METHODS

This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use.

RESULTS

Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups.

CONCLUSIONS

Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.

Exploring the impact of patient, physician and technology factors on patient video consultation satisfaction

Objective

Video consultations (VCs) were made available to the general population during the COVID-19 pandemic to compensate for the cutback of face-to-face doctor-patient interactions. However, little is known about what patient-related (e.g. age), physician-related (e.g. patient-physician relationship) and technology-related (e.g. online privacy concerns) factors contribute to video consultation satisfaction among patients. This study aims to gain a better understanding of what makes patients satisfied with video consultations.

Methods

A total of 180 patients who recently engaged in a video consultation were invited to answer questions about patient-, physician- and technology-related variables and their satisfaction with the video consultation. To examine which factors predict patient video consultation satisfaction, a multiple hierarchical regression analysis was performed.

Results

Overall, patients were satisfied with their video consultation. The final hierarchical model, including all patient-related, physician-related and technology-related factors, significantly contributed to patient video consultation satisfaction. Predictors of higher patient video consultation satisfaction were experiencing less technical issues, having higher general positive attitudes towards online communication, reporting higher importance of less travel time and being more satisfied with physicians' affective and instrumental communication.

Conclusions

Video consultations can be appropriate in a variety of situations, provided that technical issues can be minimized, patients have a positive attitude towards online communication and attach value to reduced travel time and online patient-physician interactions can be experienced as affective and instrumental. Findings from this study contribute to understanding how video consultations can be best utilized for effective patient-physician communication.

Digital consultation in primary healthcare: the effects on access, efficiency and patient safety based on provider experience; a qualitative study

OBJECTIVE

The objective of the study was to explore the experiences of healthcare staff working with and being part of the implementation of a digital platform for patient-provider consultation across quality dimensions of access, efficiency, and patient safety.

DESIGN

The study uses qualitative design to investigate experiences and the views of healthcare professionals. Data collection combined semi-structured individual and focus-group interviews. Content analysis was used to identify categories within the content areas 'access', 'efficiency', and 'patient safety'.

SETTING

The basis for the study was an e-consultation platform introduced in three primary healthcare centres in the County of Kalmar in southeast Sweden in 2019.

RESULTS

Healthcare staff experienced that the platform offered an open channel for communication with patients in need of frequent contact. This reduced anxiety and therefore the frequency of follow-up appointments. Healthcare staff also noted that the platform offered flexibility in contact benefitting patients with mental health problems. These patients were found to make contact through the platform after closing hours when problems were more acute or intense. However, the risk of digitally illiterate groups being excluded was also noted. Efficiency gains were identified among patients with simple cases which were handled more quickly through the platform. However, low uptake and the experience that the platform did not replace, rather was added on top of other already existing functions and procedures, negatively affected the overall efficiency. Standardized questions in automated medical history-taking contributed to patient safety.

CONCLUSION

The findings suggest that text-based e-consultation platforms may bring important quality improvements to primary healthcare service in terms of access, efficiency, and patient safety. Yet, areas where e-consultation does not contribute to quality improvements puts important quality gains at risk.KEY POINTSText based digital consultation improved access for patients in need of frequent appointments and for patients with mental health problems.Efficiency gains among patients with simple cases, and in dealing with patients with mental health problems were noted. However, lack of confidence in platform functions due to low uptake, and limited control over work situation, were perceived as negatively affecting overall efficiency.Health care staff experienced improved patient safety through a standardized set of questions in automated medical history-taking.

Association of travel time with mental health service use in primary health care according to contact type - a register-based study in Kainuu, Finland

BACKGROUND

The study aim was to analyse how mental health services are used in different parts of the Kainuu region in Finland and whether travel time to primary health care services is associated with the use of different contact types (in-person visits, remote contacts, home visits).

METHODS

The study population included adults who had used mental health services under primary health care (N = 7643) between 2015 and 2019. The travel times to the nearest health centre in a municipality were estimated as the population-weighted average drive time in postal code areas. The Kruskal-Wallis test and pairwise comparisons with Dunn-Bonferroni post hoc tests were used to assess the differences in mental health service use between health centre areas. A negative binomial regression was performed for the travel time categories using different contact types of mental health service use as outcomes. Models were adjusted for gender, age, number of mental health diseases and the nearest health centre in the municipality.

RESULTS

Distance was negatively associated with mental health service use in health centre in-person visits and in home visits. In the adjusted models, there were 36% fewer in-person visits and 83% fewer home visits in distances further than 30 min, and 67% fewer home visits in a travel time distance of 15-30 min compared with 15 min travel time distance from a health centre. In the adjusted model, in remote contacts, the incidence rate ratios increased with distance, but the association was not statistically significant.

CONCLUSIONS

The present study revealed significant differences in mental health service use in relation to travel time and contact type, indicating possible problems in providing services to distant areas. Long travel times can pose a barrier, especially for home care and in-person visits. Remote contacts may partly compensate for the barrier effects of long travel times in mental health services. Especially with conditions that call for the continuation and regularity of care, enabling factors, such as travel time, may be important.

Service quality and accessibility of healthcare facilities: digital healthcare potential in Ho Chi Minh City

Background

Effective delivery of health services requires adequate quality in healthcare facilities and easy accessibility to health services physically or virtually. The purpose of this study was to reveal how the quality of healthcare facilities varies across the different parts of Ho Chi Minh City and how well residents (N = 9 million) can reach healthcare facilities. By demarcating the deficiently served areas of low accessibility, the study shows where urban planning and digital healthcare could improve accessibility to health services and the quality of services efficiently.

Methods

The analysis utilised geocoded information on hospitals, clinics, roads and population and the data of the quality scores of healthcare facilities. Quality scores were analysed by hot spot analysis and inverse distance weighting. Accessibility and formation of travel time-based service areas by travel time distances were calculated using road network, driving speed and population data.

Results

The results unveiled a centripetal spatial pattern of healthcare facilities and a similar pattern in their quality. Outside the travel time of 30 min for hospitals and 15 min for clinics, the deficiently served areas have a population of 1.1 to 1.2 million. Based on the results and the evidence of digital healthcare, this paper highlights how to develop and plan spatially effective service provision. Especially, it gives grounds to discuss how cost-effective digital healthcare could be applied to improve the accessibility and quality of health services in an urban structure of extensively varying accessibility to health services.

Conclusions

The results bring up the need and the means for improving the quality of health services and their cost-efficient availability by location optimisation, road improvements and implementing digital healthcare provided by hospitals and clinics in the city. At the same, this study provides a multidisciplinary approach for planning more equal and efficient health service provision geographically.

Virtual Care and the Inverse Care Law: Implications for Policy, Practice, Research, Public and Patients

Virtual care spread rapidly at the outbreak of the COVID-19 pandemic. Restricting in-person contact contributed to reducing the spread of infection and saved lives. However, the benefits of virtual care were not evenly distributed within and across social groups, and existing inequalities became exacerbated for those unable to fully access to, or benefit from virtual services. This "perspective" paper discusses the extent to which challenges in virtual care access and use in the context of COVID-19 follow the Inverse Care Law. The latter stipulates that the availability and quality of health care is inversely proportionate to the level of population health needs. We highlight the inequalities affecting some disadvantaged populations' access to, and use of public and private virtual care, and contrast this with a utopian vision of technology as the "solution to everything". In public and universal health systems, the Inverse Care Law may manifests itself in access issues, capacity, and/or lack of perceived benefit to use digital technologies, as well as in data poverty. For commercial "Direct-To-Consumer" services, all of the above may be encouraged via a consumerist (i.e., profit-oriented) approach, limited and episodic services, or the use of low direct cost platforms. With virtual care rapidly growing, we set out ways forward for policy, practice, and research to ensure virtual care benefits for everyone, which include: (1) pay more attention to "capabilities" supporting access and use of virtual care; (2) consider digital technologies as a basic human right that should be automatically taken into account, not only in health policies, but also in social policies; (3) take more seriously the impact of the digital economy on equity, notably through a greater state involvement in co-constructing "public health value" through innovation; and (4) reconsider the dominant digital innovation research paradigm to better recognize the contexts, factors, and conditions that influence access to and use of virtual care by different groups.

Ageism in healthcare technology: the older patients’ aspirations for improved online accessibility

Objective

To identify concerns, barriers and facilitators impacting the use of patient portals by older patients as well as desired features in future updates.

Materials and Methods

This is a cross-sectional study consisting of 2 focus group discussions culminating in an anonymous survey administered to women who were 65 years and older receiving urogynecologic care in Northwest Ohio.

Results

Of the 205 women surveyed (91% response rate), providers and healthcare systems play the primary 2 roles (73% and 69%, respectively) in facilitating patients’ use of patient portal systems and telehealth applications. Barriers to use revolved around technical difficulties (50%), privacy concerns (45%), and cost of technology (24%). The most important features desired were the ability to modify the text size within the application (47%) and an intuitive, simple interface (46%). Additional assistance for navigating technical challenges was suggested, specifically set-up of accounts (36%), saving and sharing information with caregivers (35%), and sign-in and navigation of portals (32%).

Conclusion

The paucity of age-aligned medical access software and products may lead to worsening of digital exclusion and disparities in healthcare. Portal application developers and healthcare systems must advance efforts that consider the needs of those who may be older when designing patient portals.

Healthcare professionals’ experiences in telehabilitation: a qualitative study (Preprint)

BACKGROUND

The use of digital communication in Swedish health care has increased in an effort to make health care more accessible. At the organizational level, trust in digitalization has stabilized, but a certain degree of skepticism regarding technology appears to exist among health care employees.

OBJECTIVE

This study aimed to explore health care professionals' (HCPs) experiences of digital communication with patients and colleagues in a habilitation context.

METHODS

Qualitative content analysis was used to analyze data derived from individual interviews.

RESULTS

The results revealed that there were mixed feelings regarding the digital format used at the habilitation center. Although some skepticism remained regarding the digital format, there seemed to be a parallel understanding of the motives and benefits of digitalization. Hence, positive aspects, such as increased health care accessibility, were identified. However, emphasis was placed on the considerations required to make digital consultations appropriate for each patient.

CONCLUSIONS

Managing a workday influenced by the balance between digital and physical demands forces HCPs to adjust to the digital format and new ways of working. This requires HCPs to consider whether digital means are appropriate for communication in individual patient-specific cases.

Preferences for Alternative Care Modalities Among French Adults With Chronic Illness

IMPORTANCE

The COVID-19 pandemic led to the implementation of alternative care modalities (eg, teleconsultations and task shifting) that will continue to be implemented in parallel to traditional care after the pandemic. An ideal balance between alternative and traditional care modalities is unknown.

OBJECTIVES

To quantify the ideal postpandemic balance between alternative and traditional care modalities among patients with chronic illness and to qualify the circumstances in which patients consider it appropriate to replace traditional care with alternative care.

DESIGN, SETTING, AND PARTICIPANTS

This survey study invited 5999 adults with chronic illness in ComPaRe, a French nationwide e-cohort of adults with chronic conditions who volunteer their time to participate in research projects, to participate in this study, which was performed from January 27 to February 23, 2021.

MAIN OUTCOMES AND MEASURES

Participants rated the ideal proportion at which they would use 3 alternative care modalities instead of the traditional care equivalent on a 0% to 100% scale (with 0% indicating using alternative care modalities for none of one's future care and 100% indicating using alternative care modalities for all of one's future care) of their overall future care: (1) teleconsultations, (2) online symptom-checkers to react to new symptoms, and (3) remote monitoring to adapt treatment outside consultations. The median ideal proportion of alternative care use was calculated. Perceived appropriate circumstances in which each alternative modality could replace traditional care were collected with open-ended questions. Analyses were performed on a weighted data set representative of patients with chronic illness in France.

RESULTS

Of the 5999 invited individuals, 1529 (mean [SD] age, 50.3 [14.7] years; 1072 [70.1%] female) agreed to participate (participation rate, 25.5%). Participants would choose teleconsultations for 50.0% of their future consultations (IQR, 11.0%-52.0%), online symptom-checkers over contacting their physician for 22.0% of new symptoms (IQR, 2.0%-50.0%), and remote monitoring instead of consultations for 52.3% of their treatment adaptations (IQR, 25.4%-85.4%). Participants reported 67 circumstances for which replacing traditional with alternative care modalities was considered appropriate, including 31 care activities (eg, prescription renewal and addressing acute or minor complaints), 25 patient characteristics (eg, stable chronic condition and established patient-physician relationship), and 11 required characteristics of the alternative care modalities (eg, quality assurance).

CONCLUSIONS AND RELEVANCE

Results of this survey study suggest that after the pandemic, patients would choose alternative over traditional care for 22% to 52% of the time across different care needs. Participants proposed 67 criteria to guide clinicians in replacing traditional care with alternative care. These findings provide a guide for redesigning care in collaboration with patients after the pandemic.

Telemedicine and eHealth Literacy in the Era of COVID-19: A Cross-Sectional Study in a Peripheral Clinic in Israel

The COVID-19 pandemic mandating isolation, quarantine, and social distancing has accelerated and expanded the use of telemedicine. This study examines the extent of the use of telemedicine and the relationship between eHealth literacy and satisfaction with using telemedicine during the pandemic. A total of 156 participants from a clinic in a peripheral community in southern Israel completed an online questionnaire. We found that 85% knew how to use the internet for health information, but only one third felt safe using it to make health decisions. Furthermore, 93% used the internet for technical needs, such as renewing prescriptions or making a doctor's appointment. Even lower use for telemedicine was found (38%) for consultation or treatment sessions. A positive association was found between eHealth literacy and satisfaction variables with using telemedicine (rp = 0.39, p < 0.001). Although respondents understood the benefits of telemedicine, they were not satisfied nor interested in online sessions after the epidemic's end, preferring a meeting involving personal interaction. Young people and academics benefit more from telemedicine, thereby creating usage gaps and potentially increasing existing inequality. We recommend developing intervention programs, especially among vulnerable populations, to strengthen eHealth literacy and remove barriers causing skepticism about the use of telemedicine during and after the pandemic.