During the COVID-19 pandemic, general practitioners worldwide re-organise care in very different ways because of the lack of evidence-based protocols.
This paper describes the organisation and the ...characteristics of consultations in Belgian out-of-hours primary care during five weekends at the peak of a COVID-19 outbreak and compares it to a similar period in 2019.
Real-time observational study using pseudonymised routine clinical data extracted out of reports from home visits, telephone- and physical consultations (iCAREdata). Nine general practice cooperatives (GPCs) participated covering a population of 1 513 523.
All GPCs rapidly re-organised care in order to handle the outbreak and provide a safe working environment. The average consultation rate was 222 per 100 000 citizens per weekend. These consultations were handled by telephone alone in 40% (N = 6293). A diagnosis at risk of COVID-19 was registered in 6692 (43%) consultations,. Out of 5311 physical consultations, 1460 were at risk of COVID-19 of which 443 (30%) did not receive prior telephone consultation to estimate this risk. Compared to 2019, the workload initially increased due to telephone consultations but afterwards declined drastically. The physical consultation rate declined by 45% with a marked decline in diagnoses unrelated to COVID-19.
General practitioners can rapidly re-organise out-of-hours care to handle patient flows during a COVID-19 outbreak. Forty percent of the out-of-hours primary care contacts are handled by telephone consultations alone. We recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care. The demand for physical consultations declined drastically provoking questions about patient's safety for care unrelated to COVID-19.
Recently developed chatbots based on large language models (further called bots) have promising features which could facilitate medical education. Several bots are freely available, but their ...proficiency has been insufficiently evaluated. In this study the authors have tested the current performance on the multiple-choice medical licensing exam of University of Antwerp (Belgium) of six widely used bots: ChatGPT (OpenAI), Bard (Google), New Bing (Microsoft), Claude instant (Anthropic), Claude+ (Anthropic) and GPT-4 (OpenAI). The primary outcome was the performance on the exam expressed as a proportion of correct answers. Secondary analyses were done for a variety of features in the exam questions: easy versus difficult questions, grammatically positive versus negative questions, and clinical vignettes versus theoretical questions. Reasoning errors and untruthful statements (hallucinations) in the bots' answers were examined. All bots passed the exam; Bing and GPT-4 (both 76% correct answers) outperformed the other bots (62-67%, p = 0.03) and students (61%). Bots performed worse on difficult questions (62%, p = 0.06), but outperformed students (32%) on those questions even more (p<0.01). Hallucinations were found in 7% of Bing's and GPT4's answers, significantly lower than Bard (22%, p<0.01) and Claude Instant (19%, p = 0.02). Although the creators of all bots try to some extent to avoid their bots being used as a medical doctor, none of the tested bots succeeded as none refused to answer all clinical case questions.Bing was able to detect weak or ambiguous exam questions. Bots could be used as a time efficient tool to improve the quality of a multiple-choice exam.
To determine whether a new triage system safely diverts a proportion of emergency department (ED) patients to a general practitioner cooperative (GPC).
Unblinded randomised controlled trial with ...weekends serving as clusters (three intervention clusters for each control). The intervention was triage by a nurse using a new extension to the Manchester Triage System assigning low-risk patients to the GPC. During intervention weekends, patients were encouraged to follow this assignment; it was not communicated during control weekends (all patients remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care patients (the opinion of the treating physician was the gold standard).
In the intervention group, 838/6294 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC, in the control group this was 431/1744 (24.7%, 95% CI 22.7 to 26.8). In total, 599/6294 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the reason for encounter, age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) were referred back to the ED, three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised.
ED nurses using a new tool safely diverted 9.5% of the included patients to primary care.
ClinicalTrials.gov Identifier: NCT03793972.
During the cluster randomised TRIAGE-trial, a nurse advised 13% of low-risk patients presenting at an emergency department in Belgium to visit the adjacent general practitioner cooperative. Patients ...had the right to refuse this advice. This exploratory study examines the characteristics of refusers by uncovering the determinants of non-compliance and its impact on costs, as charged on the patient's invoice.
Bivariate analyses with logistic regressions and T-tests were used to test the differences in patient characteristics, patient status, timing characteristics, and costs between refusers and non-refusers. A chi-square automatic interaction detection analysis was used to find the predictors of non-compliance.
23.50% of the patients refused the advice to visit the general practitioner cooperative. This proportion was mainly influenced by the nurse on duty (non-compliance rates per nurse ranging from 2.9% to 52.8%) and the patients' socio-economic status (receiving increased reimbursement versus not OR 1.37, 95%CI: 0.96 to 1.95). Additionally, non-compliance was associated (at the 0.10 significance level) with being male, not living nearby and certain reasons for encounter. Fewer patients refused when the nurse perceived crowding level as quiet relative to normal, and more patients refused during the evening. The mean cost was significantly higher for patients who refused, which was a result of more extensive examination and higher out-of-pocket expenses at the ED.
The nurse providing the advice to visit the general practitioner cooperative has a central role in the likelihood of patients' refusal. Interventions to reduce non-compliance should aim at improving nurse-patient communication. Special attention may be required when managing patients with a lower socio-economic status. The overall mean cost was higher for refusers, illustrating the importance of compliance.
The trial was registered on registration number NCT03793972 on 04/01/2019.
Background A total of 7,307 Ukrainian refugees moved to Antwerp, Belgium, during the study period (01 April 2022 to 31 December 2022). The city’s administration set up three care centers where these ...people were introduced to the Belgian primary care system, a medical file was created, and acute/preventive/chronic care was delivered. This community case study analyzes the organization and contents of care and reflects upon its meaning for the mainstream healthcare system. Methods This is an observational study using routine electronic medical record data to measure the uptake of care. For a sample of 200 subjects, a retrospective chart review was conducted. Participants All refugees with a medical file at one of the three participating care centers were included. Main outcomes For the observational study, 2,261 patients were reached (30% of the potential users), and 6,450 contacts were studied. The nurses (including midwives) conducted 4,929 out of 6,450 (76%) of all consultations, while the general practitioners (GPs) conducted 1,521 out of 6,450 (24%). Of the nurse consultations, 955 (19%) were followed by another nurse consultation and 866 (18%) by a GP consultation. In the structured case reviews, most contacts were concerned with acute problems (609 out of 1,074, 57%). The most prevalent reasons for encounters and diagnoses were typical primary care issues. The nurses were able to manage half of the cases independently (327, 55%), referred 37% (217) of cases to the GP, and consulted a GP (live, by telephone, or a dedicated app) for 8% (48) of cases. GPs mostly prescribed drugs, referred to a medical specialist, and advised over-the-counter drugs, while nurses more often advised over-the-counter drugs (mostly paracetamol, nose sprays, and anti-inflammatory drugs), provided non-medical advice, or ordered laboratory tests. Discussion The medical care points delivered mostly typical acute primary care in this first phase, with a key role for nurses. The care points did not sufficiently take up chronic diseases and mental health problems. These results will inform policymakers on the use of primary care centers for newly arriving patients in times of a large influx. A nurse-first model seems feasible and efficient, but evaluation of safety and quality of care is needed. Once the acute phase of this crisis fades away, questions about the comprehensiveness, continuity, and integration of care for migrants remain relevant.
ObjectivesIn the TRIAGE trial, a cluster randomised trial about diverting emergency department (ED) patients to a general practice cooperative (GPC) using a new extension to the Manchester Triage ...System, the difference in the proportion of patients assigned to the GPC was striking: 13.3% in the intervention group (patients were encouraged to comply to an ED or GPC assignment, real-world setting) and 24.7% in the control group (the assignment was not communicated, all remained at the ED, simulated setting). In this secondary analysis, we assess the differences in the use of the triage tool between intervention and control group and differences in costs and hospitalisations for patients assigned to the GPC.SettingED of a general hospital and the adjacent GPC.Participants8038 patients (6294 intervention and 1744 control).Primary and secondary outcome measures proportion of patients with triage parameters (reason for encounter, discriminator and urgency category) leading to an assignment to the ED, proportion of patients for which the computer-generated GPC assignment was overruled, motivations for choosing certain parameters, costs (invoices) and hospitalisations.ResultsAn additional 3.1% (p<0.01) of the patients in the intervention group were classified as urgent. Discriminators leading to the ED were registered for an additional 16.2% (p<0.01), mainly because of a perceived need for imaging. Nurses equally chose flow charts leading to the ED (p=0.41) and equally overruled the protocol (p=0.91). In the intervention group, the mean cost for patients assigned to the GPC was €23 (p<0.01) lower and less patients with an assignment to the GPC were hospitalised (1.0% vs 1.6%, p<0.01).ConclusionNurses used a triage tool more risk averse when it was used to divert patients to primary care as compared with a theoretical assignment to primary care. Outcomes from a simulated setting should not be extrapolated to real patients.Trial registration numberNCT03793972.
Antibiotic overprescribing is one of the main drivers of the global and growing problem of antibiotic resistance, especially in primary care and for respiratory tract infections (RTIs). RTIs are the ...most common reason for patients to consult out-of-hours (OOH) primary care. The COVID-19 pandemic has changed the way general practitioners (GPs) work, both during office hours and OOH. In Belgian OOH primary care, remote consultations with the possibility of issuing prescriptions and telephone triage were implemented. We aimed to describe the impact of COVID-19 on GPs' antibiotic prescribing during OOH primary care. In an observational study, using routinely collected health data from GP cooperatives (GPCs) in Flanders, we analyzed GPs' antibiotic prescriptions in 2019 (10 GPCs) and 2020 (20 GPCs) during OOH consultations (telephone and face-to-face). We used autoregressive integrated moving average (ARIMA) modeling to identify any changes after lockdowns were implemented. In total, 388,293 contacts and 268,430 prescriptions were analyzed in detail. The number of antibiotic prescriptions per weekend, per 100,000 population was 11.47 (95% CI: 9.08-13.87) or 42.9% lower after compared to before the implementation of lockdown among all contacts. For antibiotic prescribing per contact, we found a decrease of 12.2 percentage points (95% CI: 10.6-13.7) or 56.5% among all contacts and of 5.3 percentage points (95% CI: 3.7-6.9) or 23.2% for face-to-face contacts only. The decrease in the number of prescriptions was more pronounced for cases with respiratory symptoms that corresponded with symptoms of COVID-19 and for antibiotics that are frequently prescribed for RTIs, such as amoxicillin (a decrease of 64.9%) and amoxicillin/clavulanate (a decrease of 38.1%) but did not appear for others such as nitrofurantoin. The implementation of COVID-19 lockdown measures coincided with an unprecedented drop in the number of antibiotic prescriptions, which can be explained by a decrease in face-to-face patient contacts, as well as a lower number of antibiotics prescriptions per face-to-face patient contact. The decrease was seen for antibiotics used for RTIs but not for nitrofurantoin, the first-choice antibiotic for urinary tract infections.
In Antwerp, Belgium's second largest city, a COVID-19 surge in July 2020 predominantly affected neighborhoods with high ethnic diversity. Local volunteers reacted and set up an initiative to support ...contact tracing and self-isolation. We describe the origin, implementation, and transfer of this local initiative, based on semi-structured interviews of five key informants and document review. The initiative started in July 2020, when family physicians signaled a surge of SARS-CoV-2 infections among people of Moroccan descent. Family physicians feared that the mainstream contact tracing organized by the Flemish government through centralized call centers would not be efficient in halting this outbreak. They anticipated language barriers, mistrust, inability to investigate case clusters, and practical problems with self-isolation. It took 11 days to start up the initiative, with logistical support from the province and city of Antwerp. Family physicians referred SARS-CoV-2-infected index cases with complex needs (including language and social situation) to the initiative. Volunteer COVID coaches contacted cases, got a contextualized understanding of their living conditions, assisted with backward and forward contact tracing, offered support during self-isolation, and checked if infected contacts also needed support. Interviewed coaches were positive about the quality of the interaction: they described extensive open conversations with cases. The coaches reported back to referring family physicians and coordinators of the local initiative, who took additional action if necessary. Although interactions with affected communities were perceived as good, respondents considered that the number of referrals by family physicians was too low to have a meaningful impact on the outbreak. In September 2020, the Flemish government assigned the tasks of local contact tracing and case support to the local health system level (primary care zones). While doing so, they adopted elements of this local initiative, such as COVID coaches, tracing system, and extended questionnaires to talk with cases and contacts. This community case study illustrates how urgency can motivate people to action yet support from people with access to resources and coordination capacity is vital for effective organization and transition to long-term sustainability. From their conception, health policies should consider adaptability of new interventions to local contexts.
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