A Qualitative Exploration of How the Pregnancy and Postpartum Journey Was Shaped by the COVID-19 Pandemic: Lessons Learned.

At the time of writing, the COVID-19 pandemic has provided challenges to health services globally for close to 2 years. These challenges have included the need for enhanced infection control procedures, markedly increased demand for services, rapid upskilling and redeployment of the workforce, support for staff physical and psychological welfare as they deliver services and deal with considerable loss of life, and in many settings, responsibility for vaccine rollout. Many services have faced significant changes to daily operations, and previously unproblematized and uncomplicated aspects of service delivery, such as the presence of visitors in hospitals has been affected. Many hospitals and other health services have had strict restrictions in place about visiting, as one strategy for keeping COVID-19 out of hospitals. While the implementation of no-visitor policies has been necessary to protect the health of patients and the workforce in hospitals, such restrictions have also caused hardship to patients, families and staff. Many approaches to healthcare assume that family support (however defined) is available to patients, and that family members will be involved in care and decision-making. These approaches depend on authentic and reliable communication involving the patient, family members and health care personnel. Furthermore, visiting of friends and family can be a significant variable to the emotional well-being of patients and their loved ones and a great source of comfort to families experiencing the illness or incapacity of a family member. Thus, visitation restrictions in hospitals implemented during the COVID-19 pandemic has resulted in significant barriers to communication among clinicians, patients and families. No-visitor-policies not only have emotional impact on patients and their loved ones, but also have negative impact on patient and family-centred care initiatives due to suboptimal communication. The effects of no-visitor policies can be particularly difficult for patients and their loved ones where the patient may lack capacity, have language barriers, are critically ill or otherwise dependent on their carers. Family members can become very anxious, distressed and even distraught when unable to visit with loved ones while in hospital. Meanwhile staff who are already pressured and may also experience communication impairment due to the effects of personal protective equipment (PPE), are called on to provide additional emotional support to distressed patients and their loved ones. The importance of visiting means that health services personnel have been challenged to provide alternative means of ensuring patients can have meaningful contact with loved ones, while maintaining the restrictions necessary to reduce the spread of infection. Virtual care initiatives have been implemented in many settings. These initiatives have the advantage of providing ways that friends and family can visually and verbally engage with their family member, and connect with the health care team. It can allow for patients to have their family members (virtually) present for the purposes of visiting, as well as family-centred care initiatives. It is especially helpful given that many people have been (and many still are) affected by travel restrictions, which has imposed additional difficulties for families dealing with the illness or incapacity of a loved one. Virtual care is not a novel technology. Various forms of virtual care have been used in healthcare for several years (Webb et al., 2020). However, the pandemic has seen much more rapid and widespread implementation of virtual care and virtual visiting in hospitals to replace or supplement in-person visitation. Available literature supports the implementation of virtual care. Licurse (2016) describes the use of virtual visits for outpatients with chronic diseases where 97% of patients reported satisfaction with the experience and 74% felt the virtual interaction in fact improved their relationship with the care provider. During the current pandemic, virtual care has been particularly useful in intensive care units, with National Health Services (NHS) hospitals in the United Kingdom (n = 117) reporting changes in ICU family visiting policy during the COVID-19 surge (Rose et al., 2021). The vast majority of these hospitals (97%) had adopted virtual family visiting, and the most common indications identified were to alert and orient patients, and to facilitate family interaction for patients at the end of life (Rose et al., 2021). There are many benefits of virtual visiting, including reduced patient psychological distress, improved staff morale, reorientation of delirious patients with help of family, overcoming language barrier and enhancing patient-centred care (Rose et al., 2021). Use of virtual care can not only enhance the quality of life for patients and their loved ones, but also lead to additional benefits such as reducing anxiety and allowing non-vocal patients to communicate via computer keyboards (Nusdorfer, 2013). Furthermore, Angus and Connolly (2020) describes multiple uses of virtual care in healthcare system in the context of COVID-19 pandemic, such as monitoring patients with milder COVID-19 symptoms in their homes, being able to ensure effective contact and involvement of quarantined health workers and providing continuity of care for people with chronic illnesses remotely. Virtual care is not only relevant in the emergent COVID-19 pandemic. Looking beyond the pandemic, virtual care initiatives have long-term potential to enhance and broaden delivery of future healthcare. Virtual visiting will continue to be beneficial for families who are unable to attend hospitals regularly (Cheney, 2020; Webb et al., 2020). Use of virtual clinics could allow patients who are at a distance or have other difficulties physically attending appointments to continue to receive optimal healthcare, have increased compliance and have reduced cost of travelling. There are however some barriers to widespread adaptation of virtual care. This includes staff availability to facilitate video calls, provision of training for staff and concern for security and privacy (Rose et al., 2021). Furthermore, some healthcare providers may have difficulty implementing virtual care in their practice due to financial constraints, technological incompetence and difficulty with remote assessment with visual cues (Angus and Connolly, 2020). Some patients and family members may have difficulty with videoconferencing capability or may not have access to virtual devices (Rose et al., 2021). These barriers should be considered for effective implementation of virtual care in the future. While further research is needed to ascertain the qualitative experiences of patients, their families and friends and health care staff, and to provide thorough and accurate cost-benefit analyses, we argue that virtual care initiatives can provide important and tangible benefits to patients and families as well as to health care providers, especially in the current context of no-visiting policies and other visiting restrictions. The effective utilization of virtual care during the COVID-19 pandemic provides an opportunity for change in the future of healthcare delivery. No conflict of interest has been declared by the authors. All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content.

e13618 Background: The COVID-19 pandemic has compelled an increased use of virtual care delivery models in oncology. This study sought to examine the views of oncology health care providers (HCP) in British Columbia on the value and impact of virtual care models in clinical practice. Methods: A semi-structured interview-survey was developed to compare provider practice patterns between May 2019 and May 2020. Questions were designed to determine provider-perceived value and impact of virtual visits on clinical interactions with patients. HCP (including physicians, dentists, and nurse practitioners) at BC Cancer were invited to participate. Responses to the interview questions were de-identified and HCP names were replaced with a study code. Quantitative questions were interpreted with descriptive statistics. Qualitative results were analyzed and iteratively coded by multiple reviewers for emerging themes. Results: Among 531 invited participants, 61 completed the interview-survey and 60 were included in the final analysis. Of those interviewed, 47% were radiation oncologists and 33% were medical oncologists. The remainder of HCP interviewed (n = 12) included functional imaging physicians, general practitioners in oncology, hereditary cancer physicians, nurse practitioners, palliative care physicians, psychiatrists, and surgical oncologists. Most oncology providers (87%) desired the continuation of virtual visits as part of their clinical practice so long as barriers to integration were addressed. Barriers identified included limited access to physical resources, such as hardware (70% responses) and quiet spaces (54% responses), insufficient logistic support such as information technology services (84% responses) and operational workflows (46% responses), the absence of guidelines to select patients for this delivery model (38% responses), and concerns regarding HCP liability, security and privacy (30% responses). Conclusions: Oncology HCP value delivering patient care through virtual means, however, barriers to implementation must be better understood. These data may inform continued use and implementation of virtual care at other oncology centers.

The COVID-19 pandemic changed how Canadians accessed health care, increasing their use of virtual services. While virtual care use decreased after the pandemic lockdowns, it continues to play an important role in health care delivery. More information is needed about variations in virtual care use by sociodemographic and health characteristics. Data from the 2023 Canadian Social Survey - Quality of Life, Virtual Health Care and Trust were used. Descriptive statistics estimated the types of health care appointments individuals had in the past 12 months, access to virtual care, the types of health care providers consulted virtually, and the reasons individuals declined virtual appointments. Multivariate analyses examined whether sociodemographic and health characteristics were associated with patients' virtual care use. Over half of patients (57.5%) had in-person appointments only, 5.3% had virtual appointments only, and over one-third (37.2%) had both types of appointments. Of individuals who sought or were offered virtual care, 78.5% had a virtual appointment. Most virtual care users consulted a family doctor, general practitioner, or nurse practitioner only (62.1%). Higher education, not having a regular health care provider, and multimorbidity were positively associated with virtual care use. Greater comfort with in-person appointments was the most common reason for declining virtual care. While many individuals in Canada accessed virtual care, only a small proportion had virtual appointments only. Virtual care use varied by some sociodemographic and health factors, such as education and multimorbidity. Technological barriers were not a common reason for declining virtual appointments.

BackgroundTo reduce person-to-person contact, the COVID-19 pandemic has driven a massive shift to virtual care. Defined as the use of technology (synchronous or asynchronous) to support communication between health care providers and patients, rural-urban differences in virtual care are relatively unexplored.ObjectiveThe 2-fold purpose of this study was to examine rural and urban virtual care access, use, and satisfaction during the pandemic and to identify any unmet needs.MethodsThis study was a cross-sectional online survey exploring virtual care among rural and urban adults in summer 2021 using a combination of fixed and open-ended response options. Quantitative data were analyzed using both descriptive and inferential statistics, and qualitative data were analyzed using inductive thematic content analysis.ResultsOverall, 501 (373, 74.4% female; age range 19-86 years; 237, 47.3% rural-living) Western Canadians completed the survey. Virtual care use was high among both rural (171/237, 72.2%) and urban (188/264, 71.2%) participants, with over one-half (279/501, 55.7%) reporting having only started to use virtual care since the pandemic. The self-reported need for mental health programs and services increased during the pandemic, compared with prior for both rural and urban participants. Among virtual care users, interest in its continuation was high. Our analysis also shows that internet quality (all P<.05) and eHealth literacy (all P<.001) were positively associated with participants’ perceptions of virtual care usefulness, ease of use, and satisfaction, with no rural-urban differences. Rural participants were less likely to have used video in communicating with doctors or health care providers, compared with urban participants (P<.001). When describing unmet needs, participants described a (1) lack of access to care, (2) limited health promotion and prevention options, and (3) lack of mental health service options.ConclusionsThe increased demand for and use of virtual care may reflect increased availability and a lack of alternatives due to limited in-person services during the COVID-19 pandemic, so a balance between virtual care and in-person care is important to consider postpandemic. Further, ensuring availability of high-speed internet and education to support patients will be important for providing accessible and effective virtual care, especially for rural residents.

Racial Disparities and Excess Cardiovascular Mortality Before and During the COVID-19 Pandemic: Time for a Solution

Patient Engagement in Research and Innovation: A New Framework

Outcomes research examines the effects of healthcare interventions and policies on health outcomes for individual patients and populations in routine practice, as opposed to the idealized setting of clinical trials. A national survey from 1998 to 2000 that evaluated the extent to which patients received established processes of care for 30 medical conditions illustrated the importance of outcomes research.1 Among adults living in 12 metropolitan areas in the United States, only half of patients received proven elements of preventive care, treatments for acute illness, and chronic disease management for which they were eligible. For cardiovascular conditions, the use of proven therapies varied widely from 68% to 25% of patients who received recommended care for coronary artery disease and atrial fibrillation, respectively.1 Despite these gaps between ideal and actual care, patient outcomes have improved in many fields. For instance, the age-adjusted mortality from cardiovascular disease in the United States fell by >40% from 1980 to 2000 as a result of improvements in risk factor modification and uptake of evidence-based treatments for coronary artery disease, myocardial infarction, and heart failure.2,3 Nevertheless, many Americans do not receive the ideal recommended care (either at all or in a timely fashion), whereas others receive too much or the wrong care.4,5 In the field of cardiovascular diseases, substantial opportunities for improvement remain. Outcomes research has generated a foundation of knowledge about what constitutes ideal care and what gaps exist between ideal and actual care, but we have less understanding about how to deliver this ideal care to every patient every day. The potential for basic science breakthroughs to reach and improve the health of individual patients and populations may be substantially delayed or may not be realized if science is not efficiently translated to action. Moreover, in many cases, increased delivery of …

Use of virtual care in ophthalmology in Ontario, Canada in 2020 during the COVID-19 pandemic

In 1999, an Institute of Medicine report spurred health care organizations to implement systems-based quality improve ment efforts and tackle patient safety. Simultaneously, the Accreditation Council for Graduate Medical Education asked residency programs to address Practice-Based Learning and Systems-Based Practice competencies. Medical educators now advocate incorporation of these competencies in undergraduate medical education.The authors examine the success of these efforts both from the health care delivery and systems perspective as well as from the perspective of educators as they aspire to engage medical students and residents in these domains. The authors argue that the missing element that prevents health care systems from the full realization of the promise of quality improvement is bidirectional alignment. Included are examples from the literature to demonstrate how medical educators are moving toward alignment of learners with health system quality improvement and safety needs. Finally, the authors explore business and information technology governance literature in support of the hypothesis that bidirectional alignment should be the next step in moving from reactive to proactive systems of care.

The COVID-19 pandemic has played a role in increased use of virtual care in primary care. However, few studies have examined the association between virtual primary care visits and other health care use. To evaluate the association between the percentage of virtual visits in primary care and the rate of emergency department (ED) visits. This cross-sectional study used routinely collected administrative data and was conducted in Ontario, Canada. The sample comprised family physicians with at least 1 primary care visit claim between February 1 and October 31, 2021, and permanent Ontario residents who were alive as of March 31, 2021. All residents were assigned to physicians according to enrollment and billing data. Family physicians' virtual visit rate was the exposure. Physicians were stratified by the percentage of total visits that they delivered virtually (via telephone or video) during the study period (0% [100% in person], >0%-20%, >20%-40%, >40%-60%, >60%-80%, >80% to <100%, or 100%). Population-level ED visit rate was calculated for each stratum of virtual care use. Multivariable regression models were used to understand the relative rate of patient ED use after adjusting for rurality of practice, patient characteristics, and 2019 ED visit rates. Data were analyzed for a total of 13 820 family physicians (7114 males [51.5%]; mean [SD] age, 50 [13.1] years) with 12 951 063 patients (6 714 150 females [51.8%]; mean [SD] age, 42.6 [22.9] years) who were attached to these physicians. Most physicians provided between 40% and 80% of care virtually. A higher percentage of the physicians who provided more than 80% of care virtually were 65 years or older, female individuals, and practiced in big cities. Patient comorbidity and morbidity were similar across strata of virtual care use. The mean (SD) number of ED visits was highest among patients whose physicians provided only in-person care (470.3 [1918.8] per 1000 patients) and was lowest among patients of physicians who provided more than 80% to less than 100% of care virtually (242.0 [800.3] per 1000 patients). After adjustment for patient characteristics, patients of physicians with more than 20% of visits delivered virtually had lower rates of ED visits compared with patients of physicians who provided more than 0% to 20% of care virtually (eg, >80% to <100% vs >0%-20% virtual visits in big cities: relative rate, 0.77%; 95% CI, 0.74%-0.81%). This pattern was unchanged across all rurality of practice strata and after adjustment for 2019 ED visit rates. In urban areas, there was a gradient whereby patients of physicians providing the highest level of virtual care had the lowest ED visit rates. Findings of this study show that patients of physicians who provided a higher percentage of virtual care did not have higher ED visit rates compared with patients of physicians who provided the lowest levels of virtual care. The findings refute the hypothesis that family physicians providing more care virtually during the pandemic resulted in higher ED use.

<h3>Context:</h3> Group perinatal care (GPC) offers a “one stop” approach to clinical care and perinatal education. It has been shown to be associated with high levels of patient satisfaction and improved clinical outcomes. Co-facilitation of GPC (including postpartum care) by midwives (MW) and family medicine residents (FMR) in a family health team (FHT) has not been previously assessed. <h3>Objective:</h3> To explore the experience of participants in the academic FHT model of GPC. <h3>Study design:</h3> Descriptive qualitative study using semi-structured telephone interviews with participants who had completed GPC. Interviews were audio-recorded and transcribed verbatim. Thematic analysis was conducted by team members. <h3>Setting:</h3> Academic family health team (FHT), Toronto, Canada. <h3>Participants:</h3> 18 patients who had participated in GPC at the Mount Sinai Academic FHT who delivered between November 7, 2016 and October 26, 2018. <h3>Findings:</h3> The major theme was the value of the relationships established and the positive consequences of those relationships. Participants describe relationships with health care providers that were built on comprehensiveness, continuity and credibility. Relationships with other GPC participants were facilitated but also developed organically, continued outside the structure of GPC and persisted well beyond perinatal care. The consequences of these relationships included creating support networks, shared knowledge and experience with their partners, improved self-confidence during the pregnancy and labour journey, decreased anxiety and extended commitment to breastfeeding. <h3>Conclusions:</h3> Participants in GPC at the Mount Sinai Academic FHT, in essence, became part of a social network for their labour, birth and early parenting journey by developing relationships with their healthcare providers, partners and fellow participants through the group process. This resulted in informational and emotional support which positively affected their experience. In particular, the contributions to self-confidence and decreased anxiety deserve further exploration.

Background: Traditionally, outpatient visits for those with chronic liver disease (CLD) have been delivered in-person with the patient traveling to a centralized location to see the health care provider. The use of virtual care in health care delivery has been gaining popularity across a variety of patient populations, especially within the COVID-19 context. Performed before COVID-19, the aim of the present study was to explore the perspectives of patients with CLD toward the use of virtual care with their liver specialists. Methods: A cross-sectional, mixed methods study was used to conduct this work. Results: A total of 101 patients with CLD participated in this study. Participants had a mean age of 54.5 years (range 19-87 years). Quantitative analysis revealed that 86% were willing to attend a virtual visit with their liver specialist in the future. There was a significant relationship between both age and income level and acceptance of virtual care. The themes emerging from the qualitative analysis included: (1) past experiences attending in-person visits, (2) perspectives on the use of virtual visits, and (3) perceived challenges of virtual visits. Conclusions: Although there are many potential benefits of virtual care to both the patient and the health care system, there are instances (older age, low income level) when in-person care may be preferred by patients. A tailored approach that is mindful of the individual patient's health status, ease of access to technology, and preferences must be considered when offering virtual care. These findings are of particular relevance during COVID-19, an era that has forced us into the virtual space.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

PH Professional Network: The Benefits and Challenges in Delivering Telehealth in Pediatric Pulmonary Hypertension

Deliver Cardiac Virtual Care: A Primer for Cardiovascular Professionals in Canada