OBJECTIVE: The Medicare Benefit Schedule (MBS) telehealth items were expanded in March 2020 during the COVID-19 pandemic. We measured the use of MBS telepsychiatry items compared to consultant physician telehealth items within the context of these item changes, to understand differences in telepsychiatry and physician telehealth utilisation.
METHODS: Monthly counts of face-to-face and telehealth (videoconferencing and telephone) MBS items for psychiatrists and physicians from January 2017 to December 2022 were compiled from Services Australia MBS Item Reports. Usage levels were compared before and after telehealth item expansion. Usage trends for MBS telepsychiatry and physician telehealth items were compared in time-series plots.
RESULTS: Telehealth item expansion resulted in a greater rise of telepsychiatry services from 3.8% beforehand to 43.8% of total services subsequently, compared with physician telehealth services (from 0.6% to 20.0%). More physician telehealth services were by telephone compared with telepsychiatry services. Time-series of both telehealth services displayed similar patterns until mid-2022, when physician telehealth services declined as telephone items were restricted. Telepsychiatry services consistently comprised a greater proportion of total services than physician telehealth services.
CONCLUSIONS: MBS psychiatrist services showed a more substantial and persistent shift to telehealth than physician services, suggesting a greater preference and use of telepsychiatry.

UNASSIGNED: Over the past decade, the adoption of virtual wards has surged. Virtual wards aim to prevent unnecessary hospital admissions, expedite home discharge, and enhance patient satisfaction, which are particularly beneficial for the older adult population who faces risks associated with hospitalization. Consequently, substantial investments are being made in virtual rehabilitation wards (VRWs), despite evidence of varying levels of success in their implementation. However, the facilitators and barriers experienced by virtual ward staff for the rapid implementation of these innovative care models remain poorly understood.
UNASSIGNED: This paper presents insights from hospital staff working on an Australian VRW in response to the growing demand for programs aimed at preventing hospital admissions. We explore staff\'s perspectives on the facilitators and barriers of the VRW, shedding light on service setup and delivery.
UNASSIGNED: Qualitative interviews were conducted with 21 VRW staff using the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework. The analysis of data was performed using framework analysis and the 7 domains of the NASSS framework.
UNASSIGNED: The results were mapped onto the 7 domains of the NASSS framework. (1) Condition: Managing certain conditions, especially those involving comorbidities and sociocultural factors, can be challenging. (2) Technology: The VRW demonstrated suitability for technologically engaged patients without cognitive impairment, offering advantages in clinical decision-making through remote monitoring and video calls. However, interoperability issues and equipment malfunctions caused staff frustration, highlighting the importance of promptly addressing technical challenges. (3) Value proposition: The VRW empowered patients to choose their care location, extending access to care for rural communities and enabling home-based treatment for older adults. (4) Adopters and (5) organizations: Despite these benefits, the cultural shift from in-person to remote treatment introduced uncertainties in workflows, professional responsibilities, resource allocation, and intake processes. (6) Wider system and (7) embedding: As the service continues to develop to address gaps in hospital capacity, it is imperative to prioritize ongoing adaptation. This includes refining the process of smoothly transferring patients back to the hospital, addressing technical aspects, ensuring seamless continuity of care, and thoughtfully considering how the burden of care may shift to patients and their families.
UNASSIGNED: In this qualitative study exploring health care staff\'s experience of an innovative VRW, we identified several drivers and challenges to implementation and acceptability. The findings have implications for future services considering implementing VRWs for older adults in terms of service setup and delivery. Future work will focus on assessing patient and carer experiences of the VRW.

BACKGROUND: The COVID-19 pandemic created unprecedented challenges for people with type 2 diabetes (T2D) and prediabetes to access in-person health care support. Primary care teams accelerated plans to implement digital health technologies (DHTs), such as remote consultations and digital self-management. There is limited evidence about whether there were inequalities in how people with T2D and prediabetes adjusted to these changes.
OBJECTIVE: This study aimed to explore how people with T2D and prediabetes adapted to the reduction in in-person health support and the increased provision of support through DHTs during the COVID-19 pandemic and beyond.
METHODS: A purposive sample of people with T2D and prediabetes was recruited by text message from primary care practices that served low-income areas. Semistructured interviews were conducted by phone or video call, and data were analyzed thematically using a hybrid inductive and deductive approach.
RESULTS: A diverse sample of 30 participants was interviewed. There was a feeling that primary care had become harder to access. Participants responded to the challenge of accessing support by rationing or delaying seeking support or by proactively requesting appointments. Barriers to accessing health care support were associated with issues with using the total triage system, a passive interaction style with health care services, or being diagnosed with prediabetes at the beginning of the pandemic. Some participants were able to adapt to the increased delivery of support through DHTs. Others had lower capacity to use DHTs, which was caused by lower digital skills, fewer financial resources, and a lack of support to use the tools.
CONCLUSIONS: Inequalities in motivation, opportunity, and capacity to engage in health services and DHTs lead to unequal possibilities for people with T2D and prediabetes to self-care and receive care during the COVID-19 pandemic. These issues can be addressed by proactive arrangement of regular checkups by primary care services and improving capacity for people with lower digital skills to engage with DHTs.

OBJECTIVE: Telephone appointments are now widely used in seizure treatment, but there is little understanding of how they compare to face-to-face appointments. Studies from other fields suggest that comparisons can be done on three levels: 1) Abstract level: duration of appointment. 2) Structural level: distribution of talk. 3) Detailed level: aspects of communication. This study aims to compare seizure clinic face-to-face and telephone appointments based on their duration, distribution of talk, and the number of questions asked by patients/companions.
METHODS: Statistical comparison between recordings and transcripts of 34 telephone appointments (recorded in 2021) and 56 face-to-face appointments (recorded in 2013).
RESULTS: There was no significant difference between the duration of face-to-face (median: 16.5 min) and telephone appointments (median: 16.2 min). There was no significant difference in the ratio of neurologist to patient/companion talk (face-to-face: 55% vs. 45%, telephone: 54% vs. 46%). Patients/companions asked significantly more questions per minute in face-to-face (median: 0.17) than telephone appointments (median: 0.06, p < 0.05).
CONCLUSIONS: At a broad level, seizure clinic face-to-face and telephone appointments are similar. Examining the details of the interaction, however, reveals important differences in questioning.
CONCLUSIONS: Practitioners could take steps to facilitate patient questioning in telephone appointments.

OBJECTIVE: To explore how nurses working in general practice experienced remote and technology-mediated working during the COVID-19 pandemic.
METHODS: Exploratory qualitative study with nursing team members working in general practices in England and national nurse leaders.
METHODS: Data were collected between April and August 2022. Forty participants took part in either semi-structured interviews or focus groups. Data were analysed using Framework Analysis informed by the PERCS (Planning and Evaluating Remote Consultation Services) Framework. University of York ethics approval [HSRGC/2021/458/I] and Health Research Authority approval were obtained [IRAS:30353. Protocol number: R23982. Ref 21/HRA/5132. CPMS: 51834]. The study was funded by The General Nursing Council for England and Wales Trust.
RESULTS: Participants continued to deliver a significant proportion of patient care in-person. However, remote and technology-mediated care could meet patients\' needs and broaden access in some circumstances. When remote and technology-mediated working were used this was often part of a blended model which was expected to continue. This could support some workforce issues, but also increase workload. Participants did not always have access to remote technology and were not involved in decision-making about what was used and how this was implemented. They rarely used video consultations, which were not seen to add value in comparison to telephone consultations. Some participants expressed concern that care had become more transactional than therapeutic and there were potential safety risks.
CONCLUSIONS: The study explored how nurses working in general practice during the COVID-19 pandemic engaged with remote and technology-mediated working. It identifies specific issues of access to technology, workload, hybrid working, disruption to therapeutic relationships, safety risks and lack of involvement in decision-making. Changes were implemented quickly with little strategic input from nurses. There is now an opportunity to reflect and build on what has been learned in relation to remote and technology-mediated working to ensure the future development of safe and effective nursing care in general practice.
CONCLUSIONS: The paper contributes to understanding of remote and technology-mediated working by nurses working in general practice during the COVID-19 pandemic and indicates to employers and policy makers how this can be supported moving forward.
UNASSIGNED: Standards for Reporting Qualitative Research (O\'Brien et al., 2014).
UNASSIGNED: This was a workforce study so there was no patient or public contribution.
UNASSIGNED: The paper highlights specific issues which have implications for the development of remote, technology-mediated and blended working for nurses in general practice, care quality and patient safety. These require full attention to ensure the future development of safe and effective nursing care in general practice moving forward.

UNASSIGNED: Following a pandemic-driven shift to remote service provision, UK general practices offer telephone, video or online consultation options alongside face-to-face. This study explores practices\' varied experiences over time as they seek to establish remote forms of accessing and delivering care.
UNASSIGNED: This protocol is for a mixed-methods multi-site case study with co-design and national stakeholder engagement. 11 general practices were selected for diversity in geographical location, size, demographics, ethos, and digital maturity. Each practice has a researcher-in-residence whose role is to become familiar with its context and activity, follow it longitudinally for two years using interviews, public-domain documents and ethnography, and support improvement efforts. Research team members meet regularly to compare and contrast across cases. Practice staff are invited to join online learning events. Patient representatives work locally within their practice patient involvement groups as well as joining an online patient learning set or linking via a non-digital buddy system. NHS Research Ethics Approval has been granted. Governance includes a diverse independent advisory group with lay chair. We also have policy in-reach (national stakeholders sit on our advisory group) and outreach (research team members sit on national policy working groups).
UNASSIGNED: We expect to produce rich narratives of contingent change over time, addressing cross-cutting themes including access, triage and capacity; digital and wider inequities; quality and safety of care (e.g. continuity, long-term condition management, timely diagnosis, complex needs); workforce and staff wellbeing (including non-clinical staff, students and trainees); technologies and digital infrastructure; patient perspectives; and sustainability (e.g. carbon footprint).
UNASSIGNED: By using case study methods focusing on depth and detail, we hope to explain why digital solutions that work well in one practice do not work at all in another. We plan to inform policy and service development through inter-sectoral network-building, stakeholder workshops and topic-focused policy briefings.
The pandemic required general practices to introduce remote (phone, video and email) consultations. That policy undoubtedly saved lives at the time but there are also clear benefits of face-to-face consultations in some circumstances, and the exact role of remote care still needs to be worked out. Despite best efforts, remote care tends to worsen health inequities (people who were poor or less well educated are less able to access and navigate the system and secure the type of appointment they need or prefer). Workstream 1: We will look at 11 GP surgeries across England, Scotland and Wales. We have selected a variety of sites: urban and rural, serving a range of different communities. Each surgery has a different approach to technology. A researcher from our team will work alongside surgery staff to learn what methods and technologies each practice uses to deliver care. They will gather information (mostly qualitative) about how different technological solutions are playing out over time. Workstream 2: Many people experience barriers to accessing care when it is done through technology. This could be because they lack understanding of how to do it, don’t have the right equipment, can’t afford data, or other reasons. We will ask patients about their experiences and work with them and staff to develop ideas about how to overcome barriers. Workstream 3: We will take what we have learnt in Workstreams 1 and 2 to make suggestions to inform national stakeholders and to influence policymakers. Patients and members of the public helped shape the research design. They continue to help guide our research by reading our reports, giving us their opinions and advising on how best to share our research so everyone can benefit from what we have learnt. Our governance panel is chaired by a member of the public.

UNASSIGNED: Accessing and receiving care remotely (by telephone, video or online) became the default option during the coronavirus disease 2019 (COVID-19) pandemic, but in-person care has unique benefits in some circumstances. We are studying UK general practices as they try to balance remote and in-person care, with recurrent waves of COVID-19 and various post-pandemic backlogs.
UNASSIGNED: Mixed-methods (mostly qualitative) case study across 11 general practices. Researchers-in-residence have built relationships with practices and become familiar with their contexts and activities; they are following their progress for two years via staff and patient interviews, documents and ethnography, and supporting improvement efforts through co-design. In this paper, we report baseline data.
UNASSIGNED: Reflecting our maximum-variety sampling strategy, the 11 practices vary in size, setting, ethos, staffing, population demographics and digital maturity, but share common contextual features-notably system-level stressors such as high workload and staff shortages, and UK\'s technical and regulatory infrastructure. We have identified both commonalities and differences between practices in terms of how they: 1] manage the \'digital front door\' (access and triage) and balance demand and capacity; 2] strive for high standards of quality and safety; 3] ensure digital inclusion and mitigate wider inequalities; 4] support and train their staff (clinical and non-clinical), students and trainees; 5] select, install, pilot and use technologies and the digital infrastructure which support them; and 6] involve patients in their improvement efforts.
UNASSIGNED: General practices\' responses to pandemic-induced disruptive innovation appear unique and situated. We anticipate that by focusing on depth and detail, this longitudinal study will throw light on why a solution that works well in one practice does not work at all in another. As the study unfolds, we will explore how practices achieve timely diagnosis of urgent or serious illness and manage continuity of care, long-term conditions and complex needs.
We describe early results from the Remote by Default 2 study, which is following 11 UK general practices for two years as they introduce various kinds of remote appointment booking and clinical consultations. We have been using interviews and ethnography (watching real-world activities), and analysing documents (such as practice reports and websites) to prepare case studies of the 11 practices, which vary widely in size, ethos, geographical location, practice population and digital maturity. Our initial interviews identified the following cross-cutting themes, which showed both commonalities and differences across the 11 practices: - The ‘digital front door’ (patients gaining access using digital portals), which was used to a greater or lesser extent in all practices; some found these systems frustrating and inefficient.- Quality and safety. Staff were concerned about the risk of missing an important diagnosis when consulting remotely, and felt that digitisation could threaten continuity of care.- Digital inclusion. All practices were keen to ensure that patients who lacked digital devices or skills were not disadvantaged; this goal was achieved in different ways (and to different degrees) in different settings.- Staff support and training. Some practices are finding current workload unsustainable due to (among other things) rising patient demand, unfilled staff posts, a post-pandemic backlog of unmet need, and task-shifting from secondary care. Digitisation appears to have increased workload in most practices.- Technologies and infrastructure. The IT infrastructure in each practice had grown in a particular way over time, and was in this sense ‘path-dependent’ (hence, not easily changed). In conclusion, different practices are responding to the ‘disruptive innovation’ of digital technologies in very different ways, reflecting their different practice populations, settings and priorities. We plan to follow the above themes over time and explore additional themes including the experience and role of patients.

Objective The coronavirus disease 2019 (COVID-19) pandemic prompted major changes to the delivery of care. There was a move towards remote consultations in order to mitigate the risk of viral exposure and the risk of delaying care. Remote consultations will play a prominent role within the National Health Service (NHS) in the future. This project aimed to evaluate the effectiveness of remote consultations relative to face-to-face (F2F) consultations. Methods A local retrospective audit of remote consultations in ENT was performed by comparing outcome data for video and telephone appointments during the first peak of the pandemic to outcomes for F2F consultations during the same months of the preceding year. Chi-square tests were employed to determine whether there was any statistically significant discrepancy between the two modalities. Results Outcomes from a total of 314 patient consultations were reviewed. One hundred and fifty-four patients were male, and 160 were female; 111 patient consultations were conducted F2F, and 203 remotely (101 via telephone and 102 via video). There was no statistically significant difference detected between remote and F2F groups for rates of investigation, listing for theatre, referral to other specialties, and initiating treatment. Patients reviewed remotely were less likely to be discharged than those reviewed F2F (p=<0.001). Comparing the two remote modalities, telephone patients were more likely to undergo investigation than patients reviewed over video (p = 0.031). Conclusions Remote consultations were an effective and reliable resource for maintaining a high standard of care during the COVID-19 pandemic. Our findings suggest that remote consultations will prove a valuable tool for clinicians in the remobilisation of health services in the post-pandemic era.

An evaluation of accessibility, appropriateness, acceptability and efficiency of telephone consultations, implemented at Monash Health Refugee Health and Wellbeing (MH RHW) throughout the COVID-19 pandemic, was conducted. A convergent mix-methods design was used, with both patients (n = 50) and clinicians (n = 11) participating in a survey, and two focus groups (n = 14) involving clinicians being conducted. Service utilization data was sourced from the MH RHW database. During May to December 2020, 61% (n = 3012) of the consultations were conducted by telephone, 42% (n = 11) of these required interpreters in a 3-way conversation Most patients were satisfied with telephone as a medium for providing care and with the quality of telephone-based care. Similarly, clinicians considered telephone consultations to be an acceptable mode-of-care for most patients during the pandemic, however, expressed caution in relation to certain patient cohort. Finally, the provision of care by telephone was considered no more efficient than face-to-face service provision, as reflected in the time required for each consultation, with some clinicians reporting adverse workload outcomes. This study highlighted the benefits and challenges of telephone consultations from patient and clinician perspectives. It also highlighted the types of patients that may not be suited to telephone consultations. Overall, this study showed that telephone service delivery is a feasible option in providing care to people of refugee background and should be considered in future decisions as an ongoing Medicare (Australia\'s universal healthcare insurance scheme) billing item. However, clinical discretion should prevail in determining the most appropriate means of delivering care.

OBJECTIVE: To compare outcomes of telephone and face-to-face consultations for new otology referrals and discuss the wider use of telemedicine in otology.
METHODS: Retrospective cohort study including new adult otology referrals to our unit, sampled consecutively between March 2021 and May 2021, seen in either a face-to-face or telephone clinic. Primary outcome measure was the proportion of patients with a definitive management outcome (discharged or added to waiting list for treatment) versus the proportion of patients requiring follow-up for further assessment or review.
RESULTS: 150 new patients referred for a routine otology consultation (75 telephone, 75 face-to-face) were included. 53/75 patients (71%) undergoing a face-to-face consultation received a definitive outcome following initial review, versus 22/75 (29%) telephone patients (χ2 < 0.001, OR 5.8). 52/75 (69%) telephone patients were followed up face-to-face for examination. The mean (SD) number of appointments required to reach a definitive outcome was 1.22 (0.58) and 1.75 (0.73) in the face-to-face and telephone cohorts, respectively (p < 0.001).
CONCLUSIONS: Telephone clinics in otology have played an important role as part of the COVID19 response. However, they are currently limited by a lack of clinical examination and audiometry. Remote assessment pathways in otology that incorporate asynchronous review of recorded examinations alongside audiometry, either conventional or boothless, may mitigate this problem; however, further research is required.