Introduction: Assessing the effectiveness of antibiotics and communicating the problem of resistance are essential when devising antimicrobial stewardship programs (ASPs) in hospital settings. The Drug Resistance Index (DRI) is a useful tool that combines antibiotic consumption and bacterial resistance into a single measure. In this study, we used the DRI to assess the impact of introducing a new antibiotic restriction form on antibiotic effectiveness for the treatment of Gram-negative infections in the intensive care unit (ICU).Methods: This was an observational study to assess and evaluate the antibiotic susceptibility of Gram-negative bacteria and antibiotic prescribing rates for the antibiotics indicated for Gram-negative bacteria following the introduction of a new antibiotic restriction form. The study was conducted from 2015 to 2017 at King Abdulaziz Medical City, a tertiary care facility in Jeddah, Saudi Arabia. Changes in antibiotic effectiveness before and after the introduction of the form were evaluated by calculating the DRI for four of the most common Gram-negative pathogens and eight commonly used antibiotic classes.Acinetobacter baumannii had the highest DRI followed by Klebsiella pneumoniae in both the adult ICU and hospital-wide. After the implementation of antibiotic restriction in the adult ICU, the DRI for carbapenems was significantly lower in the post-intervention phase (from 31.61 to 26.05) (p = 0.031).Results: The overall DRI for the adult ICU was higher (59.45) in comparison to the hospital-wide DRI (47.96). A higher DRI was evident for carbapenems and antipseudomonal penicillins + beta-lactamase inhibitors. Conclusion: The DRI is a useful tool for tracking the effectiveness of antibiotics over time. The results of our study are significant in the way that it highlights the importance of having an effective antibiotic stewardship program in healthcare settings and regular feedback of antibiotic consumption data to the stakeholders to keep the antibiotic prescriptions in check, thereby ensuring their sustained effectiveness. Antibiotics are useful agents against common infectious diseases and have proven to save many lives since their invention. However, antibiotic resistance, driven in part by the overuse and inappropriate prescribing of antibiotics , has becAcinetobacter baumannii, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli [In Saudi Arabia, several research studies have found a predominance of MDR infections caused by Gram-negative bacteria, including hia coli -8. Charahia coli . MonitorTo address these challenges, the Drug Resistance Index (DRI) was created as a simple and effective means of communicating gaps in antibiotic effectiveness. Similar to stock market indices computed from market valuations across companies of comparable sizes, the DRI aggregates measurements of antibiotic resistance and consumption across multiple drug-pathogen combinations into a single measure. The simple metric can then be used to compare changes in antibiotic effectiveness over time and across geographic settings . In thisMonitoring antibiotic consumption and resistance and sharing results with stakeholders, especially prescribers, can guide policy toward more effective antibiotic usage. However, it is a challenge to present this information to policymakers and prescribing physicians in a way that is easily understandable when the data on antibiotic resistance and antibiotic consumption is presented separately. The DRI can bridge this gap by presenting this information in a single measure that is easily understandable. The index can also be useful when trying to compare between different geographic settings and types of infections and indicating changes in antibiotic effectiveness over time .This was an observational study to assess and evaluate the antibiotic susceptibility of Gram-negative bacteria and antibiotic prescribing rates for the antibiotics indicated for Gram-negative bacteria following the introduction of a new antibiotic restriction form. The study was conducted from January 2015 to December 2017 at King Abdulaziz Medical City, a tertiary care hospital located in the city of Jeddah in the Western region of Saudi Arabia. King Abdulaziz Medical City, Jeddah, is an over 500-bed tertiary care hospital serving the National Guards and their eligible dependents in the Western Region of Saudi Arabia. The adult ICU is a combined unit of medical and surgical patients with a bed capacity of 28 beds.In July of 2016, an antibiotic restriction form was introduced to the adult ICU as part of the hospital’s antimicrobial stewardship program (ASP). The form required physicians to get approval for an antibiotic therapy from either the clinical pharmacist or an infectious disease physician assigned to the antimicrobial stewardship program (ASP) prior to prescribing. To evaluate the impact of implementing antibiotic restriction on drug effectiveness in the ICU using the DRI, data on antibiotic prescribing and resistance was obtained from the adult ICU, in addition to facility-wide data.The DRI was calculated using the formula introduced by Laxminarayan and Klugman (2011): 𝐷𝑅𝐼 = ∑kptk𝑞tk, where ptk is the proportion of resistance among all included pathogens to drug k for time t and 𝑞tk is the proportion of drug k used for the treatment of those pathogens in all drugs included in the index for time t. The resulting score is between 0 and 100, where 0 indicates 100% susceptibility and 100 indicates 100% resistance [A. baumannii, K. pneumoniae, P. aeruginosa, and E. coli. These organisms were isolated from routine clinical samples sent from inpatient wards/units and obtained from patients suffering from infections of the bloodstream, respiratory tract, skin and soft tissue, or urinary tract. Eight classes of antibiotics commonly used in the treatment of the aforementioned Gram-negative infections were included in the study: aminoglycosides , carbapenems , third- and fourth-generation cephalosporins , fluoroquinolones , glycylcyclines , penicillins + beta-lactamase inhibitors , antipseudomonal penicillins + beta-lactamase inhibitors , and polymyxins .The organisms included in the study were Data were collected for three years from January 2015 to December 2017. Resistance data based on antimicrobial susceptibility tests were extracted from the Cerner Millennium software used for ordering and reporting all microbiology laboratory results. Antibiotic consumption data were extracted by the Information Services from the electronic QuadraMed software used by hospital physicians and pharmacists for prescribing and dispensing medications. The number of antibiotics consumed was measured based on days of therapy (DOT), defined as the sum of days for which any amount of antibiotics was administered to individual patients regardless of dose and standardized over 1,000 patient days. To calculate the DOT, patient admissions and discharge data were provided by the Bed Management. Patient days were calculated based on the number of patients admitted to the hospital for any portion of each day (including admission and discharge days) during the study period irrespective of antibacterial consumption. Data analysis was conducted using the statistical software IBM SPSS. T-test analyses were conducted to identify whether increasing or decreasing trends in the DRI were statistically significant at the 5% level.A. baumannii had the highest DRI, followed by K. pneumoniae , the average DRI for the adult ICU was higher (59.45), as shown in Figure A. baumannii was the bacteria that had the highest resistance, followed by K. pneumoniae and P. aeruginosa . Regarding antibiotic consumption, we found that the combined DOT for any antibiotic was much higher in the adult ICU 99.55) as opposed to the entire hospital 47.99). In the adult ICU and across the facility, the top two consumed antibiotic classes were carbapenems and antipseudomonal penicillins + beta-lactamase inhibitors  to explore the incidence of in-hospital inappropriate empiric antibiotic use in patients and the relationship with patient outcomes reported that up to 79% of general antibiotic consumption for the treatment of severe infections in hospitals is inappropriate . In SaudAcinetobacter baumannii, in particular, had the highest DRI among all organisms in both settings. This was due in part to high rates of antibiotic resistance among A. baumannii, which in previous studies have also been shown to be the most resistant organisms among the common Gram-negative bacteria with the highest DRI [To the best of our knowledge, this is the first study in Saudi Arabia to calculate the DRI for a healthcare facility. This is also the first study to apply the DRI in a clinical setting. We calculated the DRI for our hospital as a whole and the adult ICU. The DRI in the adult ICU was calculated separately to evaluate the effectiveness of implementing an antibiotic restriction protocol as part of an antibiotic stewardship program (ASP) to control and rationalize antibiotic consumption. The results from the analysis suggested that antibiotic effectiveness was lower in the adult ICU than in the overall hospital throughout the study period indicated by higher DRI in the adult ICU. hest DRI .As far as the DRI by antibiotic class is concerned, in the adult ICU, carbapenems had the lowest antibiotic effectiveness, followed by antipseudomonal penicillins + beta-lactamase inhibitors. For the overall hospital, this finding was reversed. High DRIs and, in effect, low antibiotic effectiveness among carbapenems and antipseudomonal penicillins + beta-lactamase inhibitors upon further analysis appeared to be driven by high rates of consumption of these antibiotic classes.It seems that carbapenems are the drug of choice for ICU physicians, as many studies have reported the same results. A study conducted by Balkhy et al. (2018) showed carbapenems to be the highest consumed antibiotic class in the adult ICUs of a tertiary care hospital in Saudi Arabia . LikewisA. baumannii infections. On the other hand, higher consumption of antipseudomonal penicillins in the adult ICU leads to higher DRI. Antipseudomonal penicillins were not included in the list of restricted antibiotics, so it was easier for the physicians to switch from carbapenems to antipseudomonal penicillins without any restriction, leading to their higher consumption.The results of our study suggested a possible association between the reduction of carbapenem consumption in the adult ICU and decreased carbapenem resistance among Our study also had some limitations. First, we did not have separate data on clinical areas other than the adult ICU to have a clearer comparison of the DRI. The data on the adult ICU was also included in the hospital-wide results. At least having separate data from the pediatric ICU would give us an opportunity to have a fair comparison of the DRI between ICUs. Second, we did not ascertain the appropriateness of antibiotic use to check what percentage of antibiotics was used judiciously. The results of our study are statistically significant in a way that it highlights the importance of having effective antimicrobial stewardship programs in healthcare settings and regular feedback of antibiotic consumption data to the stakeholders to keep the antibiotic prescriptions in check and ensure their sustained effectiveness.A. baumannii infections. On the other hand, higher consumption of antipseudomonal penicillins in the adult ICU leads to higher DRI. Antipseudomonal penicillins were not included in the list of restricted antibiotics, so it was easier for the physicians to switch from carbapenems to antipseudomonal penicillins without any restriction, leading to their higher consumption. Further research is required in this field.The results of our study suggested a possible association between the reduction of carbapenem consumption in the adult ICU and decreased carbapenem resistance among


Staphylococcus aureus is 60.5%; and resistance types and rates are similar in patients originating from Yemen, Syria and Iraq.Médecins Sans Frontières (MSF) has designed context-adapted antibiotic resistance (ABR) responses in countries across the Middle East. There, some health systems have been severely damaged by conflict resulting in delayed access to care, crowded facilities and supply shortages. Microbiological surveillance data are rarely available, but when MSF laboratories are installed we often find MDR bacteria at alarming levels.As a result, MSF has created a multifaceted, context-adapted, field experience-based, approach to ABR in hospitals in Middle Eastern conflict settings. We focus on three pillars: (1) infection prevention and control (IPC); (2) microbiology and surveillance; and (3) antibiotic stewardship.,We see many nosocomial MDR infections related to poor IPC.The second pillar of our approach improves access to microbiological diagnostic tools. MSF has established reliable microbiology laboratories in Amman (Jordan), Koutiala  and Aden (Yemen) with simplified protocols and quality control measures in place. All of these sites have formidable challenges: staff with microbiological expertise  are frequently lacking. Technology can be prohibitively expensive, require reagents with limited shelf-lives and be ill-adapted to resource-limited settings without regular electricity supplies or a cold chain for sensitive items (such as antibiotic discs).Microbiological capacity, including human resources, expertise, and coordination, must be expanded in resource-limited and complex settings. Innovations such as MSF’s Mini-lab, which simplifies microbiological diagnostics for resource-poor settings, could help with this Figure .7 MappinMSF’s antibiotic stewardship programmes have trained clinicians to rationally use antibiotics in projects in the Middle East, from an orthopaedic reconstructive surgery project for conflict-related injuries  to an acute trauma facility (Yemen), with future activities planned in Gaza and Iraq.Finding skilled human resources remains a primary challenge in addressing ABR in MSF settings, so building local capacity can create a degree of sustainability. MSF capacity-building endeavours are not passive learning experiences for staff but provide hands-on practical training and continued support. Often, a non-local IPC expert,  microbiologist or infectious disease specialist is sent to a field site for 3–6 months to identify and train a local team member to lead anti-ABR activities . In the Middle East, ongoing ‘regional’ advisory positions provide clinical support to multiple countries’ projects and enhance the expertise being built in individual facilities. Coaching is provided by these regional experts about implementing IPC programmes, antibiotic activity spectrum, evidence-based antibiotic decision-making (based on infection site and severity), indications for microbiological testing and microbiology result interpretation.MSF’s experience in Aden, Yemen, an acute trauma facility, demonstrates how feasible this approach can be. A Yemeni general practitioner was initially sent to MSF’s Jordan project to become familiar with an established, structured antibiotic stewardship programme.Microbiological sampling, processing, and interpretation remains a cornerstone of antibiotic stewardship in MSF settings. Coaching is provided to local laboratory staff, and simplified, context-adapted laboratory standard operating procedures (SOPs) and quality assurance practices have been developed. Surgeons use SOPs for sampling intra-operative specimens for osteomyelitis diagnoses. Antibiotic stewards guide relevant clinicians using microbiological results, employing a collaborative stewardship approach that optimizes antibiotic prescription. Results are collated and reviewed to generate local antibiograms and inform empirical choices for sepsis treatment.Maintaining high-quality microbiology in MSF contexts is not easy, however, and often demands flexibility. For example, in Gaza over 3000 patients with live ammunition gunshot wounds  in MSF’s budget-constrained environments. Newer antibiotics and modes of delivery (such as portable infusers) hold promise and are being evaluated to find savings.In projects where MSF has integrated ABR control measures, concrete action has been possible despite resource constraints and instability. But to prevent new resistant pathogens from emerging and to halt the spread of existing resistance, patient management must be optimized and addressed by all actors, including Ministries of Health in resource-poor and conflict settings. Field support from trained specialists, including via telemedicine, remains a key point of interaction that should be expanded, as should context-adapted, standardized ABR training and capacity-building tools for local staff. Shared protocols for prophylaxis and treatment in these contexts will help harmonize ABR approaches and introduce antibiotic stewardship. Ensuring affordable antibiotics and diagnostics supplies, sharing surveillance data and limiting over-the-counter availability of broad-spectrum antibiotics are all necessary steps to address ABR.None to declare.


Immunoglobulin (Ig)G4‐related disease (IgG4‐RD) is a systemic condition associated with fibroinflammatory lesions and is characterized by elevated serum IgG4 levels and IgG4‐positive cell infiltration into the affected tissues. It has been reported that IgG4‐RD affects a variety of organs but uncommonly affects the gastrointestinal tract. In particular, there are few cases of lesions in the small intestine, except for sclerosing mesenteritis, which were mostly diagnosed from surgical specimens. Herein, we describe the case of a 70‐year‐old man who initially presented with abdominal pain, headache, later cognitive decline, and gait disturbance caused by IgG4‐RD. Colonoscopy revealed irregular ulcers in the terminal ileum, and computed tomography of the head showed hypertrophic pachymeningitis. Numerous IgG4‐positive cells were detected in the ileal and dural biopsies. We diagnosed the patient with IgG4‐RD and started steroid pulse therapy. After initiation of treatment, the symptoms quickly improved. The patient was discharged from the hospital after starting oral prednisolone treatment (30 mg). The dosage was gradually reduced to 10 mg. A follow‐up colonoscopy revealed scarring of the ileal ulcers. This case may provide valuable information regarding the endoscopic findings of small intestinal lesions in IgG4‐RD. IgG4‐related disease (IgG4‐RD), a systemic condition associated with fibroinflammatory lesions, is characterized by increased serum IgG4 levels and infiltration of IgG4‐positive cells into the affected tissues.In this report, we describe a case of IgG4‐related intestinal lesions and endoscopic findings before and after steroid therapy.A 70‐year‐old man suffering from abdominal pain and headache visited his family doctor and was prescribed non‐steroidal anti‐inflammatory drugs (NSAIDs) and a mucosal protectant for 2 weeks. He was referred to our hospital because of unresolved symptoms and the onset of melena. On arrival, he showed hemodynamic instability with low blood pressure (80/56 mmHg), high pulse rate (100 bpm), and severe anemia . Initial esophagogastroduodenoscopy (EGD) and colonoscopy (CS) were performed immediately after the patient was stabilized by a blood transfusion. EGD showed gastric and duodenal ulcers, potentially due to NSAIDs, and atypical esophagitis lesions for reflux esophagitis Figure . CS showOne month later, the patient developed cognitive decline , gait disturbance, and worsening of headache. Head computed tomography revealed falx cerebri and tentorium cerebelli as high‐density areas, suggesting hypertrophic pachymeningitis Figure  due to IIgG4‐RD was first recognized as a distinct disease in the case of sclerosing pancreatitis reported by Hamano et al. in 2001.In this study, the endoscopic image showed that the terminal ileal lesion was characterized by oval or map‐like shallow ulcers with no longitudinal trend and intact mucosa around the ulcer Figure . MultiplThere has been only one report on endoscopic images of small intestinal lesions in IgG4‐RD previously by Fujita et al.In conclusion, we report a case of a small intestinal ulcer accompanied by IgG4‐RD. The lesion responded to steroid therapy and became scarred on improvement. A biopsy is useful for diagnosis, but caution should be exercised because IgG4 cell infiltration may be observed in other diseases. It is difficult to diagnose IgG4‐RD from gastrointestinal lesions alone. Thus, it is necessary to perform a thorough systemic examination and associated symptom check.The authors declare that they have no conflict of interest.None.


Recently, there has been remarkable progress of the host-guest doped pure organic room-temperature phosphorescence (RTP) materials. However, it remains a great challenge to develop highly efficient host-guest doping systems. In this study, we have successfully developed a heavy atom free pure organic molecular doped system  with efficient RTP through a simple host-guest doping strategy. Furthermore, by optimizing the doping ratios, the host-guest material with a molar ratio of 100:1 presented an efficient RTP emission with 46% quantum efficiency and a long lifetime of up to 9.17 ms under ambient conditions. This work will provide an effective way to design new organic doping systems with RTP. Recently, purely organic room temperature phosphorescence (RTP) materials are gaining more and more attention because of their long luminescent lifetimes, larger Stokes shift, convenient syntheses, low cost, and so on , showing3 and CzS-C2H5) as guests and their corresponding dioxide derivatives (CS-CH3 and CS-C2H5) as hosts, showing high phosphorescence efficiency (43%) as well as a long afterglow of up to 25 min in an aqueous environment. As can be seen from the above analysis, the phosphorescence efficiency of host-guest doping materials without heavy atoms is lower than that of RTP materials containing heavy atoms. Therefore, it remains a challenge to further improve the phosphorescent quantum efficiency of RTP materials without heavy atoms.To avoid or overcome these shortcomings, heavy atom free host-guest interactions are an important approach in this research field. For instance, In the present study, we have developed a heavy atom free pure organic host-guest doped material, in which thianthrene (TTR) was selected as a guest molecule and benzophenone (BPO) as a host. TTR was selected as the guest because it contains dual-heteroatom of sulfur with abundant lone-pair electrons which can effectively facilitate the SOC and further increase the intersystem crossing . BPO wasReagents and materials: Unless otherwise noted, all reagents used in the experiments were purchased from commercial sources without further purification. For flash column chromatography, silica gel with 200–300 mesh was used.Measurements: The Steady-state luminescence, delayed luminescence spectra, and lifetimes were recorded on an Edinburgh Instruments LTD FLS1000 photoluminescence spectrometer, which is equipped with a xenon arc lamp, xenon flash lamp (μF2), picosecond pulsed diode laser (EPL), and picosecond pulsed led (EPLED). The delayed luminescence spectra were collected with a delay time of 1 or 8 ms. Photoluminescence efficiency was collected on a Hamamatsu Absolute PL Quantum Yield Spectrometer C11347. Luminescent photos were taken by a Canon EOS 700D camera. Powder X-Ray diffraction (XRD) patterns at room temperature were measured on an X-ray diffractometer  using Cu Kα radiation (λ = 1.54051 Å). All the measurements of the photophysical properties for emissive materials are made carried out in air.The molecular structures of TTR (m. p. 151–155°C) and BPO (m. p. 48.5°C) are shown in Next, their photophysical properties were studied through steady-state photoluminescence (PL) spectra, and time-resolved emission decay curves in solid state. Pure crystalline BPO powders showed almost identical multiple peaks for steady-state photoluminescence (PL) and phosphorescence with emission peaks at 416 nm (409.91 μs), 446 nm (409.49 μs), 479 nm (409.63 μs) and a shoulder band around 521 nm (409.79 μs) under ambient conditions . After d1→T1) and accelerate the subsequent T1→S0 phosphorescence processes  of the host material (BPO) were reduced to their lowest level compared to other doped molar ratios . Besides, the phosphorescence lifetime of all doped materials is higher than the individual host (BPO) at their maximum emission peak at 540 nm and the doped material with a 100:1 molar ratio showed the longest emission lifetime of 9.17 ms . From throcesses .. molecule. Among these experiments, the doped material with a molar ratio of 100:1 presented the highest phosphorescence quantum yields of up to 46% , which iTo gain insight into the mechanism of the highly efficient RTP for BPO/TTR composite, we conducted a series of control experiments including excitation and phosphorescence spectra of BPO, TTR, and composites, as well as luminescent lifetime change. From In conclusion, we have developed an efficient RTP doping material based on two heavy atom free organic small molecules, benzophenone and thianthrene. The doped materials have contained different heteroatoms  with abundant lone pair electrons, which make them promising candidates to enhance SOC, leading to an efficient ISC in pure organic metal-free RTP materials, instead of commonly used heavy atoms. We achieved an efficient RTP emission with phosphorescence efficiency of up to 46% under ambient conditions by tuning the doping molar ratio of the host and guest molecules. Our work not only provides a new approach to develop heavy atom free pure organic host-guest doped RTP materials but also expands the methods to enhance their quantum efficiency.


Introduction: Variation in practice patterns among physicians is well-documented despite professional guidelines and increasingly uniform medical training. Variations may lead to improper utilization of healthcare resources, misdiagnosis, overdiagnosis, unnecessary treatments, and forgoing of needed interventions. One area of clinical variation and overuse of particular interest is the prescribing of antibiotics, which can lead to eventual antibiotic resistance and other negative consequences. Variations in antibiotic prescribing along with other practice patterns have been studied previously but no attempt has been made to examine the correlation between multiple practice patterns. The purpose of this study was to determine if a correlation existed between the provider behaviors studied.Methods: A small area network of 39 pediatric providers was analyzed to determine if antibiotic prescription percentages varied. Antibiotic prescription percentages were further broken down by visit type (sick versus well). Two other practice measures, in-office lab utilization and diagnoses of food and drug allergies, were then analyzed. Data were explored primarily with Spearman’s correlation tests.Results: Strong positive correlation was seen between a provider's antibiotic prescription percentage at sick and well visits. Strong positive correlation was seen between the antibiotic prescribing percentage and the number of in-office labs ordered. Moderate positive correlation was seen between antibiotic prescribing percentage and the percentage of a provider’s empaneled patients with any allergy diagnosis .Conclusion: This retrospective study demonstrates that variation in provider practice patterns continues to exist despite established practice guidelines from national organizations. It also demonstrates a linear correlation between multiple provider behaviors that have not previously been explored together. The presence of a correlation between clinical behaviors may suggest an underlying practice philosophy and present an opportunity for personalized, provider-specific education and quality improvement. Variation in practice patterns and behaviors among physicians is documented in the scientific literature. Differences in the frequency of tonsillectomies performed were noted as early as the 1930s by Dr. J. Alison Glover ,3. A morThese variations affect the quality of care and contribute to healthcare disparity, especially when they lead to the overuse of diagnostic tools and treatment. Overdiagnosis is considered to occur when people are labeled with or treated for a disease that would never cause them harm . This ofThe overprescribing of antibiotic therapies to infants and children is one example of this overuse. Many guidelines for the diagnosis of bacterial illness and the use of antibiotic therapy exist. Some examples of these include the Infectious Diseases Society of America (IDSA) guidelines for the management of community-acquired pneumonia in infants and children older than three months of age , the AmeWhile the benefits of antibiotic therapies are obvious, their overuse can lead to resistance and increases in both the length and severity of the disease. Antibiotic resistance continues to evolve and represents a growing danger to all populations, including children. Resistance, however, is not the only concern with excessive or unnecessary antibiotic prescription. A 2019 study found that all commonly prescribed antibiotics during infancy are associated with subsequent diagnosis of allergic disease, and that administration of more than one class of antibiotic was associated with increased risk .Antibiotic prescription is not the only area of pediatric care where overuse occurs. Excessive and unnecessary ordering of imaging, laboratory tests, and other diagnostic and screening services has been shown . Using pAll these behaviors have been previously studied in isolation but analyzing various behaviors for correlations may yield insights not previously recognized. It was hypothesized that a provider’s antibiotic prescription behaviors, one of the most common and routine practices in outpatient pediatric offices, might serve as a marker for other clinical behaviors. A correlation between behaviors may suggest an underlying practice philosophy that guides the provider’s decision-making. A provider with a low threshold for prescribing antibiotics may also have a lower threshold when it comes to using in-office labs or diagnosing a child with an allergy.To this end, a retrospective review of electronic medical records of the patients empaneled to providers within a pediatric primary care network was conducted. The primary objectives of this study were: (A) To determine whether a variation is present regarding the percentage of visits with an antibiotic prescription among the outpatient providers in a pediatric primary care small area network; (B) To determine if a correlation exists between a provider’s percentage of visits with an antibiotic prescription and the percentage of visits where an in-office lab was ordered; (C) To determine if a correlation exists between a provider’s percentage of visits with an antibiotic prescription and allergy diagnoses among a provider’s empaneled patients.The population in this study included general pediatricians and nurse practitioners (NPs) who are employees of the pediatric primary care network. All data used in this research was extracted from the electronic medical records system using Research Electronic Data Capture (REDCap) data collection software. For the period of January 1 to December 31, 2019, data were collected on the total number of patient visits, the total number of well visits, and the total number of sick visits for each provider that meets the inclusion criteria. A well visit was defined as any visit with the primary goal is preventative care, which can include a review of health history and medical history, counseling about ways to improve health, a physical exam tailored to preventative care needs, immunizations, and screening tests if needed. A sick visit was defined as any visit focused primarily on an acute health issue arising outside of a normal preventative health schedule including treatment, symptom management, and education regarding home care.To be included in this study, providers must have conducted their practice at pediatric outpatient clinics within the pediatric primary care network. Those who work shifts in urgent care centers in addition to outpatient clinics were included, but visits conducted at urgent care centers were not included. To be included in the study, providers must have been employed for the entire 2019 calendar year. Only visits conducted at primary care locations were included. The sample size was calculated using the G*Power software. Data on antibiotic prescriptions, in-office labs, and allergy diagnoses were also obtained. Data were explored primarily with Spearman’s correlation tests by using IBM SPSS Statistics for Windows, Version 26.0 . Statistical significance was set at p<0.05.For each provider, the percentage of all visits at which an antibiotic was prescribed, the percentage of well visits at which an antibiotic was prescribed, and the percentage of sick visits at which an antibiotic was prescribed were analyzed. Data were standardized by dividing the number of visits at which an antibiotic was prescribed by the total number of visits by type . Any dose, suspension, brand name, or generic version of antibiotic were included. Data on appropriate use, unnecessary use, escalated use of extended-spectrum antibiotics, incorrect spectrum of antibiotics, and combined antibiotic use was not examined in this study, although this could be an area for future research.In-office laboratory utilization data were standardized by dividing the total number of each laboratory test a provider ordered by the total number of visits for that provider. The six most ordered tests among all providers were included in the analysis. Laboratory tests that were included in the analysis were the influenza test, rapid strep test, respiratory syncytial virus (RSV) test, mononucleosis test, urinalysis, and the blood glucose test. Because each test may be ordered by the provider in a variety of ways, data were extracted for all possible ordering codes.Data on allergy diagnoses for each provider were extracted as the total number of empaneled patients with at least one allergy diagnosis. The data were standardized by dividing the total number of patients with at least one allergy diagnosis by the total number of empaneled patients per provider.Data were gathered on 33 physicians and six NPs who met the inclusion criteria. Provider data were de-identified and provider names were replaced with a three-letter code. After examining the data for outliers, one physician was excluded due to a low number of total and well visits. The mean number of total visits per provider was 3257 with a standard deviation of 997. Eight providers  were excluded from the allergy and vaccine portion of the study due to a lack of empaneled patients.Variation in the percentage of visits where an antibiotic was prescribedThe mean percentage of all visits where an antibiotic was prescribed was 15.3% with a standard deviation of 7.3%. A high variation existed in the percentage of total visits at which an antibiotic was prescribed, with antibiotic prescription percentages as high as 42.9% and as low as 4.8% observed  was found between the percentage of total visits at which a provider prescribed an antibiotic and the number of labs ordered. When separated by visit type, the strength of the correlation increased slightly  when lab use was compared against the percentage of sick visits where an antibiotic was prescribed Figure . Among tA moderate correlation was found between antibiotic prescribing percentage and influenza tests . Correlation results between antibiotic prescription, RSV, and glucose were not significant (p>0.05).Correlation between antibiotic prescribing percentage and allergy diagnosesAllergy diagnosis data were analyzed for all the providers with empaneled patients . Data were standardized by dividing the total number of a provider’s empaneled patients with an allergy diagnosis by that provider's total number of empaneled patients. Moderate positive correlation  was found between the percentage of total visits at which a provider prescribed an antibiotic and the percentage of empaneled patients with an allergy diagnosis Figure .As hypothesized, large variation was found in pediatric primary care antibiotic prescription percentage at total visits, with a difference of 38.1% between the highest and lowest prescribers. An even larger variation of 44% was observed when a patient was seen for a sick visit. Despite many providers practicing in the same geographic area - and even the same clinic - variation was still observed. When antibiotic prescription percentage was separated by visit type, a strong positive correlation was seen between well and sick visits. This finding suggests that, regardless of the reason for an appointment, certain providers may be more inclined to prescribe an antibiotic to their patients.After establishing the presence of variation in antibiotic prescribing patterns, in-office lab ordering data were analyzed. Like antibiotic prescription, lab utilization is a marker of provider practice behavior and should not vary greatly from one provider to another. However, variation was present here as well, with lab-utilization percentages ranging from 13.7% to 57.1% of a provider’s total visits. When analyzed using Spearman’s correlation test, a strong positive correlation existed between the antibiotic prescribing percentage and the ordering of in-office labs. Providers that were higher utilizers of antibiotics were also those that more frequently ordered labs for their patients.Lastly, the data related to allergy diagnoses among providers were analyzed. While antibiotic prescription and lab orders are both considered provider behaviors, allergy diagnosis is a patient outcome. Wide variation should not exist in the percent of empaneled patients with allergies among different providers. However, a range of 13.9% to 29.2% was seen in allergy diagnoses among providers’ empaneled patients. Additionally, a moderate correlation was seen between antibiotic prescribing percentage and the percentage of a provider’s empaneled patients with an allergy diagnosis in their medical records.LimitationsA weakness of this study is the small sample size consisting of only one general pediatric provider network. Future studies that expand this work to include larger care networks across many regions may yield additional information as to whether location impacts a provider’s practice philosophy. Additionally, while data on antibiotic prescription percentages were extracted from the electronic medical record, the study did not differentiate between appropriate use, unnecessary use, escalated use of extended-spectrum antibiotics, incorrect spectrum of antibiotics, or combined antibiotic use.Large variation in the percentage of visits at which providers prescribed an antibiotic was found in a small pediatric primary care network. This variation persisted regardless of the visit type (sick versus well). Even though many providers worked with the same population and in the same clinic, variation in practice patterns was evident. Positive correlation existed between a provider's percentage of visits with an antibiotic prescription and the percentage of visits with at least one in-office lab ordered. Positive correlation was also found between a provider's percentage of visits with an antibiotic prescription and the percentage of his or her empaneled patients with at least one allergy diagnosis  on their medical record.In summary, providers who were high prescribers of antibiotics were, in general, more likely to be high utilizers of in-office labs and their empaneled patients were more likely to have an allergy diagnosis on their chart. The opposite was also seen - those providers who were low prescribers of antibiotics were, in general, less likely to be high utilizers of in-office labs and their empaneled patients were less likely to have an allergy diagnosis on their chart. This data suggests an underlying practice philosophy that accounts for these correlations and may present an opportunity for quality improvement.Quality improvement measures might take a general approach. However, the data presented here and its ability to show correlations and comparisons with peers may provide an opportunity for individualized insight and education, the ultimate goals being improved patient care and judicious utilization of healthcare resources. Future analysis might look at provider behavior and correlations between specialty referral patterns, utilization of imaging, and utilization of reference laboratories. Additional studies looking at provider variables  might give further insight.


The COVID-19 pandemic impedes therapy and care activities. Tele-health, i.e., the provision of health care at a distance (HCD), is a promising way to fill the supply gap. However, facilitators and barriers influence the use and experience of HCD for occupational therapists (OTs) and midwives.We identified use of services and appraisal of experiences of Switzerland-based OTs and midwives regarding the provision of HCD during the lockdown as it pertains to the COVID-19 pandemic in spring 2020. 1. Hypothesis: Profession, age in years, and area of work have a significant and meaningful influence over whether HCD is provided. 2. Hypothesis: Profession, age in years, area of work, possibility of reimbursement by health insurance, and application used have a significant and meaningful influence on the experience of HCD.In a cross-sectional survey, 5755 OTs and midwives were contacted to fill out an online questionnaire with 13 questions regarding demographic information, use of HCD, and experiences while providing the service. Eleven potential facilitators and barriers and areas where there was desire for support were identified.n = 431) and midwives (n = 501) provided HCD during the COVID-19 pandemic lockdown. Profession and area of work had a significant influence on whether HCD was provided. Age only had a significant influence on the use of videotelephony, SMS, and chat services.The questionnaire was completed by 1269 health professionals (response rate 22.5%). 73.4% of responding OTs (p ≤ .01). Video-telephony  and use of phone  were positive predictors for positive experience, while use of SMS  was a negative predictor.OTs experienced HCD significantly more positively than midwives , followed by law and data protection (60.4%).HCD during the early COVID-19 pandemic was generally perceived as positive by OTs and midwives. There is need for training opportunities in connection with HCD during the COVID-19 pandemic.The online version contains supplementary material available at 10.1186/s12913-021-06527-9. Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. As SARS-CoV-2 is highly contagious, the World Health Organization (WHO) announced the spread of COVID-19 as a pandemic in March 2020. Most states worldwide decided in March 2020 to substantially lock down public life to prevent the spread of the disease . Those who tested positive for COVID-19 and vulnerable persons  were isolated. Unfortunately, those who require rehabilitation are often made vulnerable by the disease  [The COVID-19 pandemic caused additional strain through a high prevalence of disease, limited resources, and staff under pressure .This being the case, birth dates could only be rescheduled to a limited extent. At the beginning of the pandemic, studies provided contradictory evidence whether pregnant and postpartum women were at increased risk during the infectious disease outbreak , 6. The Tele-health, i.e., the provision of health care at a distance (HCD), might be suitable for continuing therapy under these circumstances . The useAlthough HCD may represent the first option for the treatment of people in isolation, most occupational therapists (OTs) and midwives were not adequately prepared to change therapy settings and care from in-person to remote during the rapid lockdown caused by the COVID-19 pandemic. Measures associated with the successful implementation of tele-health services such as education and training, as well as administrative and technical support could not be implemented in time. Little scientific literature exists to support health providers with information about the successful application of tele-health. To our knowledge, only Australia’s Nursing and Midwifery Federation has developed HCD professional practice standards and guidelines written specifically for nurses and midwives which provide recommendations regarding communication, technology, consent, privacy, and confidentiality .In the literature, facilitators and barriers for successful implementation of HCD have been described , 19. TheTo integrate HCD technology into routine practice during the COVID-19 pandemic and in the case of future pandemics, it is necessary to understand by whom, how, and in which areas of work HCD is provided, and to evaluate the experiences and perceptions of health care professionals regarding the appropriateness and meaningfulness of HCD. We were therefore interested in the experiences and attitudes of health professionals who normally have physical contact with their clients and regularly care for them in 1:1 settings. OT and midwives in Switzerland were interested in exploring the experience of HCD during the COVID-19 pandemic. Their work before the pandemic has been predominantly performed in physical presence. Moreover, touch is an essential part of the work of OT and midwives, whether in guiding clients within therapies (indispensable for OT in particular) or in physical check-ups (midwives). Until before the pandemic, therefore, both professions offered only very limited HCD. The aim of the survey was to identify the use of services and to appraise the experiences of Switzerland-based OTs and midwives regarding the provision of HCD during the lockdown due to the COVID-19 pandemic in spring 2020. The study presented helps to understand facilitators and barriers for successful implementation of tele-health applications in occupational therapy and midwifery and facilitates the development of workshops and guidelines to support health care providers during COVID-19 pandemic .The two professions differ in the type of services  they provide. Also, HCD may be seen as more appropriate for services typically provided in certain areas of work, e.g., in an outpatient setting or at clients’ homes. Furthermore, it is reasonable to assume that health professionals are more likely to provide services they can be reimbursed for . It’s alWe hypothesize that profession , age in years, and area of work have significant and meaningful influence on the provision of HCD.Furthermore, we hypothesize that profession, age in years, area of work, possibility of reimbursement by health insurance, and application used  have a significant and meaningful influence on experience of a given HCD service by health care providers.In our reporting of the survey we follow the CHERRIES guidelines that were mainly designed for web-based surveys , 22.N = 2454 members) and midwifes  professionally registered in Switzerland. We collected data by means of an online survey. Representatives of the respective professional associations contacted OTs and midwives directly by email and provided them with information about the survey as well as a link to the online questionnaire. Participants received no financial incentives.The cross-sectional survey was accessible from May 11, 2020 to May 26, 2020. The population of interest encompasses OTs  must not only treat clients effectively, but must also observe the legal requirements. We would like to ask you a few questions about your experiences during the COVID-19 pandemic. Based on your answers, we would like to develop recommendations for you in cooperation with the professional associations.Potential participants were provided with information about the approximate length of time to fill in the survey . The function and contact information of the two main investigators were provided.Before filling in the questionnaire, we informed potential participants about the purpose of the study, which stated:The questionnaire consisted of 13 questions. The demographic section asked for information about the following: age in years, work experience in years, profession , the field of activity of the institution/organization of employment, specific outpatient area  inpatient sector , the home environment, or school setting. Multiple answers were possible here.Doxy.me, Skype, Viber, WhatsApp, MS Teams, FaceTime, Messenger, Zoom or others. Doxy.me is a US-based videotelephony and instant messaging service geared especially towards telemedicine. Skype is a videotelephony service that also allows audio calls and instant messaging. MS Teams is a workplace-focused collaboration platform that includes instant messaging, video- and audio telephony, and file sharing services. Both Skype and MS Teams are owned and operated by Microsoft Inc. FaceTime is a VoIP (voice over internet protocol) and videotelephony service operated by Apple Inc. that exclusively runs on macOS and iOS devices. Whats-App and Viber are VoIP and instant messaging software applications that allow for video calls. WhatsApp is owned by Facebook Inc., while Viber is operated by the Japan-based multinational company Rakuten Inc. Messenger is a feature of Facebook’s main platform and offers instant messaging as well as audio and video calls between the platform’s users. Zoom is another US-based videotelephony service.If a participant confirmed that during the COVID-19 pandemic, he/she performed HCD  rather than in his/her office or the client’s home, the following questions concerning which media were used  as well as their respective suitability for examinations, treatments, and therapies at a distance . If he/she did not confirm this, the questionnaire skipped ahead to a question about perceived advantages and disadvantages of HCD. If participants confirmed that they had used videotelephony, they were then asked about which specific videotelephony apps and services they used when providing HCD. Possible answers were Participants were asked how 1. they, and 2. their clients, “experienced necessary urgent examinations, treatments, and therapies at a distance” .Participants were asked about the possibility of reimbursement of the HCD services they provided by health insurance .Regarding desired training opportunities when carrying out HCD, participants could choose among multiple answers in terms of knowledge about 1. infrastructure, 2. applications (apps), 3. law and data protection, 4. reimbursement by health insurance, 5. federal and cantonal ordinances, 6. client needs, 7. client requirements, 8. effectiveness, 9. communication methods, 10. the examination and treatment process, and 11. suitable methods. Similarly, participants could choose multiple answers with respect to the need for training opportunities within these 12 topics. Moreover, OTs and midwives reported with comments to open-ended questions what they perceived as advantages and disadvantages of HCD. Answers to questions that allowed for commentary on further desired support are not reported here.The questionnaire was available in German, French, and Italian  . All thrThe questionnaire was driven by the immediate need for survey data during the COVID-19-induced lockdown. As it is a new tool, psychometric properties regarding the construction, validity, and reliability of measurement could not be collected . InterviAs the data was anonymized, Institutional Review Board approval was not required.We used descriptive statistics including frequency distributions and means and standard deviations to analyze sociodemographic data. We calculated frequency distributions to describe the respondents’ use of media, their opinions of the media’s applicability, their experience of HCD, reimbursement of services, and desired training opportunities. We performed chi-square tests of independence to examine differences in media use patterns between OTs and midwives.We tested data for Gauss-Markov theorems 1 to 6. To test for the first hypothesis  we performed a binary logistic regression analysis. To test the second hypothesis  we performed an ordinal logistic regression. We calculated response and cooperation rates according to Smith . Missingn = 1052), six clearly distinguishable categories were formed, each containing different topics/motives. The assessment of all answers to the question about the disadvantages and limitations of HCD (n = 1129) resulted in five categories, one of which comprised three sub-categories. We concentrated the analysis on the first points mentioned in the answers, since this is the most spontaneous reaction to the question and most likely reflects what is seen as most important for the respondents.The analysis of answers to the open questions was based on the principles of the Quantitative Content Analysis according to Früh . The catn = 639; midwives: n = 630). Response rate  was 22.5%, cooperation rate  was 52.6% [The online questionnaire was completed by 1.269 health professionals, with OTs and midwives making up roughly half of respondents, respectively  and had longer professional experience on average (20.5 years) than the subsample of OTs . The respondents were predominantly female (96.6%), reflecting the gender distribution in these professions. 73% were German-speaking, 22.4% were French-speaking, and 4.6% were Italian-speaking, roughly reflecting the distribution of languages in the general Swiss population of 62.2% German, 22.9% French, and 8.0 Italian, with a slight overrepresentation of German-speakers, especially in the midwife subsample. More midwives than OTs worked in clients’ home settings (87.1 and 39.4%) and in inpatient care (37.0 and 25%). In contrast, more OTs worked in outpatient care (76.8 and 52.9%) and in school settings (19.2 and 1.4%) compared to midwives.n = 431) and 79.5% percent of midwives (n = 501) provided HCD during the COVID-19 pandemic lockdown . Seven respondents  who denied providing HCD nevertheless provided information on media they used for providing such services, bringing this subsample to a total of 940 respondents. Out of the forms of media that were used for HCD, the form that was used most was phone, followed by chat services, email, videotelephony, and SMS , and by those who worked in the home environment  and in the outpatient area . It was less likely to be provided by those who worked in inpatient settings . “School setting” as area of work and age had no influence on whether HCD was provided or not. However, age correlated positively with use of SMS  and chat services , and negatively with the use of videotelephony . Use of phone was independent from age.HCD was more likely to be provided by midwives compared to OTs  followed by law and data protection (60.4%). Roughly a third of respondents desired support regarding knowledge about suitable methods (34.4%), applications 32.5%), effectiveness (31.6%), and cantonal and federal ordinances (31.4%), respectively. More than half of respondents voiced a need for training opportunities in the following areas: reimbursement (65.6%), law and data protection (64.4%), and effectiveness (52.2%). OTs seemed to clearly voice a greater need for education about applications (51.5%) than midwives (31.4%). See also Table .5%, effep < .001) and regarding law and data protection . Desire for knowledge about the remaining topics had no influence on whether HCD was provided or not.Those who provided HCD were more likely to desire support regarding reimbursement by health insurance , while 27.0% (n = 117) experienced it as negative or mostly negative. Among midwives, only 39.5% experienced it as positive or mostly positive (n = 198), while 57.5% (n = 288) experienced it as negative or mostly negative.The question on how healthcare was experienced at a distance during the COVID-19 pandemic lockdown was answered by 933 respondents. Among OTs, 67.5% experienced it as positive or mostly positive (p ≤ .001). Furthermore, videotelephony  and use of phone  were positive predictors for positive experience of HCD, while use of SMS  was a negative predictor. Age, area of work, use of email and chats had no significant influence on experience. However, there was a non-significant tendency  for reimbursement by health insurance as a positive predictor.OTs experienced HCD significantly more positive than midwives  stated that they were able to be reimbursed for these services and 55.4% (n = 517) stated that they were partially able to be reimbursed, and 15.2% (n = 142) stated that were not able to be reimbursed. Those numbers were similar for both professions.The question concerning their ability to get reimbursed for HCD was answered by 933 respondents. Of these, 17% (WhatsApp (67.5%), Skype (56.9%), Zoom (50.1%), and Facetime (41.1%), while only few used MS Teams (8.0%), Messenger (6.4%), or Viber (0.6%). Doxy.me was not used by any respondent.The applicability of media used for HCD was rated only by those respondents who had used the media in question. Applicability was rated on an ordinal 4-point scale . Videotelephony was the medium deemed applicable or well applicable by the highest percentage of respondents (90.2%), followed by phone (59.9%), and chat (54.9%). While email was deemed well or rather applicable for HCD by 59.3% of responding OTs, only 19.1% of responding midwives chose these answers  advantage of HCD is the possibility to maintain the relationship with clients and to carry out consultations under extraordinary circumstances such as the COVID-19 pandemic. Other advantages often named were the reduction in the (unpaid) workload through the simpler clarification of low-level questions from clients and through the elimination of the largely unpaid travel time (18.7%), as well as the fact that HCD gave certain clients easier access to health care (16.7%).Several respondents stating advantages stressed that the benefits of HCD were limited and that HCD was no substitute for direct care. Some (12.7%) denied any advantages of HCD.In the statements on the disadvantages, two themes predominated: First, OTs and midwives saw themselves as considerably restricted in their ability to recognize and assess the complexity of the situation as a whole due to the lack of physical presence (42.9%). Second, for OTs and midwives a large number of examinations, interventions, and therapies were hardly possible at a distance due to absence of direct physical interaction (31.9%). As a result, they would only have access to part of the available information, which could sometimes lead to situations that felt difficult for both sides. The importance of scent and touch for the intervention and care work was particularly emphasized: “Hands-on is an indispensable part of work”, OTs typically noted, whereas a midwife emblematically remarked: “Smelling, touching do not work via videotelephony”. The perceived limitations to relationship building, seen as an essential prerequisite for a successful intervention and care (10.1%), as well as the added value of presence for the instructional work  were also repeatedly mentioned (6.7%). In addition, entire client groups were being disadvantaged from the perspective of the respondents (7.1%). They reported that this was especially true for clients with mental health and anxiety problems, clients who lack technical proficiency, clients without sufficient language skills, and/or who have a shy and inhibited demeanor.This was the first study investigating HCD among OTs and midwives in the context of the COVID-19 pandemic in Switzerland. There is evidence that HCD is effective in assessing and improving clients’/patients’ health conditions . HoweverOur first hypothesis that profession, age, and area of work had a significant and meaningful influence on whether HCD was provided, was partially proven. About two out of three OTs and four out of five midwives provided services remotely. Not surprisingly, HCD was used mainly for care in the outpatient and home environments. Our assumption that age has an influence on provision, as technological affinity may decrease with age, was not proven. However, the younger the caregiver, the more likely videotelephony was used. In contrast, older caregivers preferred SMS and chat services when providing services and care.It has been described in the literature that the implementation of novel telemedicine solutions can pose difficulties . Chat seWith the phone being the most ubiquitous and low threshold communication technology available, it is no surprise that it was the medium most frequently used for HCD by health professionals during the COVID-19 pandemic lockdown. However, videotelephony was seen as being much more applicable. This may be the case as videotelephony more closely resembles in-person encounters contrasted to audiotelephony alone. Despite its apparent applicability, videotelephony was only used by about half of respondents who performed HCD. This may be due to a lack of familiarity with the relevant technology and/or data protection concerns on the part of the health professionals and/or their clients. In fact, law and data protection seem to be a concern among health professionals. Education and advocacy are described as central to the continued use of HCD . Legal iAlthough OTs provided fewer HCD services than midwives, their experience of HCD was more positive. Interestingly, whether the remote service was reimbursed by the health insurance provider only played a minor role  for the experience of HCD. The Swiss Federal Office for Public Health (FOPH) launched a factsheet on reimbursement of costs for HCD during the COVID-19 pandemic on April 6, 2020 which was valid until June 22, 2020 . The facHCD reimbursement appeared to be a major concern for health care professionals, as reflected in the open-response section of the survey and in the preferences selected regarding support and continued teaching. HCD were only reimbursed if they were carried out via videotelephony  and a maximum of 30 min a day were deemed billable. This restriction is not reflected in a greater use of videotelephony by OTs, but it may be reflected in their greater desire for education about applications.Accordingly, the most desired topic for training opportunities in relation to HCD was education about reimbursement. About three quarters of respondents who performed HCD stated they could not be or could only partially be reimbursed for these services by insurers. This was the case for both OTs and midwives alike.The convenience aspect of HCD, mainly concerning the elimination of travel and waiting times, and the ability to carry out consultations from the comfort of one’s home at any time have been described in many earlier studies .A considerable number of the responding OTs and midwives had concerns about the use of HCD. They associated HCD with restricted professional abilities and lowered effectiveness. This is in line with findings of other studies about health care professionals’ perceptions of HCD  –33. HoweOf particular interest was the scepticism noted in the comments. This conflicts with the attitude of OT and midwifery students who associate digital media primarily with the promise of efficiency .The questionnaire focused on the attitude of the health care professionals. As a next step, it would be important to ask patients and clients about their experiences with HCD during the pandemic to optimize HCD provisions.The data provided is only a snapshot of how the situation was perceived by OTs and midwives at a certain time . Furthermore, the generalizability of the results is limited, as only about one in five of the contacted OTs and midwives filled out the survey completely within the short open time window of 16 days. We also cannot exclude the existence of bias, e.g., the probability that health professionals with a distinct opinion (either positive or negative) or those who had (or had not) provided HCD were more likely to answer the survey. Nevertheless, with more than 1200 participants, the results provide valuable insights into the perceived experiences and challenges of HCD as a result of the COVID-19 pandemic.The application of information and communication technologies (ICT) for remote health care is nothing new, with some initial efforts already dating back to the 1980’s . SeveralAdditional file 1:. Study Questionnaire. Survey on opportunities and limits regarding health care at a distance during the Covid-19-pandemic.