*Article* **Increase in Video Consultations During the COVID-19 Pandemic: Healthcare Professionals' Perceptions about Their Implementation and Adequate Management**

**Diana Jiménez-Rodríguez 1,\* , Azucena Santillán García 2 , Jesús Montoro Robles <sup>3</sup> , María del Mar Rodríguez Salvador <sup>4</sup> , Francisco José Muñoz Ronda <sup>4</sup> and Oscar Arrogante 5,\***


Received: 16 June 2020; Accepted: 12 July 2020; Published: 15 July 2020

**Abstract:** In response to the COVID-19 pandemic, health care modalities such as video consultations have been rapidly developed to provide safe health care and to minimize the risk of spread. The purpose of our study is to explore Spanish healthcare professionals' perceptions about the implementation of video consultations. Based on the testimonies of 53 professionals, different categories emerged related to the four identified themes: benefits of video consultations (for professionals, patients, and the health system, and compared to phone calls), negative aspects (inherent to new technologies and the risk of a perceived distancing from the professional), difficulties associated with the implementation of video consultations (technological difficulties, lack of technical skills and refusal to use video consultation among professionals and patients), and the need for training (technological, nontechnical, and social-emotional skills, and adaptation of technical skills). Additionally, the interviewees indicated that this new modality of health care may be extended to a broader variety of patients and clinical settings. Therefore, since video consultations are becoming more widespread, it would be advisable for health policies and systems to support this modality of health care, promoting their implementation and guaranteeing their operability, equal access and quality.

**Keywords:** clinical skills; COVID-19; healthcare providers; implementation; interpersonal skills; perception; qualitative research; telemedicine; training; video consultation

### **1. Introduction**

Telemedicine is the use of telecommunication systems to provide health care from a distance [1]. This modality comes in different variations: online consultations, by telephone or videoconference, telemonitoring/screening with devices that monitor a patient's vital signs, sensors with GPS trackers, and chatbots for recommendations [2]. However, the most commonly used are video consultations [1,3]. The main medical conditions that require video consultations are hypertension, diabetes, heart failure, asthma, chronic obstructive pulmonary disease and the care of elderly patients [3]. Therefore, video

consultations have been widely used with patients who have common chronic conditions [4] and primary care needs [5]; these types of consultations are even considered the future of healthcare [6]. More specifically, nursing professionals have used video consultations in follow-up care for patients after surgery, patients with chronic diseases, families of children with cancer and premature newborns [7]. Telemedicine has demonstrated similar health outcomes and patient/healthcare professional satisfaction compared with in-person healthcare consultations, and has improved access to health care services [1,8]. In addition, some cost-utility and cost-effectiveness studies have demonstrated that telemedicine can reduce costs [1,8,9].

On March 11, 2020, the World Health Organization declared the novel coronavirus disease 2019 (COVID-19) outbreak as a pandemic. Most positive cases are asymptomatic or self-limiting, but the clinical spectrum of the disease extends to severe progressive pneumonia with acute respiratory distress syndrome (ARDS), which is a life-threatening condition requiring mechanical ventilation and intensive care support [10]. The symptomatology of COVID-19 infection is not specific, which makes it clinically indistinguishable from other viral respiratory illnesses [11]. According to recent systematic reviews, the most common disease-related symptoms are fever, cough, muscle aches and/or fatigue, dyspnea, headache, sore throat, and gastrointestinal symptoms [11] and skin lesions with different clinical characteristics [12]. In addition, there is evidence that COVID-19 may exacerbate certain cardiovascular symptoms and lead to cardiovascular complications [13]. Finally, some mental disorders have even been aggravated during this pandemic [14]. In this sense, nurses are central to COVID-19 prevention and the care of infected patients. Nurses are not only providing frontline care in severe COVID-19 cases that require hospitalization, but are also monitoring outpatients in community settings, and providing education to patients and the general public about the outbreak [15]. However, the rapid progression of COVID-19 around the world has become a real challenge for health organizations and policies, exemplified by the implementation of social distancing measures, such as quarantine periods [16]. As all healthcare professionals are at risk of contagion, new modalities of care are emerging in order to avoid face-to-face contact with patients and to ensure that patients receive the care they need [17,18]. Furthermore, as governments have been promoting social distancing, the creation of safe medical settings has become a priority [19] in order to avoid the risk of spreading the disease [20]. For instance, in Spain, 24.1% of positive COVID-19 cases have been reported among healthcare professionals [21].

In this sense, video consultations are considered the perfect solution during this worldwide pandemic [18], mitigating its impact on the population's health and the use of health resources, and are being promoted, especially in the United Kingdom and the United States of America [22]. In addition, the population's interest in telehealth and the number of telemedicine visits have dramatically increased during the pandemic, owing to restrictions on in-person clinical encounters [23,24]. Moreover, telemedicine platforms are ideal for responding to global infectious disease outbreaks and preventing overcrowding in emergency departments in hospitals, primary care clinics and emergency services [25]. Consequently, many governments have been forced to adapt to the sudden implementation of telemedicine to promote safety for low-acuity patients, their family members and healthcare professionals, and to avoid delays in the provision of health care that may result in more health problems or complicate existing clinical situations, jeopardizing patients' future health [19]. For instance, online mental health services have been promoted within the context of COVID-19 [20]. Therefore, this pandemic is a call to action in countries without integrated telemedicine in their national health system [22].

In Spain, 100% of the population has access to the public health system. In response to the COVID-19 pandemic, the Spanish health authorities implemented follow-up systems at the primary care level, mainly consisting of phone calls [2]. In addition, some private health providers offered video consultations for the general public free of charge. Consequently, some Spanish health authorities are currently strengthening the use of teleconsultations and telemedicine as a public health policy for the reorganization and normalization of health care services.

However, studies have paid surprisingly little attention to the perception of telemedicine among healthcare professionals, mainly focusing rather on barriers to and difficulties with this modality of healthcare [3]. Thus, when a new approach is implemented, it is important to examine how it is perceived by healthcare professionals, as this could influence its usefulness and effectiveness. Furthermore, introducing video consultations to healthcare services is far more difficult than healthcare professionals assume, as they need to change their routines and the manner in which they care for patients [17]. Healthcare professionals need to understand that interactions during video consultations are different from face-to-face consultations, and thus, they need to be ready to deal with certain challenges: establishing a connection and starting a video consultation, dealing with disruption to the conversational flow, breakdowns of video consultation platforms and latency in the conversation [26]. Although at present health authorities are racing to implement virtual health-care technologies as fast as they can, and healthcare professionals are motivated to use them to reduce the spread of COVID-19 [27], their perceptions about this new modality of healthcare provision must be examined in order to ensure and improve its effectiveness.

For this reason, the purpose of our study is to explore Spanish healthcare professionals' perceptions about the implementation of video consultations and its management in the provision of high-quality health care.

### **2. Materials and Methods**

### *2.1. Study Design*

A descriptive observational study was carried out using a qualitative methodology. This methodology is the most suited to achieving a deep understanding of the phenomenon of interest [28], such as the emerging implementation of a modality for the provision of health care that has an impact on the professionals who have to manage it. In this way, understanding their perception regarding video consultations may help us to understand this phenomenon and make more informed decisions regarding future courses of action. In addition, to ensure the quality and transparency of our research, The Consolidated Criteria for Reporting Qualitative Research (COREQ checklist proposed by Tong et al. [29]) was followed.

### *2.2. Sample and Setting*

Although the sample size was not selected a priori, qualitative data were collected following two precepts: the data saturation precept proposed by Morse [30] (interviews continue until new elements of discourse are no longer collected) and the novelty precept proposed by Mayan [31] (data is collected until it is considered that something important and novel could be derived therefrom about the phenomenon of interest).

All study informants were working healthcare professionals in the public health system in the same Spanish region. Consequently, biases related to different organizational and care environments were avoided.

According to the recommendations for sample selection proposed by Patton [32], our purpose was to use selected participants (healthcare professionals with or without experience in video consultation) to obtain the greatest quantity of information in order to understand the phenomenon under study in depth. In this way, snowball or chain sampling was carried out, identifying relevant participants with the collaboration of key informants (training and research managers in healthcare departments) who nominated good candidates for our study.

Ultimately, the study included a total of 53 healthcare professionals. The study was carried out between 02 April 2020 and 25 May 2020.

### *2.3. Data Collection*

A structured interview, comprising four closed-ended and four open-ended questions, was used to collect sociodemographic data and to facilitate in-depth discussion of all relevant topics (see the interview outline in Table 1). All participants were interviewed online (using the Google MeetTM video platform (Google, Mountain View, CA, USA)) due to social distancing restrictions during the COVID-19 pandemic. The interviews lasted 15 min on average and were carried out by a researcher with extensive experience in qualitative research, who had no working relationship with any healthcare professional and strictly followed the interview outline, thus ensuring objectivity and avoiding possible biases. The entire content of the interviews was recorded with the participants' consent.



### *2.4. Data Analysis*

The mean and standard deviation (SD) were calculated to analyze sociodemographic data and responses to closed-ended questions. Qualitative data were obtained from the healthcare professionals' responses to the four proposed open-ended questions. All perceptions and opinions from the healthcare professionals were transcribed and reviewed by two different members of the research team who were experts on qualitative methodologies. A content analysis of the qualitative data was performed; this allowed us to discover the views of each health professional by analyzing their responses and perceptions about the phenomenon of interest [33]. The themes identified were aligned with the four proposed open-ended questions.

Subsequently, qualitative data were analyzed to identify reiterated words, sentences, or ideas that were finally codified into different categories and grouped into the identified themes [31]. Firstly, an initial reading of the discourses was performed to analyze the categories. Then, the emerging categories were codified through the consensus and refinement reached by the two researchers [31].

All data were stored, managed, classified, and organized using the qualitative data analytical software, ATLAS.ti 8 Windows (Scientific Software Development GmbH, Berlin, Germany).

### *2.5. Ethical Considerations*

This study was approved by the Research and Ethics Board of the Department of Nursing, Physiotherapy, and Medicine at the university (nº EFM 75/2020), and was carried out following the ethical principles for medical research of the international Declaration of Helsinki [34]. All participants received information about the study, participated voluntarily, and provided their written consent. In addition, and to ensure anonymity, the participants were numerically labeled in chronological order according to the date of the interview, preceded by the letter "S" (subject).

### **3. Results**

The quantitative data collected from the closed-ended questions showed that 96.2% of the healthcare professionals considered videoconference consultations to be an adequate option for providing health care, indicating which patients would most benefit from this modality. The types of patients that were mentioned most often, i.e., in 14 to 7 informant responses, were chronic patients, patients who required medical follow-ups and examinations, difficulties in movement (either due to physical disability or geographical dispersion, or work reasons), and administrative petitions (such as prescriptions, work leaves due to illness or accident, etc.). However, the types of patients that were mentioned least often, i.e., in 4 to 2 responses, were resolutions of medical questions (from patients, caregivers, mothers, etc.), any type of medical condition that did not require physical examinations, on-demand consultations such as screening to evaluate in-person assistance or not, health education, mental health disorders, common, minor diseases, and dermatology. Furthermore, most interviewed professionals had not provided health care via videoconference (*n* = 44; 83%). Conversely, the number of video conferences among healthcare professionals who had used this modality ranged from 1 to 5 (mean = 2.66; SD = 1.322). Lastly, 90.6% of participants considered it necessary to train and educate professionals in this modality of healthcare. It should be noted that no differences were found based on gender or professional category in any quantitative data collected.

As for the qualitative data, results were obtained after analyzing the contents of the open-ended questions. During this content analysis, possible divergence in the participants' discourse according to their professional category and workplace (primary care or hospital services) was taken into account, although these factors did not affect the majority of the categories identified, with a few exceptions, as described in the corresponding category, presented below and grouped into four main themes (aligned with the four open-ended questions) and the categories that emerged from the participants' narratives and that were strongly supported by them (see also Table 2).


**Table 2.** Comprehensive list of themes and categories identified after thematic analysis.

*Int. J. Environ. Res. Public Health* **2020**, *17*, 5112

### *3.1. Theme 1. Benefits of Video Consultations*

Within the context of the COVID-19 pandemic, where interviews were conducted, the clear benefit of avoiding spreading the disease was confirmed by healthcare professionals. In addition, they considered that video consultations may provide numerous benefits, with no significant differences according to their professional category or workplace. In this way, the categories that emerged, in order of repetition frequency, are as follows:

3.1.1. Benefits of Video Consultations for Both Healthcare Professionals and Patients

Our healthcare professionals referred to avoiding movement that may be unnecessary (both for patients who do not have to visit to health centers in person and healthcare professionals who do not have to travel to patients' homes). This benefit was repeated in the discourse of most healthcare professionals.

*"It avoids the patient's travels to health centers"* (S39)

*"You can solve their problems without having to travel and they see you, which is important for them"* (S42)

*"To avoid the loss of working hours in patients when the medical consultation coincides with their working time, avoiding the time required to the movement from their works centers to the health centers and the waiting for their turn"* (S7)

*"The management of time, of the patient and the professional, convenience, flexibility, less bureaucracy"* (S43)

3.1.2. Benefits for the Health System

This category includes benefits such as efficient consultations, avoiding agglomerations and waiting lists, quick resolutions of common, minor diseases, a decrease in workload at healthcare centers, and cost reduction. In this sense, our healthcare professionals perceived that the implementation of video consultations may have direct benefits for the health system.

*"It favors accessibility and immediacy, and serves as an e*ffi*cient filter for in-person consultation".* (S2)

*"in specific situations, it can decrease the waitlist time"* (S10)

*"(* . . . *) less crowds in waiting rooms, streamlining of banal diseases"* (S11)

3.1.3. Benefits of Video Consultations Compared to Phone Calls

The informants indicated benefits of video consultations compared to phone calls, which is currently the most used modality of telemedicine in Spain. In this sense, informants perceived as beneficial the possibility of assessing patients' physical aspect, in contrast to phone consultations. Since the interaction is direct, contact with the patient is ensured, allowing both verbal and nonverbal communication to occur.

*"You can see the patient's face (* . . . *) you can assess aspects of non-verbal communication"* (S3)

*"I have provided care on the phone with information* via *Telematics, although I think that the video consultation goes beyond, because it allows you to assess the expression and transmit more to the patient, re-enforcing communication"* (S21)

*"A faithful contact with the patient is maintained, dedicating the time needed without interruptions"* (S49)

### *3.2. Theme 2. Negative Aspects*

Two quite different categories emerged: the first was consistent among the interviewed professionals, while the second was almost anecdotal.

3.2.1. Negative Aspects Inherent to New Technologies

Obviously, since it is a technology that does not require physical contact, there are some medical procedures that are impossible. Our healthcare professionals highlighted two main issues: the impossibility of physical examinations or procedural techniques during video consultations, and its management and/or technological difficulties, such as a lack of access for both professionals and patients (especially for the elderly). In this case, general practitioners mainly indicated the impossibility of performing physical examinations as a major drawback. Although our informants considered some negative aspects of this modality, they did not propose any solutions to address them.

*"There is a lack of examination if it was needed"* (S38)

*"The elder population and those who are not so old, for them to have the tools necessary to conduct it, and the knowledge, and this is relevant to some professionals"* (S43)

*"For some patients, it use could be complex. For those who are older, they need the necessary support to be able to use this means of communication"* (S50)

### 3.2.2. Risk of Perception of Distancing From Professional

Healthcare professionals were concerned that their patients may perceive the use of video consultations as a form of distancing from the health professional. In this sense, healthcare professionals were concerned that relationships with their patients may deteriorate and/or the internet connection required to hold a video consultation may create an environment of mistrust for patients.

*"The perception of some patients of distancing"* (S33)

*"Mistrust in the use of technology, di*ffi*culties for older people, who do not have the devices, the relationship can be seen as more distant"* (S34)

### *3.3. Theme 3. Di*ffi*culties in the Implementation of Video Consultations*

The difficulties that emerged from the informants' discourse were inherent to the use of new technologies, which may be unfamiliar or challenging. The needs to provide resources to healthcare professionals so that they could hold a video consultation, and the need to train and shape them for the adequate use of this new modality, were underlined.

### 3.3.1. Technological Difficulties

In anticipation of the future implementation of this healthcare modality, technology was a re-emphasized issue, related to certain patients having access to the required resources and technological difficulties for both professionals and patients, with particular emphasis on the elderly.

*"Not all the patients, especially the older ones, have access to these technologies or they don't know how to handle them"* (S12)

*"Lack of use by the professionals and the older patients"* (S20)

*"Computer problems and the older patients who do not know how they work"* (S38)

### 3.3.2. Lack of Technical Skills Among Professionals and Patients

Another difficulty for the implementation of this healthcare resource is the lack of technical suitability of both professionals and patients, mainly regarding the elderly.

*"It needs more time and adequate technical skills from both parties"* (S2)

*"Perhaps at first, until the population is familiarized with this technique"* (S26)

*"Di*ffi*culty of older people to adapt to this method"* (S50)

3.3.3. Refusal to Use Video Consultations by Healthcare Professionals and Patients

This issue emerged in a handful of the analyzed discourses. Our informants were concerned about the possible refusal to use this new modality by professionals and/or patients.

*"Technical di*ffi*culties. Rejection of specific patients*/*doctors to this type of distance care"* (S7)

*"Mistrust, resistance from both parties towards the use of the technology"* (S34)

*3.4. Theme 4. Skills Needed to Hold a Video Consultation and the Need for Training*

Within in this theme, technological skills appeared once again to be the main issue, while nontechnical and social-emotional skills were second. To a lesser extent, the need emerged to adapt the technical skills that are required for this modality.

3.4.1. Technological Skill

This is related to the need to adequately manage the software or application used and the technological requirements.

*"Handling of telematics tools"* (S20)

*"Correctly use the technology"* (S29)

*"Use of the informatics tools or applications"* (S34)

3.4.2. Nontechnical and Social-Emotional Skills

Informants emphasized a wide variety of skills, since they were concerned that such skills may not be adequately managed using a modality without physical proximity. In this way, they indicated the following skills in order of importance: effective communication (the most repeated), empathy and patience, verbal and nonverbal language, skills required for structured and guided clinical interviews, assertiveness, and conflict resolution.

*"Communication skills (active listening, empathy, emotional support), motivation, creativity, conflict resolution, patience"* (S35)

*"Active listening, communication and clinical interview skills, deferred conflict resolution, fomenting trust through this medium"* (S48)

3.4.3. Adaptation of Technical Skills

This is related to the need to find a substitute for physical contact. Although the interviewees raised this concern, they did not propose any solutions.

*"Probability of guiding a self-examination"* (S16)

*"Assess clinical aspects that can replace the clinical examination in part"* (S32)

### **4. Discussion**

Our results show that even though 83% of the interviewed informants had not conducted a video consultation, they considered it to be an adequate option for health care (96.2%). Most of our participants had not used this modality because the most common form of telemedicine in Spain is the phone call, although the Spanish health system is currently encouraging the use of video consultation as a public health policy for the reorganization and normalization of healthcare services [2]. Taking into account that video consultations are currently considered a necessary tool, the present study was proposed to explore Spanish healthcare professionals' perceptions about their future implementation and adequate management in this country; it is very important to gauge health care providers' perceptions of this approach, given that the they are the ones who will conduct such consultations, and therefore, the quality of this modality will be dependent on them. These perceptions have not been investigated to date, although recent studies have focused on the general population, indicating a growing interest in telehealth, as it is a highly-demanded modality of health care during the pandemic [24].

In addition, the interviewed professionals indicated numerous clinical situations and diseases where video consultations may be used (for both chronic and acute disease conditions). In this sense, they are in agreement with the reviewed evidence, in that this technology could be useful in cases such as chronic diseases, medical follow-ups, and mental health or dermatology examinations [7,35]. However, the interviewed healthcare professionals extended video consultation use to almost all patients who had access to this technology, as also indicated by new research on this growing field [36–38].

Furthermore, as this modality of healthcare may be complex, the healthcare professionals interviewed considered that training was needed (90.6%). This is because the most-utilized modality of telehealth in Spain is still the phone call [2]. However, it should be taken into account that the implementation of an effective program in telemedicine takes time [18], so it is logical that training and education would be needed. In this sense, this finding is consistent with the study by Portnoy et al. [39], who stated that healthcare professionals may be trained and shaped to be "telefacilitators".

Telemedicine has been shown to be an ideal response to the COVID-19 pandemic, with its use having been greatly extended in recent months [25]. This was shown by healthcare professionals themselves, who indicated the avoidance of infection and spread as a clear benefit of video consultations. Also, many other benefits for both patients and healthcare professionals were noted, e.g., avoiding travel, wider availability, its immediate nature, saving time, ease of use and consequent increased efficacy [40]. In this way, video consultations improve accessibility, and can be used to opportunely tend to urgent concerns. Regarding time-saving, Calton et al. [40] stated that video consultations saved "windshield time" for home-visiting general practitioners.

Additionally, the healthcare professionals interviewed considered that video consultations offered efficient screening for consultations, avoiding crowds and waiting lists, allowing for quick resolutions of common, minor diseases, and decreasing workloads and costs in healthcare centers, as shown by other studies [1,8,9,25].

In contrast, our informants considered as negative the improper use of the technology and the inability to perform physical examinations. However, there are current platforms, applications, and medical devices that may compensate for the need to perform such examination at patients' homes, so medical procedures or techniques may be adapted to some patients [41,42]. In this sense, it is important to ensure that remote healthcare professionals are able to see that the patients are performing the examination correctly [41].

The difficulties identified by our informants regarding the implementation of video consultations were consistent with those of other studies [1,3,8,39,41]. Technological difficulties are the most worrisome issue among healthcare professionals. In addition, it should be noted that the refusal to use video consultations may be solved by performing preliminary trials, which often improve attitudes towards technology [40]. However, problems may arise among patients of advanced age, who may have reduced cognitive abilities [3]. Conversely, the barriers perceived by patients for the implementation of video consultations should also be taken into account. In this study, the perception of patients was not addressed. In this sense, a previous study indicated that although patients were willing to use them, they will likely go back to in-person consultations, as they may prefer to be attended to by their usual healthcare provider, or they may even ignore video consultations if they do not know how to use them [39]. There is no doubt that video consultations are needed in different health systems; therefore, this pandemic is a call to action in countries without such an option already integrated into their health systems [22]. However, most countries have not created a regulatory framework to authorize and integrate telemedicine into their national health systems, including during emergency and outbreak situations [22]. Although our informants did not indicate any ethical issues related to the use of video consultations, previous studies have raised concerns that exchanging health information and providing care electronically could create new risks regarding the quality of healthcare, safety, privacy and confidentiality [43,44]. As for the skills needed to hold a video consultation, the healthcare professionals perceived that they needed to be trained to improve their technological skills. This is congruent with other studies that identified the need for staffing qualified professionals in this modality of healthcare [45]. In addition, our informants indicated the need for training regarding both nontechnical and social-emotional skills, such as effective communication, empathy, patience, nonverbal and verbal language, skills required for a structured and guided clinical interview, assertiveness, and conflict resolution. They emphasized a wide variety of skills which they felt may not be adequately managed using this healthcare modality. Although social-emotional skills related to video consultations have not been analyzed in depth, Humphreys et al. [46] stated that the interaction between patients and health care providers during video consultation care was substantially different from in-person care, mainly in cases of palliative care or cancer patients. However, other studies indicated that both types of care may be similar if the internet connection is of high-quality [40,41]. In this way, patients and healthcare providers tend to communicate in the same manner as in in-person consultations. Minor technical breakdowns have been demonstrated not to cause major disruptions to clinical interactions [41]. In fact, video consultations have been considered an effective modality in the provision of health care to cancer and palliative patients and their relatives [40,47,48], for whom nontechnical and social-emotional skills are essential. Therefore, training regarding video consultation, to facilitate its adequate adaptation in the provision of high-quality care, is needed [46]. Furthermore, our informants perceived that they should be trained in adapting medical procedures and techniques, although this is more complex, as specific devices may sometimes be required at patients' homes [41].

Video consultations were considered as a promising tool before the COVID-19 pandemic [49], and at present, are being used around the world [1,3] due to the need to avoid the spread of the virus [17,18]; therefore increased training and research in this field are required to ensure that high-quality health care is being provided. However, patients will also need to be provided with the devices required to adequately perform video consultations [41,44].

Lastly, as we carried out a small-scale qualitative study, there could be limitations related to the transferability of our findings. Nonetheless, this study aimed to address healthcare professionals' perceptions about the immediate implementation of video consultations in their daily clinical practice, and this objective was achieved. In this sense, it should be noted that most interviewed informants had never held a video consultation, so their perceptions may change when they use this modality of health care. In addition, video consultations may differ according to the platform, software, or devices used. Consequently, more research on this topic is recommended. Lastly, it would be advisable to study the barriers perceived by patients related to the implementation of video consultations.

### **5. Conclusions**

For the effective implementation of video consultations as a modality of health care within a health system, it is important to examine how it is perceived by healthcare professionals, as this could have an impact on its effectiveness. Our informants identified the positive and negative aspects related to video consultations, the difficulties associated with its implementation, and the skills required for its management; they also acknowledged that training is required. During the COVID-19 pandemic, the implementation of video consultations may yield information on the future of telemedicine with the goal of providing healthcare not only to chronic patients, but also to those with acute diseases. They have been shown to be useful in a broader sense, and so should not be stopped when the pandemic is mitigated. As our informants indicated, the use of video consultations may be extended to a wide variety of patients and clinical situations. It would be advisable to implement health policies and systems to support this modality of health care, promoting its implementation and guaranteeing its operability, equal access and quality of healthcare.

**Author Contributions:** Conceptualization, D.J.-R., M.d.M.R.S., F.J.M.R. and O.A.; data curation, D.J.-R.; formal analysis, D.J.-R. and F.J.M.R.; investigation, D.J.-R., M.d.M.R.S., J.M.R., F.J.M.R. and O.A.; methodology, D.J.-R., M.d.M.R.S., F.J.M.R. and O.A.; project administration, D.J.-R.; supervision, D.J.-R.; validation, D.J.-R.; visualization, O.A.; writing—original draft, D.J.-R., A.S.G. and O.A.; writing—review & editing, D.J.-R., A.S.G., J.M.R., M.d.M.R.S., F.J.M.R. and O.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Acknowledgments:** We wish to publicly recognize our gratitude to the Provincial Headquarters of the Foundation for Biosanitary Research of Eastern Andalusia (FIBAO, in Spanish) in Almería, for their invaluable collaboration in the strategic and methodological organization of this study.

**Conflicts of Interest:** The authors declare no conflict of interest.

### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

### *Article* **Use of the Barthel Index to Assess Activities of Daily Living before and after SARS-COVID 19 Infection of Institutionalized Nursing Home Patients**

**Bibiana Trevissón-Redondo <sup>1</sup> , Daniel López-López <sup>2</sup> , Eduardo Pérez-Boal <sup>3</sup> , Pilar Marqués-Sánchez <sup>1</sup> , Cristina Liébana-Presa <sup>1</sup> , Emmanuel Navarro-Flores <sup>4</sup> , Raquel Jiménez-Fernández <sup>5</sup> , Inmaculada Corral-Liria <sup>5</sup> , Marta Losa-Iglesias 5,\* and Ricardo Becerro-de-Bengoa-Vallejo <sup>6</sup>**


**Abstract:** The objective of the present study was to evaluate the activities of daily living (ADLs) using the Barthel Index before and after infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and also to determine whether or not the results varied according to gender. The ADLs of 68 cohabiting geriatric patients, 34 men and 34 women, in two nursing homes were measured before and after SARS-CoV-2 (Coronavirus 2019 (COVID-19)) infection. COVID-19 infection was found to affect the performance of ADLs in institutionalized elderly in nursing homes, especially in the more elderly subjects, regardless of sex. The COVID-19 pandemic, in addition to having claimed many victims, especially in the elderly population, has led to a reduction in the abilities of these people to perform their ADLs and caused considerable worsening of their quality of life even after recovering from the disease.

**Keywords:** activities of daily living; Barthel index; SARS-CoV-2

### **1. Introduction**

Coronavirus 2 (severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)) is an infectious disease that causes a severe acute respiratory syndrome. This virus belongs to the family of positive-sense enveloped RNA beta coronaviruses that emerged in Wuhan, China, in December 2019 [1]. It is the cause of the clinical disease known as COVID-19, which has caused more than 50 million infections and more than 1.25 million deaths according to the World Health Organization (WHO) [2].

In Spain, 5417 nursing homes exist, with 690 of these in Castilla y León, of which 71% are private [3].

According to the recent monographic report on Spain from the ltccovid.org portal, a site that belongs to the International Long-Term Care Policy Network, which is a network managed by the London School of Economics (LSE), data updated on May 28 indicate that 237,906 people have been infected by COVID-19 in Spain and 27,119 have died from this disease. Deaths in nursing homes have risen to 19,194, which is 70% of the total number of deaths, with 2449 in Castilla y León [4].

**Citation:** Trevissón-Redondo, B.; López-López, D.; Pérez-Boal, E.; Marqués-Sánchez, P.; Liébana-Presa, C.; Navarro-Flores, E.; Jiménez-Fernández, R.; Corral-Liria, I.; Losa-Iglesias, M.; Becerro-de-Bengoa-Vallejo, R. Use of the Barthel Index to Assess Activities of Daily Living before and after SARS-COVID 19 Infection of Institutionalized Nursing Home Patients. *Int. J. Environ. Res. Public Health* **2021**, *18*, 7258. https:// doi.org/10.3390/ijerph18147258

Academic Editor: Robbert Huijsman

Received: 25 May 2021 Accepted: 5 July 2021 Published: 7 July 2021

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In a disease as infectious as COVID-19, host factors are the key to determining the severity and progression of the disease [5]. For severe COVID-19 disease, the main risk factors include age, male gender, obesity, smoking, and comorbid chronic diseases, such as hypertension, type 2 diabetes mellitus, and others [6–8].

Symptoms that are presented by COVID-19-infected patients vary from one person to another and can mimic symptoms present in other common infections. The most frequently found symptoms are fever, cough, myalgia, fatigue, dyspnea, anosmia, and ageusia [9,10]. Sometimes, these patients report having increased sputum production, headache, hemoptysis, diarrhea, and myalgia [11–16], although it is believed that approximately 20% of patients do not present any type of symptom [17]. The average recovery time in someone with mild illness is two weeks, while in severe illness, it can be 3–6 weeks [18]. After several weeks of convalescence, rehabilitation is essential to recover functionality as soon as possible, especially in the elderly population. The goal of rehabilitation in patients with COVID-19 infection is to facilitate improvements in the sensation of dyspnea, relieve anxiety and depression, reduce virus-associated complications, improve functionality, preserve pre-existing functions, and improve the quality of life by helping these patients to regain the same level of physical and functional independence that they had before contracting the disease.

After resolution of the acute phase, physical, emotional, and psychological impairments can often persist for a prolonged period and contribute to complex and multi-factorial disabilities that require continuous care and rehabilitative multimodal management [19–21]. As part of the rehabilitative therapy of these patients, evaluation of several factors that can affect these individuals once they have recovered from the virus is recommended: (1) deterioration of general functionality, (2) deterioration in the ability to carry out activities of daily living (ADLs), and (3) social disadvantages, which are evaluated using scales such as the Performance Status, the Barthel index, and the Functional Independence Measure [22].

In a community dwelling, screening of older people and assessing their abilities to conduct ADLs, such as getting out of bed, toileting, bathing, dressing, grooming, and eating, are frequently used as indicators of the functional status of an individual. These measures are applied to detect early onset of disability and are key factors for care management [23].

Geriatric assessment using the Barthel index is very important when aiming to optimize the care of elderly patients during a new epidemic outbreak. Therefore, the goal of this study was to evaluate ADLs in residents before and after contracting COVID-19 by establishing a period of time in which no underlying disease or prompt rehabilitation could invalidate the results. The Barthel index was selected as the assessment tool to verify if an individual's ADLs decreased after overcoming the infection, which activities were most affected, and whether or not the gender of the elderly person affected the results.

### **2. Materials and Methods**

The clinical study was designed as a longitudinal prospective cohort study. This study was approved by the ethics committee of the San Carlos Clinical Hospital of Madrid with internal code 21/251-E. Authorization was requested from the management of the two geriatric residences under study, and all patients provided informed consent before enrolling in the study. From March 2020 to December 2020, 68 residents contracted and overcame the SARS-CoV-2 virus, with different degrees and affectations.

For the sample size, we based our calculations on previous results obtained by Masanori Okamoto et al. [24] in which they analyzed the Barthel index in patients who had been diagnosed with benign tumors and then underwent surgery. They then compared these patients to the patients diagnosed with atypical lipomatous tumors who were surgically treated and obtained results of 98.01 ± 0.62 and 97.08 ± 2.49, respectively. For a two-tailed test with an α level of 0.05 and 95% confidence interval (CI) and a statistical analysis of the desired power of 80% (error β = 20%), a minimum sample size of 59 people was obtained, and after estimating a 15% dropout rate, a total of 68 people was needed.

The ADLs were evaluated in the residents periodically by the nurse using the Barthel index. The Barthel index (or Barthel scale) is an instrument used in medicine for the functional assessment of a patient.

In the homes for the elderly in Spain, more specifically in those of Castilla y León, the community in which our study was conducted, the ADLs of residents were evaluated in order to establish the degree of dependency, a scale established by Royal Decree 504/2007 of 20 April for determining the dependency situation established by the Law 39/2006, of 14 December. This decree addresses the promotion of personal autonomy and care for people who are in a dependent situation. Based on this decree, it is mandatory for nursing homes to conduct at least two determinations of the Barthel index in these types of residences annually; therefore, based on this regional law and the Barthel Index, which has a track record of being used in numerous studies and is still widely used today as a simple method to assess ADL for various diseases [25], we decided that this index would be a good indicator for evaluating the impact that the pandemic had had on our institutionalized elders.

This scale is used to measure the ability of a person to perform 10 basic ADLs; in this way, a quantitative estimate of their degree of independence can be obtained. The scale is also known as the Maryland Disability Index. The patient is questioned with respect to different activities, and their abilities to perform each of the corresponding activities is assigned a score according to their ability to perform the activity.

In the case of washing and grooming, if a patient can perform it without any complication, a maximum score of 5 points is given; however, if a patient cannot perform the activity, they are assigned a score of 0. The activities of eating, dressing, stooling, urinating, using the toilet, and climbing steps can have maximum score of 10 points if an individual can successfully perform the activity; however, if they need help with the activity, 5 points are given; if they are unable to perform it, a score of 0 is assigned. Finally, moving and walking carry maximum scores of 15 points each. If a person needs a minimal amount of help to carry out the activity, the person receives a score of 10 points, whereas if the person needs more help, they will be awarded 5 points. If the person is completely dependent on help, a score of 0 is assigned.

Once all of the scores are obtained, the sum is organized in such a way that the totally independent residents will have a score of 100, the residents with mild dependency will have a score of 91 to 99 points, moderate dependency is established with a score of 61 to 90, severe dependence entails scores ranging from 21 to 60 points, and total dependence is considered as a score of 20 points or less [25,26]. The Barthel index values obtained at a maximum of three months before the disease was contracted were used as the reference values. Indices were obtained at a maximum of three months after overcoming the infection and being discharged by the medical team in order to assess whether the infection had changed the status of the ADLs and therefore the degree of dependence had changed.

All of the individual Barthel scores were collected in an Excel table after scores were collected in the morning to ensure that the tiredness derived from the daily activity was not a factor that would have altered the results.

All of the results were added to determine the score by item and the total score.

The facilities used in the sample are among those with the greatest number of elderly people, and they are the residences that have more control over the ADLs. Among these places, some of them are arranged (indicating that part of the care derived from living in the residence receives public funding) in which the administration performs a very exhaustive monitoring of the places. This type of residence conducts Barthel assessments every three months; thus, when the pandemic affected these facilities, all of the elderly residents had been tested with the index, at most, three months prior to the start of the pandemic. After taking into account that SARS-CoV-2 was contracted by residents in the facility, affecting almost all them in a short period of time, we were able to obtain the Barthel index values in the survivors immediately after contracting the virus up to a maximum post-exposure time of three months, thus assessing the pure effects of the virus without the possibility of improvement after rehabilitation, derived diseases, and complications.

The ability to eat in the dining room of the residence hall or in the resident's room was evaluated, the ability to dress was assessed in the resident's room and always with their usual clothes, and the ability to go to the toilet and pass urine and stool was evaluated in their own toilet so as not to change the usual conditions under which the elderly perform these activities. The ability to climb stairs and wander was evaluated in the presence of the physiotherapist and at places that the elderly residents usually walked.

Based on the information from medical records, we analyzed the following factors: (1) age, (2) sex, (3) height, (4) weight, and (5) body mass index (BMI).

All residents belonged to two nursing homes in the province of León, Castilla y León, Spain. The study population was Caucasian and Spanish-speaking, with a medium–low sociocultural level and a medium economic level. Regarding the religion of the elderly, they were Catholic and the level of education in the majority was basic.

This index has been described by many authors as the most widely used index for evaluating ADL in chronically ill patients and periodically evaluating their progression [27–29]. The reliability of the test according to Cronbach's alpha is 0.86–0.92 for the original version and 0.90–0.92 for the version proposed by Shah et al. [28].

A sample of 68 residents was taken. These people were divided into two groups according to gender (men and women). The inclusion criteria dictated that the patients were older than 65 years [30], that they lived together in the nursing home, and that they had a clinical diagnosis of COVID-19 infection.

The elderly who had contracted and recovered from SARS-CoV-2 were recruited into the study.

The follow-up period was defined as the time that had elapsed from prior to the SARS-CoV-2 infection until recovery. The Barthel index was evaluated over a maximum time frame of six months, a maximum of three months before contracting COVID-19 and a maximum of three months post-infection using the score obtained before infection and after recovery in a certain period of time to evaluate only the impact on the ADL caused by the COVID-19 infection and not the possible events that could happen a posteriori or the improvements derived from rehabilitation.

The protocols used for assessing the elderly were followed at all times according to the guidelines established by the health authorities. Controls were evaluated by polymerase chain reaction (PCR) and antigen tests administered to detect when the virus went into remission and when the patients were transferred to what was called the "clean zone" (the residences had to carry out isolation protocols and divide the buildings into clean and dirty zones, depending on whether the resident had an active infection). Therefore, once the residents obtained a negative result on the tests, they were transferred to the clean zone, free of SARS-CoV-2, and the Barthel assessment was performed. It should be noted that the elderly who went to the COVID-19-free zone had substantially improved their situation and were well enough to be able to resume their pre-infection life, although the majority had limitations.

Indeed, most of the elderly in this study were polymedicated and presented a variety of pathologies. It is true that comorbidities could affect ADL in a manner similar to lung infections suffered in winter (flu, pneumonia, catarrhal processes), which could cause an elderly person to become bed-ridden for days or even weeks. However, the virulence of this infection is devastating, not only for the lives it has claimed, but for the substantial loss of independence for an elderly patient.

Of course, during the days of convalescence, the elderly stopped their physical activities, as happens with other seasonal or bacterial infections, but no infection had caused a loss of muscle function or energy in patients in such a short time as did the COVID-19 induced virus.

The residence was divided into zones, which were delineated by floors, so that residents could move around on the floor on which they were located. Dining and living

rooms were doubled so that the elderly could maintain their normal activities as much as possible, but it is true that during the most acute days, as in other infections, the elderly patients remained bedridden.

The habits of the elderly were effectively suspended since the entire operation of the facilities was forced to switch to contingency plans and most types of activities were suspended, which is one reason that the ADLs of the elderly were not the same, but this would not explain such a marked loss in such a short period of time in the ADLs of these patients.

Regarding the issue of comorbidities, we could have conducted a study on whether the comorbidities of the patients studied were a decisive factor in causing the loss of independence when performing ADLs, whether any of the administered medications caused confusion in these patients, or how much the elderly regained their independence in their ADLs once rehabilitation was initiated (it must be taken into account that the elderly began rehabilitation with physiotherapy and occupational therapy after the convalescent period and once discharged with negative PCR results) but the Barthel assessment was administered before rehabilitation to accurately determine the impact of the virus on our participants.

### *Statistical Analysis*

A descriptive analysis of the characteristics of the participants from both groups was performed. Continuous variables were reported using the mean and standard deviation (SD) and confidence interval 95% (IC95%). The normality of the data was tested using the Shapiro–Wilk test.

For parametric data, paired T-tests were used to determine differences within the same group, and an independent T-test was used between groups.

The differences between before and after COVID-19 were analyzed using one-way repeated-measures analysis of variance (ANOVA). The age, weight, height, and BMI were analyzed as quantitative covariates to test within-subjects effects, and sex was analyzed as a categorical variable to test between-subjects factors, followed by pairwise comparisons using the Bonferroni correction.

For demonstrating the effect size of the comparisons, the Cohen's d coefficient was calculated. Cohen's d effect size can be interpreted as described previously: (1) values ≤0.20 indicate slight effects, (2) values between 0.20 and 0.49 indicate fair effects, (3) values between 0.50 and 0.79 indicate moderate effects, and (4) values >0.79 indicate large effects [31].

For all analyses, a value of *p* < 0.05 was considered statistically significant. The data were analyzed using SPSS software for Mac (Version 22; IBM Corp, Armonk, NY, USA).

### **3. Results**

All of the variables showed a normal distribution (*p* > 0.05). A significant difference between the ages, heights, and weights of the group of men with respect to the group of women was found; however, for BMI, no significant difference was noted. All data are shown in Table 1.

As can be seen in Table 2, the results of the Barthel index, pre- and post-COVID-19 infection, present significant differences for all evaluated and for the total score.

As can be seen in Table 3, the pre-COVID-19 results of the Barthel index based on gender were compared. Significant results were obtained for both the transfers and ambulation of women compared to men with women, who obtained lower scores for both items; however, after recovering from the COVID-19 infection, the difference in ambulation was still significant between genders. In this case, men obtained worse scores than women, while in transfers, a significant difference did not exist. Urination appeared to be significantly different between men and women, with the latter obtaining the worst scoring, whereas before contracting the infection, differences were insignificant.


**Table 1.** Demographic and descriptive data of the sample population according to male and female groups.

Abbreviations: BMI, body mass index; SD: standard deviation; IC95%: confidence interval; independent T-tests were used. *p* > 0.05 (with a 95% confidence interval) was considered statistically significant.


Abbreviations: DS: standard deviation; IC95%: confidence interval; \* one-way repeated-measures analysis of variance (ANOVA) was used. *p* < 0.05 (with a 95% confidence interval) was considered statistically significant.


**Table 3.** Pre- and post-COVID-19 results based on the Barthel index by gender.

Abbreviations: DS: standard deviation; IC95%: confidence interval; NA: not applicable; \* independent T-tests were used. *p* < 0.05 (with a 95% confidence interval) was considered statistically significant.

### **4. Discussion**

In this study, using the Barthel index, the ADLs of patients who had contracted the SARS-CoV-2 infection were evaluated. The Barthel index was applied to evaluate 10 items of ADL in two to four stages; its efficacy is widely accepted for this type of assessment [29,32,33]. The Barthel index has been used to assess functional impairment resulting from multiple sclerosis, cerebrovascular accidents, physical disabilities in the elderly, and many other neurological diseases [29,34,35].

At the end of 2019, a new coronavirus, SARS-CoV-2, began to spread rapidly throughout the world, endangering the health of people around the planet [36]. This new disease causes serious sequelae in 20% of affected patients, and admission to the intensive care unit (ICU) is often necessary due to the respiratory problems; it can even cause death [16].

Muscle weakness is one of the most frequent problems in patients with long bedtime periods and in patients seen in ICUs [37,38]. Critical illness survivors experience marked disability and deficits in physical and cognitive function that can even persist for years after their initial ICU stay [39].

Disability acquired after ICU is associated with reduced health-related quality of life and worse ADL [40].

Our study suggests that ADLs could be reduced after contracting COVID-19. In a study by Iwashyna et al., it was concluded that the elderly, after suffering with severe septicemia, present cognitive impairment and substantial disability that worsens their ability to perform ADLs [41]. Our study shows that COVID-19 infection causes a significant deterioration in all basic ADLs, including eating, washing, dress, getting ready, defecation, urination, using the toilet, transfers, ambulation, and steps, if the results of institutionalized elderly patients with respect to the results of ADL pre- and post-COVID-19 are compared.

Gender and age are the main risk factors for contracting COVID-19 disease [42]. A study found that in similar age groups, the infection was more serious for men than for women [43], and it was men who had the highest mortality rates [44]. These data could explain why, after contracting COVID-19, men obtained worse ADL scores than women despite having a lower average age.

However, the results before contracting the infection were worse for women, a finding that could be explained because aging is the main cause of deterioration [45]. The women in this study had an average age of 87.72 years, which was greater than that of the men; it should be noted that studies conclude that it is from the age of 80 and upward when the death rate of >95% is more significant [46].

The state of emergency resulting from the COVID-19 pandemic, which has had a greater impact on older people, especially with respect to those in institutions, has been minimally studied in terms of the quality of post COVID-19 ADL. Few reports evaluate the relationship between the Barthel index and COVID-19-derived sequelae. We found that the Barthel index, which is a simple and widely used method for assessing ADL, showed a significant correlation with the sequelae suffered by institutionalized patients who had contracted COVID-19, and the total results of the Barthel index could potentially be used to predict the related quality of life after recovering from COVID-19. We believe that the Barthel index is a useful tool for classifying and quantifying impairment in ADLs.

This study has a limitation with respect to the number of participants, but due to the unpredictability of the pandemic, not many elderly people who had undergone a Barthel assessment three months before contracting the COVID-19 infection could be found, regardless of the dramatic mortality caused by the infection (>94%). This situation made it even more difficult to increase the study sample number since it was important to perform the Barthel assessment in a short time frame and ensure that other aspects, such as emerging diseases or improvements due to the rehabilitation of these subjects, did not influence our results.

### **5. Conclusions**

Of course, the pandemic has completely taken the worldwide population out of their normal lives, especially the older institutionalized population. It is important to develop maintenance programs for ADLs in situations of this type; perhaps it would be interesting to develop an early rehabilitation plan so that a patient suffering from the infection could continue to undergo rehabilitation despite continuing to test positive on the PCR test in order not to lose ADL capability. This could apply not only to this infection but to all types of illnesses. Promoting the autonomy of patients despite suffering from infection in order to prevent deterioration should be carried out. These pandemic situations must be addressed in order to be prepared and minimize the impact that they may cause on the elderly population.

In summary, this study shows a significant reduction in the quality of ADLs among the elderly institutionalized population in two nursing homes immediately before contracting and after recovering from the COVID-19 infection as measured by the Barthel index.

It appeared that the infection induced by SARS-CoV-2 caused a deterioration in the ADLs more in men than in women and that undoubtedly age was closely related to the loss of the ability to carry out ADLs. Elderly men, especially, saw their abilities diminish more than women, who, although their capacities diminished, did so to a lesser extent.

All of these findings should be taken into account to alleviate the impact that this infection is having not only on the health of our elders and the consequential health expenses that this situation will have but also in terms of the barrier to personal autonomy in the day to day lives of patients. It should be highlighted that the results of this study were not altered by the possible improvement derived from early rehabilitation or the worsening caused by an emerging disease. Data that substantiate our results would be of vital importance for a multidisciplinary team in order to evaluate the deterioration of the ADLs of the surviving elderly people, in order to establish an immediate and personalized rehabilitation plan, not only to preserve their health but also to preserve the quality of life of these people after they recover from this disease.

**Author Contributions:** Data curation, B.T.-R.; Formal analysis, B.T.-R. and R.B.-d.-B.-V.; Investigation, B.T.-R. and C.L.-P.; Methodology, B.T.-R., M.L.-I. and R.B.-d.-B.-V.; Project administration, R.B.-d.-B.-V.; Resources, E.P.-B.; Supervision, D.L.-L., P.M.-S. and R.B.-d.-B.-V.; Validation, E.P.-B., E.N.-F., R.J.-F., I.C.-L. and M.L.-I.; Visualization, D.L.-L., M.L.-I. and R.B.-d.-B.-V.; Writing—original draft, B.T.-R.; Writing—review & editing, D.L.-L., E.P.-B., P.M.-S., C.L.-P., E.N.-F., R.J.-F., I.C.-L., M.L.-I. and R.B.-d.-B.-V. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Hospital Clínico San Carlos (protocol code 21/251-E and 7 April 2021.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The dataset supporting the conclusions of this article is available in the marta.losa@urjc.es in the Faculty of Health Sciences, Universidad Rey Juan Carlos, 28933 Madrid, Spain.

**Acknowledgments:** The authors thank to all the people for their participation in this study.

**Conflicts of Interest:** The authors declare no conflict of interest.

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