The effect of COVID-19 pandemic and lockdown on consultation numbers, consultation reasons and performed services in primary care: results of a longitudinal observational study

[Influence of health care crises on the treatment of cancer pain: a presentation using the example of the COVID-19 pandemic from the provider's perspective]

BACKGROUND

The COVID-19 pandemic led to significantly restricted access to pain medicine services. Patients with cancer-related pain are considered a vulnerable group in terms of care deficits. A questionnaire among providers providing treatment to this group was used to assess limitations and solutions in this critical situation.

MATERIALS AND METHODS

The online survey, developed by the 'Tumour Pain Working Group' of the German Pain Society using the Delphi method, included questions on site structure, pandemic-related care problems, and burdens experienced by those treating patients. It was distributed several times via the mailing lists of the German Pain Society and the 'Palliative Medicine Working Group' of the German Society of Anaesthesiology and Intensive Care Medicine.

RESULTS

In all, 175 fully completed questionnaires were analysed. Over 75% of participants reported pandemic-related staff shortages and closures of pain medicine facilities, with 32% of facilities temporarily not treating elective pain patients and 13% not treating any emergencies. Care was hampered by numerous logistical problems such as very frequent pandemic-related cancellations by patients or in the transmission of prescriptions. Alternative forms of consultation by telephone or telemedicine, rarely used before the pandemic, were reported by 79 and 31% of respondents respectively, but deficiencies were noted. In addition, 52.1% of respondents complained of severe and 26.8% of moderate psychological stress due to the pandemic, and 74.1% evaluated working conditions as moderately to severely difficult. Medical training was still possible for 86% through format changes.

CONCLUSION

The COVID-19 pandemic revealed numerous deficits in the care of patients with cancer-related pain, as well as burdens on healthcare providers. The development of new concepts could help to ensure better care in future crisis situations.

[Changes in the provision and utilization of health care in German primary care practices during the COVID-19 pandemic - A survey of patients in three federal states]

INTRODUCTION

During the COVID-19 pandemic general practitioners (GP) practice teams were temporally confronted with major challenges which were accompanied by changes in practice organization and service provision. So far, little has been known about the views of patients who visited the GP practice for other than COVID-related reasons with regard to provision and use of GP services, the adjustments in the practice and the work of the practice team members.

METHODS

The patient survey is a sub-study of the mixed-methods study VeCo-Praxis (GP healthcare for patients not suffering from COVID during the Corona pandemic) of the research practice network RESPoNsE (Research Practice Network East), which was conducted in the federal states of Berlin, Brandenburg and Thuringia. The questionnaire-based survey was carried out among patients who visited their GP practice in November 2022. The topics covered in the survey were developed by two focus groups consisting of 13 members of the RESPoNsE patient advisory board. The questionnaire was developed and piloted in a participatory approach with the RESPoNsE Patient Advisory Board. The results were analyzed descriptively using SPSS and discussed with the advisory board.

RESULTS

1,405 questionnaires from 37 practices were analyzed. 97% of respondents felt that the treatment they received at their GP practice during the COVID-19 pandemic was good. For the vast majority, appointments and acute consultations, prescriptions, laboratory tests, discussions of diagnostic results, routine follow-up check-ups and health checks were available to a sufficient extent. From the patients' perspective, the practices have successfully adapted to the challenges caused by COVID-19. Overall, the patients' trust in and their appreciation of the work of the practice staff have increased since the pandemic. Patients stated that GP practices should continue hygiene procedures, such as wearing a mask or keeping physical distance, in the future.

DISCUSSION

Despite multiple reports of a significant decline in both provision and utilization of standard care in GP practices during the pandemic, our survey showed that the majority of patients felt that they received adequate GP care and were highly satisfied. The results should be interpreted against the background of possible selection bias.

CONCLUSION

In this survey, GP patients were predominantly appreciative of GP care during the COVID-19 pandemic. The patients' assessment of the provision and use of GP services during the pandemic complements the corresponding perspective of GPs and medical practice assistants.

Effects of coronavirus disease 2019 on the spread of respiratory-transmitted human-to-human bacteria

OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic has necessitated significant changes in medical systems, social behaviours, and non-pharmaceutical interventions (NPIs). We aimed to determine the effect of the COVID-19 pandemic on changes in the epidemiology of respiratory-transmitted bacteria that have been unexplored.

METHODS

We utilised a comprehensive national surveillance database from 2018 to 2021 to compare monthly number of patients with four respiratory-transmitted human-to-human bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes) before and after the COVID-19 pandemic, stratified by specimen sources and age groups.

RESULTS

The incidence of detected patients with S. pneumoniae, H. influenzae, and S. pyogenes from both respiratory and blood cultures significantly decreased from 2019 to 2020. In 2021, the incidence of detected patients with the respiratory-transmitted bacterial species, except for S. pyogenes, from respiratory cultures, increased again from April to July, primarily affecting the 0-4-year age group.

CONCLUSIONS

Our comprehensive national surveillance data analysis demonstrates the dynamic changes and effects of NPIs on respiratory-transmitted bacteria during the COVID-19 pandemic, with variations observed among species, specimen sources, and age groups.

E-Health-based, trans-sectoral, geriatric health service - Geriatric Network (GerNe)

Currently, exchange of information between the geriatric clinic and the attending general practitioner (GP) occurs primarily through the doctor's letter after discharging from the clinic. The aim of our study was to reduce readmissions of multimorbid, geriatric patients to the clinic by establishing a new form of care via an electronic case file (ECF) and a consultation service (CS). The discharging geriatric clinic filled out an online ECF. The patient's GP should document quarterly follow-ups in the ECF. The case file was monitored by the discharging clinic due to a consultation service. The primary efficacy endpoint was the rehospitalization rate within one year. The hospitalization rate for patients managed in the project was 83.1/100 person years (PY), while the control group from insurance data had a rate of 69.0/100 PY. The primary endpoint did not show a statistically significant difference (p = 0.15). A total of 195 contacts were documented via CS for 171 participants, mostly initiated by the clinics. The clinical queries primarily concerned drug therapy. The Covid pandemic had an overall impact on hospitalizations. There are many approaches to reducing hospital readmissions after discharge of older patients. Supporting the transition from inpatient to outpatient care by different professional groups or care systems has been shown to have a positive effect. Furthermore, the utilisation of an ECF can also be beneficial in this regard.

Association between continuity of care and inappropriate prescribing in outpatient care in Germany: a cross-sectional analysis conducted as part of the LoChro trial

OBJECTIVES

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients.

DESIGN

Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC.

SETTING

Southern Germany, outpatient setting.

PARTICIPANTS

321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool.

PRIMARY OUTCOMES

Numbers of PIMs and PPOs.

RESULTS

The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337).

CONCLUSION

The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904.

The impact of the SARS-CoV2 pandemic on the prescription of thyroid medication in Austria - A nationwide population-based registry analysis

BACKGROUND

Case reports indicate a clinical connection between SARS-CoV-2 and thyroid dysfunctions. However, evidence from large population-based registry analyses is sparse, especially in Europe, where iodine deficiency is common. This study aimed to analyze the impact of the COVID-19 pandemic on healthcare provision for thyroid diseases in Austria.

METHODS

We performed a retrospective, population-based registry analysis of the Austrian health insurance fund database, covering more than 9 million inhabitants. Data from all patients with prescriptions of thyroid-specific drugs and/or inpatient thyroid-related diagnoses from 2017 to 2019 (pre-pandemic years) were compared to 2020 and 2021 (pandemic years; characterized by high numbers of SARS-CoV2 infections and population-wide vaccination strategy). The incidence rates of thyroid medication prescriptions for hypothyroidism and hyperthyroidism were calculated for every year to evaluate the impact of the pandemic.

RESULTS

The incidence rate for total thyroid medication prescription was 539.07/100,000 individuals (534.23-543.93 95%CI) in 2018 and declined during the pandemic (2020: 387.19/100,000 (383.12-391.29 95%CI); 2021: 336.90/100,000 (333.11-340.73 95%CI)). Similarly, the incidence rate for levothyroxine prescription was higher pre-pandemic (2018: 465.46/100,000 (460.97-469.98 95%CI) and declined during the pandemic (2020: 348.14/100,000 (344.28-352.03 95%CI); 2021: 300.30/100,000 (296.7-303.91 95%CI). The incidence rates of thiamazole prescriptions (2018: 10.24/100,000 (9.58-10.93 95%CI); 2020: 8.62/100,000 (8.03-9.26 95%CI); 2021: 11.17/100,000 (10.49-11.89 95%CI) were stable.

CONCLUSIONS

These findings suggest no clinically significant impact of SARS-CoV2 and/or vaccination on thyroid function at a population level.

Effects of Two COVID-19 Lockdowns on HbA1c Levels in Patients with Type 1 Diabetes and Associations with Digital Treatment, Health Literacy, and Diabetes Self-Management: A Multicenter, Observational Cohort Study Over 3 Years

INTRODUCTION

Short-term studies reported improved glycemic control and a decrease in eHbA1c (estimated hemoglobin A1c) in patients with type 1 diabetes during COVID-19 lockdown, but long-term changes are unknown. Therefore, the main objectives are to (1) analyze whether laboratory-measured HbA1c changed during and after two lockdowns and (2) investigate potential variables influencing HbA1c change.

METHODS

In this cohort study, 291 adults with type 1 diabetes were followed over 3 years including the prepandemic phase and two lockdowns. The data from medical records and validated questionnaires assessing health literacy (HLS-EU-Q16), diabetes self-management (DSMQ-R27), general self-efficacy (GSE), and social support (F-SOZU-K14) were used to analyze associations with HbA1c levels (N = 2370) by performing multivariable linear regressions.

RESULTS

The median age was 54 (38-63) years and 159 (54.6%) were male. All phases of the COVID-19 pandemic were associated with a significant increase in laboratory-measured HbA1c levels in percent (e.g., during first lockdown β = 0.23, 95% confidence interval (CI) 0.07-0.39, p = 0.005; during the second lockdown, β = 0.27, 95% CI 0.15-0.38, p < 0.001). HbA1c change during lockdowns was significantly affected by the number of checkups (β = -0.03, 95% CI -0.05 to -0.01, p = 0.010), the value of HbA1c at previous observation (β = 0.33, 95% CI 0.29-0.36, p < 0.001), educational level (secondary versus tertiary: β = 0.22, 95% CI 0.06-0.38, p = 0.008; primary versus tertiary: β = 0.31, 95% CI 0.10-0.52, p = 0.004), health literacy score (for each point: β = -0.03, 95% CI -0.05 to - 0.002, p = 0.034), and diabetes self-management score (for each point: β =  -0.03, 95% CI -0.04 to -0.02, p < 0.001). The use of continuous glucose monitoring or insulin pump had no effect on HbA1c change.

CONCLUSIONS

Lockdowns can lead to worsening glycemic control in patients with type 1 diabetes. Particularly patients with few check-ups, poor blood glucose values, deficits in diabetes self-management, low health literacy, and a low level of education seem to be at greater risk of worsening glycemic control during lockdowns and, therefore, require special medical care, e.g., through telemedicine.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT04821921.

Patients' experience with German primary care practices during Covid-19: an interview study

BACKGROUND

Patient access to and communication with German primary care practices (PCPs) changed due to Covid-19. Patients had to comply with Covid-19 regulations, which included closed waiting rooms and appointment-based consultations. It is unclear how patients experienced these changes and how the pandemic impacted their primary care attendance.

AIM

The aim of the study was to explore how patients, who frequently attended PCPs before the pandemic, perceived primary care during the initial phase of Covid-19 in Germany.

DESIGN & SETTING

Between January and June 2021, we completed 17 semi-structured interviews. Participants included primary care patients from two regions in Germany who frequently attended their physician before the start of the pandemic.

METHOD

Data were analysed using content analysis.

RESULTS

Four interconnected themes emerged in the analysis: 'fear of COVID-19 infection', 'practice organisation', 'information about COVID-19', and 'telemedicine'. Participants were unconcerned about being infected in their practice and mostly agreed with COVID-19 regulations, although waiting outside for their appointment was uncomfortable for some. Participants consulted their primary care physician in relation to different vaccines but felt they were sufficiently informed regarding general information about COVID-19. Views on telemedicine, which was mostly understood as contact via telephone or video call, differed widely, with some participants being very accepting and interested, while others dismissed telemedicine categorically.

CONCLUSION

Participants regarded the new COVID-19 regulations as sensible. Telemedicine using telephone or video call consultations should be further explored under the assumption that this would be acceptable for some but not all patients.

[Burnout, anxiety, insomnia and depressive symptoms among French outpatient physicians in the second wave of COVID-19: Comparison between general practitioners and specialists]

INTRODUCTION

The 2019 coronavirus (COVID-19) pandemic has caused a public health crisis worldwide. Concerns have been expressed about the rapid deterioration of mental health among primary care physicians among whom burnout already had a high prevalence prior to the pandemic. However, there is little data on private doctors during the pandemic. France experienced a second wave with a second lockdown. We aimed to assess and compare physicians' burnout, anxiety and depression symptoms and insomnia between general practitioners (GP) and all other private specialists during the second Covid-19 wave.

METHODS

We conducted an online survey of private practitioners registered on Doctolib® (n=32,655), the interface software most used by private practitioners for booking medical appointments in France. Doctors were invited by email to complete an online survey in November 2020. Inclusions were closed on 1st December. The 2nd lockdown lasted from 30th October to 15th December 2020. We used the Copenhagen Burnout Inventory (CBI) to assess burnout syndrome. A mean score of>50 in at least one subscale defined burnout. The Hospital Anxiety and Depression Scale assessed anxiety and depression symptoms. We used two cut-offs, 8 (>7) and 11 (>10), as both are validated in the ability to find cases. The Insomnia Severity Index (ISI) measures sleep-related complaints among physicians (cut-off >7). To link variations in the psychological scales to the COVID-19 pandemic, one of the items asked explicitly whether participants considered that "the COVID-19 epidemic we are currently experiencing is a source of excess stress, psychological suffering or burnout". Approval for this study was obtained from the local institutional review board of the University of Paris-Saclay, France. The questionnaires were collected anonymously. Statistical significance was tested using the chi-square test and student's t-test to compare the prevalence between GPs and other specialities. Subsequently, logistic regression models were run for statistically significant associations.

RESULTS

1992 physicians replied, a response rate of 12.8% of those who received the invitation email. Among them, 79.4% suffered from psychological distress (symptoms of anxiety or depression or burnout), of which 71.3% suffered from burnout, 26.7% from depressive symptoms, 58.9% from anxiety symptoms and 45.8% from insomnia. There was no difference in gender between GPs and specialists, but there was an age difference (P<0.001). GPs had a higher prevalence of burnout (OR=1.33 CI95 [1.09;1.63]) and took more psychotropic drugs (1.38 CI95 [1.05;1.81]). They were also more likely to perceive their stress as work-related (OR=1.50 CI95 [1.23;1.81]) or COVID-19-related (OR=1.43 CI95 [1.16;1.77]).

CONCLUSION

Our study is the first to assess the mental health of private practitioners in the second wave in association with COVID-19 stress. Firstly, GPs who provide primary care have a significantly higher burnout rate than other doctors. Secondly, COVID-19 stress is associated with more significant psychological distress. Thirdly, almost 80% of the private doctors surveyed suffer from psychological pain, and 71% suffer from burnout. This study has strengths and limitations. Firstly, this study assesses mental health and stress related to its COVID-19 association. Second, this is the largest population of private physicians during the COVID-19 pandemic. The low response rate is the main limit of this study. The alarming rates of psychological distress among private doctors and, in particular, GPs should lead to intervention to help doctors reduce stress, burnout and other mental disorders. This study gives a picture of the situation during the second wave and the lock-in, and we need to be cautious with the next waves.

Diabetes-related amputations in Germany: analysis of time trend from 2015 to 2022 and differences by area-level socioeconomic deprivation

Background

Diabetes-related amputations reduce health-related quality of life and are an indicator of the quality of care of diabetes.

Methods

Population-based age-standardized rates for diabetes-related cases of major and minor amputation were calculated and reported for the years 2015 - 2022 using the Diagnosis-related groups statistics. For 2022 these rates were also reported according to area-level socioeconomic deprivation.

Results

Diabetes-related major amputations decreased from 6.8 to 5.2 per 100,000 residents in women and from 18.6 to 17.5 per 100,000 residents in men between 2015 and 2022. In 2021 and 2022, there was no further decrease in men compared to the previous year. Diabetes-related minor amputations decreased in women between 2015 and 2022, but increased in men. Amputation rates were higher in regions with high deprivation than in regions with low deprivation.

Conclusions

Diabetes care should consider socioeconomic differences into account. The monitoring of the trends in amputations needs to be continued.

Change of perspective: impact of COVID-19 pandemic on axial spondyloarthritis-related web searches in Germany

Several conventional cross-sectional studies have investigated the impact of the coronavirus disease (COVID-19) pandemic on patients with axial spondyloarthritis (axSpA) and reached contrary results regarding health and well-being. As analysis of web search data already provided insights into public interest and unmet needs, this study aimed to examine axSpA-related web searches before and during COVID-19 pandemic to gain a different perspective on the impact of COVID-19 on this disease. The Google Ads Keyword Planner was used to generate axSpA-related keywords and their monthly number of searches between June 2018 and November 2021 in Germany. These keywords were qualitatively classified into seven categories. A total of 538 axSpA-related keywords were used for the analysis. The number of axSpA-related searches increased during COVID-19 pandemic (before: n = 1,525,010 vs. during: n = 1,848,300), particularly searches for symptoms, disease outcomes, and causes, while interest in disease management and diagnosis decreased. This study demonstrated a shift in public interest in axSpA during COVID-19 in Germany and highlights an urgent expansion of telemedicine to be prepared for exceptional situations such as a pandemic.

Outpatient Health Service Utilization Among Adults with Diabetes, Hypertension and Cardiovascular Disease During the COVID-19 Pandemic - Results of Population-Based Surveys in Germany from 2019 to 2021

Purpose

Fear of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and lockdown measures may have an impact on health care utilization particularly for people with chronic diseases. We investigated changes in outpatient utilization behavior in pandemic phases among people with selected chronic diseases in Germany.

Methods

The nationwide population-based telephone surveys German Health Update (GEDA) 2019/2020 (April 2019 to September 2020) and GEDA 2021 (July to December 2021) covered 4 out of 7 pandemic phases from the pre-pandemic to the 4th pandemic wave. Data on hypertension, diabetes and major cardiovascular diseases (CVD) in the past 12 months and visiting a general practitioner (GP) or a specialist (excluding dentist) in the past 4 weeks was collected using a standardized questionnaire. Proportions and odds ratios were derived from logistic regression models adjusted for age, sex, education and federal states.

Results

Among 27,967 participants aged ≥16 years, 8,449, 2,497 and 1,136 individuals had hypertension, diabetes and major CVD. Participants with these chronic diseases visited a GP or specialist significantly more often than the overall study population, irrespective of pandemic phases. Compared to the pre-pandemic phase, a significant reduction in specialist-visiting was found in the first pandemic wave among people with hypertension (34.3% vs 24.1%), diabetes (39.5% vs 25.5%) and major CVD (41.9% vs 25.6%). GP-visiting was lower only among people with hypertension (53.0% vs 46.0%). No difference in GP or specialist visiting was found in the 4th pandemic wave compared to the pre-pandemic phase.

Conclusion

The observed decrease particularly in specialist utilization among people with the selected chronic diseases at the beginning of the pandemic was not observed for the second half of 2021 despite the ongoing pandemic. Further studies are required to examine whether the temporary changes in the utilization of ambulatory health care have affected the disease management of people with chronic diseases.

Practice Changes in Checkpoint Inhibitor-Induced Immune-Related Adverse Event Management at a Tertiary Care Center

Understanding of immune-related adverse events (irAEs) has evolved rapidly, and management guidelines are continually updated. We explored temporal changes in checkpoint inhibitor-induced irAE management at a tertiary cancer care center to identify areas for improvement. We conducted a single-center retrospective study of patients who developed a gastrointestinal, pulmonary, renal, or cardiac irAE between July and 1 October in 2019 or 2021. We collected patient demographic and clinical information up to 1 year after toxicity. Endoscopic evaluation and specialty follow-up after discharge for patients with gastrointestinal irAEs declined between the 2019 and 2021 periods. Symptom duration and steroid taper attempts also declined. For pulmonary irAEs, rates of specialty consultation, hospital admission and readmission, and mortality improved in 2021 compared with 2019. Follow-up rates after hospital discharge were consistently low (<50%) in both periods. For cardiac irAEs, consultation with a cardiologist was frequent and prompt in both periods. Outpatient treatment and earlier specialty consultation improved outcomes with gastrointestinal irAEs. Our study exploring irAE practice changes over time identified areas to improve management; specifically, timely specialty consultation was associated with better outcomes for gastrointestinal irAEs. These findings can help improve the quality of management algorithms at our institution and may inform policies in other institutions.

Impact of two COVID-19 lockdowns on HbA1c levels in patients with type 2 diabetes and associations with patient characteristics: a multicentre, observational cohort study over three years

Introduction

Glycemic effects of COVID-19 lockdowns on patients with type 2 diabetes (T2D) are controversial. In this long-term observation, we aimed (1) to analyze changes in HbA1c levels during lockdowns in Germany, and (2) to investigate whether diabetes medication, comorbidities, and sociodemographic data influenced these changes.

Materials and methods

This cohort study observed 1,089 patients aged ≥18 years over the years 2019 to 2021. Patients were recruited from 14 physicians specialized on diabetes. As dependent variable, 7,987 HbA1c values were analyzed by multivariable linear regression adjusted for random effects of physicians and patients.

Results

Patients had a median age of 68 (60/76) years and 623 (57.2%) were male. Before the pandemic, median HbA1c level (in %) was 6.9 (6.3/7.7). Average HbA1c level increased during first lockdown (0.21,0.11/0.31,p < 0.001), after first lockdown (0.23,0.18/0.28,p < 0.001), during second lockdown (0.40,0.33/0.47,p < 0.001) and after second lockdown (0.27,0.18/0.36,p < 0.001). The increase of HbA1c levels was more pronounced in male patients (0.08,0.01/0.15,p = 0.019), if patients did not have German as native language (0.12,0.01/0.23,p = 0.041) and if they were widowed (0.19,0.05/0.32,p = 0.008). End organ damages (0.12,0.01/0.23,p = 0.039), atherosclerotic cardiovascular disease (ASCVD; 0.23,0.10/0.36,p = 0.001) and cardiovascular events (0.25,0.10/0.40,p = 0.001) as well as oral medication (0.09,0.03/0.15,p = 0.002), intermediate- or long-acting insulins (0.24,0.16/0.32,p < 0.001), and fast-acting or mixed insulins (0.30,0.23/0.36,p < 0.001) were also related to a greater increase in HbA1c levels.

Conclusion

Both lockdowns resulted in a significant increase in HbA1c levels. In particular, patients with ASCVD, cardiovascular events, and insulin therapy appear to be at risk for worsening glycemic control in crisis and thus require special medical attention.

Clinical Trial Registration

ClinicalTrials.gov (NCT04821921).

The COVID-19 pandemic and disruptions to maternal and child health services in public primary care Malaysia: a retrospective time-series analysis

INTRODUCTION

The COVID-19 pandemic has posed significant challenges to healthcare systems worldwide. Maintaining essential health services, including maternal and child health (MCH), while addressing the pandemic is an enormous task. This study aimed to assess the impact of the COVID-19 pandemic on the utilisation of MCH services in Malaysian public primary care.

METHODS

A retrospective analysis was conducted using national administrative data from 1124 public primary care clinics. Eight indicators were selected to measure service utilisation covering antenatal, postnatal, women's health, child health, and immunisation services. Interrupted time-series analysis was used to evaluate changes in levels and trends of indicators during four different periods: pre-pandemic (January 2019-February 2020), during pandemic and first lockdown (March-May 2020), after the first lockdown was lifted (June-December 2020) and after the second lockdown was implemented (January-June 2021).

RESULTS

Most indicators showed no significant trend in monthly utilisation prior to the pandemic. The onset of the pandemic and first lockdown implementation were associated with significant decreasing trends in child health (-19.23%), women's health (-10.12%), antenatal care (-8.10%), contraception (-6.50%), postnatal care (-4.85%) and postnatal care 1-week (-3.52%) indicators. These indicators showed varying degrees of recovery after the first lockdown was lifted. The implementation of the second lockdown caused transient reduction ranging from -11.29% to -25.92% in women's health, contraception, child and two postnatal indicators, but no sustained reducing trend was seen afterwards. Two immunisation indicators appeared unaffected throughout the study period.

CONCLUSION

The COVID-19 pandemic significantly impacted MCH services utilisation in Malaysia. While most MCH services were negatively affected by the lockdown implementation with varying degrees of recovery, infant immunisation showed resilience throughout. This highlights the need for a targeted preparedness plan to ensure the resilience of MCH services in future crises.

Impact of Non-Pharmaceutical Interventions on the Incidence and Treatment of Chronic Rhinosinusitis during the COVID-19 Pandemic: A Nationwide Retrospective Cohort Study

Many countries have implemented non-pharmaceutical interventions (NPIs) to prevent the spread of COVID-19. However, the impacts of NPIs on the epidemiology and treatment of chronic rhinosinusitis (CRS) remain unclear. We analyzed 671,216 patients to investigate changes in the incidence rate and treatment frequency of CRS using Korean nationwide health insurance data between 2017 and 2021. The incidence rate (p < 0.001) and the number of outpatients (p < 0.001), patients hospitalized (p < 0.001), and patients prescribed antibiotics (p < 0.001) or steroids (p = 0.024) were significantly lower in the pandemic period than in the pre-pandemic period; however, the number of patients who underwent surgery was not different (p = 0.205). Additionally, the frequency of surgeries per patient was significantly lower in patients during the pandemic period (p < 0.001). In the interrupted time series analysis, the trends in the number of outpatients (p < 0.001), patients hospitalized (p < 0.001), patients who underwent surgery (p < 0.001), and patients prescribed antibiotics (p < 0.001) or steroids (p < 0.001) significantly changed after the onset of the COVID-19 pandemic. In summary, NPI implementation during the COVID-19 pandemic was associated with a reduction in the incidence and treatment of CRS.

Delivering Primary Health Care (PHC) Services for Controlling NCDs During the COVID-19 Pandemic: A Scoping Review

Non-communicable diseases (NCDs) are the leading cause of death worldwide. NCDs also increase mortality from COVID-19 and primary health care (PHC) services are an important component in the prevention and control of long-term NCDs. The main goal of the present study was to review primary healthcare services for the NCDs patients via primary healthcare network during COVID-19 pandemic. In this scoping review, Search engines including PubMed, Scopus, and Science-direct up to 1st February 2022 were searched to identify studies regarding primary care services for NCDs patients via primary health care during COVID-19 pandemic. A total of 42 studies met the inclusion criteria and were included in our analysis. 24 studies were about the status and changes of primary health services for NCDs patients in PHC settings, while 18 studies focused on adaptive strategies used during COVID-19 in different countries including United States, Canada, United Kingdom, Portugal, Georgia, South Africa, Thailand, Mexico, India, Kenya, Guatemala and Saudi Arabia. These strategies included remote monitoring, follow up, consultation, empowerment and educational services as well as home visiting Disruption of NCDs services in PHC during the COVID-19 pandemic was observed in different countries, which highlights the urgency of attention of researchers and policy-makers to development of appropriate and adaptive policies to improve PHC service coverage and its quality during the pandemics.

New Zealanders with low back pain seeking health care: a retrospective descriptive analysis of Accident Compensation Corporation-funded low back pain healthcare service usage

Introduction Most New Zealanders experience low back pain (LBP) at least once throughout their lifetime and many seek help from the large range of health providers in primary care. Accident Compensation Corporation (ACC) funds a significant proportion of those claims, but which services are they funding and what are the costs? Method This was a retrospective audit and descriptive analysis of ACC-funded, non-public hospital healthcare service use by people with LBP in New Zealand (NZ). Outcome measures were the healthcare services accessed by people with ACC-funded LBP,the claims (all occurrences for a service that has generated a payment/year), single contact (with a service), and costs (NZ$) for services between 2009 and 2020. Results The number of claims for services were 129 000 for physiotherapy, 105 000 for general practitioner and 59 000 for radiology services. Per single contact, elective surgery and radiology services were the most expensive. During 2009-2020, there were 3.3 million ACC claims for LBP with a total cost of NZ$4 billion. Over this time, there was an increase in claims, costs and single contacts. Costs decreased slightly during 2010 due to changes in healthcare funding and in 2020 due to the COVID-19 pandemic. Discussion Consumers have considerable choice in where they access health care for ACC-funded LBP services. This study shows the services they use most frequently and the cost to NZ for those services. These data can inform service planning for ACC-funded LBP health care in NZ.

General practitioners' perspectives regarding early developmental surveillance for autism within the australian primary healthcare setting: a qualitative study

BACKGROUND

Significant challenges remain in the early identification of child developmental disabilities in the community. Implementing supports and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental disabilities, including autism. As part of a cluster randomised controlled trial, this study seeks to examine and compare the perspectives and experiences of Australian general practitioners (GPs) in relation to a digital developmental surveillance program for autism and usual care pathway, in general practice clinics.

METHODS

A qualitative research methodology with semi-structured interviews and thematic inductive analysis underpinned by grounded theory was utilised. All GPs from South Western Sydney (NSW) and Melbourne (Victoria) who participated in the main program ("GP Surveillance for Autism") were invited to the interview. GPs who provided consent were interviewed either over online or in-person meeting. Interviews were audio-recorded, transcribed, and coded using NVivo12 software. Inductive interpretive approach was adopted and data were analysed thematically.

RESULTS

Twenty-three GPs across the two sites (NSW: n = 11; Victoria: n = 12) agreed to be interviewed; data saturation had reached following this number of participants. Inductive thematic coding and analysis yielded eight major themes and highlighted common enablers such as the role of GPs in early identification and subsequent supports, enhanced communication between clinicians/professionals, relationship-building with patients, and having standardised screening tools. Specific facilitators to the feasibility and acceptability of a digital screening program for the early identification of developmental disabilities, including the early signs of autism, and encouraging research and education for GPs. However, several practical and socioeconomic barriers were identified, in addition to limited knowledge and uptake of child developmental screening tools as well as COVID-19 lockdown impacts. Common and specific recommendations involve supporting GPs in developmental/paediatrics training, streamlined screening process, and funding and resources in the primary healthcare services.

CONCLUSIONS

The study highlighted the need for practice and policy changes, including further training of GPs alongside sufficient time to complete developmental checks and appropriate financial remuneration through a Medicare billing item. Further research is needed on implementation and scale up of a national surveillance program for early identification of developmental disabilities, including autism.

Glycaemic monitoring and control among high-risk patients with type 2 diabetes in Australian general practice during COVID-19

BACKGROUND

The COVID-19 pandemic disrupted general practice worldwide, primarily due to public health measures that restricted access to care for chronic diseases, such as type 2 diabetes. These measures disproportionately affected higher risk groups with type 2 diabetes, such as older people and those with obesity. This study aims to identify factors that may have influenced the rates of compliance with testing guidelines and target glycaemic control in Australian general practice settings during the COVID-19 pandemic.

METHODS

We used a serial cross-sectional study design of patient record data from general practices representative of the Nepean Blue Mountains Local Health District between 2020 and 2022. Aggregated patient records were analysed to determine percentages of subgroups with a blood glycaemic testing interval consistent with guidelines (≥1 within 15 months) and achieving target glycaemic control (by glycated haemoglobin of ≤7%). Linear regression models were used to test the association between independent and dependent variables, and to generate regression coefficients and 95% CI, corrected for time trends.

RESULTS

Of the average 14 356 patient records per month, 55% were male, 53% had a body mass index (BMI) <30 and 55% were aged 55-74 years. Compliance to testing guidelines slightly decreased (75-73%) but was positively associated with male sex (2.5%, 95% CI 1.7%, 3.4%), BMI≥30 (9.6%, 95% CI 8.8%, 10.4%) and 55-74 years (7.5%, 95% CI 6.6%, 8.5%) and 75 years and over age groups (7.1%, 95% CI 6.2%, 7.9%). Mean percentage of patient records achieving target glycaemic control slightly increased and was negatively associated with male sex (-3.7%, 95% CI -5.2%, -2.2%), but positively associated with 55-74 years (4.5%, 95% CI 3.8%, 5.1%) and 75 years and over age groups (12.2%, 95% CI 4.5%, 20.0%). Compliance to testing guidelines increased with each additional general practice per 10 000 persons (8.4%, 95% CI 4.9%, 11.8%).

CONCLUSIONS

During the COVID-19 pandemic, people with type 2 diabetes in Australia continued to follow glycaemic testing guidelines at the same rate. In fact, there was a slight improvement in glycaemic control among all subgroups of patients, including those at higher risk. These findings are encouraging, but the longer term impact of COVID-19 on type 2 diabetes care is still unclear.

Predictors of worse outcome after postponing non-emergency cardiac interventions during the COVID-19 pandemic

OBJECTIVE

Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalisation. This study aimed to identify predictors of worse clinical outcome after deferral of non-emergency cardiovascular interventions.

METHODS

This observational case-control study included consecutive patients whose non-emergency cardiac intervention has been postponed during COVID-19-related lockdown between 19 March and 30 April 2020 (n=193). Cox regression was performed to identify predictors of the combined 1-year end point emergency cardiovascular hospitalisation and death. All patients undergoing non-emergency interventions in the corresponding time period 2019 served as control group (n=216).

RESULTS

The combined end point of death and emergency cardiovascular hospitalisation occurred in 70 (36.3%) of 193 patients with a postponed cardiovascular intervention. The planned intervention was deferred by a median of 23 (19-36) days. Arterial hypertension (HR 2.27; 95% CI 1.00 to 5.12; p=0.049), chronic kidney disease (HR 1.89; 95% CI 1.03 to 3.49; p=0.041) as well as severe valvular heart disease (HR 3.08; 95% CI 1.68 to 5.64; p<0.001) were independent predictors of death or emergency hospitalisation. Kaplan-Maier estimators of the combined end point were 31% in patients with arterial hypertension, 56% in patients with severe valvular heart disease and 77% with both risk factors (HR 12.4, 95% CI 3.8 to 40.7; p<0.001) and only 9% in patients without these risk factors (log rank p<0.001). N-terminal pro-B-type natriuretic peptide (NT-proBNP) cut-point of ≥1109 pg/mL best predicts the occurrence of primary end point event in deferred patients (area under the curve 0.71; p<0.001; sensitivity 63.8%, specificity 69.4%).

CONCLUSION

Our results suggest that patients with either arterial hypertension, chronic kidney or severe valvular heart disease are at very high risk for emergency hospitalisation and increased mortality in case of postponed cardiac interventions even in supposed stable clinical status. Risk seems to be even higher in patients suffering from a combination of these conditions. If the ongoing or future pandemics force hospitals again to postpone cardiac interventions, the biomarker NT-proBNP is an applicable parameter for outpatient monitoring to identify those at risk for adverse cardiovascular events.

[Medical care in GP practices during the Covid-19 pandemic: A questionnaire-based survey among general practitioners and medical practice assistants asking for their opinion about changes, needs and burdens]

INTRODUCTION

The coronavirus pandemic did not only result in changes in the provision and utilization of health care services in general practice but also in an increased workload for physicians and medical practice assistants. The VeCo practice study retrospectively explores the experiences of both professional groups two years after the start of the pandemic.

METHODS

In March and April 2022, general practitioners and medical practice assistants in the three German federal states of Berlin, Brandenburg and Thuringia were asked to complete a paper-based questionnaire.

RESULTS

657 general practitioners and 762 medical practice assistants completed the questionnaire. Both professional groups agreed to statements indicating a reduction in regular health care provisions. Nevertheless, 74% of the physicians and 82.9% of the medical practice assistants considered the health care provided to their patients during the pandemic as good. This was only possible through considerable additional effort and stress. While more than half of both groups reported that work was still enjoyable, three quarters of both groups stated that the challenges arising from the pandemic outstripped their capacity. Both groups would like to receive more recognition from society (medical practice assistants 93.2%, general practitioners 85.3%) and from their patients (87.7% and 69.9%, respectively).

DISCUSSION

General practitioners and medical practice assistants reduced regular health care provision but were still able to maintain a good quality of care for their patients during the pandemic. It became clear that more appreciation and adequate financial compensation are necessary to ensure long-term sustainability of GP care.

CONCLUSION

The subjective view of general practitioners and medical practice assistants on their health care provision shows that appreciation and adequate financial renumeration, particularly when working under most difficult conditions, are necessary to increase the attractiveness of a career in general practice, for both physicians and medical practice assistants.

Association between patient-related factors and avoided consultations due to fear of COVID-19 during the first lockdown in northern Germany: Results of a cross-sectional observational study

Introduction

During the COVID-19 pandemic, many people were anxious about a coronavirus infection due to the high infection rate and the mortality risk associated with the disease. Fear of COVID-19 might have influenced patients’ utilisation of medical services, even if it meant that a postponed therapy had severe consequences. Our aims were to analyse (a) to what extent fear of COVID-19 contributes to forgone consultations, (b) if patient characteristics, health literacy and social support influence the effect of fear of COVID-19 on the utilisation behaviour and (c) whether interactions between these possible predictor variables are responsible for a higher extent of avoided consultations due to fear of COVID-19.

Methods

We conducted a retrospective, cross-sectional observational study in an emergency department. The study was based on personal standardized interviews of patients. The interviews took place between July 15 and August 5, 2020. Patients over the age of 18 were included if there was no urgent need for treatment on the day of the interview, no severe functional limitations, sufficient knowledge of German, ability to consent and health problems requiring treatment between March 13 and June 13, 2020. Differences between patient subgroups were described and analysed using the t-test and chi² test. Data were analysed by logistic regression including socio-demographic data, health literacy and social support assessed by standardised instruments. Additionally, we assessed interactions between possible predictor variables by a descriptive tree analysis.

Results

103 patients participated in personal standardized interviews. 46 patients (44.6%) reported that at least one necessary consultation did not take place in the observation period. Among those, 29 patients (63.0%) avoided consultations due to fear of COVID-19. Women had 3.36 times higher odds (95% confidence interval: 1.25 to 9.04, p = 0.017) for avoiding a consultation due to fear of COVID-19. There were no other statistically significant predictors in our analysis.

Discussion

Almost half of the required consultations did not take place. Avoidance of consultations needs to be closely monitored during the pandemic. Policy makers as well as health care providers should give consideration to the collateral effects of COVID-19 and COVID-19-related reactions of patients, especially women.

Conclusion

In the course of the COVID-19 pandemic, physicians should ensure that their patients take advantage of necessary consultations in order to avoid negative effects of a delayed examination or treatment. Particular attention should be paid to anxious female patients. Studies are needed to analyse the association between health literacy, social support and avoidance of consultations triggered by fear of COVID-19.

Differences between Rural and Urban Practices in the Response to the COVID-19 Pandemic: Outcomes from the PRICOV-19 Study in 38 Countries

This paper explores the differences between rural and urban practices in the response to the COVID-19 pandemic, emphasizing aspects such as management of patient flow, infection prevention and control, information processing, communication and collaboration. Using a cross-sectional design, data were collected through the online PRICOV-19 questionnaire sent to general practices in 38 countries. Rural practices in our sample were smaller than urban-based practices. They reported an above-average number of old and multimorbid patients and a below-average number of patients with a migrant background or financial problems. Rural practices were less likely to provide leaflets and information, but were more likely to have ceased using the waiting room or to have made structural changes to their waiting room and to have changed their prescribing practices in terms of patients attending the practices. They were less likely to perform video consultations or use electronic prescription methods. Our findings show the existence of certain issues that could impact patient safety in rural areas more than in urban areas due to the underlying differences in population profile and supports. These could be used to plan the organization of care for similar future pandemic situations.

Impact of COVID-19 on cardiovascular clinics: Are we ready for telemedicine?

Objective

The need for telemedicine was felt more than ever during the COVID-19 pandemic, which impacted health care worldwide. Therefore, this study aimed to determine the difficulties faced by patients in visiting the cardiac outpatient department during COVID-19, along with assessing the awareness and acceptability of telemedicine.

Methods

In this cross-sectional study, selected patients presenting to outpatient department of a tertiary care cardiac hospital were interviewed regarding the difficulties faced by patients in visiting the outpatient department during COVID-19 and their awareness and acceptability of telemedicine using a self-designed structured questionnaire.

Results

Of the 403 patients, 58.3% were male, the mean age was 53.04 ± 11.73 years, and most (77.7%) were urban residents. Ischemic heart disease was present in 69.5%, followed by hypertension (38.7%) and heart failure (29.3%). A total of 26.6% required emergency room visits. Limited appointments (55.6%) was the most common problem faced by patients during COVID-19, followed by financial issues (17.1%), fear of acquiring infection (13.4%), and limited mobility due to lockdown (22.6%). Only 12.2% were aware of telemedicine, 4.5% had previously used it, and 41.2% were willing to opt for telemedicine in the future. No internet access (39.2%) was the key barrier to the usage of telemedicine, followed by a lack of free medicine (39%) and a lack of a smart device (31.5%).

Conclusion

Limited appointments due to COVID-19 restrictions has made it difficult for patients to visit the clinics, which has led to increased emergency room visits. Telemedicine awareness was found to be limited; however, many patients were willing to adopt it provided their limitations could be overcome.

Changes in consultation mode during different phases of the COVID-19 pandemic in Croatian family medicine: a cross-sectional study

OBJECTIVES

To describe the changes in the type, length and reasons for consultations in primary healthcare during the COVID-19 pandemic in Croatia. This study aimed to test a hypothesis regarding the increased workload of general practitioners (GPs) by introducing more virtual consultations (VCs).

DESIGN

The study design was cross-sectional and comprised two phases: retrospective and prospective. The retrospective phase included data from April, May and June of 2019, 2020 and 2021, and the prospective phase included data from 2 weeks in June 2021. Additionally, the number, length and reasons for face-to-face consultations (FTFC), VCs and telephone consultations (TCs) with nurses were collected.

SETTING AND PARTICIPANTS

Overall, 6 GPs from different regions in Croatia with 10 125 enlisted patients.

MAIN OUTCOMES MEASURES

The retrospective phase compared data for consultation types obtained from electronic medical records. The prospective phase collected the number, length and reasons for FTFCs, VCs and TCs with nurses.

RESULTS

FTFCs decreased from 58.1% of the total number of visits in 2019 to 41.2% in 2020, while VC increased from 41.9% in 2019 to 58.8% in 2020. Furthermore, an eightfold increase in email consultations was recorded. The average lengths of an FTFC and TC were 7.13±3.38 and 4.01±2.09 min, respectively; FTFCs were significantly longer than TCs (t=7.038, p<0.0001). There was an increase in the total workload (9.4%) in 2021 compared with 2019.

CONCLUSION

Croatian GPs faced changes in work organisation along with increased workload during the pandemic. Despite the shortening of time in FTFCs, the workload has increased due to the increase in VCs. An appropriate legal framework should be implemented for this new form of consultation. Future research is needed to address the impact of these changes on healthcare quality.

COVID-19 Continues to Burden General Practitioners: Impact on Workload, Provision of Care, and Intention to Leave

General practitioners (GPs), already in a profession with a high workload, have been at the frontline of providing COVID-19-related healthcare in addition to routine care. Our study examined the impact of pandemic-related consultations and changes in practice organization on GPs' current workload and provision of healthcare in summer 2021 (May 2021-July 2021) and early 2022 (January 2022-February 2022). In total, 143 German GPs participated in an online survey in the summer of 2021. Of these, 51 GPs participated in the follow-up survey in 2022. Most GPs perceived an increase in consultation frequency, consultation times, and workload since the pandemic outbreak. Increased consultation times were related to the reduced provision of medical care to other patients with chronic diseases. More SARS-CoV-2 vaccination consultations were associated with reduced home visits, acute consultation times, and cancer screenings. A quarter of GPs considered leaving their job. Pandemic-related bureaucracy, restricted access to therapy and rehabilitation services specialized on COVID-19, unreliable vaccine deliveries, mandatory telematics-infrastructure implementation, and frequent changes in official regulations were the main reasons reported for dissatisfaction. Our results provide insights into how the pandemic continues to burden GPs' work routines and how better working conditions in times of high demand could be achieved in future pandemics.

Medical appointments and provision of medical care during the COVID-19 pandemic in Mainz, Germany

Previous evidence suggested that non-COVID-19-related medical care was reduced during the first wave of the COVID-19 pandemic, but it remained unclear whether or to which extent this effect lasted beyond the first wave, or existed in a longer time frame. Here, we consider questionnaire data of the Gutenberg-COVID-19 study together with pre-pandemic baseline data of the Gutenberg Health Study concerning the region around Mainz, Germany, to study the effects of the pandemic on the provision of medical care until April 2021. We observed that the proportion of cancelled medical appointments was low and that the fraction of participants with a medical appointment as an indicator for the number of appointments being made was in line with pre-pandemic levels. Appointments were more likely cancelled by the patient (rather than the provider), and more likely cancelled by medical specialists such as dentists or ophthalmologists (rather than GPs). In conclusion, we found some evidence that, at least with regard to realized appointments, the medical system and the provision of medical care were not harmed by the COVID-19 pandemic on a longer time scale.

Pediatricians' experiences of managing outpatient care during the COVID-19 pandemic: A qualitative study in Germany

Background

Pediatricians are important sources of information for parents regarding their children's health. During the COVID-19 pandemic, pediatricians faced a variety of challenges regarding information uptake and transfer to patients, practice organization and consultations for families. This qualitative study aimed at shedding light on German pediatricians' experiences of providing outpatient care during the first year of the pandemic.

Methods

We conducted 19 semi-structured, in-depth interviews with pediatricians in Germany from July 2020 to February 2021. All interviews were audio recorded, transcribed, pseudonymized, coded, and subjected to content analysis.

Results

Pediatricians felt able to keep up to date regarding COVID-19 regulations. However, staying informed was time consuming and onerous. Informing the patients was perceived as strenuous, especially when political decisions had not been officially communicated to pediatricians or if the recommendations were not supported by the professional judgment of the interviewees. Some felt that they were not taken seriously or adequately involved in political decisions. Parents were reported to consider pediatric practices as sources of information also for non-medical inquiries. Answering these questions was time consuming for the practice personnel and involved non-billable hours. Practices had to adapt their set-up and organization immediately to the new circumstances of the pandemic, which proved costly and laborious as well. Some changes in the organization of routine care, such as the separation of appointments for patients with acute infection from preventive appointments, were perceived as positive and effective by some study participants. Telephone and online consultations were established at the beginning of the pandemic and considered helpful for some situations, whereas for others these methods were deemed insufficient (e.g. for examinations of sick children). All pediatricians reported reduced utilization mainly due to a decline in acute infections. However, preventive medical check-ups and immunization appointments were reported to be mostly attended.

Conclusion

Positive experiences of reorganizing pediatric practice should be disseminated as "best practices" in order to improve future pediatric health services. Further research could show how some of these positive experiences in reorganizing care during the pandemic are to be maintained by pediatricians in the future.

General practitioner care in nursing homes during the first wave of the COVID-19 pandemic in Germany: a retrospective survey among nursing home managers

BACKGROUND

Though evidence on the detrimental impact of the COVID-19 pandemic in nursing homes is vast, research focusing on general practitioners' (GP) care during the pandemic in nursing homes is still scarce.

METHODS

A retrospective online survey among 1,010 nursing home managers in Germany was conducted during the first wave of the COVID-19 pandemic between November 2020 and February 2021. Associations between perceived deficits in GP care (routine and acute visits) and both general and COVID-19-related characteristics of nursing homes were analysed using multiple logistic regression analyses.

RESULTS

The majority of nursing home managers reported no deficits in GP care (routine visits, 84.3%; acute visits, 92.9%). Logistic regression analyses revealed that deficits in GP care (routine visits) were significantly associated with visiting restrictions for GPs and nursing home size. Small nursing homes (1-50 residents) were significantly more likely to report deficits in GP care (routine visits) compared to medium (51-100 residents) and large nursing homes (> 100 residents). Further, deficits in GP care (acute visits) were significantly associated with dementia as a focus of care and the burden of insufficient testing for SARS-CoV-2 among residents. Moreover, visiting restrictions for GPs were significantly associated with dementia as the focus of care and the COVID-19 incidence at the federal state level. Finally, COVID-19 cases in nursing homes were significantly associated with size of nursing homes, COVID-19-incidence on the federal state level and the burden of insufficient testing capacities for SARS-CoV-2 among residents.

CONCLUSION

We found structural factors associated with GP care deficits during the pandemic. New concepts for GP care should be implemented in pandemic preparedness plans to ensure high quality, consistent, and reliable GP care as well as effective infection prevention measures in nursing homes.

Consultation Management during the COVID-19 Pandemic: The Experience of Lithuanian Physicians

Crises in the medicine sector such as the COVID-19 pandemic encourage the search for effective solutions for the provision of health care services, when conventional face-to-face consultations may be difficult to deliver effectively due to contact restrictions. The main objective of this study was to investigate consultation management provided by physicians during the COVID-19 pandemic in Lithuania. The dependence of diagnostic testing and vaccination of patients on the socio-demographic characteristics of physicians was also assessed. An anonymous survey was carried out during the COVID-19 pandemic, between 21 June 2021 and 17 September 2021, involving 191 physicians (9% of the total population) working in family physician teams in Lithuania. Thirty-nine Lithuanian Primary Health Care Institutions (PHCIs) were selected for this study, of which 11 were public and 28 were private. Private and public PHCIs employed 31% and 63% of the respondents, respectively, and 6% of respondents worked at both types of institutions. Concerning telemedicine, the physician-respondents frequently provided consultations over the telephone (79.6%) and in-person (63.9%), but less so via the Internet, with the latter option never being used at all by 57.1% of the respondents. Whilst telephone consultations were frequently provided by Lithuanian physicians, only half of the respondents chose to provide services over the Internet. Private, smaller, and rural-based PHCIs should more actively offer viral diagnostics and vaccination services.

COVI-Prim international: Similarities and discrepancies in the way general practices from seven different countries coped with the COVID-19 pandemic

Objectives

General practitioners (GPs) are frequently patients' first point of contact with the healthcare system and play an important role in identifying, managing and monitoring cases. This study investigated the experiences of GPs from seven different countries in the early phases of the COVID-19 pandemic.

Design

International cross-sectional online survey.

Setting

General practitioners from Australia, Austria, Germany, Hungary, Italy, Slovenia and Switzerland.

Participants

Overall, 1,642 GPs completed the survey.

Main outcome measures

We focused on how well-prepared GPs were, their self-confidence and concerns, efforts to control the spread of the disease, patient contacts, information flow, testing procedures and protection of staff.

Results

GPs gave high ratings to their self-confidence (7.3, 95% CI 7.1-7.5) and their efforts to control the spread of the disease (7.2, 95% CI 7.0-7.3). A decrease in the number of patient contacts (5.7, 95% CI 5.4-5.9), the perception of risk (5.3 95% CI 4.9-5.6), the provision of information to GPs (4.9, 95% CI 4.6-5.2), their testing of suspected cases (3.7, 95% CI 3.4-3.9) and their preparedness to face a pandemic (mean: 3.5; 95% CI 3.2-3.7) were rated as moderate. GPs gave low ratings to their ability to protect staff (2.2 95% CI 1.9-2.4). Differences were identified in all dimensions except protection of staff, which was consistently low in all surveyed GPs and countries.

Conclusion

Although GPs in the different countries were confronted with the same pandemic, its impact on specific aspects differed. This partly reflected differences in health care systems and experience of recent pandemics. However, it also showed that the development of structured care plans in case of future infectious diseases requires the early involvement of primary care representatives.

Has the COVID-19 Pandemic Led to Changes in the Tasks of the Primary Care Workforce? An International Survey among General Practices in 38 Countries (PRICOV-19)

The COVID-19 pandemic has had a large and varying impact on primary care. This paper studies changes in the tasks of general practitioners (GPs) and associated staff during the COVID-19 pandemic. Data from the PRICOV-19 study of 5093 GPs in 38 countries were used. We constructed a scale for task changes and performed multilevel analyses. The scale was reliable at both GP and country level. Clustering of task changes at country level was considerable (25%). During the pandemic, staff members were more involved in giving information and recommendations to patients contacting the practice by phone, and they were more involved in triage. GPs took on additional responsibilities and were more involved in reaching out to patients. Problems due to staff absence, when dealt with internally, were related to more task changes. Task changes were larger in practices employing a wider range of professional groups. Whilst GPs were happy with the task changes in practices with more changes, they also felt the need for further training. A higher-than-average proportion of elderly people and people with a chronic condition in the practice were related to task changes. The number of infections in a country during the first wave of the pandemic was related to task changes. Other characteristics at country level were not associated with task changes. Future research on the sustainability of task changes after the pandemic is needed.

The long-term impact of the COVID-19 pandemic on primary and specialized care provision and disease recognition in Germany

Background

The COVID-19 pandemic and the imposed lockdowns severely affected routine care in general and specialized physician practices.

Objective

To describe the long-term impact of the COVID-19 pandemic on the physician services provision and disease recognition in German physician practices and perceived causes for the observed changes.

Design

Observational study based on medical record data and survey data of general practitioners and specialists' practices.

Participants

996 general practitioners (GPs) and 798 specialist practices, who documented 6.1 million treatment cases for medical record data analyses and 645 physicians for survey data analyses.

Main measures

Within the medical record data, consultations, specialist referrals, hospital admissions, and documented diagnoses were extracted for the pandemic (March 2020-September 2021) and compared to corresponding pre-pandemic months in 2019. The additional online survey was used to assess changes in practice management during the COVID-19 pandemic and physicians' perceived main causes of affected primary and specialized care provision.

Main results

Hospital admissions (GPs: -22% vs. specialists: -16%), specialist referrals (-6 vs. -3%) and recognized diseases (-9 vs. -8%) significantly decreased over the pandemic. GPs consultations initially decreased (2020: -7%) but compensated at the end of 2021 (+3%), while specialists' consultation did not (-2%). Physicians saw changes in patient behavior, like appointment cancellation, as the main cause of the decrease. Contrary to this, they also mentioned substantial modifications of practice management, like reduced (nursing) home visits (41%) and opening hours (40%), suspended checkups (43%), and delayed consultations for high-risk patients (71%).

Conclusion

The pandemic left its mark on primary and specialized healthcare provision and its utilization. Both patient behavior and organizational changes in practice management may have caused decreased and non-compensation of services. Evaluating the long-term effect on patient outcomes and identifying potential improvements are vital to better prepare for future pandemic waves.

Resilience of the primary health care system - German primary care practitioners' perspectives during the early COVID-19 pandemic

BACKGROUND

Primary care is a relevant pillar in managing not only individual, but also societal medical crises. The COVID-19 pandemic has demanded a rapid response from primary care with interventions in the health care system. The aim of this paper was to explore the responses of primary care practitioners (PCP) during the early COVID-19 pandemic and to analyze these with a view on the resilience of the primary health care system from the PCPs perspective.

METHODS

Shortly after the first COVID-19 wave (July-October 2020) n = 39, semi-structured telephone interviews were conducted with PCP in practices and at Corona contact points (CCP) in Baden-Wuerttemberg (Germany). Qualitative content analysis was applied, and the evolved categories were related to in a framework for resilience.

RESULTS

Primary care had an overall strong ability to adapt and show resilience, albeit with wide variance in speed and scope of the responses. When coping with uncertainty, the reasons given by PCPs in favor of opening a CCP mainly involved intrinsic motivation and self-initiative; the reasons against doing so were i.e. the lack of personal protective equipment, problems with space, and worries about organizational burden. A strong association existed between the establishment of a CCP and the use of resources (i.e. existing networks, personal protective equipment, exercising an office of professional political function). Our study predominantly found adaptive aspects for measures taken at medical practices and transformative aspects for setting up outpatient infection centers. PCPs played an important role in the coordination process (i.e. actively transferring knowledge, integration in crisis management teams, inclusion in regional strategic efforts) reaching a high level in the dimensions knowledge and legitimacy. The dimension interdependence repeatedly came into focus (i.e. working with stakeholders to open CCP, interacting among different types of primary care facilities, intersectoral interfaces). A need for regional capacity planning was visible at the time of the interviews.

CONCLUSIONS

The results can be used for practical and research-based institutional and capacity planning, for developing resilience in primary care and for augmentation by perspectives from other stakeholders in the primary health care system.

Underuse of primary healthcare in France during the COVID-19 epidemic in 2020 according to individual characteristics: a national observational study

Background

The organization of healthcare systems changed significantly during the COVID-19 pandemic. The impact on the use of primary care during various key periods in 2020 has been little studied.

Methods

Using individual data from the national health database, we compared the numbers of people with at least one consultation, deaths, the total number of consultations for the population of mainland France (64.3 million) and the mean number of consultations per person (differentiating between teleconsultations and consultations in person) between 2019 and 2020. We performed analyses by week, by lockdown period (March 17 to May 10, and October 30 to December 14 [less strict]), and for the entire year. Analyses were stratified for age, sex, deprivation index, epidemic level, and disease.

Results

During the first lockdown, 26% of the population consulted a general practitioner (GP) at least once (-34% relative to 2019), 7.4% consulted a nurse (-28%), 1.6% a physiotherapist (-80%), and 5% a dentist (-95%). For specialists, consultations were down 82% for ophthalmologists and 37% for psychiatrists. The deficit was smaller for specialties making significant use of teleconsultations. During the second lockdown, the number of consultations was close to that in 2019, except for GPs (-7%), pediatricians (-8%), and nurses (+ 39%). Nurses had already seen a smaller increase in weekly consultations during the summer, following their authorization to perform COVID-19 screening tests. The decrease in the annual number of consultations was largest for dentists (-17%), physiotherapists (-14%), and many specialists (approximately 10%). The mean number of consultations per person was slightly lower for the various specialties, particularly for nurses (15.1 vs. 18.6). The decrease in the number of consultations was largest for children and adolescents (GPs: -10%, dentists: -13%). A smaller decrease was observed for patients with chronic diseases and with increasing age. There were 9% excess deaths, mostly in individuals over 60 years of age.

Conclusions

There was a marked decrease in primary care consultations in France, especially during the first lockdown, despite strong teleconsultation activity, with differences according to age and healthcare profession. The impact of this decrease in care on morbidity and mortality merits further investigation.

TLC-Ag dressings: a prospective, multicentre study on 728 patients with wounds at risk of or with local infection

OBJECTIVE

This study aimed to evaluate the management of an unselected cohort of patients with wounds at risk of or with clinical signs of local infection, treated with two antimicrobial contact layers impregnated with silver (TLC-Ag healing matrix), under real-life conditions during the COVID-19 pandemic.

METHOD

A large, prospective, multicentre, observational study with two TLC-Ag dressings (UrgoTul Ag/Silver and UrgoTul Ag Lite Border, Laboratoires Urgo, France) was conducted in Germany between May 2020 and May 2021. The main outcomes included a description of the treated patients and their wound management, the changes in wound infection and wound healing outcomes over a maximum period of four weeks of treatment, as well as the overall clinical assessment of the performance, local tolerance and acceptability of dressings.

RESULTS

A total of 728 patients with wounds of various aetiologies and wound infection status were treated with the evaluated dressings in 39 centres for a mean duration of 26±19 days, with an intermediate visit conducted in 712 (97.8%) patients after a mean period of 12±9 days. At the initial visit, it was established that the majority of patients (60.4%) had a wound infection, while the remaining cohort presented first clinical signs of a local wound infection (25.1%) or were at risk of wound infection (13.2%) (unclear status in 1.2%). Throughout the study period, all the parameters of wound infection continuously decreased, resulting at the final visit in a reduction by 78.9% of the prevalence of local wound infections and by 72.0% of the clinical signs of wound infection, the most rapidly diminished clinical sign being wound deterioration. Concurrently, in terms of the healing process, 92.1% of the wounds healed or improved, 3.2% remained unchanged and 1.7% worsened (data missing for 3.0%), and an improvement of the periwound skin was reported in 65.7% of the patients. Overall, the two dressings were 'very well accepted' by the majority of patients, with no uncomfortable feeling at wearing and no pain at dressing removal, and were assessed by the physicians as 'very useful' in the majority of the cases with a 'very good' efficacy in terms of antimicrobial activity and promotion of the wound healing process. Similar results were reported regardless of the wound type treated or of the TLC-Ag dressing evaluated.

CONCLUSION

These results are consistent with previous clinical evidence on TLC-Ag dressings. They support the good efficacy, good tolerability and usefulness of these antimicrobial dressings in the management of patients with wounds at risk or with clinical signs of local infection, in association with appropriate standard of care.

Nationwide Initiation of Cardiovascular Risk Treatments During the COVID-19 Pandemic in France: Women on a Slippery Slope?

Objectives

This study examines the initiation of prescribed medication treatments for cardiovascular risk (antihypertensives, lipid-lowering drugs, oral anticoagulants in atrial fibrillation, and smoking cessation medications) during the COVID-19 pandemic in the French population.

Methods

For each year between 2017 and 2021, we used the French National Insurance Database to identify the number of people with at least one reimbursement for these medications but no reimbursement in the previous 12 months. We computed incidence rate ratios (IRRs) between 2017–2019 and, respectively 2020 and 2021 using Poisson regression adjusted for age and 2017–2019 time trends. We recorded the number of lipid profile blood tests, Holter electrocardiograms, and consultations with family physicians or cardiologists.

Results

In 2020, IRR significantly decreased for initiations of antihypertensives (−11.1%[CI95%, −11.4%;−10.8%]), lipid-lowering drugs (−5.2%[CI95%, −5.5%;−4.8%]), oral anticoagulants in atrial fibrillation (−8.6%[CI95%, −9.1%;−8.0%]), and smoking cessation medications (−50.9%[CI95%, −51.1%;−50.7%]) compared to 2017–2019. Larger decreases were found in women compared to men except for smoking cessation medications, with the sex difference increasing with age. Similar analyses comparing 2021 to 2017–2019 showed an increase in the initiation of lipid-lowering drugs (+ 11.6%[CI95%, 10.7%;12.5%]) but even lower rates for the other medications, particularly in women. In addition, the 2020 number of people visiting a family physician or cardiologist decreased by 8.4 and 7.4%. A higher decrease in these visits was observed in those over 65 years of age compared to those under 65 years of age. A greater use of teleconsultation was found in women.

Conclusion

The COVID-19 pandemic heavily impacted the initiation of medication treatments for cardiovascular risk in France, particularly in women and people over 65 years.

Impact of covid-19 on primary care contacts with children and young people aged 0-24 years in England; longitudinal trends study 2015-2020

Background: The NHS response to covid-19 altered provision and access to primary care. Aim: To examine the impact of covid-19 on general practitioner (GP) contacts with children and young people in England. Design and Setting: Longitudinal trends analysis using electronic health records from the Clinical Practice Research Datalink Aurum database. Methods: We included all children and young people younger than 25 years registered with a GP. We compared the number of total, remote and face-to-face contacts during the first UK lockdown (March to June 2020) with the mean contacts for comparable weeks from 2015 to 2019. Results: We examined 47 607 765 GP contacts with 4 307 120 million children and young people. GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1-14 had greater falls in total contacts (>50%) compared with infants and 15-24s. Face-to-face contacts fell by 88% with the greatest falls occurring among children aged 1-14 (> 90%). Remote contacts more than doubled, increasing most in infants (over 2.5 fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote, mitigating the total fall (31%). Conclusion: During the covid-19 pandemic, children and young people’s contact with GPs fell, particularly for face-to-face assessment. This may be explained by a lower prevalence of respiratory illnesses due to fewer social contacts and changing health care seeking behaviour. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions.

Internal dynamics within primary care teams in two Spanish regions during the COVID-19 pandemic: a qualitative study

BACKGROUND

Pandemics and epidemics have represented public health emergencies with severe consequences at a global level. Primary care teams have played a crucial role in disease surveillance and monitoring during the COVID-19 pandemic through early detection, contact tracing, and isolation of positive cases. The objective of this study was to explore the impact of the COVID-19 pandemic on primary care teams regarding their internal dynamics and their professional performance.

METHODS

Qualitative study carried out between July and December 2020 in two large central and southern Spanish regions (Castilla la Mancha and Madrid). Semi-structured interviews and focus groups were conducted with primary care workers. Data was analysed using thematic content analysis. Participants were accessed using purposive sampling.

RESULTS

A total of 53 primary care workers participated in the study, of which 38 were individually interviewed, and 15 participated in three focus groups.The analysis of their experiences revealed two main themes regarding the impact of the COVID-19 pandemic on primary care teams: 1) The need to reorganise traditional roles: Primary care settings closed their doors to the public and their workers restructured their roles to ensure the delivery of essential services; 2) The need to implement a new primary care delivery model: Each primary care team had to self-organise, making sure their reference population was cared for and developing resource optimisation strategies.

CONCLUSIONS

Primary care teams have quickly adapted their roles and internal dynamics to respond to the demands generated by COVID-19. In the new delivery model, some positive aspects could be highlighted - such as increased communication between professionals and the use of telemedicine for some cases. However, it is important to address the negative impact that the COVID-19 crisis has had on of the main functions of primary care. These measures are necessary to promote well-being in primary care teams, and to provide quality care that addresses the complex and individual needs of each person and reduces inequalities in healthcare delivery.

Intended healthcare utilisation in cases of severe COVID-19 and inflammatory gastrointestinal disease: results of a population survey with vignettes

OBJECTIVES

To examine variations in intended healthcare utilisation in severe cases of COVID-19 and inflammatory gastrointestinal disease (IGD).

DESIGN

Representative cross-sectional telephone survey.

SETTING AND PARTICIPANTS

1207 randomly drawn adults of the city of Hamburg, Germany, between November 2020 and January 2021.

OUTCOME MEASURES

Different vignettes with severe symptoms were presented varying in sex, age (child, middle-aged person, older person), daytime (Tuesday morning or Tuesday evening) and disease (COVID-19 or IGD), while the degree of urgency was equivalent for all cases. The respondents were asked for the intended healthcare utilisation resulting in three different alternatives: general practitioner (GP)/paediatrician, medical on-call service ('116117') and emergency care (accident and emergency department, emergency practice, rescue service). In multivariate analyses, associations of characteristics of the vignettes and participants (sex, age, education, migration background) with intended healthcare utilisation were tested. In a further step, analyses were conducted separately for IGD and COVID-19.

RESULTS

Regarding the vignettes' characteristics, intended utilisation of GP/paediatrician is associated with female sex, higher age, daytime (morning) and COVID-19 symptoms, the medical on-call service with male sex, daytime (evening) and COVID-19 symptoms and the emergency medicine with younger age, daytime (evening) and IGD. Women chose more often the GP/paediatrician, men preferred emergency medicine. Only in case of IGD, higher educated persons more often chose the medical on-call service while people with a migration background decided less often for medical on-call service and emergency medicine.

CONCLUSIONS

Despite comparable urgency, the findings suggest variations of intended healthcare utilisation depending on various characteristics of the vignettes and respondents. Depending on the type of disease inequalities vary. Overall, information about healthcare alternatives in severe cases has to be improved and clear pathways to facilitate healthcare utilisation has to be further developed.

Breakdown of Diabetic Foot Ulcer Care during the First Year of the Pandemic in Poland: A Retrospective National Cohort Study

The COVID-19 pandemic revealed a breakdown of the system of DFU patient care. This retrospective national cohort study analyses the epidemiological status of DFU patients in relation to urgent and elective hospitalizations, amputation rates, and deaths in Poland from 2017 to 2019, and during 2020 when the COVID-19 pandemic began. The data were obtained from national medical records gathered by the National Health Fund (NHF). Discharge diagnoses were categorized according to ICD-10 and ICD-9 codes. Analysis of the data showed a statistically significant decrease in elective hospital admissions (from 29.6% to 26.3%, p = 0.001). There was a decrease in the percentage of hospitalizations related to limb-salvage procedures (from 79.4% to 71.3%, p = 0.001). The opposite tendency was observed among urgent hospital admissions (from 67.0% to 73.2%, p = 0.01), which was related to a significant increase in the number of minor amputations (from 3146 to 4269, p = 0.017). This rise was in parallel with the increase in the percentage of patients who died during hospitalization due to DFU (from 3.9% to 4.8%, p = 0.03). The number of deaths has not changed significantly (from 590.7 to 668.0, p = 0.26). The results of the conducted analyses confirm the negative tendencies in the medical care of patients with DFU during the first year of the pandemic in Poland. Changes in therapy schemes and stronger patient support following this period are necessary to avoid further complications in patients with DFU.

Patients' Engagement in Early Detection of COVID-19 Symptoms: An Observational Study in the Very Early Peak of the Pandemic in Italy in 2020

COVID-19 exerted a strong impact on the Italian healthcare systems, which in turn resulted in a reduction in the citizens’ trust towards healthcare authorities. Moreover, the focused attention on the typical COVID-19 symptoms (fever, cough) has also impacted the social representation of health priorities, potentially reducing the perceived importance and severity of other symptoms. This study aimed to determine the association of general-practitioner (GP) contact with various symptoms during the COVID-19 pandemic in Cremona, an Italian city at the very epicentre of the pandemic. Between April and June 2020, an anonymous survey was completed by 2161 respondents. Logistic-regression analyses were used to examine the associations of GP contact with sociodemographic characteristics and the presence of symptoms. Of the 2161 respondents (43.5% female, 75.0% aged less than 55 years), 959 (44.4%) reported experiencing various symptoms and 33.3% contacted a GP. GP contact was significantly associated with poor appetite (OR, 2.42; 95% CI 1.63 to 3.62; p < 0.001), taste dysfunctions (OR 1.67; 95% CI 1.20 to 2.34; p < 0.001) and sleepiness during the day (OR 4.15; 95% CI 2.13 to 8.09; p = 0.002). None of the gastrointestinal symptoms resulted in significantly increasing the likelihood of contacting a GP. This study offers a unique observation of citizens’ attitudes and behaviours in early symptom communication/detection during the initial peak of the Italian COVID-19 pandemic.

COVID-19 Pandemic Impact on Orthopaedic Trauma Practice: A Global Perspective

BACKGROUND AND OBJECTIVE

We conducted a systematic review to evaluate the global impact on orthopaedic trauma admissions during the COVID-19 crisis and compare it to that in Saudi Arabia.

METHODS

We conducted an extensive search of the PubMed and the Cochrane Central Register of Clinical Trials databases for articles published on orthopaedic trauma during the pandemic. We used the terms "orthopaedic trauma", "coronavirus", "covid-19", and "Sars-cov-2" for the search. We retrieved data to assess the impact of COVID-19 on orthopaedic and trauma patients attending hospitals during the pandemic. Secondary outcomes included reports from various regions of the world, differences in patient age, gender, and comparison to the nonlockdown period. We excluded questionnaires, surveys, reviews, and meta-analyses. The studies were divided based on where they were conducted: the Americas; the United Kingdom; Europe; Asia; the Middle East; and Australia, including New Zealand.

RESULTS

We retrieved 763 studies using the keywords and initially analyzed 70. We chose 23 studies for final analysis, which were all retrospective studies, from which we extracted 50% of our preset data. These articles included 16,383 patients who sought advice related to orthopaedic and trauma necessities during the pandemic. Before the pandemic, 61,559 patients sought advice for orthopaedic and trauma necessities. Most of the reports focused on adults, and in three studies, researchers reported on paediatric on orthopaedic patients. The average decrease in patients seeking orthopaedic and trauma assistance during the pandemic was 45.5 ± 20.4 (range 18.9-86%, p < 0.001). The largest decrease in patients seeking advice occurred in Asia (>60%), and the lowest occurred in Australia and New Zealand (about 20%, p < 0.001).

CONCLUSION

Presentations of orthopaedic trauma during the COVID-19 during pandemic lockdown was less but not as profoundly as one may have expected.

Common Infections and Antibiotic Prescribing during the First Year of the COVID-19 Pandemic: A Primary Care-Based Observational Cohort Study

Presentation and antibiotic prescribing for common infectious disease episodes decreased substantially during the first COVID-19 pandemic wave in Dutch general practice. We set out to determine the course of these variables during the first pandemic year. We conducted a retrospective observational cohort study using routine health care data from the Julius General Practitioners’ Network. All patients registered in the pre-pandemic year (n = 425,129) and/or during the first pandemic year (n = 432,122) were included. Relative risks for the number of infectious disease episodes (respiratory tract/ear, urinary tract, gastrointestinal, and skin), in total and those treated with antibiotics, and proportions of episodes treated with antibiotics (prescription rates) were calculated. Compared to the pre-pandemic year, primary care presentation for common infections remained lower during the full first pandemic year (RR, 0.77; CI, 0.76–0.78), mainly attributed to a sustained decline in respiratory tract/ear and gastrointestinal infection episodes. Presentation for urinary tract and skin infection episodes declined during the first wave, but returned to pre-pandemic levels during the second and start of the third wave. Antibiotic prescription rates were lower during the full first pandemic year (24%) as compared to the pre-pandemic year (28%), mainly attributed to a 10% lower prescription rate for respiratory tract/ear infections; the latter was not accompanied by an increase in complications. The decline in primary care presentation for common infections during the full first COVID-19 pandemic year, together with lower prescription rates for respiratory tract/ear infections, resulted in a substantial reduction in antibiotic prescribing in Dutch primary care.

Healthcare professionals' perceptions of impacts of the Covid-19-pandemic on outpatient care in rural areas: a qualitative study

Background

Measures to manage the COVID-19 pandemic have led to impacts on healthcare systems and providers worldwide. Outpatient healthcare professionals (HCPs) provide the majority of patient care. Insight into their experiences during a pandemic is rare. Therefore, we explored how primary and secondary care HCPs in a rural area in Germany experienced their work during the pandemic and what health-related outcomes they perceived in their patients. In this context, we also examined the impact on access to and utilization of healthcare and working conditions.

Methods

We conducted a qualitative interview study with outpatient HCPs. We recruited by e-mail, telephone, professional networks and personal contacts. Data were collected between August 2020 and January 2021. All interviews were audio recorded, transcribed, and analysed using qualitative content analysis.

Results

Our sample consisted of 28 HCPs (15 family physicians, 7 cardiologists, and 6 non-physician assistants, 12 female) from Saxony-Anhalt, Germany. HCPs experienced fewer consultations as well as cancellations by hospitals and secondary care physicians, especially at the beginning of the Covid-19-pandemic, while they continued throughout to provide outpatient care. They quickly adopted changes in practice organisation and healthcare provision. There was a shift towards telephone consultations, home visits as well as unconventional consultations e.g. through the practice window. Family physicians used personal relationships to support utilization of healthcare and to avoid health-related effects. Social tension and burden seemed to interact with a perceived lack of preparedness, the pandemic-related changes in their working condition as well as access to and utilization of healthcare. Chronic disease monitoring was postponed, which could have consequences in the course of disease of patients. HCPs experienced effects on patients’ psychological well-being.

Conclusion

Our study demonstrates the impacts of Covid-19-pandemic on outpatient care in rural areas and emphasizes its importance. HCPs experienced impacts on access to and utilization of healthcare, working conditions and health-related outcomes. Health policy should create a framework for healthcare to support outpatient care in rural areas with a looming undersupply of primary and secondary care in order to maintain healthcare and reduce pandemic impacts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07261-y.

The impact of the COVID-19 pandemic on autoimmune diagnostics in Europe: A lesson to be learned

INTRODUCTION

The first wave of COVID-19 pandemic has disrupted almost all areas of the health care services to some extent throughout the world. Although the negative impact of COVID-19 on patients with autoimmune diseases has also been recognized, available data in this regard are limited. In the current study of the European Autoimmunity Standardisation Initiative (EASI) we aimed to provide reliable data on the extent of the impact of COVID-19 pandemic on test requests for different autoantibodies in European countries.

METHODS

Data on test numbers and on the number of positive results were collected in 97 clinical laboratories from 15 European countries on a monthly basis for the year before (2019) and the year during (2020) the COVID-19 pandemic.

RESULTS

A reduction in the number of autoantibody tests was observed in all European countries in the year 2020 compared to 2019. The reduction affected all autoantibody tests with an overall decrease of 13%, ranging from 1.4% (Switzerland) to 25.5% (Greece). In all countries, the decrease was most pronounced during the first wave of the pandemic (March-May 2020) with an overall decrease in those three months of 45.2%. The most affected autoantibodies were those commonly requested by general practitioners (anti-tTG IgA (-71%), RF IgM (-66%) and ACPA (-61%)). In the second wave of the pandemic (October-December 2020) the decrease was less pronounced (6.8%). With respect to the rate of positive results, subtle differences were observed for distinct autoantibodies during the pandemic, but the total rate of positive results was similar in both years.

CONCLUSIONS

Our study demonstrated a strong decrease in autoantibody requests during the first wave of the COVID-19 pandemic in 15 European countries. The second wave was characterized by a less pronounced impact, with some participating countries hardly affected, while some other countries experienced a second decline. The decrease was clearly associated with the level of lock-down and with the required adjustments in the health care systems in different countries, supporting the importance of an effective strategy for the coordination of autoimmune testing in challenging situations as the COVID-19 pandemic.

Pandemic-related impairment in the monitoring of patients with hypertension and diabetes and the development of a digital solution for the community health worker: quasi-experimental and implementation study (Preprint)

Background

The restrictions imposed by the COVID-19 pandemic reduced health service access by patients with chronic diseases. The discontinuity of care is a cause of great concern, mainly in vulnerable regions.

Objective

This study aimed to assess the impact of the COVID-19 pandemic on people with hypertension and diabetes mellitus (DM) regarding the frequency of consultations and whether their disease was kept under control. The study also aimed to develop and implement a digital solution to improve monitoring at home.

Methods

This is a multimethodological study. A quasiexperimental evaluation assessed the impact of the pandemic on the frequency of consultations and control of patients with hypertension and DM in 34 primary health care centers in 10 municipalities. Then, an implementation study developed an app with a decision support system (DSS) for community health workers (CHWs) to identify and address at-risk patients with uncontrolled hypertension or DM. An expert panel assessment evaluated feasibility, usability, and utility of the software.

Results

Of 5070 patients, 4810 (94.87%) had hypertension, 1371 (27.04%) had DM, and 1111 (21.91%) had both diseases. There was a significant reduction in the weekly number of consultations (107, IQR 60.0-153.0 before vs 20.0, IQR 7.0-29.0 after social restriction; P<.001). Only 15.23% (772/5070) of all patients returned for a consultation during the pandemic. Individuals with hypertension had lower systolic (120.0, IQR 120.0-140.0 mm Hg) and diastolic (80.0, IQR 80.0-80.0 mm Hg) blood pressure than those who did not return (130.0, IQR 120.0-140.0 mm Hg and 80.0, IQR 80.0-90.0 mm Hg, respectively; P<.001). Also, those who returned had a higher proportion of controlled hypertension (64.3% vs 52.8%). For DM, there were no differences in glycohemoglobin levels. Concerning the DSS, the experts agreed that the CHWs can easily incorporate it into their routines and the app can identify patients at risk and improve treatment.

Conclusions

The COVID-19 pandemic caused a significant drop in the number of consultations for patients with hypertension and DM in primary care. A DSS for CHW has proved to be feasible, useful, and easily incorporated into their routines.

Factors influencing access and utilization of health services among older people during the COVID - 19 pandemic: a scoping review

BACKGROUND

Access to healthcare and service utilization are both considered essential factors for improving the general health and wellbeing of older people, especially at the time of COVID-19 pandemic. The aim of the study is to explore factors affecting healthcare access and health service utilization for older people during the pandemic.

METHODS

PubMed, Web of Science, Scopus and Embase were systematically searched for relevant articles. Access, utilization, health, elderly and COVID-19 were used as keywords in the search strategy. A total of 4308 articles were identified through the initial database search; 50 articles were included in the review as passing the eligibility criteria. The searches were conducted up to August 2021. Data extraction was performed, and evidence was descriptively illustrated. Thematic analysis was used to explore factors influencing the elderly's access and utilization of healthcare services, using Max QDA10, a qualitative analysis software.

RESULTS

Among articles included in the review (n = 50), a majority of the studies were from the United States (36%), followed by India (8%). According to the main healthcare services, a large number of articles (18%) were related to mental health services, followed by digital health services (16%). Factors were identified at an individual, provider and systems level. Seven main themes emerged from the thematic analysis, as determinants of elderly's access and utilization of healthcare services during COVID-19 pandemic. These included: access to non-COVID related services, access to COVID-related services, literacy and education, accommodation challenges, perceived attitudes of aging, and policies and structures, and social determinants.

CONCLUSION

Mental health and digital health services were identified as major issues influencing or contributing to or influencing older people's health during the COVID-19 pandemic. We also argue on the importance of a rounded view, as attention to a range of factors is vital for policy decisions towards sustainable care and equitable interventions for improving the health of older people.