Capacity and adaptations of general practice during an influenza pandemic

Impact of the Swine flu pandemic on General Practitioner (GP) visits in Finland: sex and age differences

BACKGROUND

Swine flu might serve as a model for challenges that primary care faces during pandemics. This study examined changes in the numbers and diagnoses of general practitioner (GP) visits during and after the Swine flu pandemic in Vantaa, a Finnish city, and how GP activities recovered after the pandemic. Putative sex and age group differences were also evaluated.

METHODS

The study was an observational retrospective study. The monthly number of patient visits to primary care GPs by women and men in age groups 0-19, 20-64 and 65 + years was recorded before, during and two years after the Swine flu pandemic. The recorded diagnoses were also examined. The investigation period was from 2008 to 2012.

RESULTS

The numbers of monthly visits to primary care decreased from 12 324 (mean) to 10 817 in women and from 8563 to 7612 in men during the first six months of the Swine flu, returning to the original level afterwards. This decrease was thus slightly more prominent in women. However, as the size of the population increased during the follow-up period, the actual number of GP visits adjusted for the size of population remained at a decreased level for two years after the Swine flu. This decrease was observed especially in office-hours visits of men (from 3692 to 3260) and women (from 6301 to 5428) of 20-64 years. Swine flu did not alter the number of visits to the primary care Emergency Department. The proportion of visits with diagnostic recordings of common infectious diseases mostly decreased during the Swine flu. Only a minor impact on the distribution of recordings of chronic diagnoses was found.

CONCLUSION

A pandemic, such as Swine flu, may decrease office-hours visits to primary care GPs. This in turn may lead to activities of primary care being adjusted downward for a long time following the pandemic. Especially the age group 20-64 years may be affected. This risk should be considered when recovery from the COVID-19 pandemic begins. Swine flu did not affect the proportion of consultations of chronic diseases, but the number of diagnoses of common infectious diseases had diminished.

Parental Concerns for Children With Cold-like Symptoms With Reduced Access to Evaluation in Primary Care Settings During the COVID-19 Pandemic: A Qualitative Study

INTRODUCTION

We aimed to explore the concerns of parents when their children had symptoms of infection during the COVID-19 pandemic.

METHOD

Two Norwegian internet forums were searched for parents' experiences when their children had upper respiratory infection symptoms in 2020-2021. A total of 197 posts were included and analyzed using thematic analysis.

RESULTS

Parents described COVID-19-related and general worries regarding their children with upper respiratory infection symptoms. The first theme, "It is not 'just a cold' during the pandemic," captures how infection control measures influenced parents' concerns. The second theme, "Concerns and consequences of fever and cold symptoms," describes general parental worries. Varying levels of worries regarding health care services, limitations of family life, and concerns for relatives were highlighted.

DISCUSSION

Knowledge of parents' concerns about cold symptoms may help primary health care providers target individual patient counseling and provide background information when policymakers develop information material for infection prevention and treatment.

Extended access to general practice services during weekends in the first wave of the COVID-19 pandemic

OBJECTIVE

The incidence, symptoms, and trajectories of COVID-19 in the community were unknown in the early phase of the pandemic. Consequently, organizing a primary health care response was challenging. The aim of this study was to investigate whether reorganizing general practice services with extended weekend access for patients was feasible, and to assess the extent to which patients used this service.

DESIGN

Observational study with registration after a simple intervention.

SETTING

General practice services in the second half of March 2020 when the first wave of the COVID-19 pandemic hit Bergen, the second largest city in Norway.

SUBJECTS

All general practices in Bergen were asked to be available during weekends for their patients with respiratory tract infections (RTIs), by telephone, video-, or e-consultation.

MAIN OUTCOME MEASURES

Number of practices participating, patients connected to these practices, and consultations for RTIs and suspected COVID-19.

RESULTS

During the first weekend, 33 of 71 practices (45%) covering 51% of the population participated. The following weekend this increased to 39 practices (53%) covering 64% of the population. The first weekend 25 practices reported a total of 336 consultations for RTIs, eight of which were for confirmed and 113 were for suspected COVID-19. The corresponding numbers reported from 23 practices the second weekend were 158 RTI consultations, four for confirmed and 41 for suspected COVID-19.

CONCLUSIONS

On short notice about half the practices in Bergen were made accessible during weekends for their patients with RTIs. The number of consultations per practice was small, but combined this amounted to a substantial improvement in the emergency services.

Primary care gatekeeping during the COVID-19 pandemic: a survey of 1234 Norwegian regular GPs

BACKGROUND

In the Nordic healthcare systems, GPs regulate access to secondary health services as gatekeepers. Limited knowledge exists about the gatekeeper role of GPs during public health crises seen from the perspective of GPs.

AIM

To document GPs' gatekeeper role and organisational changes during the initial COVID-19 lockdown in Norway.

DESIGN & SETTING

A cross-sectional online survey was addressed to all regular Norwegian GPs (n = 4858) during pandemic lockdown in spring 2020.

METHOD

Each GP documented how patients with potential COVID-19 disease were triaged and handled during a full regular workday. The survey also covered workload, organisational changes, and views on advice given by the authorities.

RESULTS

A total of 1234 (25.4%) of Norway's GPs participated. Together, they documented nearly 18 000 consultations, of which 65% were performed digitally (video, text, and telephone). Suspected COVID-19 symptoms were reported in 11% of the consultations. Nearly all these patients were managed in primary care, either in regular GP offices (55.7%) or GP-run municipal respiratory clinics (40.7%), while 3.7% (n = 73) were admitted to hospitals. The GPs proactively contacted an average of 0.8 at-risk patients per day. While 84% were satisfied with the information provided by the medical authorities, only 20% were able to reorganise their practice in accordance with national recommendations.

CONCLUSION

During the early stage of the COVID-19 pandemic in Norway, the vast majority of patients with COVID-19-suspected symptoms were handled in primary care. This is likely to have protected secondary health services from potentially detrimental exposure to contagion and breakdown of capacity limits.

The impact on primary care of a large waterborne campylobacter outbreak in Norway: a controlled observational study

OBJECTIVE

Document the impact of an outbreak of gastroenteritis on local primary health care services, compared to a control period.

DESIGN

Controlled observational study with data from the outbreak and a control period. Data obtained from electronic medical records (EMR) of general practitioners (GPs) and the out-of-hours (OOH) service. Telephone data from the OOH service's telephone records.

SETTING

Campylobacteriosis outbreak in Askøy municipality, Norway in 2019. Over 2000 individuals were infected.

SUBJECTS

Patients in contact with GPs and the OOH service during the outbreak and a control period.

MAIN OUTCOME MEASURES

Patient contacts with GPs and the OOH service during the outbreak and a control period.

RESULTS

There was a 36% increase in contacts during the outbreak compared to the control period (4798 vs. 3528), with the OOH service handling 78% of outbreak-related contacts. Telephone advice was the dominant method for managing the increase in contacts to primary care, both in OOH services and daytime general practice (OR 3.73 CI: [3.24-4.28]). Children aged 0-4 years had increased use of primary care during the outbreak (OR 1.51 CI: [1.28-1.78]). GPs referred 25% and OOH services referred 75% of 70 hospitalized cases.

CONCLUSION

The OOH service handled most of the patients during the outbreak, with support from daytime general practice. The outbreak caused a shift towards telephone advice as a means of providing care. Young children significantly increased their use of primary care during the outbreak.

The association between municipal pandemic response and COVID-19 contacts to emergency primary health care services: an observational study

BACKGROUND

Norwegian municipalities had diverse strategies for handling tasks related to the COVID-19 pandemic. The emergency primary health care services were involved to different extents. The aim of this study was to describe how contacts with the emergency primary health care service were affected by the pandemic, in terms of patient contacts related to COVID-19, prioritisation and first actions taken, and to analyse differences between the services.

METHODS

In this observational study, patient contacts to seven emergency primary health care services, from January 2020 to June 2021, were analysed. Descriptive analyses were applied. Data on the seven services' involvement in the municipal pandemic response, in relation to testing the inhabitants for COVID-19, were collected.

RESULTS

There were 145 685 registered patient contacts within the study period. In total, 24% (n = 35,563) of the contacts were related to COVID-19, varying from 16 to 40% between the seven services. Of the COVID-19 related contacts, 96% (n = 34,069) were triaged to the lowest urgency level (range 76-99%) and 66% (n = 23,519) were patients contacting the services in order to be tested for COVID-19 (range 5-88%). The number of COVID-19 related contacts were unrelated to the number of confirmed COVID-19 cases among the inhabitants of the respective municipalities. The burden of COVID-19-related contacts mainly reflected the services' involvement in COVID-19 testing as part of the municipal pandemic response.

CONCLUSIONS

During the COVID-19 pandemic, several of the emergency primary health care services were assigned new tasks, such as being part of the municipalities' system for carrying out testing for COVID-19. This had a major impact on their activity level. In the preparation for future pandemics, it should be discussed to which extent such use of the emergency primary health care system is appropriate, as additional tasks might affect the services' preparedness to provide urgent medical care among the inhabitants.

Pandemic preparedness and management in European out-of-hours primary care services - a descriptive study

BACKGROUND

Primary care is the first point of contact for all acute health problems. As such, primary care was at the frontline in the COVID-19 pandemic, playing a significant role in clinical responses and information to the public. This study aimed to describe the variations in patient management strategies used in the out-of-hours services in different European countries during the first phase of the pandemic.

METHOD

We conducted a cross-sectional web-based survey in August 2020, selecting key informants from European countries using European networks. The questionnaire was developed in collaboration with researchers in the field of out-of-hours primary care. We performed descriptive analyses per region, structuring results into themes.

RESULTS

Key informants from 38 regions in 20 European countries responded. Seven regions reported that their out-of-hours services had a pandemic preparedness plan, three had trained on the plan, and two had stockpiles of personal protection equipment before the outbreak. Extension of telephone triage lines and establishment of local infection-control teams and clinics were the main patient management strategies. Other strategies for patient contacts were also used in the regions, such as video-consultations (13 regions), electronic consultations (21 regions), patient's car as alternative waiting room (19 regions), outside tents for testing (24 regions), "drive-through" testing (26 regions), and separate departments for infected patients (14 regions).

CONCLUSION

Few out-of-hours services were well prepared for a pandemic, but all expanded and reorganized rapidly, adopting new strategies for patient management and treatment. The results could be useful for planning of organization preparedness of out-of-hours primary care service for future pandemics.

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study

OBJECTIVE

When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change.

DESIGN

Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September-December 2020, the second round from January-April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2-4 months apart. To analyze the data, we used thematic analysis.

RESULTS

The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal.

CONCLUSIONS

Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response.Key PointsFacing the COVID-19 pandemic, the primary health care service in Norway had to reorganize to ensure safe patient treatment and maintain infection control.Several GPs experienced challenges in collaboration with the municipalities.There is a need for clarification of responsibilities between GPs and the municipality.

Preparedness and management during the first phase of the COVID-19 outbreak - a survey among emergency primary care services in Norway

BACKGROUND

The emergency primary care (EPC) services in Norway have been at the frontline of the COVID-19 pandemic. Knowledge about the EPC services' management of the COVID-19 outbreak can be used to prepare for future outbreaks and improve patient management. The objectives of this study were to identify pandemic preparedness and management strategies in EPC centres in Norway during the COVID-19 outbreak.

METHODS

Questions regarding patient management of the COVID-19 outbreak were included in data collection for the National Out-Of-Hours Services Registry. The data collection was web-based, and an invitation was sent by email to the managers of all EPC services in Norway in June 2020. The EPC services were asked questions about pre-pandemic preparedness, access to personal protective equipment (PPE), organizational measures taken, and how staffing was organized during the onset of the pandemic.

RESULTS

There were 169 municipal and inter-municipal EPC services in Norway in 2020, and all responded to the questionnaire. Among the EPC services, 66.7% (n = 112) had a pandemic plan, but only 4.2% had performed training for pandemic preparedness. Further, fewer than half of the EPC centres (47.5%) had access to supplies of PPE, and 92.8% answered that they needed extra supplies of PPE. 75.3% of the EPC services established one or more respiratory clinics. Staffing with other personnel than usual was done in 44.6% (n = 74) of the EPC services. All EPC services except one implemented new strategies for assessing patients, while about half of the wards implemented new strategies for responding to emergency calls. None of the largest EPC services experienced that their pandemic plan was adequate, while 13.3% of the medium-sized EPC services and 48.9% of the small EPC services reported having an adequate pandemic plan.

CONCLUSIONS

Even though the EPC services lacked well-tested plans and had insufficient supplies of PPE at the outbreak of the COVID-19 pandemic, most services adapted to the pandemic by altering the ways they worked and by hiring health care professionals from other disciplines. These observations may help decision makers plan for future pandemics.

Respiratory tract infections in Norwegian primary care 2006-2015: a registry-based study

OBJECTIVE

Examine characteristics and time trends of respiratory tract infection (RTI) consultations in Norwegian primary care and compare consultations in daytime general practice and out-of-hours (OOH) services.

DESIGN

Registry-based study using reimbursement claims data.

SETTING

All in-person primary care consultations during 2006-2015.

PATIENTS

All patients visiting primary care during the study period.

MAIN OUTCOME MEASURES

The main outcome variable was RTI consultations. Differences regarding service type (general practice or OOH services) and changes over time were investigated. We report associations with patient age and sex, season, point-of-care C-reactive protein (CRP) test use, and sickness certificate issuing.

RESULTS

RTI consultations (n = 16 304 777) represented 11.6% of all consultations (N = 140 199 637) in primary care over the ten-year period. The annual number of RTI consultations per 1000 inhabitants decreased from 335 to 314, while the number of consultations for any reason increased. Of RTI consultations, 83.2% occurred in general practice. OOH services had a higher proportion of RTI consultations (21.4%) compared with general practice (10.6%). Young children (0-4 years) represented 18.9% of all patients in RTI consultations. CRP testing was used in 56.2% of RTI consultations, and use increased over time. Sickness certificates were issued in 31.9% of RTI consultations with patients of working age (20-67 years).

CONCLUSION

Most RTI consultations occurred in general practice, although the proportion was higher in OOH services. Laboratory testing and/or issuing of sickness certificates were part of most consultations. This could be an important reason for seeking health care. Key PointsPatients with a respiratory tract infection (RTI) are mostly managed in primary care, where they represent much of the workload.Most consultations for RTIs took place in daytime general practice, but out-of-hours services had a higher proportion of RTI consultations.RTIs were the dominating reason for encounter among young children both in out-of-hours services and daytime general practice.CRP tests were used in over half of RTI consultations, and their use expanded over time.

COVI-Prim survey: Challenges for Austrian and German general practitioners during initial phase of COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) represents a significant challenge to health care systems around the world. A well-functioning primary care system is crucial in epidemic situations as it plays an important role in the development of a system-wide response.

METHODS

2,187 Austrian and German GPs answered an internet survey on preparedness, testing, staff protection, perception of risk, self-confidence, a decrease in the number of patient contacts, and efforts to control the spread of the virus in the practice during the early phase of the COVID-pandemic (3rd to 30th April).

RESULTS

The completion rate of the questionnaire was high (90.9%). GPs gave low ratings to their preparedness for a pandemic, testing of suspected cases and efforts to protect staff. The provision of information to GPs and the perception of risk were rated as moderate. On the other hand, the participants rated their self-confidence, a decrease in patient contacts and their efforts to control the spread of the disease highly.

CONCLUSION

Primary care is an important resource for dealing with a pandemic like COVID-19. The workforce is confident and willing to take an active role, but needs to be provided with the appropriate surrounding conditions. This will require that certain conditions are met.

REGISTRATION

Trial registration at the German Clinical Trials Register: DRKS00021231.

Health workforce surge capacity during the COVID‐19 pandemic and other global respiratory disease outbreaks: A systematic review of health system requirements and responses

Health system decision‐makers need comprehensive evidence to mitigate surges in the demand for human resources for health (HRH) during infectious disease outbreaks. This study aimed to assess the state of the evidence on policy and planning responses to HRH surge capacity during the coronavirus disease (COVID‐19) pandemic and other viral respiratory disease outbreaks of global significance in the 21st century. We systematically searched eight bibliographic databases to extract primary research articles published between January 2000 and June 2020 capturing temporal changes in health workforce requirements and responses surrounding respiratory virus pandemics. Following the Preferred Reporting Items for Systematic Reviews and Meta‐analyses standard, 16 studies met our inclusion criteria. Five focused on COVID‐19, three on H1N1, and eight modelled a hypothetical pandemic. Investigations of different training, mobilization, and redeployment options to address pandemic‐time health system capacity were reviewed; however, few scenarios drew on observational HRH data, and heterogeneity of study approaches and outcomes generally precluded comparability across contexts. Notable evidence gaps included occupational and psychosocial factors affecting healthcare workers' absenteeism and risk of burnout, gendered considerations of HRH capacity, evaluations in low‐ and lower‐middle income countries, and policy‐actionable assessments to inform post‐pandemic recovery and sustainability of services for noncommunicable disease management.

Increasing workload in Norwegian general practice - a qualitative study

Background

General practitioners (GPs) play a key role in securing and coordinating appropriate use of healthcare services, by providing primary and preventive healthcare and by acting as gatekeepers for secondary healthcare services. Historically, European GPs have reported high job satisfaction, attributed to high autonomy and good compatibility with family life. However, a trend of increasing workload in general practice has been seen in several European countries, including Norway, leading to recruitment problems and concerns about the well-being of both GPs and patients. This qualitative interview study with GPs and their co-workers aims to explore how they perceive and tackle their workload, and their experiences and reflections regarding explanations for and consequences of increased workload in Norwegian general practice.

Methods

We conducted seven focus groups and four individual interviews with GPs and their co-workers in seven GPs’ offices in Mid-Norway: three in rural locations and four in urban locations. Our study population consisted of 21 female and 12 male participants; 23 were GPs and 10 were co-workers. The interviews were analysed using systematic text condensation.

Results

The analysis identified three main themes: (1) Heavy and increasing workload – more trend than fluctuation?; (2) Explanations for high workload; (3) Consequences of high workload. Our findings show that both GPs and their co-workers experience heavy and increasing workload. The suggested explanations varied considerably among the GPs, but the most commonly cited reasons were legislative changes, increased bureaucracy related to documentation and management of a practice, and changes in patients’ expectations and help-seeking behaviour. Potential consequences were also perceived as varying, especially regarding consequences for patients and the healthcare system. The participants expressed concerns for the future, particularly in regards to GPs’ health and motivation, as well as the recruitment of new GPs.

Conclusions

This study found heavy and increasing workload in general practice in Norway. The explanations appear to be multi-faceted and many are difficult to reverse. The GPs expressed worries that they will not be able to provide the population with the expected care and services in the future.

Pandemic influenza and subsequent risk of type 1 diabetes: a nationwide cohort study

AIMS/HYPOTHESIS

Case reports have linked influenza infections to the development of type 1 diabetes. We investigated whether pandemic and seasonal influenza infections were associated with subsequent increased risk of type 1 diabetes.

METHODS

In this population-based registry study, we linked individual-level data from national health registries for the entire Norwegian population under the age of 30 years for the years 2006-2014 (2.5 million individuals). Data were obtained from the National Registry (population data), the Norwegian Patient Registry (data on inpatient and outpatient specialist care), the Primary Care Database, the Norwegian Prescription Database and the Norwegian Surveillance System for Communicable Diseases. Pandemic influenza was defined as either a clinical influenza diagnosis during the main pandemic period or a laboratory-confirmed test. Seasonal influenza was defined by a clinical diagnosis of influenza between 2006 and 2014. We used Cox regression to estimate HRs for new-onset type 1 diabetes after an influenza infection, adjusted for year of birth, sex, place of birth and education.

RESULTS

The adjusted HR for type 1 diabetes after pandemic influenza infection was 1.19 (95% CI 0.97, 1.46). In the subgroup with laboratory-confirmed influenza A (H1N1), influenza was associated with a twofold higher risk of subsequent type 1 diabetes before age 30 years (adjusted HR: 2.26, 95% CI 1.51, 3.38).

CONCLUSIONS/INTERPRETATION

Overall, we could not demonstrate a clear association between clinically reported pandemic influenza infection and incident type 1 diabetes. However, we found a twofold excess of incident diabetes in the subgroup with laboratory-confirmed pandemic influenza A (H1N1).

Point-of-care testing with CRP in primary care: a registry-based observational study from Norway

Background

Norwegian primary health care is maintained on the regular general practitioners (RGPs), GP’s contracted to the municipalities in a list patient system, working at daytime and at out-of-hours services (OOH services). Respiratory disease is most prevalent during OOH services, and in more than 50 % of the consultations, a CRP test is performed. Children in particular have a high consultation rate, and the CRP test is frequently conducted, but the contributing factors behind its frequent use are not known. This study compares the RGPs rate of CRP use at daytime and OOH in consultations with children and how this rate is influenced by characteristics of the RGPs.

Methods

A cross-sectional register study was conducted based on all (N = 2 552 600) electronic compensation claims from consultations with children ≤ 5 year during the period 2009–2011 from primary health care. Consultation rates and CRP use were estimated and analysed using descriptive methods. Being among the 20 % of RGPs with the highest rate of CRP use at daytime or OOH was an outcome measure in regression analyses using RGP-, and RGP list characteristics as explanatory variables.

Results

One third of all RGPs work regularly in OOH services, and they use CRP 1.42 times more frequently in consultations with children in OOH services than in daytime services even when the distribution of diagnosis according to ICPC-2 chapters is similar. Not being approved specialist, have a large number at their patient-lists but relatively few children on their list and a large number of consultations with children were significantly associated with frequent use of CRP in daytime services. The predictors for frequent CRP use in OOH services were being a young doctor, having many consultations with children during OOH and a frequent use of CRP in daytime services.

Conclusions

The increase in the frequency of CRP test use from daytime to OOH occurs in general for RGPs and for all most used diagnoses. The RGPs who use the CRP test most frequently in their daytime practice have the highest rate of CRP in OOH services.

Primary care utilization among patients with influenza during the 2009 pandemic. Does risk for severe influenza disease or prior contact with the general practitioner have any influence?

BACKGROUND

Little is known about how patients belonging to risk groups for influenza used the primary care system during the influenza pandemic.

AIMS

To investigate the use of general practice and out-of-hours (OOH) services in patients with influenza-like illness (ILI) according to (i) risk for severe influenza disease and (ii) the number of regular general practitioner (GP) visits before the pandemic.

METHOD

Observational study of all ILI patients during the 2009 pandemic. Data were recorded prospectively and collected after the pandemic. Patients at risk were identified during an 18-month period by diagnoses from GPs' billing claims. Associations between risk factors for severe influenza disease and utilization of primary care were analysed using bivariate and multivariate regression analyses. Similar analyses were used for the association between number of GP visits before the pandemic and the primary care utilization during the pandemic.

RESULTS

ILI patients who were pregnant [odds ratio (OR) 1.70; 95% confidence interval (CI) 1.52, 1.89], had diabetes (OR 1.68; 95% CI 1.49, 1.89) or chronic lung disease (OR 1.44; 95 CI 1.34, 1.55) had increased risk of attending OOH services compared with patients with no risk factor. ILI patients with at least one GP visit prior to the pandemic used OOH services less during the pandemic compared with those with no GP visit.

CONCLUSION

An increased use of OOH services was found in ILI patients who were pregnant, with diabetes or with chronic lung disease. Having visited the GP before the pandemic was associated with less use of OOH services among ILI patients.