Impact of the COVID-19 pandemic on the intensity of health services use in general practice

Background

The COVID-19 pandemic affects non-COVID-19-related health services use due to shutdown measures and fears of potential coronavirus infection or fears of overwhelmed health systems. We aimed to explore the impact of the shutdown in spring 2020 on the intensity of health services use (consultation counts, chronic disease measurement counts) in Swiss general practice.

Methods

Based on electronic medical records from 278 general practitioners in Switzerland, we built two patient cohorts: (1) Jan-Jun 2019 (173,523 patients); (2) Jan-Jun 2020 (179,086 patients). We used linear regression analysis to model weekly consultation counts, as well as weekly blood pressure (BP) and glycated hemoglobin (HbA1c) measurement counts, per 100 patients. We calculated expected values in absence of a shutdown and compared them to actual observed values in 2020. The analyses were repeated for selected at-risk groups (patients with hypertension, diabetes, or cardiovascular disease) and different age groups (<60 years, 60-80 years, and >80 years).

Results

During the shutdown period (calendar weeks 13-19 in 2020), weekly consultation counts were lower than non-shutdown models predicted. Consultation rates reduced by 17.2% for the total population, 16.5% for patients with hypertension, 17.5% for patients with diabetes, and 17.6% for patients with cardiovascular disease. Between different age groups, consultation counts reduced by 15.7% for patients aged <60 years, 20.4% for patients aged 60-80 years, and 14.5% for patients aged >80 years. Weekly BP counts reduced by 35.3% in the total population and by 35.0% for patients with hypertension. Weekly HbA1c counts reduced by 33.2% in the total population and by 29.8% for patients with diabetes. P-values were <0.001 for all reported estimates.

Conclusions

We found a significant decrease in the intensity of health services use in Swiss general practice during the shutdown in spring 2020.

Key messages

We demonstrate that the intensity of health services use in general practice decreased during the first Swiss shutdown in spring 2020, overall and among patients with chronic conditions. It is crucial that health systems remain able to meet the non-COVID-19-related health care needs of patients during shutdowns, especially for patients with chronic conditions who require regular care.

Continuity of care during the COVID-19 pandemic: Qualitative results from a mixed-methods study

Background

Decreases in health service use were observed globally during the COVID-19 pandemic. In the quantitative part of this mixed-methods study, we documented similar trends in Switzerland, with a retrospective cohort study showing a 15-20% decrease in general practitioner (GP) consultations/chronic disease monitoring in spring 2020. These changes need to be understood, particularly for individuals at risk of COVID-19 complications, as many have conditions requiring regular monitoring.

Methods

With a mixed-methods design, we examine continuity of care for at-risk groups (people: ≥65-years-old, with cancer, diabetes, respiratory disease, etc.) between Mar-2020 and Apr-2021. Following quantitative analyses, we qualitatively studied changes in GP/patient practices thru semi-structured interviews with 23 GPs and 36 at-risk patients. We here focus on thematically analyzed qualitative results.

Results

Qualitative data helped explain observed reductions in consultations/monitoring: 1) some patients were discouraged to seek care by official recommendations and/or GPs during the first semi-shutdown; 2) some patients perceived GP offices as closed/overburdened; 3) some patients feared contracting coronavirus; 4) some patients sought alternatives to traditional primary care consultations (e.g., tele-consultations, consulting pharmacists/other professionals, self-reliance). Many patients did not feel that there was discontinuity of their cares. GPs commonly described feeling like an underutilized resource during the pandemic and explained how they could have been mobilized for population needs.

Conclusions

During the first wave, there was a mismatch between 1) GPs' reported availability/preparedness to adequately care for at-risk patients, and 2) some GPs discouraging at-risk patients to come for consultations, at-risk patients' perceptions that their care was not “urgent” in a pandemic setting, and patient perceptions that GPs were otherwise unavailable/overburdened.

Key messages

Qualitative data offer explanations for health service use reductions during the COVID-19 pandemic.

Results provide potential paths forward and highlight GP views of being an underutilized resource.

A multifaceted intervention: no increase in general practitioners' competence to diagnose skin cancer (minSKIN) - randomized controlled trial

BACKGROUND

General practitioners (GPs) play crucial roles in early detection of skin cancer. A pilot-study found a positive short-term effect of a 1-day dermatologic education programme on GPs' diagnostic competence.

OBJECTIVE

To determine effects of a multifaceted intervention, including technical equipment and continuing feedback by a dermatologist, on GPs' diagnostic skills regarding skin cancer.

METHODS

Randomized controlled trial with 78 GPs of the Canton of Zurich, Switzerland.

INTERVENTION

GPs in intervention group received a 1-day training, a Lumio (magnifying glass with polarized light, 3Gen), a Nikon digital camera and - during 1 year - feedback on skin lesion pictures sent to the dermatologist. GPs in control group only received the 1-day training.

MAIN OUTCOME AND MEASURES

PRIMARY OUTCOME

structured assessment of GP's diagnostic skills in correctly diagnosing images of skin lesions regarding skin cancer. At baseline prior to intervention (T0), after the full-day training course in both groups (T1), and after 1 year of continuing feedback (T2) to the intervention group.

MEASURES

Non-parametric unpaired (Wilcoxon-Mann-Whitney) tests were used to compare numbers of correctly classified skin lesions between both groups at T2 and for the change between T1 and T2.

RESULTS

At T0, both groups classified a median of 23 skin lesions of the 36 images correctly. This value rose to 28 for both groups at T1 and fell to 24 for both groups at T2. No difference between control and intervention group at T2. Furthermore, we compared differences in the sum scores per GP between T1 and T2 for each group. Also in this comparison, no difference between control and intervention group was found.

CONCLUSION AND RELEVANCE

No long-term effect of the multifaceted intervention was found on the competence to diagnose skin cancer by GPs. The positive short-term effect of the 1-day dermatologic education programme did not persist over 12 months.

[Modern risk assessment and stroke prevention in atrial fibrillation]

Stroke prophylaxis in patients with non-valvular atrial fibrillation is becoming an increasingly dynamic field. The new guidelines from the European Society of Cardiology (ESC) recommend a stroke- and bleeding risk-assessment in patients with non-valvular atrial fibrillation using the CHA2DS2VASc and the HAS-BLED scores, respectively. Furthermore, new drugs for stroke prophylaxis such as dabigatran, rivaroxaban and apixaban are undergoing approval in Europe and will undoubtedly challenge the well-established vitamin K antagonists. Hence, stroke prophylaxis is likely to become a much more individualized treatment in the future. This review should help to critically weigh the pros and the cons of the new therapeutic options.

[Medical check-ups on the <<Gesundheitsschiff>>. Benefit for population at risk or self-selection of healthy and health-conscious patients?]

The aim of the present study was to assess health related characteristics and reasons for participation on the <<check-up-cruise>>, second, to compare these variables with a representative Swiss Health Survey (SHS). Characteristics of the participants were collected cross-sectionally and afterwards compared with results of the SHS. Response rate was 74.6% (n = 206). Compared to the SHS population smoking rate and alcohol consumption were significantly lower and a doctor's visit within the last 12 months more frequent. Considerable differences in health related characteristics exist between our study and the SHS suggesting a self-selection of healthy people. Thus a potential health gain by this kind of medical prevention program is at least questionable.

[A 35-year old bricklayer with malperfusion of the left hand]

A 35-year old man with coldness, paleness, numbness, and pain at Dig. IV of the left hand comes to the consultation. The Allen test is pathological, the angiography shows an occlusion at the length of 4 cm of the Arteria ulnaris beginning at the Hamulus ossis hamati. After therapy with prostaglandin E1, aspirin 100 mg for 10 days and a smoking stop, the symptom disappeared at the re-consultation after 10 days.

1-Antitrypsin deficiency and lung disease: risk modification by occupational and environmental inhalants

Chronic obstructive pulmonary disease (COPD) is a prevalent and preventable disease associated with high morbidity and mortality. Severe and intermediate alpha1-antitrypsin (AAT) deficiency (serum levels <11 and 11-20 micromol.L(-1), respectively) increase the risk of COPD in active smokers. However, little is known about the interaction of severe and intermediate AAT deficiency with modifiable COPD risk factors other than active smoking. In this study, a MEDLINE search was carried out for studies investigating the combined effect of environmental inhalants (occupation and passive smoking) and AAT deficiency in the lung. A total of 18 studies using established methods for the assessment of AAT deficiency were included in this review. Occupational exposures and passive smoking affected lung function decline or prevalence of respiratory symptoms in four out of five studies investigating subjects with severe AAT deficiency, and in eight out of 13 studies with a focus on intermediate AAT deficiency. While study designs mostly prohibited formal assessment of effect modification, an interaction between intermediate AAT deficiency and passive smoking was identified in two studies with children. Additional study limitations included small sample size, poor adjustment for confounding and misclassification of environmental exposure as well as AAT activity. In conclusion, population-based epidemiological studies with associated biobanks are needed to identify gene-environment interactions and population subgroups susceptible to alpha1-antitrypsin deficiency.

Acute mountain sickness is related to nocturnal hypoxemia but not to hypoventilation

The purpose of the study was to investigate determinants of acute mountain sickness after rapid ascent to high altitude. A total of 21 climbers were studied ascending from <1,200 m to Capanna Regina Margherita, a hut in the Alps at 4,559 m, within <24 h. During their overnight stay at 4,559 m, breathing patterns and ventilation were recorded by calibrated respiratory inductive plethysmography along with pulse oximetry. In the following morning, acute mountain sickness was assessed. Altogether, 11 mountaineers developed pronounced symptoms of acute mountain sickness (Lake Louise score > or =5) and 10 did not (controls). Compared to controls, subjects with acute mountain sickness had lower nocturnal oxygen saturation (mean+/-SD 59+/-13% versus 73+/-6%), higher minute ventilation (7.94+/-2.35 versus 6.06+/-1.34 L x min(-1)), and greater mean inspiratory flow, a measure of respiratory centre drive (0.29+/-0.09 versus 0.22+/-0.05 L x s(-1)). Periodic respiration was prevalent but not significantly different among the two groups (apnoea/hypopnea index 60.1+/-34.6 versus 47.1+/-42.6 events per h). The data suggest that pronounced nocturnal hypoxemia, which was not related to hypoventilation, may have promoted acute mountain sickness. Periodic breathing seems not to play a predominant role in the pathogenesis of acute mountain sickness.