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.

OBJECTIVES: The aims of our study were to describe the effect of the COVID-19 pandemic and lockdown on primary care in Germany regarding the number of consultations, the prevalence of specific reasons for consultation presented by the patients, and the frequency of specific services performed by the GP. METHODS: We conducted a longitudinal observational study based on standardised GP interviews in a quota sampling design comparing the time before the COVID-19 pandemic (12 June 2015 to 27 April 2017) with the time during lockdown (21 April to 14 July 2020). The sample included GPs in urban and rural areas 120 km around Hamburg, Germany, and was stratified by region type and administrative districts. Differences in the consultation numbers were analysed by multivariate linear regressions in mixed models adjusted for random effects on the levels of the administrative districts and GP practices. RESULTS: One hundred ten GPs participated in the follow-up, corresponding to 52.1% of the baseline. Primary care practices in 32 of the 37 selected administrative districts (86.5%) could be represented in both assessments. At baseline, GPs reported 199.6 ± 96.9 consultations per week, which was significantly reduced during COVID-19 lockdown by 49.0% to 101.8 ± 67.6 consultations per week (p < 0.001). During lockdown, the frequency of five reasons for consultation (-43.0% to -31.5%) and eleven services (-56.6% to -33.5%) had significantly decreased. The multilevel, multivariable analyses showed an average reduction of 94.6 consultations per week (p < 0.001). CONCLUSIONS: We observed a dramatic reduction of the number of consultations in primary care. This effect was independent of age, sex and specialty of the GP and independent of the practice location in urban or rural areas. Consultations for complaints like low back pain, gastrointestinal complaints, vertigo or fatigue and services like house calls/calls at nursing homes, wound treatments, pain therapy or screening examinations for the early detection of chronic diseases were particularly affected.

Prognostic factors associated with quality of life in heart failure patients considering the use of the generic EQ-5D-5L™ in primary care: new follow-up results of the observational RECODE-HF study.

BACKGROUND: The implementation of care concepts fitting the needs of patients with chronic heart failure (HF) remains challenging. In this context, psycho-emotional well-being is not routinely assessed, and under-researched despite indications that it is of great relevance for, e.g., acceptance, adherence, and prognosis. The aim of this study was to observe clinical characteristics for their prognostic utility in HF patients, and to compare the patients' health-related quality of life (QoL) with German population norm values. METHODS: The current post-hoc analysis was performed on data collected amongst participants of the RECODE-HF study who had fully answered the EQ-5D-5L™ items at both baseline and 12 months (n = 2354). The status in the patients' self-assessment items, EQ-5D visual analog scale (VAS) and EQ-5D index was categorized into worse/unchanged/improved. General linear mixed models (GLMM) with logit link were applied. Subgroups included 630 patients (26.8%) screened positive and 1724 patients (73.2%) screened negative for psychosocial distress (PSD). RESULTS: The 12-months change in EQ-5D index, generally resulting from change in individual EQ-5D items, additionally associated not only with high NYHA class but sociodemographics (employment/living alone/GP practice years) (96.2% correctly classified in GLMM). The 12- months change in individual QoL aspects showed associations with age*NYHA, gender, body-mass index, and comorbidities dyslipidemia, myocardial infarction, asthma/chronic pulmonary disease. Important social roles were reflected in particular when HF patients lived alone or the doctor mentioned to the patient that the patient had HF. Patients with/without PSD differed in some sociodemographic and clinical parameters. However, no influence of PSD could be demonstrated in the 12-month follow-up of the EQ-5D-5L™. Nonetheless, comparison of the 12-months QoL with general German population norm values by age groups < 75 years and 75+ showed markedly health restrictions in HF patients in all EQ-5D-5L™ aspects. CONCLUSION: Our analysis revealed different prognostic factors primarily associated with change of burden in different QoL aspects in HF patients. In GP practice it is important to consider in addition to the overall day-related VAS all the individual health-related QoL aspects to take a holistic view of the patient, as well as to pay particular attention to the interrelation of individual characteristics.

Compliance and patient satisfaction with treatment settings recommended by the medical on-call service 116117 in Germany using computer-assisted structured initial assessment: a cross-sectional observational study accompanying the demand intervention.

OBJECTIVES: In order to reduce the use of emergency departments, computer-assisted initial assessment was implemented at the medical on-call service 116117. Our study assessed compliance and patient satisfaction. DESIGN: Cross-sectional observational postal survey. SETTING: Medical on-call service 116117 by eight Associations of Statutory Health Insurance Physicians in Germany. PARTICIPANTS: The intervention was observed between January 2020 and March 2021. Minors and patients with invalid contact data were excluded. A random sample of eligible patients received standardised questionnaires by mail. OUTCOME MEASURES: We analysed associations of sociodemographic data, health status, previous service use, health literacy, and recommended settings with compliance and patient satisfaction by multivariable, multilevel logistic regression. INTERVENTIONS: Based on symptoms and context factors, the computer software suggested service levels. Staff and patient discussed if higher levels were indicated, services were available and self-transport was possible. They then agreed on recommendations for treatment settings. RESULTS: Of 9473 contacted eligible patients, 1756 patients (18.5%) participated. Median age was 66 years (IQR=50-79), and 986 (59.0%) were women. At least one recommended setting was used by 1397 patients (85.4%). General practitioner (GP) practices were used by 143 patients (68.4%). Generally, better compliance was associated with lower depression levels (OR 1.59, 95% CI 1.17 to 2.17, p=0.003), fewer previous hospital stays (OR 2.02, 95% CI 1.27 to 3.23, p=0.003) and recommendations for any setting other than GP practices (OR 0.13, 95% CI 0.06 to 0.29, p<0001, to OR 0.37, 95% CI 0.19 to 0.72, p=0.003). A total of 606 patients (50.7%) were completely satisfied. Patient satisfaction was associated with higher age (OR 1.30, 95% CI 1.13 to 1.49, p<0.001), better self-rated health (OR 1.30, 95% CI 1.10 to 1.53, p=0.002), not having musculoskeletal disorders (OR 0.68, 95% CI 0.49 to 0.94, p=0.021), better health literacy (OR 0.69, 95% CI 0.54 to 0.89, p=0.005, and OR 0.49, 95% CI 0.36 to 0.67, p<0.001) and receiving no recommendation for GP practices (OR 0.61, 95% CI 0.43 to 0.87, p=0.006). CONCLUSIONS: Most patients were compliant and satisfied. Lowest compliance and satisfaction were found in GP practices, but nonetheless, two of three patients with respective recommendations were willing to use this setting. TRIAL REGISTRATION NUMBER: German Clinical Trials Register DRKS00017014.

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.

Patient satisfaction with computer-assisted structured initial assessment facilitating patient streaming to emergency departments and primary care practices: results from a cross-sectional observational study accompanying the DEMAND intervention in Germany.

BACKGROUND: Patient numbers in emergency departments are on the rise. The DEMAND intervention aims to improve the efficacy of emergency services by computer-assisted structured initial assessment assigning patients to emergency departments or primary care practices. The aims of our study were to evaluate patient satisfaction with this intervention and to analyse if reduced patient satisfaction is predicted by sociodemographic data, health status or health literacy. METHODS: We conducted a cross-sectional patient survey in emergency departments and co-located primary care practices. Each intervention site was planned to participate for two observation periods, each with a duration of one full week. Study participants were recruited by the local staff. The patients filled out a written questionnaire during their waiting time. Patient satisfaction was assessed by agreement to four statements on a four point Likert scale. Predictors of patient satisfaction were identified by multilevel, multivariable logistic regression models adjusted for random effects at the intervention site level. RESULTS: The sample included 677 patients from 10 intervention sites. The patients had a mean age of 38.9 years and 59.0% were women. Between 67.5% and 55.0% were fully satisfied with aspects of the intervention. The most criticised aspect was that the staff showed too little interest in the patients' personal situation. Full satisfaction ("clearly yes" to all items) was reported by 44.2%. Reduced patient satisfaction (at least one item rated as "rather yes", "rather no", "clearly no") was predicted by lower age (odds ratio 0.79 for ten years difference, 95% confidence interval 0.67/0.95, p = 0.009), presenting with infections (3.08,1.18/8.05,p = 0.022) or injuries (3.46,1.01/11.82,p = 0.048), a higher natural logarithm of the symptom duration (1.23,1.07/1.30,p = 0.003) and a lower health literacy (0.71 for four points difference, 0.53/0.94,p = 0.019). CONCLUSIONS: The patients were for the most part satisfied with the intervention. Assessment procedures should be evaluated a) regarding if all relevant patient-related aspects are included; and whether patient information can be improved b) for patients with strong opinions about cause, consequences and treatment options for their health problem; and c) for patients who have problems in the handling of information relevant to health and healthcare. TRIAL REGISTRATION: German Clinical Trials Register ( https://www.drks.de/drks_web/setLocale_EN.do ) no. DRKS00017014.

Is subjectively perceived treatment urgency of patients in emergency departments associated with self-reported health literacy and the willingness to use the GP as coordinator of treatment? Results from the multicentre, cross-sectional, observational study PiNo Bund.

OBJECTIVES: Aim of this study was to analyse if subjectively perceived treatment urgency of patients in emergency departments is associated with self-reported health literacy and the willingness to use the general practitioner (GP) as coordinator of treatment. DESIGN: A multicentre, cross-sectional, observational study. SETTING: Emergency departments in five hospitals. Each hospital was visited 14 times representing two 8-hour shifts on each day of the week. Calendar dates were randomly assigned. PARTICIPANTS: All patients of legal age registered at the emergency department or hospital reception desk. Exclusion criteria included immediate or very urgent need of treatment, high level of symptom burden and severe functional impairments in terms of hearing, vision and speech. We conducted standardised personal interviews. Additionally, clinical data were extracted from patient records. PRIMARY AND SECONDARY OUTCOME MEASURES: Our target variable was subjectively perceived treatment urgency. Predictor variables included age, sex, education, health-related quality of life (EuroQol Five-Dimension Scale, value set UK), anxiety and depression (Hospital Anxiety and Depression Scale), somatic symptoms (Patient Health Questionnaire, 15 items version), self-reported health literacy (European Health Literacy Questionnaire, 16 questions version) and the commitment to the GP (Fragebogen zur Intensität der Hausarztbindung, 'F-HaBi'). Data were analysed by multilevel, multivariable linear regression adjusted for random effects at the hospital level. RESULTS: Our sample comprised 276 patients with a mean age of 50.1 years and 51.8% women. A low treatment urgency (defined as 0-5 points on a Numerical Rating Scale) was reported by 111 patients (40.2%). In the final model, lower subjective treatment urgency was associated with male sex (ß=0.84; 95% CI 0.11/1.57, p=0.024), higher health-related quality of life (-2.27 to -3.39/-1.15, p<0.001), lower somatic symptoms score (0.09, 0.004/0.17, p=0.040), higher anxiety score (-0.13 to -0.24/-0.01, p=0.027) and lower commitment to the GP (0.08, 0.01/0.14, p=0.029). CONCLUSIONS: A lower level of subjectively perceived treatment urgency was predicted by a lower willingness to use the GP as coordinator of treatment. Self-reported health literacy did not predict the patients' urgency rating.