By Malte Kohns Vasconcelos, MD MSc on behalf of the authors
In our report, we describe the perspective of paediatric primary care providers in a densely populated area in Germany on patient care in the early pandemic. Why should you read on? In the current scientific literature, the COVID-19 pandemic is most widely explored from the inpatient care perspective or from the angle of public health decision making. In contrast, decentralised primary care is the mainstay of health provision in most settings across the globe. Perspectives of primary care providers are underrepresented in the published literature. Our article provides in-depth exploration of responses of paediatricians in primary care to the beginning of the pandemic in Germany.
Despite case numbers that were low compared to the later course of the pandemic, the first COVID-19 wave caused significant disruption to health care provision globally. WHO, on the basis of numerous scientific publications, has highlighted the need to maintain routine healthcare provision and especially routine vaccination programmes. In our setting in Western Germany, we identified reduced routine visit numbers as a concern very early on. The surveys and interviews with paediatric primary care providers, that we designed in a mixed team of university academics and front-line primary care paediatricians, provide an insight into the perspective of staff in primary care in a time of many uncertainties. Primary care facilities quickly adapted to the pandemic by rearranging patient flows and incorporating officially issued case definitions into their daily practice. We were able to show that well baby visits, especially during the first year of life, continued unimpaired. In contrast, we documented markedly reduced unscheduled visits and providers participating in the surveys estimated that their overall visit numbers were reduced by around one third. To better understand what factors contributed to reduced patient numbers, and what patient groups might be at increased risk of deteriorated care, we followed the surveys up with interviews in a sub-group of care providers. Primary care paediatricians identified a broad range of issues surrounding patients with chronic health conditions: (1) their families seemed to perceive higher risks of COVID-19 and were probably more likely to cancel or postpone follow-up visits, (2) they were dependent on complementary healthcare by medical specialists whose visits were often cancelled and (3) they were suffering from suspended long-term therapies, most prominently including physiotherapy and speech and language therapy. The interviews conveyed something additional, which is hugely important, but less easy to express as a scientific finding: primary care paediatricians felt a very high degree of responsibility for the overall care and wellbeing of their patients, including but not restricted to patients with comorbidities. Some important components of the WHO recommendations for consistent care were independently identified by paediatricians in our area, namely the need to prepare for catch-up visits after the most intense phase of the pandemic is over and a responsibility to actively follow up with families who had visits cancelled during times of high COVID-19 case numbers.
The main concerns primary care paediatricians voiced regarding continuing patient care in the pandemic centred on constrained resources. In Europe, acute respiratory infections follow a strong seasonality. The surveys and interviews took place in the summer, when very few children would be expected to present with respiratory infections. At the time of the interviews, the very first observations from the southern hemisphere regarding disrupted seasonality of respiratory infections and low case numbers in the winter were just beginning to trickle in. The general expectation for the European winter was still: rising case numbers of respiratory infections. In this context, the interviewed paediatricians expected rising patient pressure as usual, but interspersed with cases of the new, clinically indistinguishable and highly contagious coronavirus disease. Additionally, they were at the time beginning to see increasing numbers of patients with very mild respiratory symptoms who were brought in to be assessed for COVID-19, not because parents were concerned but for mainly organisational reasons like sick notes for the parents’ employers or health certificates for day care facilities. Projecting these trends into the winter, primary care providers were worried that facing these combined pressures, they might not be able to uphold their usual quality of care. Asked for possible solutions, the interviewed paediatricians revealed an interesting observation that is most likely not restricted to the current pandemic: they felt that guidance and recommendations issued by the state and public health authorities were ambiguous at times and that whenever parents or day care providers were facing this ambiguity, they would resort to their primary care paediatrician for resolution instead of resolving the resulting uncertainties themselves. The impression was that this was partly for genuine uncertainty, but partly in order to pass on a responsibility that they were not willing or equipped to shoulder themselves. If the primary care provider, operating under the same guidance, was unable to resolve the problem, they would be left to manage the resulting frustration. In this way, imperfect guidelines from officials would directly translate into increased workload and dissatisfaction in primary care.
Almost a year later, what do we do with these observations? Paediatric patient care in the European winter was much less impacted than the interviews suggested, and the study was limited in scope, focusing on primary care in our immediate geographical area. However, our report provides a snapshot into the reasoning and expectations of primary health care providers at a time of high uncertainty. The findings may well be transferable to other settings and similar situations in the future. In addition, to understand paediatric primary care it is important to document the high amount of identification paediatricians show with their role and with their patients. They understand themselves as both their patients’ advocates and as their last resort in case of uncertainty.
In the article, we aggregate and analyse the survey and interview participants’ replies, but also provide some direct quotations. In this mixed format, we hope that the article is not only informative to our you as our readers, but also an engaging and entertaining read.
Conflict of Interest: None