Paediatric primary care in Germany during the early COVID-19 pandemic: the calm before the storm

Abstract

Objectives: Globally, the COVID-19 pandemic has a major impact on healthcare provision. The effects in primary care are understudied. This study aimed to explore changes in consultation numbers and patient management during the COVID-19 pandemic, and to identify challenges for patient care.

Design: Survey of paediatric primary care practices on consultation numbers and patient management changes, and semistructured interviews to identify challenges for patient care. Surveys and interviews were partially linked in an explanatory sequential design to identify patient groups perceived to be at higher risk for worse care during the pandemic.

Setting: In and around Düsseldorf, a densely populated area in Western Germany. The primary care facilities are spread over an area with approximately 2 million inhabitants.

Participants: Primary care in Germany is provided through practices run by self-employed specialist physicians that are contracted to offer services to patients under public health insurance which is compulsory to the majority of the population. The sample contained 44 paediatric primary care practices in the area, the response rate was 50%.

Results: Numbers of consultations for scheduled developmental examinations remained unchanged compared with the previous year while emergency visits were strongly reduced (mean 87.3 less/week in March-May 2020 compared with 2019, median reduction 55.0%). Children dependent on developmental therapy and with chronic health conditions were identified as patient groups receiving deteriorated care. High patient numbers, including of mildly symptomatic children presenting for health certificates, in combination with increased organisational demands and expected staff outages are priority concerns for the winter.

Conclusions: Primary care paediatricians offered stable service through the early pandemic but expected strained resources for the upcoming winter. Unambiguous guidance on which children should present to primary care and who should be tested would help to allocate resources appropriately, and this guidance needs to consider age group specific issues including high prevalence of respiratory symptoms, dependency on carers and high contact rates.

Keywords: COVID-19; child Health; community-acquired infections; primary health care.

Figure 1

Patient consultation numbers in 2019 and 2020. Panel A: estimated proportion of patient consultations during the first pandemic wave as compared with regular numbers of consultation (left box), other boxes proportion of documented visits in sample weeks in March, April and May 2020 compared with corresponding weeks in 2019; first year of life (yol) developmental examinations comprise U1–U6 examinations, later developmental examinations U7–J2 examinations that are compulsory for all German children; Panel B: absolute weekly consultation numbers for sample weeks between March and May, 3 upper range outliers for right box (emergency–2019) not shown; first yol and >first yol indicating developmental examinations as specified for panel A; no difference for first yol (p=0.611), mean difference >first yol 5.8 consultations per week (*p=0.002), mean difference emergency 87.3 consultations per week (**p=0.001).

Figure 2

Venn diagram of topics worrying primary care paediatricians most when thinking about patient care in the upcoming winter. ARI, acute respiratory infection. Resource constraints in the intersectional areas are further illustrated by selected interviewee responses (see box 2).