Impact of COVID-19 national response on primary care utilisation in Singapore: an interrupted time-series analysis … – Nature.com

Following early implementation and national responses to suppress the spread of COVID-19, Singapore reported one of the lowest mortality rates in the world25. Having experienced two pandemics previously, the severe acute respiratory syndrome (SARS) in 2003 and influenza A (H1N1) in 2008, the government developed the DORSCON risk assessment to facilitate containment measures across sectors26. The government responded swiftly by activating the risk assessment to the second highest level of DORSCON Orange just 15days after the first case was reported. Early efforts to contain the virus focused on reducing the risk of transmission.

At the start of the pandemic, the public was advised to exercise social responsibility if feeling unwell by seeking medical attention immediately. To ensure primary care remains accessible and affordable in times of national emergency, the government activated the Public Health Preparedness Clinics (PHPC) scheme involving more than 900 general practitioners on 18 February 202027. In addition to polyclinics, patients with respiratory symptoms were offered subsidised treatment and medications at PHPC, where the wait times are usually shorter. This reduces the load of patients with acute conditions on polyclinics as similar treatment options were available at PHPC. At the same time, pre-emptive measures were also put in place. Patients with respiratory symptoms were issued with mandatory five days of sick leave and they were legally required to stay home and only leave to seek additional medical attention28. However, for patients who were sick but had work attendance incentives tied to sick leave, this policy could have deterred them from seeking treatment, overall reducing the number of acute visits29.

Non-pharmaceutical interventions, such as mask-wearing, good hygiene practices and social distancing, were also encouraged to reduce the transmission of COVID-19. These measures were found to reduce the transmission of other viral respiratory infections with similar modes of transmission as COVID-1930,31. Additionally, travel restrictions also limited the spread of other respiratory infections across national borders32. In Singapore, the implementation of non-pharmaceutical interventions was associated with a reduction in the prevalence of respiratory viruses such as influenza, which consistently remained low until the end of 202033.

In the early stages of the pandemic, primary care was used to test for suspected cases before they were referred to hospitals for further treatment. Despite efforts to mitigate the risk of cross-infection between patients by setting up segregation zones and triaging patients by their COVID-19 risk profile, patients may be reluctant to visit the doctor lest they be exposed to infected cases34. A study conducted in Singapore revealed that 40% of patients with chronic conditions missed their healthcare appointments during the outbreak, with 72% doing so voluntarily due to a greater perceived risk of infections at a healthcare institution35. This sentiment was also prevalent in other countries36. Studies elsewhere have shown that patients with underlying chronic conditions did not seek medical care for fear of exposure to COVID-1937. These could have led to a drop in overall primary care visits.

As the number of cases started to spike, the government imposed Circuit Breaker to keep cases under control. The public was advised to avoid going out unless necessary as work-from-home arrangements became the default and schools shifted to home-based learning. Non-essential services were deferred while essential services were scaled down whenever possible. For patients who required medication refills, these were done through a medication delivery service if applicable38. All social gathering events were also banned, which reduced the spread of acute respiratory infections.

Our analysis revealed a contrasting pattern in the reduction of acute and chronic visits associated with Circuit Breaker in the unadjusted and adjusted models. In the unadjusted model, we observed a larger reduction in acute visits, while the adjusted model showed a greater reduction in chronic visits. Notably, patients were 0.85years older during Circuit Breaker compared to DORSCON Orange (average age: 60.9 vs. 60.1years, p<0.001), a demographic factor that likely contributed to the increased reduction in chronic visits in the adjusted model. This divergence in the reduction of acute and chronic visits, evident across both models, highlights the vulnerability of specific patient populations, particularly those older and with chronic conditions. This underscores the need for targeted interventions and strategic resource allocation during public health crises.

During this period, there was also a push for telehealth services39. This may have resulted in the conversion of some face-to-face primary care visits from polyclinics to telehealth visits, which could have freed up some of the appointments in polyclinics to be reallocated to patients with chronic conditions. Towards the end of Circuit Breaker, primary healthcare services in hospitals were allowed to resume in phases where patients with chronic medical conditions were attended to first to ensure continuity of chronic care22. This might also have encouraged patients with chronic medical conditions to seek care in polyclinics, as the fear of seeking primary care subsided. Thus, the proportion of daily chronic visits appears to increase faster than acute visits during Circuit Breaker.

Similar findings have been observed in other countries. Following the lockdown in the UK, there was a significant reduction in virtual and face-to-face primary care consultations related to specific health conditions, including acute respiratory and cardiovascular conditions40. Three months after the restriction was lifted, remote and in-person consultations were still lower than pre-lockdown levels. Other studies conducted in the UK also reported substantial reduction with slow recovery in primary care attendance associated with asthma exacerbation and chronic obstructive pulmonary disease41,42,43. The authors hypothesise that the reduction in primary care visits may have been due to the reprioritisation of primary health services in which general practitioners (GPs) were required to balance COVID-19 infection care with primary care services coupled with fears associated with COVID-19 infection. To protect the patients, GPs were advised to minimise the number of in-person consultations. Across the world, healthcare services for other conditions were scaled back as resources were redirected to care for COVID-19 cases. This has caused delays in healthcare delivery for other conditions. This delay or avoidance of seeking care can increase morbidity and mortality44.

There are limitations to this study. The data used in this study is limited to a cluster of public primary care clinics. Primary healthcare services in Singapore are delivered through a network of public primary care clinics and private general practitioner clinics. At the time of this study, 20 public primary care clinics were in operation, comprising only 20% of the sector45. Additionally, the distribution of chronic care needs addressed by public clinics is significantly imbalanced, with 80% of chronic care needs addressed by public care clinics45. Likewise, the proportion of acute care needs addressed by private clinics is much higher. Furthermore, telemedicine played a crucial role in providing primary care services during the pandemic while minimizing physical contact. The inherent variation in attendance patterns between public clinics, private clinics, and telemedicine may introduce complexities in generalizing the findings across the primary care landscape in Singapore.

While our study shed light on the impact of DORSCON Orange and Circuit Breaker on primary care utilisation, the impact may not be directly attributable to these policies as there were other nationwide measures concurrently rolled out such as public education and enforcement of non-pharmaceutical interventions. Additionally, the reprioritisation of primary care services also affected other primary care services that were not examined in this study. Moreover, as the relaxation of the Circuit Breaker measures occurred gradually in a phased approach, our model may only partially encapsulate the complete impact of these policies on primary care visits.

Lastly, primary care manages more than just acute and chronic medical conditions; it includes preventive health screening, immunisation, and dental services.

Despite these limitations, this study provides an understanding of primary care utilisation in the face of the COVID-19 national response. The unintended effect of restrictive measures may have been overlooked and understanding it can help inform future policy discussions on balancing infectious disease care and essential primary care services.

Our findings add to the growing body of literature on the impact of the COVID-19 national response on healthcare utilisation. Understanding the impact of national responses on primary care is especially crucial as primary care serves as the first point of contact with patients, not just in the face of COVID-19 but also in the growing burden of chronic conditions. It is important to recognise the challenges that other patients may face. Disruption in essential primary care services, particularly chronic care management, may lead to profound health consequences. Further studies with a longer observation period may be needed to understand the prolonged impact of COVID-19.

The study was approved by the ethics committee of the National University of Singapore Institutional Review Board (NUS-IRB-2021-611). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s).

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Impact of COVID-19 national response on primary care utilisation in Singapore: an interrupted time-series analysis ... - Nature.com