Changes in family practice work management in Zagreb due to the COVID-19 pandemic

Abstract

Background

Since the COVID-19 pandemic has impacted family medicine practice (FMP) workload, we aimed to determine changes in the structure of work of FMPs in the number and type of consultations, check-ups, administrative, preventive, and other diagnostic-therapeutic procedures (DTPs) during the COVID-19 pandemic (2021 and 2022) compared to 2019.

Methods

In this cross-sectional study, 172 FMPs from Zagreb (39%) were analysed based on monthly work reports for March and April of 2019, 2021, and 2022. Before being analysed, all noted DTPs were divided into 5 main groups (administration, telephone and e-mail consultations, check-ups, face-to-face consultations, preventive work, and other DTPs).

Results

In 2021 the number of check-ups and face-to-face consultations dropped by 36.20%, whereas the total number of telephone and e-mail consultations, patients per day, and DTPs done per day increased by 120.12%, 6.67%, and 13.76%, respectively. The amount of administrative work rose only in 2022 by 17.58% along with other procedures which significantly impacted the share of medical work: 42.84% in 2019, 49.58% in 2021, and 46.79% in 2022. Around two-thirds of FMPs made home visits (3 to 4 visits monthly) and performed electrocardiography (6 to 7 tests monthly) independently of the analysed year.

Conclusion

Analysing 39% of FMPs in Zagreb we found a significant workload change during the COVID pandemic, especially in the excessive increase of telephone and e-mail consultations. The already small number of examinations, diagnostic, preventive procedures, and home visits, further decreased with the arrival of the pandemic and did not significantly recover in 2022, as was expected.

Introduction

Family medicine (FM) physicians and nurses care for a fairly large number of insured persons in today’s practice. Considering the large range of competencies of the FM team, a good structural organization of daily activities is necessary to provide each insured person with the highest possible care based on healthcare principles.¹ The work performed in FM in Croatia is monitored using 179 diagnostic-therapeutic procedures (DTPs) divided into 4 levels (depending on the equipment and additional training of the staff for their implementation) determined by the new income model from 2013 (Croatian Health Insurance Institute, HZZO) which is still evolving.² DTPs are noted manually by the physician and/or the nurse for each patient separately in their electronic medical record which is sent as a monthly report to the HZZO server.

In 1999, the city of Zagreb was administratively divided into 17 city districts with a total population of 767,131 (2021) over a total area of 641 km².³ A total number of 441 family medicine practices (FMPs) in Zagreb have a contract with HZZO, of which 219 (49.65%) belong to 1 of the 4 health centres (HCs) in the city (Ministry of Internal Affairs, East, Centre, and West), whereas other practices have a private status.⁴ Although the working hours in private and HC FMPs are the same, larger differences in the number and type of DTP performed between them are possible due to the difference in equipment and work organization.

Working hours of FMPs are determined by article 8 of the ‘Ordinance on working hours’ (NN 78/04, 13 January 2014).^1,4 The morning shifts start at 7.00 AM and end at 1.30 PM, while the afternoon shifts start at 1.00 PM and end at 7.30 PM (6 h of work and 30 min of break). Home visits are made from 1.30 PM to 2.30 PM and from 7.30 PM to 8.30 PM, depending on the shift. In the area of Zagreb, 224 FMPs (50.79%) work in the morning on odd days of the month, and in the afternoon on even days. On the other hand, 198 FMPs (44.89%) work in the afternoon on odd days, and in the morning on even days. Only 19 FMPs have fixed working hours based on the day of the week (4.31%).

Development planning of the infrastructure of the city of Zagreb has not accompanied the construction and increase in the number of inhabitants of certain parts of city districts, which consequently led to large differences in the average number of registered insured persons per FMP between districts. The national average number of insured persons per FMP is 1,577, while in Zagreb it is significantly higher and amounts to 1,689.⁵ An FMP is composed of a single nurse and a physician without any additional staff, which causes multiple problems in everyday work.

The SARS-CoV-2 pandemic in the Republic of Croatia began on 11 March 2020 with the adoption of the ‘Decision on declaring an epidemic of COVID-19 disease caused by the SARS-CoV-2 virus’.⁶ In addition to the ‘universal’ rules, each practice created its own ‘pandemic rules’. The examined period of March and April 2021 represents the beginning of the third wave of the pandemic. The mentioned rules were relaxed in March and April of 2022.⁷

The aim of this study is to compare the year 2019 to the COVID-19 pandemic (2021 and 2022) and to determine whether there is a change in the structure of work of FMPs in terms of the number and type of consultation (face-to-face, telephone, and e-mail), check-ups, administrative, preventive, and other DTPs.

Methods

This cross-sectional study was conducted on a deliberate sample. All 441 FMPs in Zagreb were considered but private practices and Ministry of Internal Affairs HC were excluded due to reduced interest and/or the difficulty of collecting individual data from their practices (240 FMPs were excluded; 54.42%). Private practices (unlike FMPs in HC) work on various electronic systems which collect data on different servers, making it inaccessible without the owner’s approval. Additionally, we excluded: (i) newly opened and closed FMPs in 2021 or 2022; (ii) FMPs whose status changed from private to FMP within an HC in the researched period; and (iii) FMPs with fixed weekly working hours. Ultimately, 172 practices (39.00% of all FMPs in Zagreb) including 93, 35, and 44 from HC Zagreb—Centre, HC Zagreb—East, and HC Zagreb—West were included in the study, respectively (78.54% of all FMPs from HCs).

Research plan

Monitoring the structure of FMP daily work was performed retrogradely through noted DTPs in monthly FMP team reports available on the electronic physician work system (MCS Medicus). The numbers of all DTPs for both the COVID-19 pandemic period (from 1 March 2021 to 30 April 2021 and 1 March 2022 to 30 April 2022) and the pre-COVID-19 period (from 1 March 2019 to 30 April 2019) were obtained directly from the MCS Medicus technical service (official data server). The mentioned period was studied due to a lower number of seasonal acute respiratory infections usually burdening the workload of the practices, and because the annual vacations were still not in order. Weeks with 1 or more non-working days were excluded from the survey to avoid statistical errors. The structure of practices was monitored over a total of 6 working weeks (30 working days). Working Saturdays and days on which on-duty work was performed were not analysed.

Collected DTPs were then divided into 5 main groups and other procedures (shown in Table 1) and analysed, including the comparison of the COVID-19 pandemic and pre-COVID-19 periods. The rest of the DTPs were omitted from the analysis because their number in the monthly proceedings of the FM teams was negligible.

During the observed period, the members of the FMP team did not know that this research was going to be conducted. It is in the interest of all FMPs to record all executed DTPs regularly since, according to them, the funds are allocated to the corresponding HC at the end of the month. There is a chance of overreporting of certain DTPs since that would result in earning more money, which ultimately has no effect on the salaries of FMP team members. This system is controlled by the inspection of the HZZO or the HC. Also, there is a possibility of certain DTPs not being recorded, e.g. due to the large amount of work when FMP team members forgot to note them.

This study was approved by 3 Ethics Committees: HC Zagreb—West (No. 251-12-02-21-20), HC Zagreb—Centre (No. 251-510-03-20-22-03), and HC Zagreb—East (No. 01-1351-1/22).

Statistical analysis

The normal distribution of data was verified by the Kolmogorov–Smirnov test. Pearson’s χ² test was used to analyse categorical variables. Student’s t-test and Mann–Whitney U test were used for the analysis of quantitative variables depending on their distribution. The programs used in data analysis were Statistica v.10.0 and Microsoft Excel v. 16.0.

Results

In 33 analysed FMPs, the team leaders were male doctors (23.91%). The number of doctors in analysed FMPs significantly varied depending on the length of their work experience. Accordingly, 26 doctors worked less than 10 years (15.12%), 47 worked 10–20 years (27.33%), 79 worked 20–30 years (45.93%), and 19 doctors (11.05%) worked more than 30 years as FM practitioners in analysed FMP teams. No differences were found between genders or the amount of work experience.

In comparison to 2019 in all examined FMPs, during the COVID-19 pandemic, a significant increase of 83.67% was found in the number of telephone consultations (46 vs. 25 telephone calls per day; P < 0.001); e-mail consultations increased 6.32 times (14 vs. 2 e-mails per day; P < 0.001); the number of insured persons who contacted FMP increased by 6.67% (83 vs. 78 persons per day; P < 0.001), and the total number of all DTPs increased by 13.76% (185 vs. 163 DTPs per day; P < 0.001). All differences are shown in Fig. 1. If the whole FMP team worked without a break for 1 s (360 min per day), an average of 4.67, 4.42, and 4.08 min could have been given for consultation with 1 patient in 2019, 2021, and 2022, respectively. However, by subtracting the number of all noted consultations per day from the total daily number of patients who visited FMPs, as much as 20.41% of patients did not have any DTP noted regarding realized consultation.

Consultations

Consultations via e-mail with insured patients were performed in 150 FMPs (87.21%) in 2019, and 170 in 2021 and 2022 (98.83%, χ² = 17.92; P < 0.001). With practices that did not perform e-mail consultations being excluded from statistical analysis, in 2019 only 8.08% of consultations in referred FMPs were related to e-mail, with the number increasing to 23.17% (P < 0.001) in 2021 and 31.87% (P < 0.001) in 2022. The absolute number of e-mail consultations per day increased approximately 7.5 times from 2019 to 2022 (2.66 vs. 20.17 e-mails, P < 0.001). In 2019, 91.92% of all phone and e-mail consultations were conducted by telephone, and although the daily number of telephone consultations in 2021 was twice as high, they accounted for 76.83% of all consultations conducted in the FMP (48.79 vs. 26.52 calls, P < 0.001). The number of telephone consultations with a doctor was 2.8 times higher compared to 2019, while the number of telephone consultations with a nurse increased by 36.45% (Table 2).

Administration

The analysis of the included administrative DTPs showed a decrease in the number of issuing exemptions and referrals to the primary health care (PHC) laboratory in 2021. However, the already very high average daily number of all administrative DTPs except certificates for orthopaedic aids significantly increased in 2022 (98 vs. 84 administrative DTPs, P < 0.001) compared to 2019 (shown in Fig. 1 and Table 2).

Check-ups and diagnostic procedures

The share of face-to-face consultations and check-ups in FMPs dropped from 54.04% in 2019 to 25.42% in 2021 (P < 0.001) and then slightly increased to 29.22% in 2022 (P = NS). Compared to 2019, the average number of first check-ups per office fell by 82.82% in 2021 and then increased by 27.47% in 2022. A decrease in the number of performed control examinations (follow-ups) by 77.61% was followed by a slight increase of 8.94% in 2022 (Table 2). In 2019, 40 analysed FMPs did not make a single home visit (23.25%), while in 2021 this number increased to 55 FMPs (31.98%; χ² = 3.272, P = 0.071). Although 70% FMPs had access to an ECG device, only 7 procedures were performed monthly (6.14% of all diagnostic procedures). Spirometry and ambulatory blood pressure monitoring devices were available in a very small number of FMPs (12.8%) (Table 2). While the share of medical work was 15.73% higher in 2021 compared to 2019 (42.84% vs. 49.58%; P < 0.01), it decreased by 5.61% in 2022 (46.79%). Diagnostic procedures took 5.59%, 3.00%, and 4.51% of all medical work done in 2019, 2021, and 2022, respectively.

Preventive activities

Preventive activities accounted for only 1.46%, 0.90%, and 1.28% of all DTPs in 2019, 2021, and 2022, respectively. Only two-thirds of FMPs performed cardiovascular risk assessments while around 3-quarters of FMPs provided preventive programs to their patients. The number of FMPs who performed preventive activities in 2022, after the drop in 2021, is similar to that in the pre-COVID period. Among chronic panels, the most used one was the panel for hypertension, whereas only a quarter of FMPs used the panel for chronic obstructive pulmonary disease (Table 3). When excluding panels for hypertension, a total of 21 FMPs (12.21%) did not perform a single preventive activity in 2022.

Discussion

The COVID pandemic had a remarkably negative impact on the work structure of FMPs in 2021, which is most visible in the huge increase of telephone and e-mail consultations and the significant decrease in the number of face-to-face consultations and examinations in the FMPs. The already minimal number of diagnostic and preventive procedures, as well as the number of home visits, decreased further with the arrival of the pandemic and did not significantly increase in 2022, as was expected. The share of telephone and e-mail consultations additionally increased in 2022, as well as the number of administrative procedures and physical examinations and consultations in FMPs causing a huge rise in the total number of performed daily DTPs, thus additionally shortening the time FMPs have for quality patient management.

Several studies show the importance and benefits of a well-organized PHC in reducing health care costs, number of hospitalizations, and improving health of the population,^8–10 as well as structural reforms within FM based on the HC placing the patient at the centre.¹¹ In our study, before the pandemic in FMPs, 54% of face-to-face contacts were made, and in 2021 only 25%, without a significant decline in the number of home visits. However, the fact that even a third of FMPs in 2021 did not make a single home visit, as well as the number of home visits made in other practices (median 4) is worrying. A larger decline in examinations and face-to-face consultations with patients was probably avoided by the introduction of scheduled visits which also led to their slight increase in 2022. These results bring up the question of can every patient really be in the centre and receive quality care. Although nurses perform a significant number of procedures, the DTP system includes only 1 procedure involving their name (OM022–Telephone consultation with a nurse), making it impossible to determine the exact amount of their activity.

Administration

Due to the possibility of working from home as well as online teaching in schools during the COVID pandemic, there was a reduced need for sick leave and medical exemption. With the aforementioned, and due to the fear of infection, fewer referrals were issued for PHC laboratory procedures, which ultimately, despite new commitments, did not cause an increase in administrative work in 2021. For practical reasons, it is not possible to determine the shares of issued referrals according to the recommendation, that is the independent decision of an FM physician, nor were there data found in the literature related to the topic. However, additional tasks, such as issuing COVID certificates, and higher number of referrals and exemptions, significantly increased the amount of administrative work in 2022.

Consultations

The increase in total work by 14% and the doubling of the number of telephone (of which the number of calls to the doctor increased 2.8 times) and e-mail consultations in the analysed 2-year interval of our research shows the need to restructure working hours and the number of team members in an FMP. Although the progress of telemedicine (virtual visits) was accelerated by the COVID-19 pandemic and widely used in the United States of America, the Croatian PHC did not recognize this way of communication as an opportunity to provide better healthcare for insured persons during the pandemic.^12,13 Accordingly, to our knowledge, not a single telemedicine (video) consultation was made in the FMPs during the examined period in our research.

Research shows that a quality approach to the patient in FMP takes at least 10 min for an examination, which gives the patient a sense of security and trust, further improving the patient’s mental state, satisfaction, and treatment outcomes.¹⁴ Consultations shorter than 5 min are limited to little more than triage and issuing of prescriptions. A study by Irving et al. in 2016 showed that 18 countries covering ~50% of the world’s population have an average consultation duration of 5 min or less. Short consultation time negatively affects the care of the patient and the workload and stress of the FMP members, possibly leading to burnout thus making it a key barrier to providing expert care for the patient.^14–16 In our study, the consultation duration in Croatian FMPs in 2019 was already shorter than 5 min, while it was further shortened during the COVID pandemic. A cross-sectional national survey conducted by Pintarić Japec et al.¹⁷ in 2019 showed high score on emotional exhaustion, depersonalization, and reduced personal accomplishment by 58%, 29%, and 52% of all Croatian physicians throughout all specialties, respectively. Most of them, 63%, were burned out. If 1 FMP team is absent (due to sick leave or vacation), the other team usually takes over, consequently overseeing 2 FMP practices simultaneously. Additional activities and creativity of a family physician in carrying out new health actions are thus limited.

Preventive activities and medical work

According to the plan and program of preventive activities adopted by Katić et al.¹⁸ in 2009, every FMP team in Croatia should devote at least 1 h a day to preventive activities. Most of these activities refer to the prevention of cancer, diabetes, and cardiovascular events, which are the leading causes of death in Croatia and worldwide. However, the number of preventive activities carried out was worryingly small (<1.5%) throughout the observed periods in our study. Noteworthy, DTP procedures for preventive activities are automatically documented in the MCS system upon preventive procedure execution, making it extremely unlikely for them not to be recorded. No other similar studies were found about this topic in Croatia at the time of writing this article. A study conducted in Germany in 2011 by Holmberg and associates¹⁹ showed that only 18% of doctors sometimes manage to talk to patients about primary prevention (smoking cessation, reducing body weight and alcohol intake). Another important remark is that FMPs play a very important role in the early detection of cancer, which is another reason why the current 4 min is a frighteningly short time to do quality work.

Overall, the small share of medical work in a day of an FMP team is concerning, which according to the research of Vrdoljak and colleagues²⁰ on 6 FMPs in 2012 was 68.9%. Seven years later, according to this research of a larger scale, the share of medical work was significantly lower and accounted for only 42.8% of the total daily workload in 2019. Additionally, the share of diagnostic procedures in medical work was worryingly small, while ECG counted for only about 6% of these procedures in 2019. Although an increase was noticed in 2021 it was probably caused by numerous consultations about COVID which were reduced in 2022 leading to a decrease of medical work in 2022. It is surprising that at the time of writing this article, there are almost no scientific papers available on this topic in the databases.

Strengths and limitations

The main strength of this research is that the data were extracted from the system representing the actual work done by FMPs. By choosing this period (March and April) we have minimized the possibility for members of FMPs to be absent from their work, leading to more precise results. However, there are several limitations to this study. Firstly, the results reflect the work of less than half of all FMPs in Zagreb, and due to the design of the study, they cannot be generalized to the entire Republic of Croatia. The age structure of insured persons in analysed FMPs was not included in the data processing, which could explain the large differences in the amount of work of teams by practices. Thirdly, the analysed period is assumed to reflect FMP’s actual state and cannot be compared to the average year-round work of an FMP. Recorded DTPs reflect the workload made by the entire FMP team and it cannot be used in the analysis of work done by the nurse and physician separately. Lastly and most importantly, only registered, and available DTPs in the computer system were analysed (approximately 20% is missing), which could have changed the obtained results. Most administrative and preventive DTPs are entered automatically by the system after they are done, but all other DTPs (predominantly medical work) should be manually entered by the nurse and/or the physician in an FMP, which is why a portion of them is probably missing due to the amount of everyday work.

Conclusion

This study analysed 39% of all FMPs in Zagreb and found a significant change in FMPs’ work during the COVID pandemic, especially in the excessive increase of telephone and e-mail consultations. The already small number of examinations, diagnostic and preventive procedures, as well as the number of home visits, further decreased with the arrival of the pandemic and did not significantly recover in 2022, as was expected. FMPs need better organizational solutions and relief of administrative work, that is better-quality triage of patients should be carried out to extend the time a physician can spend with 1 patient from the current 4 to the minimum of 10 min. It should be investigated whether specialists in FMPs really work better than doctors without specialization or whether lack of time prevents them from doing so.

Author contributions

J.J. conceived and planned the study. J.J. and K.H. have contributed by collecting the data, interpretation of the results, and wrote the manuscript. K.H. provided critical feedback and helped shape the research. J.J. performed the statistical calculations and supervised the project.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

This study was approved by 3 Ethics Committees: HC Zagreb—West (No. 251-12-02-21-20), HC Zagreb—Centre (No. 251-510-03-20-22-03), and HC Zagreb—East (No. 01-1351-1/22).

Conflict of interest

None declared.

Data availability

The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author, upon a reasonable request ([email protected]).

References