Monitoring Attendance, INvestigation, Referral and OUTcomes in primary care: impact of and recovery from COVID-19 lockdown (MAINROUTE)

Abstract

Background: Coronavirus (COVID-19) spread rapidly around the world and significant restrictions on daily life were imposed to reduce the reproduction number and infection rate among the population.  Primary health care quickly altered, with most urgent face to face consultations replaced with remote video or telephone consultations. Many routine appointments, procedures and non-urgent care in both primary and secondary care were cancelled. Urgent cancer referrals and hospital admissions with stroke and acute myocardial infarctions declined dramatically. 

It is, however, unlikely that these clinical events were not occurring, but rather that healthcare seeking behaviours altered, in part due to the advice to remain at home, but also from fear of contracting COVID-19 from healthcare settings.  This will have resulted in an amount of unmet need in the population.  This unmet need and the associated inherent delays in medical care, could have long-lasting detrimental implications for clinical outcomes for some conditions or groups of patients, creating a parallel epidemic. 

As restrictions on movement are relaxed, it is expected that primary care will need to prioritise some health conditions in order to catch-up on clinical care to mitigate the unintended consequences of COVID-19.  This may have further implications for expected workload in primary care.

Objective: We will use contemporary data from the new Oxford and Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) to track changes in presenting patterns, clinical activity and outcomes related to common diseases in the community prior to, during and after lockdown for COVID-19. The dashboards developed will give primary care staff visual information on the clinical areas, or groups of patients that will be most in need of prioritisation for health care.

Method: Descriptive dashboard data analytics, time series analyses and regression analyses will be conducted to understand the impact of the lockdown in response to COVID-19. Analyses will primarily focus on non-communicable disease diagnosis and management as identified in linked primary care, hospital, and mortality datasets. 

Impact: This project has been ranked as high priority by the HDRUK and is now included on the SAGE Prioritised Question List (reference RQ094), as it has been recognised that these dashboards will enable practices to identify patient groups within their population that would benefit from prioritised 'catch-up' clinical care to avoid delays in treatment or investigations and therefore minimise any long-term adverse outcomes. By linking changes in activity to longer-term outcomes, this work will also provide insight into which clinical activities could or could not be safely reduced during any future waves of the pandemic or during times of very high workload.

 Lay summary

Health care and the way we consult doctors has changed as a result of the COVID-19 pandemic and lockdown.  Since March 2020, urgent appointments with doctors (GPs) have mostly been over the telephone or by videoconference.  Many routine appointments, blood tests, cancer screening and non-urgent treatment have been cancelled in both GP practices and in hospitals. Urgent cancer referrals and the number of people going to hospital with stroke and heart attacks have gone down dramatically. 

However, it is unlikely that these events are not occurring.  It is more likely that people are avoiding going to the doctors or hospital.  This may be because they do not want to bother doctors or nurses at this time of higher workload, or they are not sure that GPs are available to deal with non-COVID problems or they are worried about catching COVID-19. 

This will mean that there may be a build-up of medical problems that doctors are not seeing at the moment.  Delays in diagnosis or treatment may cause longer-term health problems for some groups of patients.  As social distancing rules are relaxed, and life starts to return to normal, doctors will need to ‘catch-up’ on clinical care for a wide range of conditions.

This study will use data from the new Oxford and Royal College of General Practitioners Clinical Informatics Digital Hub (ORCHID) to track changes in problems seen by the GP practice, the number of tests done, numbers of hospital appointments and longer-term outcomes for several diseases like cancer, heart disease, diabetes and mental health problems.  We will make displays of data so that primary care staff will be able to see which disease areas or groups of patients that will be most in need. 

 Keywords

COVID-19; Primary care; Routine appointments; Cancer referrals; Stroke; Acute myocardial infarctions; Parallel epidemic; Common non-communicable diseases; Presenting patterns; Descriptive dashboards