In analysing survey responses of PCPs, this study aimed to understand how COVID-19 and the public health measures to fight the disease have affected Austria’s primary care sector and how the status quo shaped physicians’ concept of “care quality”. Multinomial logistic regression uncovered distinctive differences in this concept across the pandemic stages in 2020.
Towards the end of the first COVID-19 wave in late spring 2020, PCPs associated care quality with the availability of SARS-CoV-2 tests within practice walls [17]. Austrian PCPs also raised severe concerns about the lack of proper allocation of protective equipment across the healthcare system [17, 30, 31]. So, there was a focus on healthcare’s supply side, reflecting a system struggling to provide necessities to handle patient flows in an unprecedented situation. In this context, it is plausible that the assessment of PCPs focused on the safety dimension of healthcare quality [21]. Resource supply (safety equipment, SARS-CoV-2 tests) improved towards the onset of the second wave in November 2020. Thus, “quality” was perceived (by PCPs) as a demand-driven concept (i.e., determined by patient behaviour). Austria’s PCPs were deeply concerned about their patients no longer undergoing medical check-ups and screenings, significantly influencing PCPs’ real-time quality assessment.
By the end of 2021, the Austrian Board of Auditors confirmed that PCPs’ concerns were more than just pandemic-induced doom-mongering. The Board reported that in 2020, preventive check-ups in primary care had declined by 135,000 (-10%) compared to the previous year [25]. Also, screenings in secondary care were negatively impacted. For example, colonoscopies in outpatient departments decreased by 76% in April 2020, regained 2019 levels, and collapsed again in November/December 2020 (-40% compared to 2019 levels) [25]. Austria’s outpatient departments experienced a similar pattern for mammograms [25]. Follow-up effects are still unclear, with data not yet lending themselves to statistically significant results about long-term effects on healthcare’s effectiveness (a core dimension of healthcare quality). Still, researchers have expressed concerns regarding inadequate healthcare provision for the non-infected, especially vulnerable populations [17, 32–36]. A study comparing survey data on health and social issues for the Austrian population between 2015 and 2020 named delayed treatment and non-available providers as the primary reasons for Subjectively Unmet Needs (SUNs) [37]. Pandemic-related SUNs have been predominantly observed in people with poor health, older age groups (50–64 years) and inactive and retired persons. Additionally, the prioritisation of Austria’s secondary care in the form of ringfencing beds to prepare for an expected increase of COVID-19 inpatients potentially aggravated chronic health conditions of primary care patients due to a lack of care continuity [6, 38]. The latter correlated with dodging acute treatment and increasing societal mental health problems [39, 40]. These arguments support the notion that persons with more substantial healthcare needs have experienced restrictions in access to care, thus eroding the principle of equity in healthcare (another core dimension of healthcare quality) [41].
Throughout 2020, Austria’s PCPs also worried (significantly more during the first wave than the second) about delayed or cancelled elective treatment in hospitals. Indeed, bed days in funds hospitals dropped by 1.8 million (-15%), with hip and knee replacements declining by 19% compared to 2019 [25]. Inpatient stays with a cancer diagnosis in Austria experienced the most substantial decline in April and May 2020, with − 24% compared to the previous year; in November and December, it was up to -16% [25]. Nonetheless, the timeliness of care (another core quality dimension) did not contribute to explaining the overall quality assessments of Austrian PCPs. A potential reason is that secondary care did not inform the PCPs directly about cancelling an elective operation. So, PCPs would not have instantly known that one of their patients was (potentially negatively) affected. Then, it would make sense that, during a pandemic, PCPs did not include timeliness in their quality perceptions.
Except for the impact of the short supply of SARS-CoV-2 tests, even in the early phase of the pandemic, the safety dimension of quality seemed less critical for PCPs in their quality assessment than expected. This correlated with the observation that fear of infection keeping patients away from acute healthcare (a concern during the first COVID-19 wave) was no driver of the assessment of care quality either. A possible reason is that the delivery of primary care services changed remarkably throughout 2020 [2, 30, 42–44]. Face-to-face contacts declined from 70–23%, while the number of telemedicine contacts increased broadly [45]. An Austrian study specifically reported that 77% of 606 contacted physicians who responded to their survey considered “telemedicine as the one key element for maintaining care in the current healthcare crisis” [46]. Telemedicine enabled effective and safe (and often timely) care and assisted primary care’s pandemic-induced focus on chronic disease management, medical screenings and check-ups [38, 40].
PCPs’ quality perception adjusted over time and reflected the most pressing issues in primary care in real time. Therefore, it is even more remarkable that throughout 2020, PCPs perceived proper coordination (and information exchange) within the medical profession as one of the key resources preventing even further decline in the care quality of their patients. There is, however, room for improvement. For example, the Austrian Board of Auditors recommended a well-established (bidirectional) exchange of information and the obligated cooperation of national health insurance institutions, hospitals and public health agencies to provide the best possible use of resources in a health crisis [25]. As a best-practice example, Australia’s successful response to the pandemic included regular webinars and teleconferences with primary care professionals to enable continuous and two-way communication with the primary care workforce [47].
Early in the pandemic, the Austrian Ministry of Health allegedly presumed that the health insurance institutions would continue to regulate primary care but did not systematically integrate them at the state level into national disease management. At the federal level, health insurance institutions were not integrated at all, and their resources were not used for disease control. Hence, it is no surprise that PCPs’ evaluations of the support from governmental public health agencies did poorly, and the public’s compliance with disease control measures eroded over time [15]. Undeniably, the strong siloed separation between care services and public health authorities has been a weakness of the Austrian healthcare system revealed by the pandemic [19, 48]. This study emphasises the necessity of better integrating primary care and public health to bolster the resilience of the Austrian healthcare system and safeguard care quality in case of crises or disasters [18]. Specifically, the study’s findings advocate a more substantial involvement of PCPs in Austria’s public health planning.
The system resilience framework states that sustainable healthcare systems must shift activities from inpatient care to primary care [26, 48]. PCP responses in the survey allude to a substantial degree of patient-centeredness, putting the patient at the heart of care processes. For example, PCPs expressed more profound concern about their patients’ health than personal concerns like substantial financial losses or their own risk of infection [29]. The latter is more than just paying lip service as nearly 30% of Austrian PCPs are over 60 years old and, thus, at risk of severe (COVID-19) disease.
Thus, acting at the forefront of Austria’s fragmented healthcare system, PCPs are presumably the only stakeholders in healthcare with a somewhat comprehensive picture of the health state of their patients. Their knowledge should be used for timely and needs-based public health planning.
Strength & Limitations
Unlike most studies on shifting and rearranging duties and responsibilities during the COVID-19 pandemic, our study is quantitative with a good sample size. It resonates with several qualitative studies and confirms their results [17, 24, 43, 45, 49, 50]. Additionally, independent data validate the quality perception of PCPs discussed in this paper [25]. However, since we have analysed the quality concept at different pandemic stages, a panel design would have been superior to our cross-sectional design. Nonetheless, the insight into the pandemic waves (first lockdown, summer recess, and second lockdown) and perceptions of care quality constitute an asset and show the capability of primary care to adapt.
Statistically, there are some limitations regarding the generalisability of our data. For example, the multinomial logistic regression results have a good model fit (suggesting internal validity). However, there is an issue within the dependent variable (the assessment of “care quality”). I.e., answers are limited to the subjective evaluation of overall care quality without any refined explanation if this improvement/deterioration roots in outpatient or inpatient care. Also, quality domains (effectiveness, safety, timeliness, people-centeredness, equity and efficiency) were not operationalised by standardised survey questions as we focused on adapting the Survey of Primary Care Physicians of the Commonwealth Fund for COVID-19. Also, some variables that affect PCP assessment of care quality might not be included in our regression model. For example, analysis of open questions from the survey revealed that PCPs were highly concerned about delayed medical examinations by specialists and in specialised outpatient clinics as they caused a delay in diagnostics and treatment of their patients [29].