COVID-19 pandemic has disrupted the continuity of care for chronic patients: evidence from a cross-sectional retrospective study in a developing country

Global reports indicate a serious restriction in the patients with chronic conditions` access to routine health care services during the outbreak [26‐30]. With this perspective, conducting a study to determine the access level of those patients with non-communicable diseases during the pandemic could be handy and useful for health systems and health policy makers. So, this study was conducted with the aim of determining the continuity of care for patients with hypertension and diabetes during COVID-19 pandemic in Yazd, Iran.

Our results imply that the rate of visits for both groups of the patients who were suffering from the hypertension and diabetes, both in health centers and outside them, and the average rate of the health centers’ daily admissions for these patients were significantly lower a year after COVID-19 pandemic comparing with the similar period before the pandemic. Although, a little difference in the reduction rate of visits for diabetes and hypertension patients was reported but this difference was not significant. This difference between 2 groups of patients can be caused by the nature of diseases and the different care plan for each one at health centers. Also, our findings showed that the decrease in patients’ visits outside the health centers was considerably higher than the decrease in visits in the health centers for both groups of patients.

Overall, our results approve the considerable disruption of COC for diabetes and hypertension patients during the pandemic. Such a restriction firstly occurred due to the concentration of the health systems on managing the pandemic during a long period. Other reasons for this restriction can be because of decrease in access to health care specialists, health care workers` burnout and the economic challenges at the macro level [26‐30]. Quarantine and travel restrictions as same as the fear of diabetes and hypertension patients from getting infected with Corona are the other factors that limited the access of patients to routine care during pandemic.

Serious disruption in the access of chronic patients to routine care has been evidenced and reported from other countries, as same as our findings. Comparing the present results with the available findings from other studies reveals some similarities despite the differences among the studied populations. For instance, according to the results of a time-series study conducted by Doubova et al. (2022) in Mexico, about 8.74 million visits were cancelled among the nine health services studied from the related data of the national Mexican Social Security which covers almost half of the local population. Specifically considering these results, patients suffering diabetes lost about one third of their routine care during COVID-19 pandemic. Such a decline led to a 22% decrease in the rate of those patients whose diabetes status was under control. According to Doubova et al. (2022), COVID-19 pandemic has affected the resilience of Mexican health system to a great extent particularly in the area of providing necessary health care services [31]. Another study by Hoffman (2022) has demonstrated the prevention status of chronic non-communicable diseases in the USA. Based on the results of this study, COVID-19 has acted as a factor to reveal the available declines of the global public health systems [32]. Similarly, Balasuriya et al. (2022), emphasized the significant role of COVID-19 pandemic as a factor which shows the necessity of preventing chronic disease more than ever. Regarding Balasuriya et al. (2022), COVID-19 has played a significant role as an inhibitor towards appropriate access to health care services. The pandemic caused a decline in receiving on time health care as well as socioeconomic challenges and behavioral changes [33]. Like the present results in Yazd, Iran, Kendzerska et al. (2021), in their study have reported a significant decrease in the number of in-person and elective visits for patients with chronic conditions due to the governmental restriction during the pandemic [34]. Danhieux et al. (2020) also considered the primary health care during COVID-19 in Belgium from the health care providers` perspective. According to their findings, COVID-19 was considered as a reason of decline in chronic care and continuity of primary health care in Belgium [35]. Chudasama et al. (2020), in a global opinion assessment from health care experts in 47 countries have concluded that during the pandemic, chronic patients` access was affected seriously. As a result, they have strongly recommended the continuity of care for chronic patients as a determinant factor to prevent side effects and mortalities non-related to COVID-19 [36]. Another study designed by Gadsden et al. (2022) in Southeast Asia announced that COVID-19 has declined the delivery of necessary health care services particularly for non-communicable diseases. As they mentioned, public preventive actions like national quarantine and traffic restrictions which were normally applied as a response to pandemic control, were among the main reasons of decreasing the patients` access to their routine care [37]. Resembling the present results, Statchels et al. (2022) have reported that from the beginning of the pandemic, many of the regular and routine medical visits were postponed, delayed, or cancelled due to some reasons like fear, lack of tendency, isolation, lack of health care workers, and problems in primary health care delivery [38]. As this study was concentrated on the status of continuity of care during COVID-19 pandemic in a developing country, results of Ayele Ta et al. (2022) in northeast of Ethiopia were also confirmed the effects of COVID-19 pandemic on the patients` health care seeking behaviors. According to their findings, in a developing country with the restricted resources, the condition can be worsened and significant loss of visits and increase in the number of postponed, cancelled, and delayed visits can be intensified mainly due to higher frequency and prevalence of positive or suspected cases of COVID-19, higher rate of out-of-pocket payments and lack of medical record systems [39]. Other studies such as Sumner et al. (2022), Javanparast et al. (2021), Wang. (2021), Cuschieri, and Mamo (2021), Sakur et al. (2022), Moore (2022), Hacker et al. (2021) and Burayzat et al. (2022) also reported similar findings from the negative effects of the pandemic on the COC for chronic patients and emphasized the necessity of appropriate actions by health systems to ensure the routine care of these patients during health disasters [40‐48].

In this study we analyzed a questionnaire data of patients’ experience from COC during pandemic in addition to the health system’s data. For this purpose we applied the multidimensional model of COC, which Gulliford et al. have developed. In this model, COC has been defined as a multidimensional concept that has 4 dimensions including Longitudinal Continuity (LC); Flexible continuity (FC); Relational Continuity (RC), and Team and Cross-boundary Continuity (TCB). Longitudinal continuity has been defined as the regular monitoring of a patient’s condition over the time. This monitoring should be accompanied by counseling on self-care and self-management and should be performed by as few clinicians as possible. Longitudinal continuity of care requires the development of a relationship based on familiarity, closeness and honesty between the patient and the care team. This relationship creates another dimension of continuity of care, which is called relational continuity. Chronically ill patients may sometimes need urgent consultation with their care providers due to emergency problems related to their illness. Flexible continuity refers to the extent to which care providers flexibly respond to these changing needs of patients in a timely manner. Caring for chronic patients requires a great deal of coordination and cooperation among settings and professionals who provide it. The last dimension of COC that is named experienced team and cross boundary continuity refers to the degree of coordination and consistency of care between these settings and professionals in providing care [9]. In this regards, our findings indicated that the experience of the studied patients about continuity of their routine care during the pandemic was not appropriate and acceptable. Based on the findings, the participated patients rated their experiences from the COC and its dimensions including Longitudinal; Flexible; Relational and Team and Cross-boundary continuity as moderate. In both groups of patients, relational continuity got the highest mean while longitudinal continuity got the lowest mean. HT patients rated their relational continuity significantly better than DM patients but two groups had no difference in the other dimensions as same as the total COC mean. Although we have no records of our participants’ experience before the pandemic for the comparison but there is some literature to discuss this. Gulliford et al. (2006), in their study of type 2 patients in England have reported the mean score of experienced continuity of care for diabetes mellitus (ECC-DM) as 62.1 (ranged from 0 to 100). Also, they have reported that the mean of ECC-DM varied significantly between practices, ranging from 46 to 78 at different family practices. Experienced continuity was lower for patients receiving only hospital clinic care than for those receiving some diabetes care from their family practice. Patients had higher ECC-DM scores if their family practice had a designated lead doctor for diabetes [10]. Mahdavi et al. (2021) have conducted a study to identify associations between health services operational factors and health experience for patients with type 2 diabetes in Iran. They concluded that continuity of care should be valued as an important structural element of an experience-based service delivery module for DM patients [49]. Also among the dimensions of COC, the relational continuity has een studied and focused in the most studies [50]. Chang et al. (2018) have examined the associations between COC, hospitalization and end-stage renal disease in DM patients in a cohort study in Taiwan. They have reported that COC is strongly correlated with end-stage renal disease and subsequent hospitalization among patients with DM. This study, suggested that when DM patients keep visiting the same physician for managing their disease, the progression of renal disease can be controlled [15]. Chen et al. (2022) in a cross-sectional study have studied the relationship between COC and self-management of patients with type 2 DM. They have showed that the continuity of care could explain more that 20% of total variance in self-management skill of patients that in return helps the management of the disease [51]. In another study, Hsieh et al. (2020), have examined the COC and its correlation with quality of life among 157 type 2 diabetes mellitus (T2DM) patients in Taiwan. In this study the average patient continuity of care questionnaire has reported as 50.11/60 and the mean score for each domain ranging from 4.12 to 4.21. Also, the authors have reported that the relational continuity with medical providers is among the most important predictors that effectively explore the patients’ quality of life [17]. Pandhi et al. (2006) in their study reviewed the literature regarding patients’ perceptions of interpersonal continuity of care to determine which patients value interpersonal continuity and in what context. Their study showed that Interpersonal continuity of care is important to a majority of patients, particularly those from vulnerable groups [52].

Multivariable regression analysis to investigate predictors of COC mean scores showed that only the age for the diabetes patients and insurance status for the hypertension patients act as the predictor of COC mean scores. As same as our study, Shin et al. (2021), have used multivariate regression analysis in their cross-sectional study to determine the related factors of COC in a sample diabetic patients at Seoul, Korea. They have showed that 3 categories of factors i.e. patients’ factors; clinic workforce factors and geographical factors including age, residential area, presence of disability, physician specialty, clinic location, hospitalization facility and distance between the patient location and their primary care clinic have significant correlations with the COC scores [8]. Stafford et al. (2023) in another study on the 381,474 patients suffering different conditions have reported that ethnic minority identity and socioeconomic deprivation have additive associations with lower continuity of care. They concluded that these results contribute to inequalities in experience and outcomes of patients [11]. Leniz and Gulliford (2019) in a national survey in Chile to investigate the continuity of care and delivery of diabetes and hypertensive care among regular users of primary care services have reported that COC is positively associated with age > 65 years, being female, retired, obese, high cardiovascular risk and widowed while negatively associated with educational level, smoking and physical activity [33]. Alazri et al. (2006), in another study in UK have showed that patients’ perceptions of continuity are influenced by several factors including a personal relationship between themselves and their healthcare professional, their own beliefs and behaviors, presence of diabetes, and the systems and structures of general practices [53].

Our findings documented a serious disruption in the continuity of care for chronic patients during the pandemic. This situation can intensify background diseases and impose a variety of negative outcomes to patients, families, and the whole community. Such negative outcomes could lead to a significant increase in the burden of chronic disease and health equalities globally [22]. It is obvious that this access reduction can lead to late diagnosis, inefficient treatment, and incremental trend of disease development [54]. Fekadu et al. (2021) in a review on the countries with limited resources have clarified that COVID-19 not only can led to higher risks among the elderly population and those with background chronic diseases but also it can act as a serious boundary against diagnosis, treatment, and prevention of chronic diseases [55]. Singh et al. (2022), also in a cross-sectional study conducted in several Asian countries, indicate that COVID-19 pandemic caused a poorer economic status, intensified the challenges in access to health care and worsened the chronic diseases symptoms and outcomes. Such side-effects are more tangible among rural and remote areas that can make the issue a global priority [56]. Yoon et al. (2022), in their qualitative study among micro, mezzo and macro level experts and policy makers in Singapore have demonstrated that COVID-19 made a variety of challenges in managing chronic diseases. These challenges are mainly because of limitations in direct relationships between the patients and health care providers, uncertainty in diagnostic clinical decisions due to protocol revisions and lack of access to pathological laboratories [40]. Therefore, applied interventions based on the local circumstances of each health system could be helpful here.

Serious attention to flexible and sustainable investments on global public health has been mentioned as a helpful strategy for this situation [31]. Recommendations can be focused on designing a model of care for chronic diseases which can assure the continuity of care during health disasters. Such a model should be able to facilitate the identification of high-risk patients and development of an applied plan for organizing chronic care and applying digital health for patient support. Community engagement for redesigning the health systems and attention to the community support, preparedness and surveillance of the health system also would be among considerable recommendations for health policy makers to ensure the COC for chronic patients during health crisis. Also, developing the tele-medicine infrastructures can be considered as an appropriate and applicable solution to manage the chronic non-communicable diseases. Parkinson et al. (2022) in their study have revealed the necessity for primary health care capacity building and continuity and comprehensiveness of chronic treatments now and in future. According to their findings, developing digital health, redesigning available models of care and applied research for identifications and interventions of the best solutions will be helpful [42]. Other approaches like strategic developing of Public-Private-Partnership for managing the chronic diseases and equal considerations to all the social and psychological aspects of non-communicable patients especially among the vulnerable groups should be taken into consideration.