Beliefs and practices among primary care physicians during the first wave of the COVID-19 pandemic in Baden-Wuerttemberg (Germany): an observational study

The novel coronavirus (SARS-CoV-2) which causes the disease COVID-19 was first recognized in the Chinese province of Wuhan, Hubei in December 2019 [1]. The virus quickly spread into other provinces of China, to Thailand, Japan, South Korea, the USA, and Europe [2]. In Germany, the Bavarian Health and Food Safety Authority confirmed the first patient infected with SARS-CoV-2 infection on 27 January 2020 [3]. The effectiveness and resilience of health systems have an impact on the ability of a country to contain a pandemic [4, 5].

In Germany the primary healthcare sector consists of all ambulatory care services [6] that are provided by office-based, mainly single-handed, private general practitioners/primary care physicians, general internists or paediatricians. Almost half of the ambulatory care physicians are primary care physicians, the other half are other medical specialists (e.g. cardiologists, lung specialist), thus secondary care provider. Individuals can choose their primary care provider or their medical specialist freely [6]. Primary care physicians are remunerated based on the fee-for-service model or are paid a salary in rare cases (around 16 percent). According to that, physicians receive a fee for each service they provide e.g. office visits, test, procedures, or other healthcare services [7].

After the first case of COVID-19 was detected in Baden-Wuerttemberg, Germany on 25 February 2020, the Association of Statutory Health Insurance Physicians Baden-Wuerttemberg (Kassenaerztliche Vereinigung Baden-Wuerttemberg (KVBW)) asked all patients with suspected SARAS-CoV-2 infection to contact their primary care physician by telephone prior to visit a doctor [8]. Therefore, in Germany primary care physicians were responsible for a substantial part of the medical treatment of patients with (suspected) SARS-CoV-2 infection, comprising diagnostic testing, identification of those in need of hospital care, doing home visits, and supporting patients who manage the disease at home. At the same time, Germanys primary care sector had to ensure medical treatment for patients without a SARS-CoV-2 infection to prevent undersupply and were responsible to contain the spread of the virus within their practices and other health care facilities (e.g. nursing homes) [9]. Although Germany has a reasonably strong primary care sector and a well-organized public health system [10], many challenges need to be addressed for the preventive measures adopted to be effective during the pandemic. A qualitative study conducted in Australia, Israel, and England, for example, showed many issues during the 2009/A/H1N1 pandemic: challenges in patient’s consultation e.g. high flow of patients who thought they were infected needed to be treated, overall patient segregation was difficult to maintain, supply of personal protective equipment (PPE) was limited, communication of policies and guidelines, and an increased workload had an impact on ability to contain the pandemic [11]. The influenza pandemic plan of Baden-Wuerttemberg (BW) [9], a region with about 11 million inhabitants in South-West Germany, states that patients should be treated within the primary healthcare sector as long as possible. Additionally, patients who need to be hospitalized should be referred to primary care as soon as their state of health allows it [9].

In BW a variety of ambulatory health care models (SARS-CoV-2 contact points), besides the regular primary care practices, were established in a short period during the first wave of the SARS-CoV-2 pandemic as part of a crisis management: 204 Subspecialised Primary Care Practices, 51 Fever Clinics, and 16 Testing sites (Status: June 2020) by primary care physicians in cooperation with the public health sector and the Association of Statutory Health Insurance Physicians (German: Kassenaerztliche Vereinigung Baden-Wuerttemberg (KVBW)).

This cross-sectional study was based on a paper-based survey in primary care physicians who worked in Subspecialised Primary Care Practices in BW, Germany as well as primary care practices who continued to provide care as usual during the first wave of the SARS-CoV-2 pandemic.

Out of 271 SARS-CoV-2 contact points 92 participated (16 Fever Clinics, 74 Corona-Subspecialised Primary Care Practices, and 2 Special Places for Corona-Testing) (responds rate 33.9%). Of the 400 invited primary care physicians 79 participated (responds rate 19.7%), 16 of those were excluded from the analysis since they indicated that they also worked for a SARS-CoV-2 contact point.

Table 1 shows that leads of Subspecialised Primary Care Practices were predominantly male (66.2%) and between 51 and 60 years old (40.5%), with a qualification of primary care medicine compared to other medical specialists. Almost 50% of the primary care physicians, were female and also predominantly between 51 and 60 years old. Most Subspecialised Primary Care Practices were located in places with a number of inhabitants between 5000 and 20,000, covering a catchment area between 15 and 30 kms. Primary Care Practices were mainly located in city centres with inhabitants between 5000 and 200,000. Most Subspecialised Primary Care Practices opened in March 2020, the first month of the SARS-CoV-2 pandemic in Germany. There was a difference between male and female physicians between the two groups (x² = 4.482, p = 0.034). Other sociodemographic factors such as age or professional qualification were not significant (Table 1).

The main goal of this study was to describe beliefs such as knowledge, practice, self-efficacy and fears among primary care physicians leading a Subspecialised Primary Care Practice compared to primary care physicians who “continued usual primary care practice” during the first wave of COVID-19 pandemic in Baden-Wuerttemberg, Germany. A quarter of all participating primary care physicians did not fear an infection with SARS-CoV-2 but were afraid of transmitting it to members of their families or colleagues. The majority of all participants was afraid of financial loss due to lost revenues. Acquiring knowledge about the new coronavirus disease was challenging but this changed during the pandemic and extending knowledge. Sources of knowledge varied but the Association of Statutory Health Insurance Physicians, the German Society for Hygiene and Microbiology, and medical journals represented the most important sources of information. The majority of primary care physicians of both groups felt confident in anamnestic and diagnostic procedures. Primary care physicians who led a Subspecialised Primary Care Practice were more confident compared to their peers. Hygiene regulations were implemented in all healthcare facilities. Physical separation was ensured mainly by different treatment rooms and waiting in front of the facility by both groups but the results of this study showed that leads of Subspecialised Primary Care Practice tended to introduce physical separation easier. Temporal separation was ensured via appointment allocation, overall fewer patients in Primary Care Practices or special consultation hours for patients with suspected infection. Subspecialised Primary Care Practice treated on average significant more patients with (suspected) COVID-19 compared to Primary Care Practices.

The results of this study showed that most participants did not fear an infection with the novel virus but expressed concerns regarding the possibility to spread it within their professional and private environment. It is unclear why some decided to lead a Subspecialised Primary Care Practice and some continued usual primary care practice. Interestingly, the majority of physicians who led a Subspecialised Primary Care Practice identified as male and were between 51 and 60 years old and therefore more at risk for a severe infection [13]. In Germany in general more than half of the primary care physicians are male (54.1%) [14] and are on average 55.4 years old [15]. We can only speculate about reasons of the higher participation in Subspecialised Primary Care Practice among older male physicians: Perhaps is has to do with gender differences in health oriented behavior in general. Further studies would be preferable to answer that delicate question.

The majority of both groups feared financial lose. This could be explained by the concept of fee-for-service, particularly physicians who continued to work in their own practices had overall less patients which may had an impact on the fear of financial lose. These results agree with those by Huston et al. [5]. In Australia and New Zealand for example were remuneration is mainly based on fee-for-service a rapid decrease in patient visits has led to severe financial losses [5]. The leads of Subspecialised Primary Care Practice in this study also feared financial loss. Because of the dynamic development of the Subspecialises Primary Care Practices and also the clarifying of the remuneration in the course it is unclear if results remain the same in a second survey.

In order to separate patients with potential infections they introduced special consultation hours (appointment allocation) and waiting times e.g. in front of the practice. Offering special consultation hours may had impact on their workload that was not adequately remunerated. In addition, waiting hours in front of the practice may had an impact on the decision of patients to consult their physicians at all. The specific concerns of primary care physicians should be taken into consideration since primary healthcare systems and public health systems rely on the mental and physical health of primary care physicians and their economic efficiency [16].

The majority used the Association of Statutory Health Insurance Physicians and the German Society for Hygiene and Microbiology as source of knowledge which provide an easy and accessible way of getting valid and processed information regarding a growing and changing knowledge base. Interestingly, almost half of the participants (between 36 and 42%) stated to listen to a podcast even though the majority of participants were in the age groups between 41 and 60 years. Podcasts or broadcasts are primarily used by the younger generation (between 14 and 29 years) [17]. Another reason might be the trust in a designated virologist subspecialised in Coronaviruses who chose to record an own podcast to inform the broader community about SARS-CoV-2. Interesting is that only half used information provided by professional societies.

The vast majority of primary care physicians in this study used official information provided by the Association of Statutory Health Insurance Physicians and the RKI. This may can be interpreted, as trust in official information channels by the participants. Nevertheless, various other sources of information were used additionally. This poses the questions if the participants probably felt like information of official channels may be not enough or if those sources may not suitable for the primary care sector. In addition, gathering knowledge was difficult for more than half of the participants at the beginning of the pandemic and was still evaluated as challenging by a third during the pandemic. This may made it difficult to be always up-to-date. The diversity of potential information resources and the need of being up-to-date probably had an impact on the perceived workload of primary care providers. Moreover, primary care physicians are in direct contact with patients with (suspected) SARS-CoV-2 infection and are therefore at high risk for nosocomial infections [18]. During a health crisis such as a global pandemic, primary healthcare providers need to be equipped with up-to-date-knowledge in order to practice safely and efficiently. Further, research needs to be conducted in order to evaluate which source of information is the most feasible for primary care providers and which is the preferred way of reviving information.

Self-efficacy regarding anamnestic and diagnostic procedures related to SARS-CoV-2 of primary care physicians increased over time during the first wave of the pandemic. This can be explained by the experience they gained during the first month of the pandemic. Physicians had to acquire knowledge on the novel virus first under the permission of the dynamic situation of the pandemic. For a second wave of SARS-CoV-2 pandemic primary care physicians may be better prepared since scientific as well practical knowledge improved during the first months of the pandemic. The findings of this study indicated that although self-efficacy increased over time in both groups, leads of Subspecialised Primary Care Practice felt more confident. This may be important in order to decide which structure of medical care and treatment is the most favourable during the second wave of the SARS-CoV-2 pandemic or other pandemics.

The results of our study showed that key challenges which were difficult to tackle during the 2009/A/H1N1 pandemic in Australia, Israel, and England such as segregation of patients with (suspected) infection [11] were easier implemented during this pandemic in Baden-Wuerttemberg, Germany in both settings. A study conducted in Germany during the influenza pandemic 2009/10 [16], for example, showed that changing their practice management in order to separate patients physically and in time was implemented by 74% and 38% of the participants, respectively. However, participants in this study [16] were part of the surveillance network of the German Society for Hygiene and Microbiology which may implied a selection bias. Nevertheless, physical segregation of patients was easier for primary care physicians who led a Subspecialised Primary Care Practice. Further research is needed to evaluated why this was the case.

First evaluations on accounting data have shown that seven out of eight COVID-19 patients (about 85%) were treated in an ambulatory setting [19, 20]. In our study, the average treatment capacity of patients with (suspected) SARS-CoV-2 infection varies between the different two groups. On average more patients were treated at Subspecialised Primary Care Practice.

Although the results of our study cannot be generalized, they may give a first impression on the workload primary care physicians had to manage in Baden-Wuerttemberg, Germany. As requested and expected more patients with (suspected) COVID-19 were treated in Subspecialised Primary Care Practice than in Primary Care Practices. The implementation of Subspecialised Primary Care Practice as well as the prevention measures in both settings may have contained the spread of the virus.

The results of this study showed that the Subspecialised Primary Care Practice implemented during the first wave of the SARS-CoV-2 pandemic in Baden-Wuerttemberg, Germany were a strategy to face the pandemic. Particularly, since leads of Subspecialised Primary Care Practice indicated that implementing physical separation of patients with potential SARS-CoV-2 infection was easier compared to those who continued working in their own practice. In addition, primary care physicians who lead a Subspecialised Primary Care Practice felt in general more confident in dealing with patients with COVID-19 infection. Although, primary care physicians rose to the challenges of the SARS-CoV-2 pandemic, addressing their fears is essential. Interventions such as adequate payment for COVID-19 care or loss of revenue due to the pandemic combined with measures that support the implementation of prevention measure not only in Subspecialised Primary Care Practice but also Primary Care Practices should be introduced to support the primary health care sector.

Future research should focus on strategies how primary care physicians can be better prepared for a pandemic and how to address mental, physical and financial challenges. This could be for example the expansion of adequately financially compensated points of care, support by tools for managing testing, communication with and care of patients, setting up paths of cooperation between primary care, hospital care, rescue service and health authorities. Primary care physicians will be stressed by the challenges of a prolonged response to the SARS-CoV-2 pandemic. Strengthening primary healthcare, particularly primary care physicians, is therefore of great importance.