Chronic care services disrupted during the COVID-19 pandemic

Since the onset of the pandemic, there has been a steady shift in the balance of chronic care delivery worldwide and many regular medical visits have led to delays, postponements, rescheduling or even cancellations¹⁴, as summarized in Table 1. A survey conducted by WHO, in 155 countries, showed that patients with chronic diseases did not have access to health services related to prevention, diagnosis, treatment and rehabilitation, which posed additional barriers to the effective management of chronic diseases during the unprecedented health crisis¹⁵. In addition, a large survey conducted on health professionals from 47 countries during the first wave of the pandemic showed a large reduction or even cancellation of many scheduled health appointments, and only 14% of them continued with a physical presence, while the majority of visits were converted into distance sessions²². According to the same research, the most common chronic conditions, the care of which was disrupted during the pandemic, were: DM 38%, COPD 9%, hypertension 8%, cardiovascular diseases 7%, bronchial asthma 7%, cancer 6%, and depression 6%²².

The PHC facilities around the world, in full alignment with the instructions of the WHO and the national health authorities, reorganized the provision of health services, turning it into almost monothematic and one-dimensional. Emphasis was placed on safe access and timely identification and isolation of suspected and confirmed cases of COVID-19, and as a result the provision of chronic care was largely neglected, leading many scheduled visits to postponements and cancellations^23-25. A recent OECD report, which included data from many countries around the world, showed an overall decline in conventional PHC services ranging from 11% in Norway to 51% in the US²¹. In the United Kingdom, during the period April to August 2020, there was a decrease of 20.8% in all scheduled appointments at the PHC²⁶ compared to the same period of 2019, while during the same time in Belgium, a country with the highest percentage of COVID-19 mortality in Europe, 25% of scheduled chronic care visits to the PHC were postponed and an appreciable number of visits were converted to digital^16,27.

In US, reductions in outpatient care visits reached 70%²⁸, while at the same time, in a study conducted during the first wave of the pandemic, there was an 81–90% reduction in regular laboratory re-examinations in two of the most common chronic diseases managed in PHC: DM and dyslipidemia. Also, a 52–60% reduction in the diagnosis and the initiation of new hypolipidemic and antidiabetic drug therapies was observed²⁴. In Brazil, according to a large study on patients with diabetes, the postponement of regular medical PHC visits and scheduled outpatient examinations were described among the main consequences of the COVID-19 pandemic (38.4%), while 40.2% of participants stated that they had neglected and had not scheduled a medical appointment to monitor diabetes since the onset of the pandemic²⁹.

As the priority of PHC services focused on controlling the COVID-19 pandemic, along with the management of chronic diseases, the provision of all preventive health services, including regular vaccinations, was significantly disrupted^30,3. Although there are few studies examining the effects of the pandemic on the vaccination of children and adults, a recent analysis showed that in 2020, compared to 2019, vaccination rates (with the exception of influenza vaccination, which may have increased³²), decreased by 60% in adults aged 19–49 years and by 83% in adults aged ≥65 years during the pandemic³³. Similar data were available from many countries around the world³¹, confirming the worrying WHO reports of a reduction in vaccination activities worldwide during the pandemic³⁴.

In addition to the postponements and cancellations of many scheduled PHC visits, a major disruption to the continuity of comprehensive provision of high-quality care to patients with chronic diseases during the COVID-19 pandemic was the significant reduction of referrals to specialized care. In the UK, the number of referrals from PHC to cardiology clinics decreased by up to 80%, during the period of the strict restrictive measures, while simultaneously the regular outpatient cardiologic care visits significantly decreased, with only a small number of them being replaced by digital visits⁸. Similar barriers to the provision of outpatient chronic care have been observed in many countries around the world including Greece, Italy, US, China and India¹⁵.

The entire landscape of cancer management in PHC, from prevention and early detection to the management of cancer in patients, was irreparably affected during the COVID-19 pandemic. Screening was severely affected and thus the identification and referral of suspected oncologic cases were greatly reduced^35,36. National cancer screening programs in the UK, Australia, France, US and other countries have been suspended or delayed due to the unprecedented health crisis^21,37. It is reported that in the US, at the peak of the pandemic in April 2020, the screening tests for breast, colon, prostate and lung cancer were lower by 85%, 75%, 74% and 56%, respectively, compared to the same period of 2019³⁸. Also, in a UK survey of 7500 people, almost half of the patients who experienced potential cancer symptoms (even worrying symptoms such as hemoptysis and unexplained palpable mass) avoided visiting a PHC professional³⁹. Finally, in many countries there have been delays, rescheduling, cancellations in performing laboratory (e.g. cancer markers) and imaging examinations (e.g. CT, MRI) in chronic oncology patients^36,40.

The impact of the pandemic on the treatment of acute cases was equally important. Undoubtedly, emergency departments (EDs) play a critical role in diagnosing and treating life-threatening conditions that may lead to severe disability or death, but during the pandemic their role has been significantly underestimated. Although people with chronic NCDs who show signs or symptoms of a serious illness need to seek immediate care, even during the pandemic, international empirical data reveal the opposite⁴¹.

In Italy, there was a dramatic decrease of 53% in patients who came to the ED in March 2020 and 63% in April 2020, compared to the same periods of 2019, and this decrease was with regard to emergency cases of all medical specialties and especially patients with CHD and myocardial infarction¹³, with the sole exception of an increase in attendance of patients with symptoms of the respiratory system (fever, cough, shortness of breath) that accompany the outbreak of the new coronavirus⁹. Data from US national registries showed that ED visits decreased by 42% to 50% in the first months of the pandemic compared to the pre-pandemic period²¹, while it is worth noting that the largest reductions were found in life-threatening acute events such as myocardial infarction (23%), stroke (20%) and hyperglycemic conditions (10%), which usually signal deregulation of chronic diseases⁴¹. According to a recent observational study from Greece, findings were quite similar, as a significant reduction in visits to the cardiology ED was observed in March (41.1%) and April (32.7%) of 2020, compared to January of the same year⁴².

Reasons that contributed to the disruption of chronic care during the COVID-19 pandemic

There are many reasons that contributed to the disruption of chronic care during the COVID-19 pandemic (Figure 2). Perhaps the most important reason for disrupting the continuity and quality of the chronic care provided was the change in the priorities of the health systems and the concerted effort of all stakeholders to reduce the extent of the unprecedented health crisis and to minimize its morbidity and mortality¹⁶. Indeed, the managerial and financial interest of health policy makers around the globe (Governments, Ministries of Health, Public Health Organizations) has been focused on combating the emergency of the pandemic and, as a result, the effective management of chronic diseases has been marginalized^8,22. The priorities changed, resource allocation was renegotiated and necessary logistical equipment (PPE, hospital and ICU beds, respirators), as well as human resources, were transferred not only from non-COVID to exclusively COVID^12,13,17, but also from primary to secondary and tertiary facilities, weakening further the already weakened PHC and dismantling its essential role in the effective management of the health crisis²³. Consequently, many non-emergency chronic care services have led to delays, postponements and cancellations, overturning the necessary continuity of chronic care^17,18.

Figure 2

Reasons for the disruption of chronic care during the COVID-19 pandemic

Since March 2020, when WHO declared the COVID-19 infection a pandemic⁶, local health authorities have made recommendations for staying at home and minimizing the movement of citizens, in order to slow the spread of SARS- CoV-2 and to reduce the burden on the healthcare system⁴¹. The UK government in order to raise awareness and encourage citizens to limit their social activities and contacts with the health system, organized and implemented an educational campaign with the main slogan: ‘Stay Home, Save Lives, Protect the NHS’⁸. A similar campaign was carried out in Greece by the National Organization of Public Health with the main message: ‘Stay Home. Stay Safe’, which indirectly prevented citizens from visiting health professionals except in urgent, life-threatening cases. In fact, global guidance on mitigation measures has placed particular emphasis on vulnerable populations, including patients with chronic NCDs³, risking comprehensive care, which requires regular interactions between patients and healthcare providers to educate patients, prescribe medication and treat potential physical or mental complications²³. In the same direction and in line with national recommendations, many scientific medical societies encouraged patients with chronic diseases to stay at home and visit the healthcare system only for emergencies^41,43.

As the number of cases with SASR-CoV-2 increased and the pressure on healthcare systems around the world escalated, specialists on infectious disease did not effectively respond on the increased needs of these patients, resulting in the urgent recruitment of several physicians of other specialties to assist in the management and treatment of COVID patients, without often the appropriate special training and preparation⁹. Consequently, during the pandemic due to the marked movements of doctors, nurses, and other healthcare professionals from non-COVID to COVID-19 jobs to support large numbers of suspected and confirmed cases, severe shortages of health personnel on chronic care were observed. In fact, special emphasis was given to the secondary and tertiary hospital facilities with simultaneous degradation of PHC^12,15. In the UK, for example, in June 2020 there were 1.8% fewer GPs in the PHC compared to June 2019²⁶, with similarly worrying findings from Wuhan, China¹⁷, and Brazil, which were expected to lead to rescheduling and cancellation of many chronic care services²⁹. In addition to the mandatory motivations of medical staff, quarantine, home isolation or even hospitalization of doctors and nurses, who were exposed to or infected with the new coronavirus, weakened further the healthcare system for non-COVID cases^3,12,17,37.

One of the main reasons for the reorganization of chronic care was the reluctance and fear of the general population and especially of the patients with NCDs to come to the health facilities to seek help, due to the increased risk of exposure and infection by SARS-COV-2^{8,11,12,16,22,28,42-45}. Indeed, from the very first stages of the pandemic, health facilities, especially hospitals, became high transmission hotspots of the virus, resulting in the re-adjustment of health services with an emphasis on minimizing the interactions between patients and healthcare professionals⁸. Overall, it is estimated that more than 40% of US adults have delayed or avoided seeking care due to severe pandemic anxiety and fear, with 12% referring to health emergencies or life-threatening conditions⁴⁶. In addition, in some cases, citizens were unable to access health facilities, either due to public transport problems or the inability to move due to the absence of relatives. In fact, the aforementioned situation was observed with increased frequency in the elderly or people with disabilities, who are more often plagued by multiple chronic comorbidities^9,17.

Consequences of chronic care delays during the COVID-19 pandemic

Unhealthy diet and lack of physical activity are the main modifiable risk factors responsible for chronic NCDs⁴. Restrictive measures such as social distancing, quarantine and lockdowns, adopted by many countries around the world to limit the spread of the new coronavirus, have had a negative effect on the daily habits of patients with chronic illnesses, adversely affecting, as a result, their management^3,13,14,23. More specifically, there was a decrease in physical activity levels, a significant increase in sedentary behavior and caloric intake, an increase in the consumption of alcohol and tobacco products, and a tendency to unhealthy foods consumption^{14,16,23,44,47-49}.

In France, a survey conducted during the first lockdown (April–May 2020) on a sample of approximately 37000 adults, found that 53% of participants reduced physical activity, 63% increased sedentary behavior, and 35% gained weight on average about 1.8 kg⁵⁰. In Greece, with the exception of leisure physical activity which significantly increased, all other forms of physical activity (work, transportation and sports) decreased drastically, with an overall decrease of 16.3%⁵¹. In addition, in a large study conducted in the early stages of the pandemic, among the recommended habits for the treatment of diabetes, physical activity was most affected and decreased for 59.5% of the respondents²⁹. The same study also found a significant increase in internet use and television watching, two habits associated with sedentary behavior, unhealthy lifestyle and consequently poor management of DM²⁹.

Furthermore, from the early stages of the pandemic there was reduced access to safe fresh food (e.g. fruit, vegetables and fish)⁵² and a worrying shift towards the consumption of packaged, junk and poor quality food⁴⁸. Indeed, there was an increase in calorie intake and consumption of unhealthy foods due to prolonged stay at home, increased involvement with digital media and psychological distress (anxiety, stress and insecurity)^50,52. As a result, the lack of physical activity and the alarming increase in sedentary behavior of patients with chronic diseases combined with the increased body weight due to poor diet during this unprecedented health crisis may lead to long-term adverse effects not only on physical but also on mental health^16,51,53.

Comprehensive care and continuous, regular clinical monitoring of patients with chronic NCDs are essential to maintain compliance with medication. The reduction in medical visits and the consequent difficult communication between patients and the healthcare team, in combination with the quarantine measures that exacerbate the already existing problems of access and universal coverage, had significant implications for medication adherence^3,54. The initially conflicting emerging clinical trial results regarding the management of chronic patients infected by SARS-CoV-2, combined with often unreliable information spread by media, led to the adoption of dangerous practices by chronic patients who decided to self-manage their medication. For example, in March 2020 there were reports of a possible negative effect of angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs) (two of the most common classes of antihypertensive drugs) on the risk of infection and severity of COVID-19 infection, which led many patients to discontinue their treatment^54-56. This led the European Society of Cardiology and national cardiology societies to publish clarifying guidelines about the seamless continuation of antihypertensive therapy, addressed to both physicians and patients^56,57.

Due to the adoption of unhealthy daily habits, delayed seeking help and non-compliance with the recommended treatment during the pandemic, many patients with underlying diseases will experience a worsening of their condition and inevitably negative short-term health consequences¹³. Although it is not certain that the morbidity and mortality of patients with chronic diseases will immediately increase as a result of the systematic neglect of chronic care and postponed re-examinations, it is considered almost inevitable in the long-term that a significant number of patients who would normally have been diagnosed and treated earlier may present at the rescheduled visits – or even worse in EDs – with unregulated chronic diseases, acute complications and life-threatening conditions (e.g. myocardial infarction, stroke, hypoglycemia, diabetic foot, peripheral vascular disease)^18,24,41. A large study among patients with diabetes in Brazil indicated that among the main reported effects of the COVID-19 pandemic was the elevated (59.4% of participants) blood glucose levels, as well as greater variability (31.2%) compared to the pre-pandemic period²⁹. Similarly, the results of large multicenter retrospective observational studies from US and Korea with DM found that social distancing measures adversely affected patients’ glycemic control with a significant increase in HbA1c levels^58,59. In addition, even worse were the results of observational studies conducted in Italy, US and other European countries, which indicated that mortality related to acute heart attack has almost tripled due to delayed health visits^60-62.

In addition, the impact of the pandemic and measures to limit its spread on patients with chronic psychiatric disorders are significant. Indeed, reduced social interactions have led many people, especially the elderly, to loneliness and mental health disorders, such as depression and generalized anxiety disorder⁶³. In fact, the most significant impact was on patients with pre-existing mental illness, however patients with NCDs were also greatly affected^3,64. Emotional disorders, loneliness, and social isolation have been associated with poorer health outcomes, including a wide range of health indicators from increased use of health services to increased overall mortality rates⁶⁵.

The real concern of the global medical community is the long-term consequences of delayed care seeking, which are not yet visible^3,24 (Figure 3). Indeed, delays in the diagnosis and poor management of patients with chronic conditions during the pandemic may lead to an increase in mortality rates that are not directly related to COVID-19 infection, especially in patients with oncologic or cardiovascular diseases^26,39,66,67. In fact, delayed cancer diagnoses and treatments may affect the survival rates of cancer patients^21,67,68. Researchers in the UK have suggested that cancer deaths may increase by up to 20% a year after a crisis due to delayed diagnosis and treatment^67,69, while a study in France concluded that delayed diagnoses could lead to excess mortality of 10–15% per month of delay⁷⁰. Considering that during the COVID-19 pandemic there were several reports of excess mortality, where many of the deaths unrelated to confirmed or possible COVID-19 cases may have been attributed directly or indirectly to the pandemic, one can assume that the serious effects of the systematic neglect of chronic care have already begun to appear⁴¹.

Figure 3

Disrupted chronic care short-term and long-term consequences

On the other hand, social isolation and the reduction of industrial production resulted in the reduction of air pollution levels and carbon dioxide emissions during the lockdown period^71,72. Previous studies have shown that even a mild, short-term improvement in air quality results in a reduction in mortality and morbidity rates in patients with chronic respiratory and cardiovascular disease^73,74. Therefore, the real overall impact of the positive and (short-term and long-term) negative effects of the unprecedented health crisis on the management of patients with chronic NCDs needs to be further investigated in future studies.

At this point, it is worth noting that the effects of the pandemic are expected to be more severe in chronic patients with low socioeconomic status. For socially vulnerable groups, it has been argued that the pandemic takes on the characteristics of a syndemic that interacts and exacerbates existing NCDs and the prevailing harmful inequalities of social determinants of health⁷⁵. Although during the first phases of the pandemic, COVID-19 had been characterized as a socially neutral disease^75,76, which did not make discriminations and affected both the poor and the rich, a more detailed study of epidemiological data reveals that not all people are affected proportionally, but there are clear differences that reflect the already existing health inequalities which plague the world population^75-79. In fact, socially vulnerable groups, ethnic minorities and other marginalized populations (such as the homeless and prisoners) are called upon to confront the new coronavirus from a different starting point⁸⁰. This, combined with the fact that poorer populations are more likely to engage in unhealthy habits (e.g. smoking and alcohol consumption)⁸¹, to have underlying chronic diseases and to manifest them in a more serious form and at a younger age (which are known risk factors and predispose them to severe disease, complications and increased mortality from COVID-19 infection)^76,78,81-83, to have more barriers in accessing chronic care services and to be characterized by lower level of health literacy and digital literacy, indicate the increased vulnerability of these populations to the synergistic effects of the pandemic^14,46,84.

Health systems adjustments and future perspectives regarding the continuity of chronic care

Health systems around the world have tried to adapt to new and unprecedented conditions and to ensure the continuity of chronic care, the interdisciplinary nature of the PHC team and the observance of social distancing measures^22,57. Although well-known for many years, the widespread implementation of telemedicine and self-monitoring have been taking place due to SARS-COV-2 induced health crisis and, at present, they may have become the main ways of managing chronic diseases in most countries of the world, widely accepted by both patients and healthcare professionals^21,40.

Telemedicine facilitates the patient’s remote contact with the PHC team and it is an effective adjunct in the management of chronic diseases, as it leads to improved quality of life and reduced morbidity and mortality in chronic patients^85,86. Indeed, a variety of daily medical practices, such as diagnostic, treatment and rehabilitation services, follow-up, electronic medication prescriptions, interpretation of laboratory and imaging tests, psychological support sessions, information and awareness-raising activities can take place using telemedicine (e.g. by telephone or video) in non-emergency situations^{9,14,17,53,87}. According to the CDC, in the US, in the first quarter of 2020, the number of tele-visits increased by 50%, compared to the same period in 2019, while it is worth noting that most appointments came from patients seeking treatment for non-COVID-19 diseases⁴⁵.

This increase in telemedicine use is estimated to have offset about two-thirds of the total volume of neglected chronic care visits during the COVID-19 pandemic⁸⁸. The significant decrease in total visits, despite the simultaneous increase in remote sessions, indicates the wide scope of deferred care during the first months of the COVID-19 pandemic⁸⁹. Although some deferred care represents outpatient care that could be postponed without immediate risk, these results also support concerns that chronic illness management may be seriously delayed⁸⁸.

Self-monitoring was another practice, which gained significant ground during the COVID-19 pandemic in the management of chronic diseases in PHC⁸⁷. Indeed, it has been shown that regular measurement of blood pressure and close monitoring of other modifiable risk factors (smoking, diet, exercise) at home by patients, provided that they have first procured the appropriate equipment and have been trained in its proper use, in combination with the parallel distance counseling by members of the interdisciplinary PHC team, can lead to the proper regulation of chronic diseases, early diagnosis of complications and increased compliance with medication^87,90,91. Similar practices have been adopted for other chronic diseases such as continuous monitoring of blood glucose levels for patients with DM^58,87,92,93 and empowerment of patients with HF⁸.

Finally, in order to limit the frequent visits of chronic patients to healthcare facilities and focusing on the safety of both patients and healthcare staff, an intensive and targeted effort was made to use intangible electronic medication prescription and even repeated for long periods of time, during the strict restrictive measures^16,52,53,94. The innovations introduced to address the COVID-19 pandemic need to be maintained and integrated into conventional practices so that health systems are more resilient to future public health emergencies and are able to meet the challenges of aging societies and the growing burden of chronic diseases so as to improve the quality of services provided.

In fact, the COVID-19 pandemic demonstrates more than ever the importance of placing PHC at the core of health systems, both in managing the unexpected increase in demand and in maintaining continuity of care for all. Strengthening health services so that they are better equipped (both material and human resources) to prevent, diagnose and manage NCDs in the future and under any circumstances is a guarantee of success²¹. A strong PHC – organized in interdisciplinary teams and with innovative roles for health professionals, integrated with sustainable community health services, equipped with digital technology and well-designed work incentives – helps a successful response of health systems to be achieved^14,17,26,95. Especially in the post-COVID era, PHC can be the pillar of organization and reconstruction of the ailing health system, to meet the increased health needs of the population^9,12.

It is worth mentioning the significant contribution of medical students in times of health crisis. It is their deep conviction that they have already developed a solid basic knowledge and thus they are more prepared and helpful than any other group of volunteers that could be trained to support PHC professionals⁹⁶. Besides, from the early stages of the pandemic, despite the global instability and the disruption of medical education, the desire of medical students to make a practical contribution to the pandemic response (including NCDs management) was remarkable⁹⁷, although further research is needed in the field to determine the exact role they can play in terms of safety (both their own and that of patients)⁹⁸.

Strengths and limitations

To the best of our knowledge, the present study is the first attempt to analyze the diverse direct and indirect effects of the COVID-19 pandemic on the management of patients with chronic diseases in PHC, and this is a strength of the study. However, there are some limitations to be mentioned. First, the narrative aspect of this review is a limitation. The data used were drawn from heterogeneous registries, mostly retrospective observational studies, which differed considerably in design, methodology and endpoints, while some data used came from lower-on-the-pyramid hierarchy types of studies (editorials, viewpoints, commentaries). This heterogeneity of the data as well as the overwhelming volume of peer reviewed literature due to COVID-19 make a systematic review very difficult to perform⁹⁹. Second, the inclusion of articles written only in Greek and English, the exclusion of gray literature sources and preprints archives and the search in only two databases may have limited the range of data examined and analyzed in this narrative review.