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Remote assessment of respiratory tract infections (RTIs) has been a controversial topic during the fast development of private telemedicine providers in Swedish primary health care. The possibility to unburden the traditional care has been put against a questionable quality of care as well as risks of increased utilization and costs. The COVID-19 pandemic has contributed to a changed management of patient care to decrease viral spread, with an expected shift in contact types from in-person to remote ones.
The main aim of this study was to compare health care consumption and type of contacts (in-person or remote) for RTIs before and during the COVID-19 pandemic. The second aim was to study whether the number of follow-up contacts after an index contact for RTIs changed during the study period, and whether the number of follow-up contacts differed if the index contact was in-person or remote. A third aim was to study whether the pattern of follow-up contacts differed depending on whether the index contact was with a traditional or a private telemedicine provider.
The study design was an observational retrospective analysis with a description of all index contacts and follow-up contacts with physicians in primary care and emergency rooms in a Swedish region (Skåne) for RTIs including patients of all ages and comparison for the same periods in 2018, 2019, and 2020.
Compared with 2018 and 2019, there were fewer index contacts for RTIs per 1000 inhabitants in 2020. By contrast, the number of follow-up contacts, both per 1000 inhabitants and per index contact, was higher in 2020. The composition of both index and follow-up contacts changed as the share of remote contacts, in particular for traditional care providers, increased.
During the COVID-19 pandemic in 2020, fewer index contacts for RTIs but more follow-up contacts were conducted, compared with 2018-2019. The share of both index and follow-up contacts that were conducted remotely increased. Further studies are needed to study the reasons behind the increase in remote contacts, and if it will last after the pandemic, and more clinical guidelines for remote assessments of RTI are warranted.
Respiratory tract infections (RTIs) are one of the most common reasons for contacts in Swedish primary care [
The COVID-19 pandemic has led to a fast shift in the modality by which patients and health care communicate, from in-person to remote contacts (primarily to minimize the SARS-CoV-2 spread), despite insufficient guidelines and conflicting evidence regarding its impact on health-related outcomes [
The first aim of this study was to analyze the change in number and percentage of in-person contacts and remote contacts, respectively, for RTI between January-June 2018/19 and January-June 2020. The second aim was to study whether the number of follow-up contacts after an index contact for RTI changed during the study period, and whether the type and number of follow-up contacts differed between index in-person contacts and index remote contacts. A third aim was to study whether the pattern of follow-up contacts differed depending on whether the index contact was with a traditional care provider or a private telemedicine provider.
The study design was an observational retrospective analysis describing physician contacts in primary care and at hospital emergency rooms of patients with an index contact for RTIs in January-June 2020, 2019, and 2018. The first 6 months of 2020 were chosen to study the development of RTI-related contacts during the start of the COVID-19 pandemic. The monthly development of physician contacts in 2018 and 2019 was used to illustrate seasonal patterns in the absence of a pandemic. The study was set in the Swedish region Skåne, which is the third largest region (1.4 million inhabitants), with a wide geographical variation including large, middle-sized, and small cities as well as rural areas. The region was relatively mildly hit by the first wave of the pandemic. In the first half of 2020, the number of laboratory-confirmed COVID-19 cases per 100,000 inhabitants was 219; 110 patients with COVID-19 received intensive care and 248 inhabitants died with a COVID-19 diagnosis. This may be compared with one of the worst hit regions in Sweden—Stockholm (2.4 million inhabitants), which recorded 798 confirmed cases per 100,000 inhabitants, 894 intensive care patients, and 2,331 deaths in the same period [
The study population consisted of all individuals with a registered address in Skåne (Region Skåne) on December 31 in 2017, 2018, or 2019 (according to the Swedish population register held by Statistics Sweden). For this population, data on in-person or remote contacts with care providers located in Skåne (public or contracting with the region) were collected from the regional health authority’s care register “Region Skånes Vårddatabas” (RSVD). The data included information on date of contact, type of contact (in-person/remote), and up to 8 diagnoses for all care contacts in the period August 2017 to July 2020. Data for the same population located in Skåne on contacts with private telemedicine providers, which are formally located in other regions (Region Sörmland and Region Jönköping) and therefore report to care registers in these regions, were sourced from the health authorities in those regions and a register of extra-regional care contacts of inhabitants in Skåne.
In the analysis, we distinguished between physician contacts that were in-person or remote (ie, consultations by telephone, video, or asynchronous chats). We further distinguished between remote contacts with traditional providers (defined as all primary health care centers and hospital emergency rooms) and remote contacts with pure on-demand telemedicine providers. Such telemedicine services were offered by the private companies Kry, Capio Go, Min Doktor, Doktor.se, Doktor 24, Medicoo, Accumbo. During the study period, traditional care providers mainly offered remote contacts via phone and to some extent by asynchronous chats, whereas private on-demand telemedicine providers primarily offered asynchronous chats or video calls. We linked the data from different registers using pseudo-anonymous individual identifiers provided by Statistics Sweden. The linked data set included all contacts with traditional and private telemedicine providers made by the study population.
Primary outcome variables were
The study included index contacts occurring during any of the following periods: January 1, 2018-June 30, 2018; January 1, 2019-June 30, 2019; and January 1, 2020-June 30, 2020. We studied the total number of index contacts per 1000 inhabitants, and the total number of follow-up contacts per 1000 inhabitants and per index contact. In addition, we reported the number of unique patients hospitalized with an RTI diagnosis according to
ICD-10a diagnosis codes of relevant diagnoses [
Diagnosis code ICD-10 | Diagnosis group |
J00-J06 | Acute upper respiratory infections |
J10-J18 | Influenza and pneumonia |
J20 | Acute bronchitis |
J22 | Unspecified acute lower respiratory infection |
R05 | Cough |
R06.0 | Dyspnea |
R50 | Fever of other and unknown origin |
B34.2 | Coronavirus infection, unspecified site |
B39 | Viral infection of unspecified site |
B99 | Other infectious disease |
H65-H70 | Otitis media and mastoiditis |
U07.1 | COVID-19, virus identified |
U07.2 | COVID-19, virus not identified |
ZV100 | Health care intervention related to coronavirus infection (ICD-10-SEb) |
aICD-10: International Classification of Diseases.
bICD-10-SE: the Swedish version of ICD 10.
Definitions of the outcome variables.
Type of contact | Definition | Subtype of contact |
Index contact | The first physician contact with a registered respiratory tract infection–relevant diagnosis after a period of no such diagnosis for at least 181 days. | In-person contactsa |
Remote contacts with a traditional providerb | ||
Remote contacts with a private telemedicine providerc | ||
A follow-up contact | A physician contact (regardless of diagnosis) within 30 days after the index contact. | In-person contactsa |
Remote contacts with a traditional providerb | ||
Remote contacts with a private telemedicine providerc |
aIn-person contacts at a primary care center or a hospital emergency room.
bRemote contacts with a traditional provider (a primary health care center or a hospital emergency room).
cRemote contacts with a private telemedicine provider (offering on-demand services).
Health care contacts were summarized by month and type of contact. Data were analyzed graphically to compare the development of index and follow-up contacts using monthly averages for the 3 study periods (January-June 2018, January-June 2019, and January-June 2020). Regression-based unpaired
This research and the individual-level data compilation have been approved by the Ethical Regional Review Board in Gothenburg (Dnr: 068-18) and Swedish Ethical Review Authority (2020-02405).
Number of index and follow-up contacts by year.
Contacts per 1000 inhabitants | Year | ||||||
|
2018 | 2019 | 2020 | ||||
Index contacts (total) | 107,330 | 95,955 | 87,125 | ||||
|
79.82 | 70.44 | 63.23 | ||||
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Share in-person | 0.92 | 0.90 | 0.74 | |||
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Share remote (traditional) | 0.04 | 0.04 | 0.16 | |||
|
Share telemedicine | 0.04 | 0.06 | 0.10 | |||
Follow-up contacts (total) | 52,370 | 49,399 | 57,253 | ||||
|
38.95 | 36.27 | 41.55 | ||||
|
Share in-person | 0.63 | 0.62 | 0.46 | |||
|
Share remote (traditional) | 0.34 | 0.34 | 0.47 | |||
|
Share telemedicine | 0.03 | 0.04 | 0.07 | |||
Hospitalizations/1000a | 4.75 | 4.16 | 5.12b | ||||
Populationc | 1,344,685 | 1,362,163 | 1,377,826 |
aNumber of contacts per 1000 inhabitants in the population.
bWhen subtracting diagnoses directly related to COVID-19, the number of hospitalizations/1000 is equal to 3.25.
cThe population includes all individuals with a registered address in Skåne (Region Skåne) on December 31 the preceding year (according to the Swedish population register held by Statistics Sweden).
Number of follow-up contacts per index contact (by type of contact).
Index and follow-up types | Year | ||||||
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2018 | 2019 | 2020 | |||
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All | 0.49 | 0.51 | 0.66 | |||
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All | 0.48 | 0.50 | 0.60 | |||
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In-person | 0.30 | 0.31 | 0.30 | |||
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Remote (traditional) | 0.16 | 0.18 | 0.27 | |||
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Telemedicine | 0.01 | 0.01 | 0.02 | |||
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All | 0.73 | 0.75 | 0.90 | |||
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In-person | 0.37 | 0.37 | 0.29 | |||
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Remote (traditional) | 0.35 | 0.38 | 0.58 | |||
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Telemedicine | 0.01 | 0.01 | 0.02 | |||
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||||
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All | 0.49 | 0.54 | 0.69 | |||
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In-person | 0.30 | 0.33 | 0.28 | |||
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Remote (traditional) | 0.05 | 0.06 | 0.14 | |||
|
Telemedicine | 0.13 | 0.15 | 0.26 |
While the number of remote contacts with private telemedicine providers was slightly higher in comparison to previous years already in January 2020, the number of remote contacts with traditional providers in January to February was at the same level from 2018 to 2020. Between February and March 2020, there was a substantial increase in the number of remote contacts in comparison to previous years for both provider types. However, for private telemedicine providers, the increase was only temporary, and it was smaller (in both absolute and relative terms) than that for traditional providers. Although the number of remote index contacts with traditional primary care providers decreased slightly after April, it remained more than twice as high as in January.
Index contacts by year, month, and type of contact. (A) The number of index contacts per 1000 inhabitants and (B) the share of the index contacts that were conducted remotely. The number of index contacts per 1000 inhabitants decomposed by (C) in-person and (D) remote contacts (independent of provider).
Remote index contacts by year, month, and type of provider. Graphs present the number of remote index contacts with traditional providers and remote contacts with private telemedicine providers separately.
Monthly follow-up contacts, 2018-2020.
Difference in the number of contacts within 30 days per index contact.
Type of index contact | Type of follow-upa |
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|||||
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All | In-person | Remote (traditional) | Telemedicine | χ22 |
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All | 0.25 (<0.001) | –0.032 (<0.001) | 0.24 (<0.001) | 0.037 (<0.001) | 5437 (<0.001) |
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|
In-person | 0.19 (<0.001) | –0.029 (<0.001) | 0.21 (<0.001) | 0.012 (<0.001) | 2775 (<0.001) |
|
|
Remote (traditional) | 0.17 (<0.001) | –0.080 (<0.001) | 0.24 (<0.001) | 0.014 (<0.001) | 372 (<0.001) |
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Telemedicine | 0.20 (<0.001) | –0.0087 (<0.001) | 0.13 (<0.001) | 0.16 (<0.001) | 645 (<0.001) |
|
a
The differences in the average number of follow-up contacts per index are obtained from linear regression models. Each coefficient represents the difference in the average number of follow-up contacts per index contact between March to June in 2020 and the same period in 2018 and 2019.
The first row, which considers all contacts irrespective of type, shows that the average number of follow-up contacts per index contact increased by 0.25 in 2020 compared with the same period in previous years. The composition of follow-up contacts also changed, with fewer in-person and more remote contacts. The increase was especially strong for follow-up contacts with traditional providers: the increase of this type of contact was of similar size as the total increase. The increase of 0.037 follow-up contacts with private telemedicine providers thus almost offset the decrease of 0.032 in-person follow-up contacts.
Looking at the results by type of index contact, the total number of follow-up contacts per index contact (subcolumn All) increased by a similar amount for all types of index contacts. (Note that the change for the All category [0.25] is larger than the changes for each type of index contact [0.17-0.20]). This is due to the change in the composition of index contacts illustrated in
The increase in the total number of follow-up contacts per private telemedicine index (presented in the fourth row) is of similar size as the increase in telemedicine follow-up contacts. Thus, the increase in remote follow-ups with traditional providers was offset by a decrease in in-person follow-up contacts.
The total number of index contacts for RTIs decreased in spring 2020 compared with the corresponding periods in 2018 and 2019. This pattern may partly be explained by the governmental decision in the spring of 2020 to temporarily remove the mandatory sick certificates necessary after the first sickness week [
The share of index contacts conducted remotely increased substantially, particularly for traditional care providers. The increase in remote index contacts peaked in March 2020 for both traditional and private telemedicine providers and remained high for traditional care providers until the end of our study period (June 2020). With regard to follow-up contacts, the pandemic spring 2020 was associated with both an increase in the number of follow-up contacts per index and an increasing share of remote follow-up contacts, regardless of whether the index contact was conducted in-person or remotely.
Already before the pandemic, traditional care providers provided more follow-up contacts after remote index contacts than after in-person index contacts compared with private telemedicine providers. As the composition of the index contacts with traditional providers during the pandemic shifted toward a larger share of remote contacts, part of the increase in the total number of follow-up contacts is therefore probably due to traditional providers’ habit of offering more follow-up contacts after remote index contacts. Furthermore, most patients with chronic diseases (eg, heart failure or chronic obstructive pulmonary disease) were assessed remotely during the spring of 2020 but needed increased attention in case of simultaneous symptoms for RTIs. Providers may also have been more generous with offering follow-up contacts due to the uncertainty surrounding diagnoses during the pandemic spring, before testing for SARS-CoV-2 was widely available. During the same period, elderly were generally more cautious in booking in-person contacts and preferred to contact their physician remotely if possible.
The difference in the number of follow-up contacts per index contact between 2020 and the previous years shown in
Whether the increase in follow-up contacts during the first wave of pandemic is a concern for future policy depends on the reasons behind this increase. If this reflects a change in the type of managed complaints or the severity of the cases due to the pandemic, the pattern is likely only relevant for a pandemic state. By contrast, if the trend primarily reflects a change in practice—among providers and patients—when it comes to adopting a digital/remote-first approach, the change may have lasting impacts also after the pandemic. While the increase in consultations with private telemedicine providers is demand driven, the increase in the number of remote contacts within traditional providers likely reflects a change in practice among providers (rather than among patients). The larger number of follow-up contacts for remote index contacts could possibly indicate that management of RTIs might be challenging using a remote contact for the initial symptom assessment, leading to more follow-up contacts to ensure patient safety.
The rich and detailed administrative data are one of the main strengths of the study. Using different register sources, we managed to collect information from all telemedicine providers available during the period studied. The study design, including data for all inhabitants in Skåne representing all sociodemographic and geographic varieties, indicates a high generalizability of the results.
There are also limitations of these data. We have no available data on symptom severity that can confirm or dismiss the hypothesis that the severity of symptoms managed by different providers may differ. There is variation in the number of registered diagnoses between data sources, providers, and types of contacts (see
Missing information on diagnoses implies that there is a risk that a contact is erroneously classified as an index contact because an actual RTI episode during the wash-out period has not been registered as such. It may also lead to an underreporting of actual index contacts if there is no registered diagnosis at all during an episode. Diagnosis registration is an administrative task that physicians may fail to perform consistently for follow-up contacts, mainly due to lack of time but also because the diagnosis is already documented in the electronic medical journal after the initial contact. We estimate these possible registration bias as a minor risk, due to administrative demands in the study region. Specifically, care givers in the region have financial incentives to register diagnoses, as the case-mix adjustment formula used in the regional reimbursement model relies on diagnoses registered in the electronic medical journal. Simply put, every unique diagnosis registered for a patient increases the expected reimbursement.
Because of the risk that physicians may fail to consistently register diagnoses for follow-up contacts, we included all follow-up contacts regardless of diagnosis. This means that some of the follow-up contacts may not have had any association with the index contact. However, as the same approach was used for all years and types of contact, the effects on the comparisons are likely small.
Prior to the SARS-CoV-2 pandemic, telemedicine was implemented at a low pace by traditional providers, both in Sweden and internationally [
The number of hospitalizations for RTI-relevant diagnoses was higher in 2020 compared with previous years, but when excluding diagnoses directly related to COVID-19, the number of hospitalizations was substantially lower in 2020. Previous studies have shown that the number of hospitalizations for acute cardiovascular conditions [
Compared with 2018 and 2019, there were fewer index consultations for RTIs but more follow-up contacts, both per 1000 inhabitants and per index contact, in 2020. The share of both index and follow-up contacts that were conducted remotely increased, in particular for contacts with traditional care providers. The share of contacts supplied by private telemedicine providers only increased temporarily. Hence, it seems that the COVID-19 pandemic contributed to an increased number of remote physician contacts and follow-up contacts for RTIs. This could indicate that patients with RTI needed to be reassessed more often when the physician did not have the possibility to examine the patient in-person. Further studies are needed to study the reasons behind the increase in remote contacts, and if it will last after the pandemic, and more clinical guidelines for remote assessments of RTI are warranted.
Data Source and Variable Definitions.
Difference-in-Differences Analysis.
Region Skånes Vårddatabas
respiratory tract infection
This work was funded by Jan Wallanders and Tom Hedelius stiftelse and Tore Browaldhs stiftelse (Grant P19-0064), the Swedish Research Council for Health, Working Life and Welfare (FORTE; Grant 2019-00123), Adlerbert Research Foundation, and Foundation for Economic Research in West Sweden.
All authors contributed to data analysis, drafting, and revising the article; gave final approval of the version to be published; and agree to be accountable for all aspects of the work.
None declared.