Only at the beginning of the COVID-19 pandemic, an increase was observed in consultations for COVID-19-like symptoms, likely due to fear and uncertainty concerning COVID-19. A decrease in consultation rates for other health problems unrelated to COVID-19, followed the peak in consultations for COVID-19-like symptoms, after which the consultation rates remained consistently lower than in 2019, except for the summer months in which the virus was less active. Furthermore, there was a slight shift in the health problems presented at OOH services. There are several possible explanations for the decrease in consultations rates for these other health problems: fear of contamination at healthcare locations, the overall belief that GPs and other health professionals were overloaded [8, 15, 18, 25], and patients were asked to avoid care in general when possible. Zhang (2020) argued that fear for contamination, especially among vulnerable people, had severe consequences: more avoided care and consequently more deaths [15]. A similar decline in consultation for these other health problems as observed in this study was observed in Belgium, while consultations with OOH services for patients at risk for COVID-19 were much higher [18]. This might be related to differences between these countries in the organization of primary (COVID-19) care and the availability of COVID-testing facilities.

Changes in the use of OOH services differed between age groups. Babies and young children were frequent users of OOH services. However, after an initial peak at the start of the pandemic, their overall use of care declined considerably for other health problems. A similar effect was found in GP care during office hours [9]. During the second wave of COVID-19 infections in the Netherlands (Phase 3), babies and young children had fewer consultations for COVID-19-like symptoms than in 2019, such as respiratory infections, fever, and coughing. The lower use of care is likely to be associated with policy measures that were taken to prevent the spread of the virus (i.e. lockdown measures), including the closing of daycare facilities, schools, social distancing, and a general decline in social activity. This may have eliminated potential sources of infection, not only for COVID-19 but for all respiratory infections, which are often the reason to consult the OOH services for young children. A similar pattern was observed for the yearly epidemic of respiratory syncytial virus (RSV) in young children. Circulation of RSV halted after the introduction of containment measures for COVID-19 [26].

In contrast, consultation rates for older adults (≥45 years) remained at a similar level as in 2019 for consultations for health problems unrelated to COVID-19. In GP care during office hours a decrease in consultations was found for patients aged 70 years and older [9]. For OOH services we did not observe the same effect. Despite the overall decrease in the use of OOH services, this did not occur for older adults, indicating the continued and possibly increased need for acute care by these patients. This might be related to avoided or delayed care elsewhere in our healthcare system. Routine check-ups by GPs and medical specialists were canceled or delayed, increasing the risk of exacerbations [5]. Moreover, there was an increase in consultations for COVID-19-like symptoms, which was in line with the overall higher infection rates, more severe illness, and higher mortality rates in older adults [27,28,29].

As a result of the COVID-19 pandemic, more consultations were remote, by phone, video, or digital. The triage before consultation with OOH services was more strict, applying a higher threshold for healthcare. Therefore, high urgency levels were assigned less quickly and more consultations were remote. The study of Morreel et al. (2020) also showed an increase in remote consultations in OOH care [18], however, the increase of remote consultations seemed even more prominent in the Netherlands. The implementation of, and the experiences gained, using remote consultations may benefit OOH services in the care they provide after the pandemic, keeping in mind the long-term health outcomes when using remote consultations. Some claim that the care provision became more efficient, leaving more time for consultations with patients with more severe complaints [7]. Others claim that symptoms of more serious illness might be missed and that remote consultation will lead to less person-centered care [18, 19]. Therefore, the long-term effects of this increase in remote consultations should be monitored.

During the period studied, the continued use of OOH care by older adults, while the use decreased among other ages, may suggest an effect of avoided or delayed care in other parts of the healthcare system on OOH services. Further research is necessary to study the underlying mechanisms explaining the use of OOH services in relation to decreased GP care during the day and specialized care as a result of the COVID-19 pandemic. The current study does show that the reduction in the use of OOH services was mainly for younger patients. Further analyses are necessary to provide more insight into the use of care of these specific patient groups who are frequent users of OOH services, such as older adults, people with chronic conditions or babies, and young children.

Strengths and limitations

A strength of this study was the use of routinely recorded healthcare data from about two-thirds of the Netherlands, encompassing a joint population of 12 million individuals, representative of the whole country. A limitation of the study was the lack of data on confirmed diagnosis for COVID-19 and limited means to validate the selection of ICPC1-codes that we used to identify consultations for COVID-19-like symptoms, which was theory-driven. We provided an estimate by selecting consultations for COVID-19-like symptoms in 2020 and comparing the healthcare for these health problems with the same period in 2019. However, while interpreting the results, one should consider that COVID-19 did not only add to the regular number of consultations for these symptoms but also replaced them.

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