This study showed the impact of the COVID-19 pandemic on general practitioner care for patients with asthma and COPD, both in GP practices (during office hours) and at OOH services, in terms of contact rates, how the care was provided, and the urgency levels of contacts with OOH services. Both in GP practices and at OOH services, contact rates for asthma or COPD decreased during the COVID-19 pandemic. In addition, more care was provided by telephone. In OOH services, the proportion of telephone contacts remained at an increased level during all phases of the COVID-19 pandemic, while in GP practices, the proportion decreased again during a later phase of the pandemic. Furthermore, during the pandemic, higher urgency levels were less often assigned to patients for contacts with OOH services for asthma or COPD.

From the start of the COVID-19 pandemic, a considerable decrease in contact rates for asthma or COPD was observed in GP practices and OOH services. Firstly, the decrease in contact rates in GP practices was likely initiated by the recommendations of ‘The Dutch College of General Practitioners’ (NHG) to delay routine care for patients with asthma or COPD and to suspend regular lung function tests (spirometry). The reduction in chronic care contacts was also observed in Belgium23. Secondly, reduced contact rates in both GP practices and OOH services may be explained by fewer exacerbations, as was found by Shah et al.7 for asthma patients7. The presentation of fewer exacerbations in asthma and COPD patients in both GP practices and OOH services may be related to a decreased circulation of respiratory viruses due to the containment measurements (i.e. social distancing, face masks)7,24 and a decrease in air pollution, due to less traffic25,26,27. Thirdly, some patients did not consider their complaints serious enough to make an appointment with their GP, and for other patients, doctors’ assistants have considered this. Patients’ decisions were also influenced by media reports of overcrowded healthcare facilities and they thought that it was not even possible to make an appointment with their GP28. Last, it is possible that patients with asthma or COPD improved their self-management skills, due to concerns about getting infected with SARS-CoV-2 when visiting a GP, resulting in a decreased need for care24,26. However, it remains unclear to what extent each of the above reasons played a role in the reduction of contact rates in both GP practices and OOH services.

During the COVID-19 pandemic, we observed a relative increase in telephone contacts and a decrease in face-to-face contacts for asthma or COPD-related GP care, which was in line with previous studies9,13,29. After the first wave of COVID-19 infections, the proportion of telephone contacts remained heightened in OOH services, while GP practices increased their face-to-face contacts. A possible explanation could be that GPs in GP practices wished to see their patients face-to-face again. In contrast, GPs in OOH services became accustomed to providing care remotely (i.e., telephone contacts). Furthermore, the transition to remote care at OOH services may have resulted in more efficient care and less workload and should be considered as a possible solution to the staffing shortages and high workloads in OOH services30. Several studies show that remote contacts for respiratory diseases have potential benefits for access to and effectiveness of care when fully integrated with face-to-face contacts31,32,33,34. A study into the differences between remote and face-to-face check-ups for asthma showed no significant effects with regard to exacerbations or quality of life35. This can be a first step towards the integration of remote care for asthma or COPD patients in the Netherlands. However, when implementing this, the lack of non-verbal communication when using remote care should be taken into account36.

Moreover, in this study, we demonstrated that (face-to-face) care for asthma or COPD in general practices was partially suspended during the COVID-19 pandemic. A possible consequence could be that patients with asthma or COPD are less in control of their disease and, therefore, more likely to contact OOH services in case of acute exacerbations of symptoms, as OOH services are seen as a safety net in the whole healthcare system21. However, we observed a decrease in contact rates at both GP practices and OOH services for asthma or COPD during the COVID-19 pandemic. In addition to this, the number of urgent contacts did not increase at OOH services. Based on this study, no short-term adverse effects of postponed chronic care for asthma or COPD were apparent. However, there may be long-term consequences because the expected effect of exacerbations due to postponed care in 2020 will only be visible in 2021 and beyond, indicating the need for continued monitoring. In addition, it is possible that postponed GP care may cause an increase in the need for care in other parts of the (acute) health system (i.e., emergency visits, hospital admissions). Further research is needed to assess the impact of postponed chronic care, involving primary care, secondary care, and mortality statistics, and taking into account multiple chronic diseases of patients. If no consequences are observed, the guidelines for disease management for asthma and COPD patients may be reconsidered.

A strength of our study was the inclusion of both GP practices and OOH services, enabling us to examine the impact of the COVID-19 pandemic on care for asthma or COPD for the entire GP care. Another strength was that we used a large data source (routine healthcare data), which ensures the representativeness of the data. The OOH services database covered 70% of the Dutch population and is, therefore, a representative sample of the whole country. The GP practice database consisted of data from the north, east, and south of the Netherlands. However, two of the included regions are regions in which asthma and COPD are more common37. Nevertheless, we examined relative differences, where the large population was helpful. For GP practices, we did not include the western region of the Netherlands and, therefore, we lacked data on the metropolitan area. This could potentially affect the findings. However, a Dutch study of healthcare avoidance by patients at the GP and medical specialists during the COVID-19 pandemic (2020) in the metropolitan area showed similar results, i.e. a decrease of 20.2%38. A limitation of this study was that we examined the contact rates separately for GP practices and OOH services so that patient-level statements cannot be made about whether postponed care at GP practices resulted in an increase in contact rates at OOH services. Furthermore, our analyses showed that the number of digital consultations was low and unchanged during the COVID-19 pandemic, while other studies showed that GPs in the Netherlands also intensified digital consultations during the first year of the COVID-19 pandemic39,40. This is probably due to reimbursement and/or registration bias in the electronic health records data41. The means by which contacts are registered or declared may have distorted the proportion of digital consultations in the results. Based on this, we cannot draw any conclusions about the extent of digital consultations for asthma/COPD patients in GP care. In addition, the analysis period may have been too short to observe the effects of postponed GP care for asthma or COPD patients, because the need for more (urgent) care, e.g. due to exacerbations, occurred later. Therefore, future studies should focus on patient care pathways with an extended study period to investigate the consequences of postponed care in GP practices, by linking the data of GP practices, OOH services, and secondary care. Finally, it is important to mention that the incidence of asthma and COPD has decreased in 2020 compared to 2019, which may have resulted in fewer patients with asthma or COPD. This may contribute to the fewer contacts we found in 2020.

In conclusion, the care for patients with asthma and COPD by GPs was greatly impacted by the COVID-19 pandemic, resulting in fewer contacts due to postponed chronic care and fewer exacerbations as a side effect of the COVID-19 measures. This also translated into less high urgent contacts for patients with asthma and COPD with the OOH services. Furthermore, there was a shift towards remote care, which has so far been maintained at OOH services and may also be a tool for efficient asthma and COPD care after the pandemic. This study does not yet show negative effects for patients with asthma or COPD, but it is likely that these are still to come, making it necessary to remain vigilant and continue monitoring in a broader setting, including further research on the long-term impact of the COVID-19 pandemic on care for asthma or COPD patients in primary and secondary care.