Principal FindingsThe aim of the study was to analyze the change in the types of pediatric visits to PC centers in Catalonia between 2019 and 2022, following the COVID-19 pandemic. In this context, we have been able to describe the evolution and coexistence between the different types of visits, both face-to-face and non–face-to-face visits, as well as the change in the pattern of pediatric consultations during this period. In summary, the results showed that non–face-to-face visits increased from around 10% of the total in January 2020 (before the pandemic) to almost 25% in December 2022 (after the pandemic). Half of these were telephone consultations and the other half were eConsultations.
Total visits to PC pediatric services fell from March 2020 and did not recover in overall number until September of the same year. From there, the overall volume resumed, with some subsequent fluctuations more or less in line with subsequent waves of COVID-19. In the first wave, there was a marked decrease in face-to-face visits and an increase in teleconsultations, in accordance with the literature. In a study conducted in a PC center in Madrid during the month of June 2020, it was observed that 51% of the visits were remote [18]. Other studies, both nationally and internationally, have also stated that between March and May 2020, the pattern of visits to PC centers changed [19,20]. There was a significant predominance of remote visits, especially by telephone, over face-to-face visits [21].
In the second, third, and fourth waves, face-to-face visits continued to decrease, while remote consultations continued to increase. During the fifth wave, defined by the Delta strain inmid-2021, there was a decline in both face-to-face and remote consultations, possibly because it was not a strain that affected the pediatric age group very much [22]. Nevertheless, remote visits continued to represent a significant part of the total number of visits. This fact changed with the sixth wave, starring the Omicron strain, between December 2021 and February 2022, which particularly affected children [23,24]. The corresponding peak of visits shows that more than half of the consultations at that time were non–face-to-face. During the seventh wave, in mid-2022, no change in the pattern of visits was detected. The eighth wave coincided with the marked increase in total visits, especially face-to-face visits, detected in pediatric services as of November 2022. The considerable increase in visits from November 2022 onward, which exceed prepandemic levels, could be due to the increase in infections reactive to ceasing use of protective measures against COVID-19. This phenomenon has been called immunity debt and may pose a risk for serious epidemics in the near future [25].
A breakdown of visits between face-to-face and non–face-to-face visits clearly shows a drop in the proportion of face-to-face visits and a rise in remote visits as of March 2020. Attendance recovered to prepandemic levels during November 2022 in absolute numbers but not in proportion. Although the number of total visits increased at the end of 2022 compared with 2019, the percentage of face-to-face visits decreased and the percentage of remote visits increased; thus, the results highlight that, during the pandemic, the pattern of the type of pediatric PC visits has changed, as seen in other studies [15,26].
In relation to acute demand (9C), the drop was very sharp, and the recovery was very slow, such that it was not until November 2022, two years later, that levels prior to March 2020 were reached again. This result is similar to the findings of other studies that detected a lower number of visits during the months following the onset of the pandemic, especially in acute infections [27-29]. This may be due to a lower circulation of pathogens other than the SARS-CoV-2 coronavirus. In general, it appears that the reduction in face-to-face attendance did not have much negative impact on urgent pediatric pathology care [30]. However, some studies have reported problems of diagnostic delays, such as an increase in complicated appendicitis cases [31]. On the other hand, an increase in overweight and obesity, technology use, sleep disorders, anxiety and distress, domestic violence, social isolation, and behavioral disturbances were also detected, especially in adolescents [32]. Likewise, due to the reduction in face-to-face attendance, an alteration in the circulation pattern of some respiratory viruses was observed during the subsequent season (2020-2021), especially for respiratory syncytial virus, which had an unusual peak of incidence in midsummer, as reported by the SIVIC [17].
As for the child health check-ups (9R) of the Infància amb Salut program, they recovered earlier than visits for acute diseases (9C). Although a drop was detected during March 2020, coinciding with the first wave of COVID-19 and stricter confinement, these visits recovered more quickly and were at the prepandemic level by the end of 2020. Quantification of the delay and losses of check-ups and vaccines showed that vaccination coverage decreased in all the autonomous communities of Spain by between 5% and 60%, depending on age and the type of vaccine [33]. The Spanish Society of Immunology, the Spanish Society of Paediatric Infectious Diseases, and the Spanish Association of Paediatrics published a document in April 2020 with complete information on the decreased uptake of vaccines, along with the criteria for the prioritization of childhood vaccination during the state of alarm carried out by the Ministry of Health [34]. Following the publication of similar figures, European pediatric societies called for the immediate recovery of vaccination programs, since compliance with the established vaccination schedule is one of the prerequisites for dealing with the resulting problems, such as immunity debt and the decreased uptake of vaccines [35].
Telephone consultations (9T), prior to March 2020, represented a minimal volume of total pediatric consultations. The onset of COVID-19 led to an exponential increase in the number of such consultations. They peaked during September 2020, probably coinciding with the start of that year’s school year. Later, an oscillation in the number of calls was observed, although they remained at a higher value than in the period prior to the study. Therefore, the results suggest that telephone consultations have been one of the most widely used tools, both by users and professionals, to replace face-to-face visits during the pandemic [36]. This growth could be due to the ease of use of the telephone as well as to the organization of visits in PC centers, where it was established that the first patient assessment should always be made by telephone [37].
Regarding video call consultations (9Ev), the results have shown that they were used very little during the first wave of home confinement, and this is in agreement with the literature [38]. This low use could be explained by the limited technological resources for video visits, the technical difficulty it could pose for patients with lower digital literacy, and the fact that there was an impression that they did not add value to telephone consultations or eConsultations. Although they are currently practically not used in PC, the literature shows that they have a potential yet to be explored [39,40]. A systematic review conducted in 2021 on telemedicine in pediatrics, which includes 11 studies, concluded that care through call and video-call type visits in various pathologies (obesity, asthma, mental disorders, otitis media, and skin disease) can be comparable to, and in some cases even better than, face-to-face care; for these cases, it is necessary to improve user access and the effectiveness of services [41].
As for telemedicine consultations (9E), which are conducted without the patient being present, they were already on the rise before the pandemic but skyrocketed as of March 2020. One possible explanation is that since most of the COVID-19 cases in pediatrics were mild, many visits were probably made remotely, to indicate the result of the rapid viral detection test to administrative personnel, without ever having contact with health care personnel.
The pandemic was a clear catalyst for the use of eConsultation (9Ec). High use figures were reached and maintained at the end of the study period. In pediatrics, a peak of such visits was detected during January 2022, coinciding with the Omicron wave, which affected children in large numbers but had with low morbidity. Thus, the results of this paper and the literature suggest that eConsultation is here to stay [42].
It is also worth noting that although COVID-19 was a catalyst for the use of telemedicine in clinical practice, the Catalan health system has been promoting digital transformation through various “health plans” and different initiatives since 2011 [43-45]. In this context, the use of teleconsultation during the lockdown was essential to manage the health emergency at that moment. However, the Catalan health system had the digital infrastructure to cope with the situation and provide assistance. The population’s experience of teleconsultation during the lockdown may have an impact on them, and the results also showed that currently, almost 25% of people used teleconsultation after the pandemic period.
During the COVID-19 pandemic, other modalities of pediatric telemedicine care for parents of patients were tested with good resolution and acceptance results, such as the creation of a Twitter (subsequently rebranded as X) profile called Equipo Pediatría HCSC (@EquipoHCSC) by a trained team of pediatricians in Madrid that resolved questions through private messages [46]. Another example is that of a health center in Zaragoza that had already developed an email consultation process, and they observed that during the strictest confinement, its use increased to the detriment of face-to-face consultations, although the most used modality was the telephone [47].
In relation to the use of information and communication technologies in pediatrics, there is the advantage, in general, that there is less of a digital divide on the part of users than in other areas. Several studies indicate that this is due to the age and education that parents usually have [48,49].
It was not only in pediatrics that a sharp reduction in face-to-face visits and a parallel growth in remote visits were detected. Equivalent results have been obtained from family and community medicine [50,51]. Telemedicine, however, has limitations in the human, technological, and economic spheres, and these must be understood by all parties involved. In addition, it is subject to current legislation based on the Organic Law on Data Protection and the doctor-patient confidentiality relationship. Thus, telehealth programs depend largely on the health care setting in which they are implemented. Conditions may change after the pandemic, and further studies will be needed [52].
In short, although the absolute number of face-to-face visits has recovered throughout the pandemic, telemedicine consultations established themselves as an important type of visit and made up almost a quarter of daily visits by the end of 2022. This indicates that some consultations that were previously carried out in person are now likely to be done remotely.
This analysis may contribute to a reorganization of the current model of PC pediatric services, which has been affected for years by the deficit and heterogeneous territorial distribution of professionals [53]. It can also help develop evidence-based guidelines for pediatric remote care focused on accessibility, quality, equity, and efficiency, as has been done in other territories [54,55]. It remains to be seen how, from now on, the application of digital health tools is managed in the field of PC pediatric services in Catalonia, as well as at a more global level, and whether it contributes to improving the current organization.