Do influenza and acute respiratory infective diseases weigh heavily on general practitioners’ daily practice?

Abstract

Objective: Respiratory infections are a frequent causes of medical attendance. Influenza viruses increases this phenomena. The aim of this study was to prospectively identify GPs’ increased work in terms of visits and time. Methods: Over a period of five months 5 GPs recorded sex, age, number and place of visits, telephone consultations of the patients visited for acute respiratory disease (ARD)which included acute respiratory infections (ARI), influenza (FLU) and Influenza-like illness (ILI). Upper respiratory tract infections (URTI) were classified as sinusitis, rhinitis, otitis, tonsillitis, pharyngitis, laryngitis, Lower respiratory tract infections (LRTI) were classified as tracheitis, bronchitis, pneumonia, bronchopneumonia, acute episodes of chronic obstructive pulmonary disease (COPD) and asthma. FLU and ILI were considered two different entities on the basis of symptoms. Results: Acute respiratory disease increase of 22 patients attending every GP's office monthly (from 176 to 198 total visits). 6542 patients were observed. The incidence of ARD was 33.5% (2191: 1091 female and 1100 males). URTI affected 944 patients, LRTI 739, FLU 328 and ILI 180. The increase in home visits grew from 10 to 36. Each home visit took from 15 to 45 minutes. In a high number of cases (236), home visits were necessary for sick-leave certificates. FLU (54%) and LRTI (37.5%) required more attention, and they were the primary causes for visits. Telephone consultations took place for all ILI or FLU of minor severity and in young people.

Conclusion: During the winter there is an increased work-load for GPs due to the diffusion of influenza virus and respiratory tract diseases. “Burn out syndrome” is increasing among the GPs. Territorial GPs’ action is highly efficacious. Patients self-certification should be evaluated. Vaccine therapy could be more effective if done on a larger population. More research is needed.

• GP
• Acute respiratory infections
• Influenza
• Influenza-like illness
• work overload

Introduction

Influenza (FLU), influenza-like illness (ILI) and acute respiratory infections (ARI) are an important public health problem and one of the most frequent causes of medical attendance, with high general practice consultation rates [1]. An estimated 95% of cases are seen and treated by GPs [2]. The disease increases hospitalization [3] and death [4]. Influenza and influenza-like illness are not easily distinguishable because the same symptoms present, and it is unfeasible that every person who might have influenza can be tested (high cost) [5], [6]. The relevance of the disease brought about the constitution of the European Influenza Surveillance Scheme (EISS) [7], which collects weekly data from 22 European countries.

Incidence rates of influenza vary by country. This depends on the different use of vaccine therapy. The Netherlands network (NIVEL) [8] and the UK Weekly Return Service (WRS) reported lower incidence rates for winter 2002–2003 compared to other countries, particularly Italy [9–11]. Even among the EISS partners, the case definitions used for the clinical surveillance of influenza vary [12], and this could justify the different rates. During the winter, congregations of people indoors facilitate transmission of the viruses, causing increased incidence. In spite of the disease relevance, few data are reported regarding the increased workload for GPs due to the impact of influenza on the general population. The aim of this study was to prospectively identify GPs’ increased work in terms of visits and time.

Methods

Five out of 15 GPs (minimum sample size calculation by Cochran [13]) working in a subdistrict of Caserta, Italy, recorded data using a computerized system. A high homogeneity was assured: same geographic area, climate, economic resources and interests.

Acute respiratory diseases (ARD) included acute respiratory infections (ARI), FLU and ILI. Upper respiratory tract infections (URTIs) were classified as sinusitis, rhinitis, otitis, tonsillitis, pharyngitis and laryngitis. Lower respiratory tract infections (LRTI) were classified as tracheitis, bronchitis, pneumonia, bronchopneumonia, acute episodes of chronic obstructive pulmonary disease (COPD) and asthma [14]. FLU and ILI were considered two different entities on the basis of symptoms: more than 72 h with hyperthermia, bone ache and/or myalgia for FLU; milder symptoms and lasting less than 72 h for ILI.

The observation period was 5 mo (November 2002–March 2003). Sex, age, number of visits to the patient's home and the GP's office, telephone consultations, and the reason they were asked for were recorded. Collected data were compared to those of the previous year.

Results

During the study period, 6542 patients were observed. The incidence of ARD was 33.5% (2191; 1091 female, 1100 males). URTI affected 944 patients, LRTI 739, FLU 328 and ILI 180.

Patients were stratified by age into five groups: group 1: 1–4 y; group 2: 5–14 y; group 3: 15–44 y; group 4: 45–64 y; group 5: over 65 y. Group 3 was the one with a major incidence of diseases (924). In group 1, only one case was recorded as Italian GPs usually only see patients of more than 6 y old (Table I).

Table I.  Disease incidences by age.

	Age group (y)
	1—4	5–14	15–44	45–65	>65	Total disease
ILI	0	28	112	25	15	180
FLU	1	48	172	74	33	328
URTI	0	101	464	264	115	944
LRTI	0	25	176	234	304	739
Total by age	1	202	924	597	467	2191

ILI: Influenza-like illness; FLU: influenza; URTI/LRTI: upper/lower respiratory tract infection.

Groups were stratified by age and disease, and no differences were shown. Only INF seemed to affect females more than males (Table II). No differences were found in the number of visits to GPs’ offices or at patients’ homes compared to the year before.

Table II.  Disease stratification by sex and age.

	Group 1		Group 2		Group 3		Group 4		Group 5
Age	1—4		5–14		15–44		45–65		>65
Sex	F	M	F	M	F	M	F	M	F	M
ILI	0	0	19	9	77	35	10	15	5	10
FLU	1	0	20	28	81	91	30	44	10	23
URTI	0	0	47	54	235	229	125	139	52	63
LRTI	0	0	12	13	90	86	122	112	155	149

Abbreviations: see Table I.

GPs visited 8 study patients per day and another 12 patients for different conditions, e.g. for blood pressure measurement or for bureaucratic/administrative purposes (draft certificates and chronic therapies). On average, 20 study patients per day attended the GP's office (range 16–45). On a monthly basis, 176 patients attended the GP's office during the study period for the presence of ARI and FLU-ILI symptoms. In this way, we calculated the increased workload, including patients we term “frequent attenders” [15]. An average monthly increase of 22 patients attending every GP's office was indicated (from 176 to 198 total visits).

Of 2191 ARD patients, 1314 (60%) visited GPs’ offices, 658 (30%) had home visits and 219 (10%) only needed a telephone consultation.

What was remarkable was the increase in home visits, which grew from 10 to 36. Therefore, 26 more patients asked for and received a home visit. Each home visit took from 15 to 45 min, including elapsed time at the patient's bed and travelling (Table III). In a high number of cases (236), home visits were necessary for sick-leave certificates more than for patients’ health conditions.

Table III.  Number of home visits, office visits and telephone consultations.

	Observed period			Other Period	Increase
Consultation at	5 Mth A	Mth A	Mth C	Mth C	Net C
GPs office	1314	54	198	176	22
Patient's house	658	26	36	10	26
Telephone consultation	219

5 Mth A: total number of patients affected in 5 mo; Mth A: average number of affected patients per month; Mth C: average monthly number of consultations; Net C: net increase of consultations per month.

Telephone consultations took place for all ILI or FLU of minor severity and in young people. Telephone consultations were not considered to heavily influence GPs’ daily practice, although if these were received during or outside working hours, they caused an increase in the GPs’ stay at the office and diminished their personal free time.

FLU (54%) and LRTI (37.5%) required more attention, and they were the primary causes for home visits (Table IV).

Table IV.  Home visits by disease.

	No. of home visits	Total patients	%
FLU	180	328	54.8
LRTI	277	739	37.5
ILI	55	180	30.5
URTI	146	944	15.5

Abbreviations: see Table I.

Discussion

The aim was to prospectively analyse how much FLU, ILI and ARD increase GPs’ workload. The total number of visits increased significantly. Domiciliary visits were principally due to LRTI and FLU-ILI. What is remarkable is that patients aged from 15 to 44 y were the most affected. This could be due to their social life and to the effect of vaccine therapy among the over-65s [16–18]. Over the 5-mo study period, GPs visited one third of their patients. There was an increase in workload due to the extra time spent at the office and domiciliary visits. This diminished GPs’ personal time, and could be one of the causes of the increasing “burn-out syndrome”. Connected to this problem was the number of domiciliary visits required to certify patients on sick leave, a purely administrative task in a job which is becoming more and more bureaucratic [19]. Patients’ self-certification of illness should reduce GPs’ bureaucratic incumbencies.

The effectiveness of vaccine therapy and the benefit of a more extensive vaccination should be evaluated. More research is needed to determine the effect in reducing indirect costs due to absence from the work place.

Conclusion

1. During the winter there is an increased workload for GPs due to the diffusion of influenza virus and respiratory tract diseases;

2. “Burn-out syndrome” is increasing among GPs.

3. Territorial GPs’ action is highly efficacious.

4. Patient self-certification should be evaluated.

5. Vaccine therapy could be more effective if done on a larger population.

6. More research is needed.