Otorhinolaryngology in the COVID‐19 era: Are there significant differences between hospital‐based and private practices?

Abstract

Objectives

The COVID‐19 disease has an incredible impact on both hospital‐based and private practices in the field of otorhinolaryngology and head and neck surgery. Practical issues faced by both types of practices have not been well addressed in most studies. A national survey was conducted in April 2020 to identify the challenges faced by otorhinolaryngologists practicing in the Czech Republic.

Design

Prospective questionnaire‐based study

Setting

Online Google questionnaire sent to the members of the Czech Society of Otorhinolaryngology and Head and Neck Surgery

Participants

All doctors practicing Otorhinolaryngology in the Czech Republic with access to the online questionnaire between 15th and 26th April 2020.

Main outcome measures

The primary aims of the study were to evaluate any significant differences between the two types of practice in the field of Otorhinolaryngology. We formulated null hypotheses stating there were no statistical differences in the preparation and availability of personal protective equipment amongst both practices a month after the first case of COVID‐19 in the Czech Republic. Statistical analyses including the Mann‐Whitney U test were performed to test the hypotheses.

Results

Analysis and results were based on the completion of the entire questionnaire by the doctors. There were no statistically significant differences between both the practices; however, individual analyses of both the practices showed a different outcome.

Conclusion

Despite our statistical results, it was observed that private practices faced more deficits and were more financially vulnerable. They were also other issues reported by both practices that could compromise the care of patients, functioning of workplaces and support of doctors.

Key points.

1. Otorhinolaryngology is a very vulnerable specialty with respect to COVID‐19

2. Adequate preparation of practices is of paramount importance so that the care of non‐COVID‐19 patients with urgent or serious chronic illnesses is not compromised

3. Private practices are suffering greater personal financial losses

4. Professionals working within this field should get complete support to increase efficacy and promote better functioning of a practice

5. Relevant local authorities in every region should be given situational status reports to identify problems at an earlier stage

1. INTRODUCTION

The pandemic disease COVID‐19 caused by the SARS‐CoV‐2 virus made a significant impact throughout hospital settings and private clinics, more so, in departments that are closely related to the disease. The department of Otorhinolaryngology or ear, nose and throat (ENT) is considered as one of the most vulnerable because of the symptoms related to the disease. This ailment was very probably considered as well as treated as common flu until it was actually named and deemed pandemic as well as extremely contagious. Therefore, most ENT practices were not ready and equipped for it. The aggressive nature and spread of the disease led to irreparable damage and chaos around the world. Furthermore, the rapid infiltration resulted in a massive incursion of unanticipated problems in healthcare systems including the revision of safety protocols ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ ; shortage of essential supplies ⁸ , ⁹ ; reorganisation of staff and hospital departments; reallocation of funds; and finally psychosomatic problems from the workplace, ¹⁰ Despite the publication of guidelines to protect the ENT workforce, ¹ , ² , ⁴ , ⁶ , ⁷ it still resulted in COVID‐19 related morbidity and mortality within the practice. There was also a lack of literature regarding the effect of COVID‐19 on ENT doctors. So in April 2020, we decided to create a national survey in the Czech Republic to determine the response of ENT doctors to the COVID‐19 situation. Our results were not only able to identify the strengths and weakness across various ENT practices, ¹¹ but also the psychosomatic problems encountered by the doctors. ¹² To the best of our knowledge, we also ascertained that no survey has been performed to compare the differences in clinical practice between private clinics and hospital‐based ENT departments. On this basis, we decided to further analyse our data in order to specifically compare the issues between the two types of ENT practices. It is very important to identify any deficits or specific problems faced by both types of practices to ensure that as ENT clinicians, we are well prepared for handling the future problems associated with any pandemic situations.

2. MATERIALS AND METHODS

A total of 900 ENT doctors (59.6% females, 40.4% males) were invited to complete a survey via email with an online link to a survey with the help of the Czech Society of Otorhinolaryngology and Head and Neck Surgery. This was carried out in April 2020. ¹¹

Items in the questionnaire that were relevant to this analysis were as follows: gender of the participants; type of practice (hospital‐based or private practice); position in practice (head of the department or a consultant with special duties employed by a hospital; junior doctor or consultant employed by a hospital or doctor working in private practice; private practice owner); current (refers to April 2020, a month after the first established cases of COVID‐19 in the Czech Republic and at the time of our survey being carried out) workplace preparation; current situation regarding the availability of PPE; items deficient in practice; other problems faced in clinical practices; further comments (optional question).

On the assumption, that private practices would have suffered more than hospital‐based practices, two sets of null hypotheses were formulated to compare current workplace provisions across hospital‐based and private practices.

Whilst addressing the question related to the quality of preparation of practices in response to COVID‐19, we formulated the first null hypothesis, h₀, that there is no statistical difference between the two types of practices.

Secondly, when analysing the extent to which the workplaces were equipped with PPE, another null hypothesis, h₀, was that, there is no statistical difference between both practices. Furthermore, other parameters were also analysed and finally, we performed statistical analysis in excel which included descriptive statistics along with the Mann‐Whitney U test.

3. RESULTS

One hundred and eighty‐one ENT practitioners completed the survey. Responses were received from 18 hospitals with ENT inpatient facilities and 23 private ENT clinics. Ninety‐six doctors were hospital‐based and 85 worked in private practices. One hundred and fifteen female and 66 male practitioners responded to the survey (Figure 1). Amongst all the participants, 29.3% were owners of private practices, the rest were either employed by a hospital or private clinic.

FIGURE 1.

Gender‐based comparison between private and hospital practice

The largest population comprised of doctors with experience of 21‐35 years in ENT practice (Figure 2). At least 25% of all private practitioners had more than 35 years of experience.

FIGURE 2.

Years of ENT practice after the completion of medical school

In general, at least 156 ENT doctors have reported an improvement in their workplace in comparison to the first cases of COVID‐19.

A summary of results obtained from responses to the questions of the current preparation of workplaces and supply of PPE amongst the two types of practices is shown in Table 1.

TABLE 1.

Comparison between two types of practices in Otorhinolaryngology in relation to the preparation of practices and availability of PPE

	Preparation of practices		Availability of PPE
	Hospital‐based	Private practice	Hospital‐based	Private practice
Responses
1 Completely unprepared/No equipment	0	0	0	1
2 Minimally prepared/minimum equipment	3	5	2	2
3 Moderately prepared/basic equipment	36	39	34	36
4 Well prepared/adequate equipment	46	35	53	43
5 More than well prepared/more than necessary equipment	11	6	7	3
Count	96	85	96	85

A Mann‐Whitney test indicated that there was no difference in the quality of preparation between hospital‐based (Median 2) and private practices (Median 2), U = 3539.5, P = 0.0937

The P‐value was .0937 during the time of the study in April 2020. This means that if we would reject h₀, the chance of type I error would be as high as 9.03%. Therefore, it can be shown that no difference was seen between the 2 types of practices.

In terms of the provision of PPE during the time of the survey, there was no significant difference between the two types of practices (Median of 4 in both), U = 3651, P‐value was .17139 and again null hypothesis has to be accepted since P was not <.05.

The analysis of the items deficient in current practice showed a slightly different outcome. Five options (disinfection and sterilisation products; PPE; disposable aids; discrepancy in all of the above; no discrepancy) were given and doctors were allowed to select more than one criterion with respect to the first three options). Overall, private practices reported more shortage in supplies (Figure 3) and only 20 had no shortage in their practices. Highest proportion of deficits was seen in PPE (respirators, shield, goggles, etc.) and disposable aids (protective coats, gloves, surgical instruments, gowns, etc.). About 31.5% of all doctors reported shortage in PPE, whereas a total of 75 doctors (45 from private practices) reported deficits in disposable aids. Around 18 doctors (72% working in private practices) indicated problems with disinfection and sterilisation products.

FIGURE 3.

Items deficient in current practice

Three other major problems reported by both practices were reduced staffing, patient‐related problems and unsafe working environment. Issues were raised regarding the treatment of non‐COVID‐19 seriously ill patients such as Oncology patients or those with acute problems such as deep neck space infections. Furthermore, both practices reported a lack of adequate support for healthcare professionals. No special comments were received by paediatric ENT practitioners.

The unpredicted pandemic situation caused a significant financial loss in both types of practices. In hospital settings, financial losses can be mainly attributed to a reduction in operating lists and exhaustion of funds for special equipment whilst in private practices, where they are totally dependent on the number of patients, the loss has been more significant.

4. DISCUSSION

A large population of our study group comprised of female practitioners, most of whom are associated with private practices. Amongst all the respondents, 71.7% were either employed by a private practice or a hospital. Age predilection, although difficult, it can be assumed that 15% of doctors that are practicing for more than 35 years are definitely 60 years and above in age. Furthermore, 32.6% of all doctors associated with 21‐35 years of practice comprised the largest experience‐based practicing group in this study sample. Current practice guidelines suggest not allowing older doctors to be in the frontline alongside COVID‐19 patients. ¹³ , ¹⁴ In the Czech Republic, doctors above 65 years of age and or those with chronic illnesses working in hospitals had the possibility of working from home with suitable compensation; however, it was not made mandatory; these guidelines were not reinforced by the general medical council or ministry of health. And, moreover, in this specialty, this would be difficult to achieve, since most patients present with symptoms similar to those encountered in any pandemic associated with a respiratory virus, and have to be considered as potentially positive until and unless proven otherwise. Our hypotheses were proved wrong. In terms of the current preparation of practice and availability of PPE amongst otorhinolaryngology practices in response to COVID‐19, no significant differences were observed amongst both types of practices. Furthermore, majority of practitioners reported moderately to well‐prepared workplaces. Although 53% of all doctors from both clinical settings reported having adequate PPE, nevertheless during the overall analysis of the items deficient in both practices, two major shortfalls were still seen; PPE and disposable aids. Deficits in PPE have been well published, ¹³ thus practices should maintain an inventory in helping health establishments estimate provisions. Furthermore, private clinics also suffered significantly from the shortage of disinfection and sterilisation products.

Financial losses were encountered by both practices, but owners of private practices were more vulnerable. In a survey carried out in April 2020 with 724 physician respondents, 97% of medical practices had been negatively affected by the COVID‐19 situation leading to 22% layoffs with projected layoffs of up to 36% within May 2020. ¹⁵ This further reiterates the importance of financial support in order to maintain a private practice. Although several European countries have agreed to provide incentives and also been promised supplementary funds, very few have made agreements with private practices. ¹⁶ In the Czech Republic, no such provisions have been made.

5. CONCLUSION

Although our study sample was small and responses were somewhat limited, as maybe expected under such difficult circumstances, it has led to some significant findings.

It can be concluded that although no statistically significant differences were observed in terms of preparation and provision of PPE amongst hospital‐based and private practices, both types of clinical practices have been significantly affected. It should be mentioned that, with lack of any support and shortage of medical supplies, ENT private clinics have had to bear more personal losses financially. These difficulties should be noted by relevant authorities to ensure the continued care of patients and support of personnel across private practices. In any infectious situation, all personal protective gear and medical supplies should be provided in ample amounts thus reducing the risk of cross‐contamination and ensuring the health and safety of both staff and patients. Important information related to the progress and containment of a pandemic disease including support for affected health personnel should be mandatory whether it is a hospital‐based practice or private clinic. If private practices continue to incur shortage or loss, this will lead to the closure of practices, personal financial insecurity and in turn increase the workload on hospitals, where the ENT doctors are already overwhelmed with the volume of work. In smaller cities, where there are no hospitals with ENT departments and patients are dependent on private clinics, reduced accessibility to such practices will also cause significant problems for debilitated patients and those with chronic illnesses. They will have to travel long distances. Amongst elderly or disabled patients, this is a very important factor and they may not be able to cope with this. As a result, this will delay treatment and lead to the deterioration of their health. We would recommend a more detailed follow‐up survey to fully explore all the practical problems that are currently being faced during the second and more severe phase of COVID‐19 within the otorhinolaryngology practice.

CONFLICTS OF INTEREST

The authors have no conflicts of interest

ETHICAL APPROVAL

Research involving human participants and/or animals: Formal ethical approval was not required for this survey since it was questionnaire‐based. Protocol followed in studies involving human subjects was in compliance with the Helsinki declaration and further in accordance with local ethical guidelines of the institutional ethical committee of the 3^rd Faculty of Medicine, Charles University, Prague, Czech Republic. Furthermore, it was also approved by the Czech Society of Otorhinolaryngology and Head and Neck Surgery.

Guha A, Plzak J, Schalek P, Chovanec M. Otorhinolaryngology in the COVID‐19 era: Are there significant differences between hospital‐based and private practices?. Int J Clin Pract. 2021;75:e14054. 10.1111/ijcp.14054