Table 2.

Spillover Effects of COVID-19 Control Measures on Routine Chronic Care

Theme	Subtheme	Illustrative Quotes
Workforce adjustment and its effects on routine practices	Disruption to communication and teamwork rendering less efficient patient care and rescheduling	“My clinic was taken over by other consultants as I was deployed [elsewhere]. So, I think this would invariably have much effect on patient care. Every time, when there is a change in the provider in the clinic, it causes a bit of service disruption.” #23 Doctor, F “Let's say if I want my colleague to see this patient for a second opinion, it can be very challenging because my colleague may belong to another team [due to redeployment], so communication is disrupted. And most of the time, the case cannot be resolved simply by a video or phone consult, so we have to get the patient to come back another day just to see someone else. Some patients do have a poorer outcome on their next visit, but not all.” #15 AHP, M
	Uncertainty in clinical decision making due to revision of treatment protocol and suspension of laboratory services	“Nebulizing procedure was straightaway stopped in the department. If the patients did require nebulizer, we started giving them via a spacer. How effective that was, I'm not very sure, but we have to make some adjustment during that [Circuit Breaker] period.” #19 Nurse, F “Some diagnostic tests cannot be done during this pandemic. For instance, when diagnosing asthma, we will need to perform a lung function test, but the lung function lab was closed during that time, so we could not do a proper diagnostic test. Hence, we had to treat the patient based on clinical signs and symptoms rather than confirming the diagnosis.” #24 Doctor, F
	Unprepared to handle patients' emotional responses	“There was also a lot of anger involved because appointments and surgeries were postponed. So, in general, I feel that patients are a little bit more angsty nowadays, especially when they are informed having to repeat tests because the waiting time is certainly longer now. But, that is because we are understaffed at this moment due to redeployment.” #2 Doctor, F “[From the ground] there was quite a lot of distress during that time, especially among elderly [with chronic diseases] when they could not get the services required in the hospital due to changes in protocols and they [doctors] could not do much either as they had to follow these guidelines stipulated [by the Ministry].” #14 Government Official, M
Diminished support and management of patients	Reduced access to routine therapy and diagnostics	“We used to have physiotherapists that come to our clinic to help with chronic diseases–related rehabilitation. But now we don't have physiotherapists anymore. The inability to receive regular chronic care makes it difficult for the patients to control their disease at home, so they end up getting admitted because of this.” #21 Doctor, F “Before COVID-19, we [respiratory technologists] used to go to private hospitals if there is a referral. However, this practice is suspended to avoid cross-institutional transmission. So patients from the private hospital cannot obtain the required services [lung function tests]” #5 AHP, M
	Limited access to community social services	“As the Senior Activity Centers were closed, the seniors stopped coming to the day-care center, and many of them started to deteriorate in their health due to reduced physical activities and movement.” #16 Hospital Management Officer, M “Medical Escort Transport services and community nursing [were listed as nonessential by the Ministry] have to stop during circuit breaker. As a result, many elderly patients cannot come for their appointments or receive nursing visits, making them even more vulnerable. But it was necessary as our main aim at that time was to break the transmission chain.” #14 Government Official, M
	Longer waiting time for treatment or surgery and rejection of admissions	“Let's just say for malignancies; usually we don't stop surgeries for malignancy. However, sometimes because of the decrease in slots due to lessened manpower, some may get pushed back by 1 or 2 weeks. Then some of them are not comfortable coming to the hospital, so they postpone it by themselves a little bit more. But all these add up to delays for about a month, and sometimes when they come in, their physical condition is a lot worse.” #43 Nurse, F “There was some not so necessary hospitalization that was avoided. However, we do see that it results in poorer disease outcome in such patients.” #16 Hospital Management Officer, M
	Discontinuity of care between hospital and community	“Usually, we also provide podiatry services to patients in the community; about once a week, one of us will go down to the polyclinic. However, as most of us were deployed during the Circuit Breaker period, podiatry services in the polyclinic were suspended to prevent different podiatrists visiting [the polyclinic] each week. As a result, residents in the community who need services like diabetic foot screening have to specifically come back to the hospital, causing them a bit of inconvenience.” #13 AHP, M “Community nursing services were decreased during the Circuit Breaker period. Before that, community nurses do visit the homes of my patients who are discharged from the wards to manage their chronic diseases. But home visits and nursing services were suspended because of the pandemic.” #24 Doctor, F
Adverse patient outcomes	Deterioration of existing conditions	“I have also seen patients with abnormal chest X-rays that were delayed with subsequent follow-ups, or did not make subsequent follow-ups, resulting in some diagnoses getting delayed, including that of possible cancer.” #2 Doctor, F “As appointments are cancelled, by the time patients come to see us, some damage to their heart has already occurred.” #12 Hospital Management Officer, M
	Social isolation	“Another impact of COVID-19 on the elderly is undeniably social isolation. They don't really go exercise or go out as usual anymore. It becomes harder for them to communicate and interact with one another, especially when movement and social activities are restricted. This caused distress and had profound impact on their well-being” #29 Nurse, F “As their movement was restricted, elderly who are living alone tend to experience social isolation, especially when senior activities centers are closed.” #30 Hospital Management Officer, M