PATIENTS’ OPINIONS ON OUTPATIENT MEDICAL CARE DURING THE COVID-19 CRISIS

: COVID-19 was a challenge which tested the entirety of our country’s healthcare system from 2020-2021. The pandemic was an emergency, quite dynamic, and necessi-tated quick and thoughtful actions. Ever since the official announcement of the COVID-19 pandemic in Bulgaria and the first reported cases from 08.03.2020 to 30.09.2020, the total number of registered cases has risen to 500112. This fact was the reason we conducted a survey among 531 patients from all over the country regarding the changes in their access to the doctor’s office and the methods they used for contacting their general practitioner for the period from March 2020 to April 2021.The results show that over 51.41% of participants have seen an improvement in their access to their GP’s office due to the fewer patients visit-ing the office. At the same time, 42.18% of participants reported they received phone consults or had their phone calls returned during their general practitioner’s working hours. 26.18% of respondents have received phone consults regardless of the time. 30.70% of respondents have communicated with their GP via Viber; 14.50% via messenger; 6.03% via email.


INTRODUCTION
At the beginning of 2020, the world met this unprecedented and uncontrollable disaster. It overturned a number of preconceptions about the security of the global healthcare system and the sense of safety of the modern European. COVID-19 was a challenge which tested the entirety of our country's healthcare system from 2020-2021. The pandemic was an emergency, quite dynamic, and necessitated quick and thoughtful actions. Ever since the official announcement of the COVID-19 pandemic in Bulgaria and the first reported cases from 08.03.2020 to 30.09.2020, the total number of registered cases has risen to 500112 (morbidity 7219,7 in 100 000). According to data by the European Centre for Disease Prevention and Control regarding the spread of COVID-19 across the globe, from the 31st of December 2019 to the 36th week of 2021, 225 166 539 cases of COVID-19 have been reported, and 37 521 784 have been reported in the EU/EEA, including 4 636 120 death cases globally [1].

MATERIALS AND METHODS:
Goal and tasks: The aim of this article is to analyze and evaluate the opinions of patients on the topic of the organization and access to outpatient care in the conditions of the COVID-19 pandemic. To realize this goal, we give ourselves the following tasks: 1. A legislation-based analysis of the organization of outpatient medical care in the conditions of the COVID-19 pandemic.
2. Analysis of the patients' opinions on their access to their general practitioner in the conditions of the COVID-19 pandemic in-person, on the phone or through other communication routes.
3. Formulating conclusions and recommendations on improving patient access to a GP.
To objectively observe = the results of this study, we used a documental and sociological method -a questionnaire. Legislation regarding outpatient care in the conditions of the COVID-19 pandemic was also studied.
Five hundred thirty-one patients across the country participated in the survey in the period March 2021 -April 2021. The questionnaire was anonymous and was distributed through the online platform Google Forms. The selection was random, and there was no artificial selection of the respondents, which is a basis for claiming the results are representative. The confidence interval at the level of significance P (t) = 0.05 provides information for assessing the accuracy of the analyzed indicators.
The quantity analyses are made with the help of a statistics software package -SPSS 17.0. For the tabular and graphic processing and presentation, MICROSOFT OFFICE products are used.

RESULTS:
According to Bulgarian legislation, it is the "right of every citizen to receive medical care" in accordance with the procedures laid down in the Health Act and the Health Insurance Act [2,3,4,5].
The first contact a person potentially infected with the coronavirus inflection has with the healthcare system happens in accordance with the procedures laid down in the National plan managing the SARS-CoV-2 pandemic [6]: -in healthcare facilities for outpatient care -GP, medical specialists with individual practice, medical centres, diagnostic and consultative centres and laboratories; -through emergency mobile teams by the Centres for Emergency Medical Care (CEMC) and in outpatient medical exams in their branches; -in the emergency rooms of diagnostics-consultative blacks of medical centers for hospital care; -by Regional Health Inspectorates (RHI) -either on the phone or during an epidemiological study.
In case of an announced state of emergency due to the spread of contagious disease in accordance with art. 61(1) or art. 61(3) of the Health Act or an announced epidemiological emergency state due to the epidemiological spread of contagious disease in accordance with art 61(1) of the Health Act, the Minister of Health can issue an ordinance to the Regional Health Inspectorates requiring that they implement temporary measures and actions to organize and restructure the healthcare establishments in their corresponding province for the duration of a particular time period. Establishing this organization of health activities connected to COVID-19, their coordination and control is the responsibility of RHI directors working closely with healthcare establishments. The temporary measures and actions issued by the Minister of Health are established on the territory of the province with an ordinance by the director of the local Regional Health Inspectorate [5].
To study and analyze the organization and accessi-bility of outpatient medical care in the conditions of COVID-19, we conducted a questionnaire-based survey in the period between March 2021 and April 2021, asking patients about their opinions on outpatient care for the oneyear period since the announcement of the state of emergency (13.03.2020). Women make up 56.12% of respondents, while men accounted for 43.88%. In terms of age distribution: one-third of the participants were in the "51-60" age group, followed by the "41-50" age group at 23.16%, and the "over 60" group (17.89%). This age distribution is conditioned by the manner in which the questionnaire was distributed. In terms of residence: 52.92% live in the capital, followed by those living in province centres at 22.03%, towns -16.57%, and villages -8.47%. The answers to the question "Did your in-person access to your general practitioner change in the conditions of the COVID-19 pandemic and how?" show that for over half the respondents the access to a general practitioner has become easier due to the lowered number of waiting patients ( Fig. 1.). Those results are consistent with the restrictive measures taken by the Ministry of Health (MoH), as well as the fear of the unknown risks connected to the illness, its severity and treatment. In 22.98% of respondents, the access was made harder due to a long wait in front of the doctor's office, and 18.27 didn't notice a change in access. The phone connection between the patients with their general practitioners is also of interest in the context of the restrictive measures (Table 1). 42.18 of participants have received a phone consultation or a returned phone call by the GP during his or her working hours, while 26.18at any time of the day. This shows the understanding and compassion general practitioners have for their patients' problems. The situation is quite different in 1/3 of the participants, who shared they have never received a phone consultation or a returned phone call from the doctor. The reasons for this can be varied -work overload, lack of interest in the patient's problems, or misuse of the phone connection by patients who call for problems that aren't urgent. Practice shows that, even though there are 24-hour call centres for patients to use, most have stronger trust in their general practitioner, which leads to unfounded calls at inappropriate times of the day.
We tried to find dependence between the patients' responses regarding their phone communication with their GP and their residence. The results show some interesting relations (Table 2). 51.11% of patients living in villages receive phone consults or returned calls by the GP in his or her worktime, as do 42.35% of respondents from the capital, 40.17% of those living in province centres, and 39.77% of those living in towns. The same relation is present in the patients who responded they receive phone consultations and/or returned phone calls at any time of the day: patients living in villages make up the biggest portion (33.34%) and follow by those from towns (29.54%), from province centres (23.94%), and the capital (25.91%). The relation is, however, reversed in the negative answers; i.e. patients who don't receive phone consultations by their GP are most present in province centres (35.90%), followed by the capital (32,74%), the towns (30.68%), while only 15.56% of participants from villages give this response. These results can be connected to the organization of healthcare work in different locations. While accessing a GP is easier in terms of physical accessibility in the capital and the towns, the same general practitioner might work in several villages, which means physical exams in the doctor's office can happen only on a specific day of the week, and naturally phone communication is more frequent. We asked the patients whether they use another communication method to contact their general practitioner in the conditions of the COVID-19 pandemic (Fig. 2.). Phone calls remain the most common method for contacting a general practitioner at 46.52%, but a not insignificant number of respondents uses modern communication methods like Viber (30.70%), messenger (14.50%), and email (6.03%). This indicates general practitioners are very busy when it comes to contacting their patients.

DISCUSSION:
Introducing healthcare measures in the healthcare system -in outpatient care in particular -with the goal of limiting the spread of COVID-19 has resulted in a partial change in the ways patients communicate with general practitioners. This is shown in the opinions of the patients participating in this survey, which was conducted to study the first year of the pandemic (March 2020-April 2021). In over half of the participants (51.41%), access to the GP's office has become easier due to the lower number of people coming for in-person consultations. At the same time, the communication between the patients and their GP through phone calls and information-communication technology has risen, which is most obvious in rural areas. This shows the positive evaluation patients give when they have a constant connection with their GP -both through in-person examinations and communication technology, as well as the trust built between patient and doctor. At the same time, it can be used to evaluate a GP's work quality and communication skills. In the present epidemiological emergency state in relation to the spread of COVID-19, the communication between a GP and his or her patients will probably focus on different ways to provide medical care from a distance through phone calls, Viber, Messanger, email, online consultation, etc. Telemedicine is becoming more and more common in far-off and hard to access regions where there is a shortage of medical personnel, including GPs.
Our recommendations for the National Association of General Practitioners in Bulgaria, Bulgarian Medical Associationand patient organizations with the aim of improving patient access to outpatient care in the conditions of the COVID-19 pandemic is to conduct information campaigns, which have the aim to: -improve the health culture regarding making use of all opportunities to comply with the anti-epidemic measures and prevent the spread of COVID-19.
-present the advantages of online patient consultations, contact via phone calls and other methods of communication provided by doctors if it is possible to solve the patient's problem in this way.

CONCLUSION:
There is a lack of clarity when it comes to the pandemic's length and its consequences on the economics and healthcare of our country. As one of the indicators for the overall quality of healthcare, outpatient care should be studied and analyzed deeply, both in terms of its organization and the access patients have to it. Unobstructed access to a GP is an important condition for high patient satisfaction. This means that, especially in the conditions of the COVID-19 pandemic, outpatient medics and their patients need to fully use the wide array of possibilities provided by information and communicative technology and online consultations.