Abstract
BACKGROUND: Impact of war on civilians in high-income countries has been relatively underexplored in research. Internal displacement of populations within a country during war challenges healthcare universal access, utilization, and continuity of care. Healthcare systems can prepare and adjust to mitigate detrimental effects. Therefore, our objective was to examine primary healthcare delivery adaptations during war-induced population displacement and the effects on primary healthcare utilization. METHODS: Observational, repeated cross-sectional study based on Clalit Health Services (CHS) electronic medical records (EMR) data. Outcomes were the rates of visits in primary care during five months following the war, compared to the previous year, by population group. All CHS members were included, 4.86 million, classified into four groups: (1) evacuated municipalities in the South (ES); (2) evacuated municipalities in the North (EN); (3) areas of restricted activity (RA) (4) rest of the Country (RC). The considered exposures were the state of war and internal displacement of populations, extended periods of restricted activities for areas under threat, and primary healthcare delivery adaptation measures. The main outcomes and measures were primary care visit rates grouped into four consecutive weeks clusters. Visits were further classified as in-person or telehealth visits. RESULTS: Healthcare delivery adaptation measures included fast set-up of pop-up primary clinics in evacuated population concentrations, services expansion (online visits 24/7, medication delivery range), and expanded services for internally displaced persons (designated call center lines and text-based nursing service). During the initial weeks following the outbreak of war overall visits declined, mainly in displaced populations (by 43.9% (95% CI: 42.2-45.6%) and 19.1% (95% CI: 17.1 - 21.1%) in the first month in ES and EN, respectively). Visits rates gradually recovered in all population groups, returning to baseline within 12 weeks. This was driven by a sharp initial decline of in-person visits, and attenuated by increased usage of telehealth, mainly observed in displaced populations. CONCLUSIONS: The outbreak of war and population displacement was associated with decreased primary care visits, while telehealth service utilization increased significantly. This increase was partly facilitated by telehealth consultations provided by patients' regular primary care physicians, often themselves displaced, thereby preserving continuity of care through existing trust and rapport. Healthcare systems should proactively integrate telehealth solutions into emergency preparedness plans, prioritizing continuity of patient-provider relationships even during displacement. Future research is needed to evaluate the quality and equity implications of telehealth adaptations and their impact on long-term health outcomes.