Luis Ayerbe, Centre of Primary care and Public Health, Queen Mary University of London; Carnarvon Medical Centre, Southend on Sea, UK.
Carlos Risco-Risco, Service of Internal Medicine, Hospital Universitario HM Sanchinarro, Madrid, Spain.
Maria Perez-Pinar, Carnarvon Medical Centre, Southend on Sea, UK.
Clinical interventions, delivered in the community, from the moment of diagnosis, could reduce the need for admissions, the disruption of hospitals, and the mortality associated with COVID-19. An effective management of the infection outside hospitals would also make confinement less necessary.
These interventions could be delivered in primary care as well as in outpatient clinics of internal medicine, ideally working in coordination. Primary care doctors are the most numerous medical practitioners in the health service and have plenty of experience on the management of respiratory tract infections.
Patients with COVID-19 could be seen in ambulatory clinics, for their first assessment, right after the diagnosis, even if they only have mild symptoms at the time. Those with higher risk, such as old people with underlying medical problems, are now easily identifiable.1,2
Primary care doctors are the most numerous medical practitioners in the health service and have plenty of experience on the management of respiratory tract infections.
The assessment for clinical predictors of severe disease and mortality, including persistent fever and low saturation of oxygen, can be done with a routine clinical interview and physical examination. Highly predictive information on the course and outcomes of COVID-19 can also be obtained from a blood test, with full blood count and inflammatory markers, together with a chest X-ray.1,3 Drugs that are normally administered in the community, such as anticoagulants and steroids, play a significant part in the management of the disease.3,4
Despite all this, guidelines only suggest a very basic clinical approach to COVID-19 from primary care, mainly around observation and control of symptoms. Most of the preventive or therapeutic management is based on costly and disruptive public health measures or acute interventions in overloaded hospitals after the patient has deteriorated enough to require admission.3,4
Clinical guidelines could present diagnostic and therapeutic interventions, to be delivered in primary care and internal medicine clinics, aiming to reduce the need for hospital admissions. These could include monitoring temperature and respiratory function, together with markers of inflammation and radiological images, and the prescription of antiviral drugs, anticoagulation, or anti-inflammatories in different regimes. Clinicians would require adequate personal protection equipment to run these clinics, along with access to routine laboratory and radiological tests, and specific organisation of clinical teams.
Interventions in the community should be based on the best available evidence.
Interventions in the community should be based on the best available evidence. Research, looking specifically at interventions outside the hospitals, can be put in place to cover areas where evidence is particularly poor. The effect of some treatments may be different for patients in early stages of the disease and for those who need admission.5
Interventions on compassionate grounds, when evidence is not available and research is not possible, could also be raised. Monitoring all these interventions in real time with constant analysis of routinely collected clinical data on different outcomes would help to reshape the clinical management of COVID-19 and make it more effective.
Primary care, and ambulatory medicine in general, is an extremely valuable and massive resource within the health service and its effective mobilisation could lead to a reduction on the morbimortality, and an earlier resolution of the international crisis, associated with COVID-19.
1. Berenguer J, Ryan P, Rodríguez-Baño J, et al. Characteristics and predictors of death among 4035 consecutively hospitalized patients with COVID-19 in Spain. Clin Microbiol Infect 2020; 26(11): 1525–1536.
2. Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020; 584(7821): 430–436.
3. Centers for Disease Control and Prevention. Interim clinical guidance for management of patients with confirmed coronavirus disease (COVID-19). 2020. https://stacks.cdc.gov/view/cdc/89980 (accessed 20 Nov 2020).
4. BMJ. Coronavirus disease 2019 (COVID-19): treatment algorithm. 2020. https://bestpractice.bmj.com/topics/en-gb/3000201/treatment-algorithm (accessed 20 Nov 2020).
5. Fonseca SNS, de Queiroz Sousa A, Wolkoff AG, et al. Risk of hospitalization for COVID-19 outpatients treated with various drug regimens in Brazil: comparative analysis. Travel Med Infect Dis 2020; 38: 101906.