Clinical pathway of COVID-19 patients in primary health care in 30 European countries: Eurodata study

Abstract Background Most COVID-19 patients were treated in primary health care (PHC) in Europe. Objectives To demonstrate the scope of PHC workflow during the COVID-19 pandemic emphasising similarities and differences of patient’s clinical pathways in Europe. Methods Descriptive, cross-sectional study with data acquired through a semi-structured questionnaire in PHC in 30 European countries, created ad hoc and agreed upon among all researchers who participated in the study. GPs from each country answered the approved questionnaire. Main variable: PHC COVID-19 acute clinical pathway. All variables were collected from each country as of September 2020. Results COVID-19 clinics in PHC facilities were organised in 8/30. Case detection and testing were performed in PHC in 27/30 countries. RT-PCR and lateral flow tests were performed in PHC in 23/30, free of charge with a medical prescription. Contact tracing was performed mainly by public health authorities. Mandatory isolation ranged from 5 to 14 days. Sick leave certification was given exclusively by GPs in 21/30 countries. Patient hotels or other resources to isolate patients were available in 12/30. Follow-up to monitor the symptoms and/or new complementary tests was made mainly by phone call (27/30). Chest X-ray and phlebotomy were performed in PHC in 18/30 and 23/30 countries, respectively. Oxygen and low-molecular-weight heparin were available in PHC (21/30). Conclusion In Europe PHC participated in many steps to diagnose, treat and monitor COVID-19 patients. Differences among countries might be addressed at European level for the management of future pandemics.


Introduction
The World Health Organisation (WHO) declared the coronavirus disease 2019 (COVID-19) a pandemic on the 11th of March 2020. Since then, there have been 267,529,236 cases in Europe, 2,143,708 deaths, by December 2022 [1]. Most COVID-19 patients were treated in primary health care (PHC) in Europe [2,3]. For instance, 85% of positive cases in Germany were treated outpatient [4], while 1565 per 100,000 patients were isolated at home in Italy in 2020 [5]. The coordinated European response has been key and epidemiological monitoring would not have been possible without case detection in primary care and secondary care. Nevertheless, it is not well-known how COVID-19 patients accessed COVID-19 medical care in Europe and which was PHC role in the pandemic disease control.
Pandemic medical care included SARS-CoV-2 detection, contact tracing, case management, treatment and monitoring in PHC. The WHO recommended home management for patients with mild or moderate symptoms if close monitoring for pneumonia could be arranged [6]. Re-organisation of PHC was necessary to attend COVID-19 patients' consultations by suspending non-urgent visits, promoting virtual consultations, prioritising care and providing resources (personal protective equipment, hand hygiene, ventilation, technology) [7]. Moreover, special consideration was given to guaranteeing universal healthcare access and equity, particularly to vulnerable groups. This research aimed to describe PHC work scope during the COVID-19 pandemic with emphasis on similarities and differences of patient's clinical pathways across 30 European countries.

Design
Cross-sectional descriptive study.

Participants
In October 2021, 80 key-informants ( Figure 1) were invited to participate by the World Organisation of Family Doctors (WONCA) in Europe and its networks (EGPRN and EQUIP). Information was provided by 45 GPs (42 were working clinically during the pandemic and 35 were linked to university departments), one public health expert working closely with local GPs and one medical student supervised by a participating  GP. The core research team was formed by four specialists in family medicine, preventive medicine and public health.

Questionnaire
Country-specific data regarding COVID-19 outpatients' pathways, from September 2020, was collected. The initial questionnaire was based on the WHO guidelines where PHC was involved ( Figure 2 and Supplementary file 1) [6].
Three videoconferences were met to reach agreement on the final questionnaire.
Key-informants filled the semi-structured questionnaire based on official sources considered relevant and reliable (Supplementary file 2). Definitions associated with healthcare services and professionals are in Supplementary file 3.

Data collection
At least two key-informants per country sent consensual information, after verification, regarding their national pathways implemented on September 2020.

Data validation
The information received was checked by two core research team researchers to assure the data's quality. If it was unclear, key-informants were contacted for clarification and to provide extra information. Disagreements were discussed among the core team and key-informants to achieve a consensus. Responses' language was homogenised into English during data validation.

Primary health care organisation
Different pathways to separate COVID-19 from non-COVID-19 patients in healthcare facilities were created in most countries, including special practice opening hours. Outpatient COVID-19 clinics/centres were organised in eight countries into existing PHC facilities. They provided remote assessment, testing, physical examination and some chest X-ray or phlebotomy (blood draw). In Belarus, COVID-19 centres received support from other consultants. Cyprus created a National COVID-19 department in the Ministry of Health and GPs worked 8-24 h at the Hospital COVID-19 outpatient clinic.

Case detection and SARS-CoV-2 testing
In countries under observation, the most frequent case detection was done directly by a PHC service provider (in 27/30 countries). Additionally, in 22/30 of the countries surveyed, further services such as public health agencies, infectious diseases departments, webbased portals and/or hotlines supported suspected cases (Table 1).
In all countries, RT-PCR was free in symptomatic patients and PHC was in charge, except in 8 countries. Other institutions involved were accident and emergency departments (A&E) or laboratories. In most countries, lateral flow test was also free but not available in seven countries by September 2020. It was mainly used in PHC and other services such as pharmacies or ambulances.
Testing was performed simultaneously in several places in most countries (PHC facilities, certified microbiology laboratories, public health institutions, hospitals or pharmacists for lateral flow tests). However, for immobile patients, community nurses or primary care home units were primarily the services acquiring SARS-CoV-2 samples. Sometimes, microbiology laboratories and ambulance services were involved (Table 1).

Administrative case management
Information regarding health systems and PHC organisation is described in Supplementary file 1.
Case investigation and contact tracing was part of public health services in all countries, delivered partly or entirely by PHC in Bosnia and Herzegovina, Croatia, Finland, Spain and Turkey ( Table 1). Isolation of COVID-19 patients was mandatory in all countries. The duration was generally 14 days (18 countries), followed by 10 days (9 countries). COVID-19 patients had to be isolated two or three days without symptoms and in Belarus, Czech Republic and Ukraine until having a negative test (Table 2).
Paid sick leave was exclusively managed by GPs in 21 countries. Other healthcare professionals, such as members of infectious disease departments, doctors in secondary care or public health departments helped to process them too. It was automatically set after a positive test in Poland. Only France allowed self-declaration for work absenteeism or GPs' sick note, and the United Kingdom permitted self-certified leave declarations for the first seven days of diseases. Sweden did not demand any sick leave until day 22 of the disease. In the Netherlands, sick leave was not required either; patients mentioned it to their employer without doctor's statements.  Social support became vital during isolation to guarantee basic needs. Social services provided care in 25 countries and charities gave support in most of them, in collaboration with social services. The Ministry of Health of Serbia created a website with volunteers available to facilitate the contact for those in need. In Croatia, public institutions (Ministry of Labour and Welfare, Red Cross) published a list of different volunteers/NGOs. The possibility of offering a hotel room or other resources for those who could not isolate at home was described in 11 countries. Lithuania offered beds at the municipalities.

Clinical case management
In all countries, patients' follow-up was made by PHC through phone calls. E-mail or video consultations were available in some places (Supplementary file 3). Outpatients were followed in PHC to check the symptoms' evolution, social support requirement and need for additional testing. This process was carried out exclusively in PHC in 19/30 countries. Follow-up was also shared with other specialists, including A&E doctors, infectious disease doctors and internists. If patients needed physical examination, it was performed at PHC in 27 countries, including home visits. Chest X-ray (18/30 countries) and phlebotomy (23/30 countries) were available in PHC. Patients were referred to hospitals if symptoms were worsening ( Table 2).
Ambulatory treatments, including low-molecularweight heparin and oxygen could be prescribed by PHC in 21/30 countries. In Croatia and Serbia, GPs could only prescribe low-molecular-weight heparin after hospital specialists' recommendation and/if it complied with professional guidelines. In Hungary, low-molecular-weight heparin was not reimbursed if the prescription was from PHC.

Main findings
This study describes PHC role in managing COVID-19 patients in 30 European countries. PHC was involved in nearly all steps of detection and case management, from initial medical care to diagnose, follow-up and sick leaves with varying practices across countries. Public health authorities were involved in contact tracing and, in some countries, also in testing organisation and result reporting. The length of isolation ranged from 5 to 14 days. Physical examination, additional examinations and treatment were available in most countries; however, a few countries lacked some specific interventions.

Strengths and limitations
A description of disease control pathways in the COVID-19 pandemic in different European countries has not been written before. The information was collected from publicly available reliable online resources by local researchers. They were working in PHC or in close touch with GPs describing how pathways were adapted in real practice. Changes of the pathways could have happened in some regions because of the workload of cases. Although key-informants answered the questionnaires from publicly available trusted network resources, not all relevant information may have been found. In Sweden, the information is from V€ astra G€ otaland region, and in United Kingdom, the information is from England. There were not key-informants in other regions. As the health care systems in Europe vary, the direct comparison of practices was not possible; however, we describe similarities. The different solutions described in this study may inspire other countries to adapt them to their needs.

Comparison with existing literature
A study from the United States reported that COVID-19 hotlines referred 42% of calls to a physician and of those assessed, self-isolation was recommended to 79% of the cases [8]. In this study, 12 countries launched a hotline for access to medical assessment of suspected cases. Although, telemedicine was prioritised during the pandemic, only Finland developed a web-based portal to facilitate access to medical assessment. Most mobile applications were not connected with PHC [9]. In our study, few countries developed online tools to improve the care of patients in PHC, although most patients were attended there. COVID-19 testing was mainly carried out in PHC while public health agencies were in charge of tracking. However, COVID-19 data gathered by administrations, nationally and internationally, overlooked that PHC has been the first line of medical care [10,11].
The Ministry of Health of all participating countries facilitated the accessibility of COVID-19 testing by funding the fees when it was prescribed, which was in line with the principle of universal healthcare access and the coordinated WHO pandemic response. Testing was based on RT-PCR tests in all the countries, but lateral flow testing was not available in any by September 2020. Advantages of testing was based on its price, transportability, possibility of self-managing and quick results [12]. COVID-19 testing varied through countries depending on the institution in charge of the test (PHC or public health), accessibility and affordability of tests, sensibility and specificity of tests [13].
The transmission of the SARS-CoV-2 was more frequent in the first 5 days; however, the incubation could extend until day 15 [14]. The criteria for discharging patients from isolation required three days without symptoms but the length differed from 8 days (European Control of Disease Centre) to 10 days (WHO) [14,15]. There was a remarkable lack of homogeneity in the length of isolation and protocols for ending it in Europe. Isolation is an element of pandemic control; 18 countries decided longer isolation (14 days or more) against the health institution's recommendation. More resilient health systems responded comprehensively with multi-ministry task forces [16]. The lack of a common message among European countries could hinder compliance with isolation rules [17].
In the first wave of the pandemic, sick leave for respiratory diseases nearly doubled the number of cases in the same period during 2017-2019 (4.9 cases/1000 workers vs 2.5 cases/1000 workers) [18].
Other reported data showed that 62.2% of COVID-19 patients needed sick leave in Germany and in Sweden, the median duration was 35 days [19,20]. Welldesigned paid sick leave is critical to ensure workers stay home to prevent the spread of SARS-CoV-2 and other infectious pathogens, both when the economy is open and during shutdowns. A GP sick leave certificate was needed in most countries, mainly managed by GPs in very crowded practices [21]. France, Sweden and United Kingdom allowed self-reported paid sick leave while the Netherlands did not require sick leave certificate when getting sick, which might reduce the work overload for GPs. It is crucial to prioritise GPs' time in activities that add value to patient s care as well as reduce the inverse care law [22].
We highlight the role of GPs in the management of COVID-19 patients. PHC had a significant role in clinical case management in all countries and some countries had restrictions on medical assessment and treatments. First, it will be relevant for European countries to invest in practices to guarantee safe settings to care for airborne infectious diseases, perhaps through the accreditation of PHC practices as in Denmark [23]. Second, as symptoms are not enough to diagnose COVID-19 or identify severe cases, there is a need to examine and perform chest X-ray to rule out pneumonia in PHC. Studies that analysed pathways in other countries did not describe the use of additional testing [24]. Moderate pneumonia could be managed in PHC if phlebotomy was accessible and treatment possible [25,26]. Restrictions in COVID-19 treatment in PHC or induced prescription by other specialists is inconsistent with evidence-based medicine [6]. In September 2020, there was evidence of the benefit of heparin [27], thus not allowing PHC practitioners to prescribe this or oxygen, reduced the management capacity of PHC [28], as well as, not respecting some patients' wish to be treated at home [29,30]. These restrictions may have unnecessarily hindered the effective outpatient care and pushed patients to hospitals. Therefore, it could be beneficial to study opportunities to increase diagnosing and treatment capacity of PHC during pandemics.

Implications for research and/or practice
This study showed that PHC has a significant role in COVID-19 disease control and management in most European countries, as it takes up PHC resources and may affect the ability to deliver other services. It also requires specific skills, equipment and flexibility to reorganise services. Therefore, the burden of communicable disease outbreaks for PHC should be recognised, monitored and supported by additional resources. Self-reported paid leave should be simplified during pandemics to reduce bureaucracy and GPs workload. At European level, there are three crucial needs for future pandemics: (1) a common guidance and implementation of the isolation period within Europe; (2) a legislation to reduce the bureaucracy of sick leave certification in PHC and, (3) the implementation of a European Primary Care Information System linked to the European Centre for Disease Prevention and Control (ECDC).

Conclusion
In Europe, PHC was involved in most steps of COVID-19 medical care in the community, from the suspected cases to diagnosis and follow-up. Inequalities in the access to physical examination, complementary tests and treatments were found. These differences might be addressed through the implementation of European PHC recommendations. Future pandemics must have a Europe common agreement.