Call your Doctor: Prospective Description Study of Telemedicine during the First COVID-19 Outbreak in a Swiss Primary Care Practice

Study of Telemedicine during the First Outbreak in a Swiss Practice. Abstract Background: Telemedicine is a healthcare assistance method which has been promoted during the COVID-19 pandemic for the management of patients. The aim of this study is to quantify the type of request that primary care physicians are experiencing, as well as the healthcare assistance modalities and ultimately, how many physical consultations are necessary. Methods: We conducted a prospective, descriptive study in a primary care practice in Switzerland on telephone consultations related to COVID-19. The data collected included the reasons for the call, symptoms, healthcare assistance modalities and follow-up. The categorical variables are expressed as percentages of the total cases or groups. Results: We included 200 calls corresponding to 113 patients. The majority of patients (76.1%) were taken care of solely through telemedicine. The physical consultations were due to the need: for a swab test (12.4%), for a somatic assessment at the practice (9.7%) and for an emergency services consultation (1.8%). In 64.6% of cases, patient assistance required only one phone call. Calls lasted 7.85 minutes on average and were more frequent on Mondays (24%) and Fridays (18.5%). Calls led to the prescription of medication in 12.5% of cases, of a bronchodilator in 3% of cases and of an antibiotic in 0.5% of cases. Conclusion: A rigorous telephone follow-up strategy carried out by primary care physicians requires few physical consultations in patients showing symptoms of COVID-19.


Background
The emergence of the COVID-19 virus in December 2019 in Wuhan in China, then its spread to reach the pandemic stage, declared in March 2020, caused millions of respiratory infections [1]. Due to the rapid development of the disease, unprecedented public health measures were put in place and changes in hospital structures were required [2]. Outpatient medicine and primary care practices were also immediately required to implement new assistance strategies, in particular telemedicine [3,4]. Primary care medicine has been faced with a double challenge: having to deal with a considerable number of patient requests and, at the same time, having to restrict the movement of contagious patients [5,6]. In such circumstances, we carried out this descriptive study, with the objective of quantifying the type of requests primary care physicians have to deal with, the modalities of assistance, the prescription of medication in telemedicine and finally, how many physical consultations are necessary. As a secondary objective, we gathered the patient symptoms.

Methods
This is an observational, prospective, monocentric study at a multidisciplinary private practice medical centre in Bulle. Bulle is a rural area in French-speaking Switzerland and was hit by COVID-19 in early April.
The study took place from 6 April to 28 May 2020.
The medical centre includes six general practitioners, two assistant physicians in general medicine, a paediatrician, a specialist in pain relief, two rheumatologists and several paramedic staff. The number of patients followed in the medical centre, in terms of adult general medicine, is approximately 6,700. Telemedicine consultations were not carried out at the medical centre before April 2020. The criteria for inclusion and exclusion in the study are shown in Table 1. For each call, the age and gender of the patient were recorded, as well as the characteristics of the call, symptom description and assistance offered. The data collected during the telephone interviews is shown in Table 2. The choice of symptoms was based on the published literature [7].    Figure 3 shows the distribution of calls by day of the week. Telephone calls were more frequent on Mondays (24%) and Fridays (18.5%).

Study methodology
To the best of our knowledge, this is the first study

Telemedicine assistance
The assistance for most patients (73%) only required one telephone call. During this period, the recommendations by the Swiss authorities did not include the performance of systematic PCR swabs, which explains the low number of consultations based on this reason.
Today, the results would be different due to the current broad testing policy. In addition, over the entire follow-up, only 23.9% of patients required a physical consultation, most often for carrying out a COVID-19 PCR swab (12.4% of patients). Patient described a worsening of symptoms in 15% of cases from the 9 th day of symptoms, and stability of symptoms in 30% of cases. Post-acute covid-19 (or "long covid") has been described in the literature and appears to occur in approximately 10% of cases [11]. We also found 13.6% of telephone calls which were still symptomatic calls after 3 weeks. The assistance consisted mainly in the advice of isolation, monitoring and quarantine, while only 12.5% of the calls required a prescription.
This low number is explained by the fact that many patients already had paracetamol at home and currently there is no specific treatment for COVID-19 in the outpatient setting. The prescription of antibiotics is low in our study, which is probably due to the fact that they are ineffective in the treatment of COVID-19, and patients know and accept this.

Organisational aspects
The number of telephone calls was higher on Mondays (24.2% of cases), which required more staff on that day. There were fewer calls on Saturdays and Sundays, which is explained by the fact that the medical centre is closed. However, it is possible that on weekends there were more telephone calls directed to the hotlines. Despite the fact that the medical centre had no previous experience of telemedicine consultations, we were not overwhelmed by the handling of these calls, which lasted less than 10 minutes. In our opinion, these results were possible because the physicians who carried out the telephone follow-up were the patients' family doctors, and/or had access to the patient's medical file. We believe that this in-depth knowledge of the patient allowed higher quality assistance and restricted the need for consultations. We also observed that the glossary facilitated the identification of the different situations and made our assistance more consistent. The glossary also allowed the researchers to follow the evolution of the recommendations for assistance, in particular in relation to carrying out nasopharyngeal PCR swabs.

Conclusion
This study shows that a rigorous telephone follow-up