Evaluation of the management of COVID-19 patients by general practitioners in France during the pandemic: how were best practices recommendations implemented?

doi:10.21203/rs.3.rs-2816412/v1

Download PDF

Research Article

Evaluation of the management of COVID-19 patients by general practitioners in France during the pandemic: how were best practices recommendations implemented?

https://doi.org/10.21203/rs.3.rs-2816412/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background: Since the first wave of COVID-19 in December 2019 general practitioners (GP) have had to be adaptive and to regularly update their practices.

This study aimed to assess GP practices in the management of adult patients with COVID-19 in the outpatient setting in France, and to describe GP difficulties in implementing related health authority recommandations, with a view to identifying areas for improvement.

Methods: A clinical audit was conducted on a sample of GP practicing in the Provence-Alpes-Côte d'Azur region in southeast France. Recruitment took place between March and June 2021 using a network sampling method until data saturation. Only GP who had treated more than 20 COVID-19 patients were included.

Results: The majority of GP (85.7%) stated that they had continuously adapted their COVID-19 management practices as updated recommendations were published. In contrast, the majority reported that they had not adapted their pratices to the specific needs of at-risk populations (i.e., people over 80 years old, those with stage B cirrhosis, immunocompromised patients, and women in the third trimester of pregnancy). Furthermore, clinical signs of COVID-19 specific to people over 80 years old were poorly known.

Conclusions: Despite rapidly evolving recommendations, and the fact that outpatient management is a major tool for reducing hospital burden, no study to date has investigated the clinical management of COVID-19 in the outpatient sector. Our study, conducted using a clinical audit, highlights the need to ensure GP are more aware of at-risk patients, the population most associated with hospital burden. This type of evaluation should be integrated into future epidemic crisis responses to ensure the implementation and dissemination of best practice recommendations.

primary health care

clinical audit

COVID-19

best practice analysis

- General practitioners were able to adapt their management of COVID-19 patients to scientific data. However, they did not take either the criteria to define severe forms of the disease or COVID-19 risk factors sufficiently into account in order to adapt their therapeutic strategy.

- General practitioners were confused by the multitude of different sources of information on what strategies to implement for COVID-19 management.

- A clinical audit is an appropriate and easy-to-implement method for evaluating clinical practices that deviate from recommendations in a context where knowledge is rapidly evolving.

In December 2019, the world was confronted with a new respiratory disease called COVID-19, which was caused by infection from an emerging coronavirus labelled SARS-CoV-2. The diseases acquired pandemic status in March 2020. The virus, which originated in Wuhan, China, created an unprecedented health crisis which continues today (1).

General practitioners (GP) in France had to rapidly adapt their office organization and their clinical management in order to treat patients with a disease whose characteristics were still unknown (2,3,4,5,6). In order to best support GP in this context, the Haute Autorité de Santé (HAS), which is the national agency in charge of developing best practice recommendations, published its first recommendations in June 2020. These recommendations have been updated nine times (as of March 2023) as knowledge continues to evolve. They define the main principles of i) diagnostic and therapeutic management of COVID-19, ii) identification of risk factors for severe forms of the disease, iii) surveillance methods, and iv) infection prevention.

Earlier, in April 2020, the French College of General Medicine (CMG) created a website (www.coronaclic.fr) dedicated to GP in an attempt to help them manage the barrage of rapidly evolving information coming from several entities including the Ministry, ARS, the High Council of Public Health, as well as the HAS. The goal was to collect all the different relevant information so that GP could follow changes to the official recommendations. The site, which is still operational today, also offers practical infographics that could be used by GP during consultations with patients .

Despite these recommendations and the dedicated website, various studies have shown disparities in the management of COVID-19 patients by GP in France (7).

In order to assess the dissemination and implementation of official best practice recommendations, we evaluated the knowledge and application of clinical practice recommendations in terms of the management of COVID-19 patients among a sample of GP in the Provence-Alpes-Côte d'Azur (PACA) region in southeastern France.

The study’s primary objective was to evaluate GP levels of knowledge and implementation of official COVID-19 management recommendations. The secondary objective was to describe the difficulties GP encountered when trying to implement these recommendations and to identify areas for improvement.

Study design and sampling

We conducted a telephone-based clinical audit on a sample of GP practicing in the PACA region. Clinical audits are an element of the professional practice evaluation methodology validated by the HAS (8,9).

Recruitment took place between January and April 2021 using network sampling until data saturation. GP were solicited by e-mail or telephone. They were given a brief presentation of the subject matter and told how long (estimated time) it would take to respond to the interview. If a respondent who agreed to partcipate could not be interviewed immediately by phone, he/she was invited to have the interview at another time.

Participants had to be GP practicing in the PACA region, and had to have managed more than 20 patients with COVID-19. Participation was voluntary.

Data collection

The interview guide was constructed based on the original best practice recommendations published by the HAS in June 2020.

The clinical audit consisted in collecting data on self-reported practices. GP who did not spontaneously cite a specific recommendation from the list of best practice recommendations - for example oxygen saturation measurement - were asked to assess whether or not they were aware of it; if they declared they were aware of it, they were asked why they deviated from it. This approach made it possible to assess i) GP level of knowledge of the recommendation, ii) GP level of implementation of the recommended practice. We did not quote recommendations to the interviewees in order to avoid possible acquiescence bias. Three open-ended questions dealt with (one each) i) the difficulties encountered by GP in applying recommendations, ii) follow-up management of COVID-19 patients, and iii) GP-perceived areas for improvement (i.e., to better apply the latest best practice recommendations) (Supplementary Table 1).

Interviews were audio recorded and transcribed. The inclusion of new GP was stopped when data saturation was reached (in other words when a new interview did not provide any additional information).

Data analysis

Responses to the interview questionnaires were entered into an Excel table in real time. The open-ended questions were qualitatively analyzed by two GP in charge of data collection. All the collected data were systematically cross-checked using triangulation methods. Differences were reconciled by consensus until 100% agreement was reached.

Ethics

Clinical practice evaluations do not require approval by ethics committee according to French national regulations ( General Data Protection Regulation). The GP who participated in the clinical audit were informed about the study’s objective. No nominative data were collected.

Study population characteristics

Twenty-one GP were interviewed. Women and young and urban doctors were overrepresented in terms of the GP population profile in the PACA region (Table 1).

Table 1

Characteristics of the population
	Features	Study population (21)	Percentage (%)
Gender	M	8	38
Age group	Under 30 years old	4	19
	30 to 50 years	12	57
	50 years and over	5	24
Activity	Cabinet	14	67
	Mixed	7	33
Year of installation	Less than 5 years	12	57
	5 to 10 years	3	14
	10 years and over	6	29
Exercise area	Urban	17	81
	Rural	4	19
No. of COVID-19 patients managed …
	Less than 50	2	10
	50 à 100	10	48
	More than 100	9	43
…over the last 15 days	Less than 3	13	62
	3 à 5	5	24
	More than 5	3	14

Attitudes towards recommendations

Half of the GP said they followed the HAS recommendations. (Table 2). Only one did not implement any recommendation. This GP told us: "I’ve read the HAS recommendations, but it’s mainly clinical common sense that prevails. We manage COVID-19 like we manage a bad flu". (GP7)

Most GP (n = 18) reported they had adapted their practices to new recommendations

"At the beginning, I systematically prescribed macrolides and corticotherapy to prevent any bacterial infection…. I stopped when the updated recommendations arrived" (GP3)

Fourteen GP declared they had regularly discussed the recommendations with colleagues working in the same group practice. They also used social networks and peer groups.

“Every day, my colleagues and I shared information on how to apply the recommendations; it was clearly a delegation of trust to those [GP] who were following the publications, as I was, frankly, overwhelmed and had stopped reading the recommendations directly (GP7)

“I was implementing my colleugues’ protocols. The Whatsapp group of doctors in Marseille, which included infectious disease specialists, was a great help”(GP20)

Table 2

Attitudes towards recommendations
Recommandations used (more than one answer allowed)	GPs	Percentage
Medical Press	14%	14%
Ministry of Health (DGS)	4	19%
National Board of Physicians	2	10%
Infectious Diseases Department local hospital	5	24%
www.coronaclic.fr National Board of Family Medicine Website	9	43%
High Authority of Health (HAS)	11	53%
Number of recommendations used
0	1	5%
1	7	33%
2	8	38%
3	5	24%
No. of doctors who have updated their practice to the recommendations	18	86%
If yes, please specify
Changes to prescribed treatments	10	48%
Use of antigenic tests	4	19%
Use of home monitoring by an IDE	4	19%
No. of doctors who discussed the recommendations with colleagues	15	71%
If yes, please specify
Group practice	10	48%
Social networks	4	19%
Peer group	1	5%

The sum is greater than 100% because the doctors (n = 21) were able to give more than one answer

Knowledge of clinical signs of COVID-19 and criteria for severe COVID-19 disease

(Table 3)

We noted that the clinical signs of COVID-19 specific to people over 80 years of age were poorly known by the GP interviewed, in particular repeated falls (n = 1), decompensation because of a previous pathology (n = 5), the onset of cognitive disorders (n = 6), and the onset of acute confusional state (n = 9).

Some criteria for severe COVID-19 disease were not well known by the participants, such as dehydration (n = 14 after proposal), disorders of consciousness, and sudden alteration in one’s general state. In contrast, more common criteria for severe COVID-19 such as polypnea, hypotension, and hypoxemia (known as happy hypoxemia in the case of COVID-19) were cited by all 21 GP.

“We pay close attention to oxygen saturation in the office itself even in our paucisymptomatic patients, in particular to eliminate happy hypoxia which has received a lot of media coverage” (GP18).

Table 3

Clinical signs suggestive of covid-19 (3A) and signs of severity (3B)
Clinical signs suggestive of Covid	(3A)	Number of positive responses
Clinical signs suggestive of Covid	(3A)	N (%)
	Acute respiratory infection with fever	21 (100%)
General population
	Unexplained asthenia	19 (91%)
	Unexplained myalgia	18 (86%)
	Headaches outside of a known migraine pathology	20 (95%)
	Anosmia or hyposmia without associated rhinitis, agueusia or dysgeusia.	21 (100%)
Population > 80 years
	Altered general condition	13 (62%)
	Repeated falls	1 (5%)
	Onset or worsening of cognitive disorders	6 (29%)
	Confusional syndrome	9 (43%)
	Diarrhoea	20 (95%)
	Decompensation of a previous pathology	5 (24%)
Other signs
	Chest pain	4(19%)
	Abdominal pain	2(10%)

Severity criteria (3B)	Quoted spontaneously	Quoted on proposal	Not quoted
Polypnoea > 22/min (> 30 HAS)	18 (86%)	2 (10%)	1 (5%)
Sp02 < 95% 90 HAS in room air (in the absence of chronic respiratory disease)	21 (100%)	0	0
Systolic blood pressure < 100 mmHg (90 HAS or marbures) (in the absence of antihypertensive medication)	14 (67%)	6 (29%)	1 (5%)
Altered consciousness, confusion, drowsiness	9 (43%)	8 (38%)	4 (19%)
Dehydration	7 (33%)	7 (33%)	7 (33,3%)
Sudden change in general condition in the elderly.	7 (33%)	10 (48%)	4 (19%)
Biological signs of severity ? specify
D-dimer > 0.5 (mg/L)	2 (%)
Organ failure (renal, liver, BNP)	1 (5%)
Hyperleukocytosis > 15 G/L	1 (5%)
Ionic disorders	1 (5%)

Knowledge of risk factors for severe COVID-19 (Table 4)

Some risk factors for severe COVID-19 were not well known in general. More specifically, only 9 GP spontaneously cited the existence of stage B cirrhosis, 8 pregnancy in the third trimester, 7 HIV, 8 organ transplantation or hematological malignancy (causes of immunosuppression), 11 drug immunosuppression, and 4 the date of symptom onset (despite this being essential information for follow-up).

Similarly, few GP mentioned recent travel or modes of transportation used (n = 6 after proposal) as risk factors. In contrast, all GP reported they knew that exposure to and the existence of vulnerable persons in the family circle were risk factors (n = 21 after proposal)

Table 4

knowledge of risk factors
Information sought during the interview with the patient	Spontaneously cited	Cited on proposal	Not cited
Date of onset of symptoms and their evolution	4 (19%)	17 (81%)	0
Medical history, in particular risk factors associated with the development of severe Covid-19 disease
Age ≥ 65 years	13 (62%)	8 (38%)	0
Cardiovascular history: complicated hypertension, stroke, coronary artery disease, heart surgery	19 (91%)	2 (10%)	0
Heart failure NYHA III or IV	15 (71%)	5 (24%)	1 (5%)
Chronic unbalanced diabetes or diabetes with complications	15 (71%)	4 (19%)	2 (10%)
Chronic respiratory disease likely to decompensate	17 (81%)	4 (19%)	0
Chronic renal failure on dialysis	15 (71%)	4 (19%)	2 (10%)
Cancer under treatment (excluding hormone therapy)	9 (43%)	6 (29%)	6 (29%)
Immunosuppression: Medication	11 (52%)	9 (43%)	1 (5%)
Immunosuppression: Uncontrolled HIV infection or ADC < 200/mm3	7 (33%)	5 (24%)	9 (43%)
Immunosuppression: Solid organ or haematopoietic stem cell transplantation	8 (38%)	5 (24%)	8 (38%)
Immunosuppression: Hematologic malignancy under treatment	5 (24%)	6 (29%)	10 (48%)
Cirrhosis ≥ stage B	4 (19%)	5 (24%)	12 (57%)
Obesity BMI > 30	13 (62%)	5 (24%)	3 (14%)
Pregnancy from the 3rd trimester	3 (14%)	5 (24%)	13 (61,9%)
Search for possible exposure (exposed occupation)	11 (53%)	10 (48%)	0
Public transport, possible travel	0	2 (10%)	19 (91%)
Family circle, community life - look for frail people in the home.	12 (57%)	9 (43%)	0
Recent trip if yes, specify	0	6 (29%)	15 (71%)

Management of COVID-19 patients

Biological tests

In line with the HAS recommendations, all participants declared using PCR or antigenic tests to confirm their diagnoses (compliance rate = 100%).

Furthermore, in line with the HAS recommendations, biological check-ups were more likely to be prescribed in situations of diagnostic uncertainty (for CBC/platelets (n = 18), CRP/VS (n = 18), and liver (n = 13) and kidney (n = 13) D-dimers (n = 9) and BNPs (n = 4)) than prescribed routinely (CBC/platelets (n = 6), CRP/VS (n = 6), and ionograms (n = 5)).

“I did not prescribe additional biological tests for suspected COVID-19 patients; [I did so] only if I was not sure of my diagnosis in order to eliminate another diagnosis” (GP6).

Treatments and monitoring (Table 5)

The GP surveyed deviated from the recommendations on therapy and tended to overprescribe antibiotics, especially at the beginning of the pandemic. However, most reported they had adjusted their prescribing practices (n = 17) by significantly reducing how often they prescribed antibiotics (n = 8).

At the time of the study, the most prescribed treatment was paracetamol (n = 19), followed by antibiotics (n = 11), preventive anticoagulants (n = 8), vitamin D (n = 5), decongestants/antitussives (n = 4), and zinc (n = 3).

Few practitioners routinely instructed patients about self-monitoring of temperature (n = 10) or oxygen saturation (n = 4). Most recommended a subsequent consultation if the patient’s condition deteriorated (n = XX). Monitoring was prescribed for most at-risk populations only, especially the elderly. Specifically, systematic home-based monitoring by nurses was prescribed (n = 19) with instructions to hospitalise the patient if his/her health deteriorated.

“I prescribed daily visits by nurses to all my elderly patients (…) thanks to the home nursing rounds organised by Territorial Professional Health Community (CPTS)”( GP11)

Table 5

management of COVID-19 outpatients : treatment and monitoring
Treatments in place	Systematic	Yes, sometimes	Never
Paracetamol	19 (91%)	0	2 (10%)
Macrolide antibiotic	4 (19%)	11 (52%)	6 (29%)
Preventive anticoagulation	1 (10%)	8 (38%)	12 (57%)
Vitamin D	5 (24%)	5 (24%)	11 (52%)
Zinc	2 (10%)	3 (14%)	16 (76%)
Decongestant/Cough suppressant	2 (10%)	4 (19%)	15 (71%)
Corticosteroids	2 (10%)	0	19 (91%)
Changes in treatment in the last year	Yes	No
No. of doctors who changed their prescription	17 (81%)	4 (19%)
If yes, please specify
Less use of macrolide antibiotics	9 (43%)
Prescription of preventive anticoagulation	4 (19%)
Prescription of corticosteroid therapy	1 (5%)
Prescription NSAIDs	1 (5%)
Monitoring guidelines	Yes	No
Self-monitoring
Temperature self-monitoring	11 (52%)	10 (48%)
Self-monitoring pulse oximetry	4 (19%)	17 (81%)
Other instructions
Self-monitoring sheet	2 (10%)
Dyspnea monitoring/severity sign	5 (24%)
Chest pain	5 (24%)
Call 15/MT if worsening	21 (100%)	0
Monitoring IDE
Enhanced monitoring by nurse when self-monitoring is not possible for people at risk of severe COVID-19	19 (91%)	2(10%)
Monitoring through telemedicine	14 (67%)	7(33%)

Difficulties in the management of COVID-19 patients (Fig. 1A)

Participants were confused by the multitude of different sources of information on what to do.

“It’s often difficult to extract important information from the constant flow of messages coming from the Ministry of Health; it would be better to produce summary sheets on new developments rather than whole pages of illegible text” (GP3).

Respondents also reported difficulties establishing an effective GP-hospital link (i.e., obtaining a specialist opinion from a pneumologist, infectologist etc., organising follow-up, collaboration with emergency health services, etc.)

“The hospital organised post-discharge follow-up with telephone monitoring, but it’s a shame we weren’t involved. Most of the time I was not aware that my patients had been hospitalised and had then returned home” (GP7).

Some participants reported that certain patients were aggressive: “We’re the first line of contact for their discontent, with regard to the health crisis and the restrictive measures resulting from it” (GP6).

Finally, denial of the disease by some patients was also described as an obstacle to medical care.

“Some patients did not want to hear about the COVID-19 test; for them it was a bad cold; others trivialised the risk of having a severe form” (G20).

Suggested areas for improvement in the management of COVID-19 patients (Fig. 1B)

Most of the areas for improvement in the management of COVID-19 patients suggested by the interviewed GP reflected areas where they themselves had experienced problems in managing these patients. One example concerned therapy alliance; GP suggested providing patients with “easy access to scientific, clear and proven information” to improve this alliance, especially with the least convinced patients. They highlighted that accurate information for patients was often drowned out by a constant stream of misinformation disseminated by the media and various social networks.

A second area for improvement concerned GP-hospital links. Specifically, coordination through local care protocols was identified as a key element in facilitating access to new recommendations and to harmonize COVID-19 management practices.

“The local hospital provided us with a management algorithm that allowed us to refer our patients at risk of complications or to ask for advice on the type of monitoring to be put in place”. (GP12)

"Decision-making should be brought closer to the local level through the CPTS (territorial professional health community) in order to be able to best adapt to the situation, and not at the national level as has been the case since the beginning of the crisis”. (G19)

Results and comparison with the literature

This study’s findings indicate the GP interviewed had a good overall knowledge of the clinical signs and risk factors to provide optimal management of the disease despite less thorough knowledge of the semiology and risk factors of severe COVID-19 for the elderly (10,11,12). In terms of practices, two-thirds of the participants (67%) cited (either spontaneously or after proposal) all of the HAS recommendations for the disease’s management in the general population. This compliance rate (i.e., number of responses on practices reflecting recommendations) aligns with international data, in particular a study conducted during the second wave in Australia (13) which reported that 76.6% of GP had a good theoretical knowledge of recommended COVID-19 management practices.

Some symptoms, such as headaches, anosmia, and diarrhea, have been widely publicized, and were better known by our study sample. Others specific to the elderly, such as repeated falls, and cognitive impairment were less well known; this is surprising since these are the patients most at risk of developing severe forms of the disease. A study published in JAMA (14) at the beginning of the epidemic showed that nearly 36.4% of infected elderly patients presented neurological symptoms, which highlights how important it is for GP to be aware of these symptoms, especailly in terms of avoiding diagnostic errors and related delays in suitable disease management.

All 21 GP in our study conducted complete clinical examinations in accordance with recommendations, except for the measurement of respiratory frequency, which was only conducted by half the sample. The argument put forward by GP for not implementing this recommendation was that respiratory frequency is a subjective measurement (15), and can be modified by external factors such as the patient’s state of anxiety (16).

In accordance with the HAS national recommendations, few of our sample offered their patients a biological test; only a screening test (PCR or antigenic tests) was systematically proposed to diagnose the disease and to eliminate the possibility of other pathologies and organ decompensation in comorbid patients (17,18).

Furthermore, they also adhered to HAS recommendations by only prescribing antipyretic treatment, which is still (as of March 2023) the only recommended first-line treatment in the absence of signs of severe COVID-19.

The most frequently prescribed antibiotics in cases of bacterial superinfection remains macrolides, with azithromycin at the top of the list (19,20,21).

Self-monitoring was rarely proposed by the study’s respondents, which does not reflect the HAS best practice recommendations. Moreover, despite HAS recommendations, saturometers were proposed very rarely; some GP admitted to not knowing how to prescribe them. However, some of our particiapnts were enrolled before prescribed saturometers became officially reimbursable by the national health insurance system (24 April 2021). Participants considered that the vast majority of their COVID-19 patients did not present serious symptoms, and consequently concluded that home monitoring would be of little value and would likely only generate anxiety.

Our study also revealed the challenges faced by GP during the COVID-19 pandemic. One such challenge was the lack of GP-hospital coordination, which resulted in restricted access to care. More specifically, patients could only access complementary examinations and hospitalization services (i.e., low-dose CT scan) if they first passed through the emergency department. This led to a longer, complicated and less structures care pathway, and sometimes resulted in difficult ambulatory follow-up. The deployment of CPTS (see above), which developed rapidly during the crisis, played a decisive role in the implementation of recommendations at the local level using social networks and peer groups and is a promising avenue for coordinated practice between GP and hospitals, not only in the context of COVID-19 but also for future epidemics (22,23).

The GP interviewed also raised the difficulty of conflictual relationships with patients and changes in the doctor-patient relationship. This perception is confirmed by the increase in the number of incidents of violence against care providers reported in the international literature during the pandemic (24). A recent study published in Nature (25) addressed the subject of patient aggression toward medical science in the broadest sense of the term during the COVID-19 health crisis.

In response to this, one improvement proposed by the GP in our study was to make important information easily accessible to patients.

Study strengths and limitations

To our knowledge, this is the first clinical audit to be conducted in the context of the management of COVID-19 by GP in the context of rapidly evolving disease management guidelines.

The study has several limitations. First, spontaneous answers to interview questions (i.e., Q2 and Q10) may have led to an underestimation of the real level of participants’ knowledge, unlike questions with proposals (i.e., Q3 and Q7). Second, 21 participants is a relatively small sample size. Having said that, the gender and age distribution group was comparable to GP in the PACA region (29). Third, our sample had a large active file of COVID-19 patients, and therefore they were a priori experienced in the management of this type of patient. This may have resulted in selection bias, as there was a higher than expected compliance rate.

The clinical audit method provided us with longitudinal monitoring of how GP adapted their practices to an emerging disease. The decision to use an individual face-to-face interview over a self-administered questionnaire was taken to ensure that specific data could be collected.

The culture of professional practice evaluation (PPE) is commonplace in hospitals. PPE is an integral part of Continuing Professional Development (hospital staff, Experience Feedback Committee, Morbidity and Mortality Review, etc.). Nevertheless, it is still not widespread in private practice in France, as implementation in this context is complex. More specifically, despite GP willingness to improve their practices, there are obstacles to the development of clinical audits in the French primary care system, including a lack of time, negative attitudes, and fear of being judged and criticized by peers (26,27).

However, other continuing professional development systems exist for GP; in particular, peer groups are very common in France. These allow GP to discuss complex clinical cases and recent changes in recommendations concerning various pathologies frequently encountered in family medicine (28).

The clinical audit method used here would appear to be appropriate for the study of clinical practices in a situation of continuous adaptation. Our findings highlighted the adaptability of GP to changing recommendations for COVID-19 patient management. A large majority (18/21) of the study participants reported that they adapted their practices as new best practice recommendations were published. However, risk factors were rarely fully investigated. Furthermore, knowledge about clinical signs specific to people over 80 years were generally not very well known, despite detection and follow-up of this high-risk group being a cornerstone of primary care in a context where hospital systems are under stress. A hospital crisis management system can only work if there is an effective organization of primary care for early referral to hospital of patients with severe symptoms.

In the context of emerging diseases, the present study addresses the challenge of promoting the rapid dissemination of recommendations accessible in times of crisis to physicians and their patients in the perspective of a patient-centered approach, as well as promoting a culture of practice evaluation (e.g., clinical audits) for a better implementation of best practice recommendations.

Ethics approval and consent to participate

Ethics approval is deemed unnecessary according to national regulations ( General Data Protection Regulation) as clinical practice evaluations do not require approval by ethics committee in France. Informed consent was obtained from all the participants. No nominative data were collected.

All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable

Availability of data and materials

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no conflicts of interest."

Funding

This study was funded by the Department of General Medicine and the Public Assistance Hospitals of Marseille."

Author’s contributions

RL, SG, TF, JF, PV wrote the main manuscript text. GT prepared figures and tables and participated to the interviews. ST participated to the implementation of the research. All authors reviewed the manuscript.

Acknowledgements

The authors would like to express their gratitude to the general practitioners who participated in this study. Without their willingness to collaborate, this research would not have been possible. We appreciate their time, effort, and contribution to this project."

Kaba M, Kitaw Y. Novel coronavirus (2019-nCoV) – reminiscent of Spanish flu: A challenge to global public health systems. Ethiopian Journal of Health Development [Internet]. 4 févr 2020 [cité 7 avr 2023];34(1). Disponible sur: https://www.ajol.info/index.php/ejhd/article/view/195678
Albert SL, Paul MM, Nguyen AM, Shelley DR, Berry CA. A qualitative study of high-performing primary care practices during the COVID-19 pandemic. BMC Fam Pract. 25 nov 2021;22(1):237.
Chang AY, Cullen MR, Harrington RA, Barry M. The impact of novel coronavirus COVID-19 on noncommunicable disease patients and health systems: a review. J Intern Med. avr 2021;289(4):450‑62.
Sharma SC, Sharma S, Thakker A, Sharma G, Roshan M, Varakantam V. Revolution in UK General Practice Due to COVID-19 Pandemic: A Cross-Sectional Survey. Cureus. 5 août 2020;12(8):e9573.
Huston P, Campbell J, Russell G, Goodyear-Smith F, Phillips RL, van Weel C, et al. COVID-19 and primary care in six countries. BJGP Open. oct 2020;4(4):bjgpopen20X101128.
Marshall M, Howe A, Howsam G, Mulholland M, Leach J. COVID-19: a danger and an opportunity for the future of general practice. Br J Gen Pract. juin 2020;70(695):270‑1.
Xu X, Ong YK, Wang DY. Role of adjunctive treatment strategies in COVID-19 and a review of international and national clinical guidelines. Mil Med Res. 5 mai 2020;7(1):22.
Paton JY, Ranmal R, Dudley J, RCPCH Clinical Standards Committee. Clinical audit: still an important tool for improving healthcare. Arch Dis Child Educ Pract Ed. avr 2015;100(2):83‑8.
Cottrell E, Crabtree V, Edwards JJ, Roddy E. Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice. BMC Fam Pract. 14 nov 2013;14:170.
Grygiel-Górniak B, Oduah MT. COVID-19: What Should the General Practitioner Know? Clin Interv Aging. 2021;16:43‑56.
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 28 mars 2020;395(10229):1054‑62.
Tsopra R, Frappe P, Streit S, Neves AL, Honkoop PJ, Espinosa-Gonzalez AB, et al. Reorganisation of GP surgeries during the COVID-19 outbreak: analysis of guidelines from 15 countries. BMC Fam Pract. 17 mai 2021;22(1):96.
Sotomayor-Castillo C, Nahidi S, Li C, Hespe C, Burns PL, Shaban RZ. General practitioners’ knowledge, preparedness, and experiences of managing COVID-19 in Australia. Infect Dis Health. août 2021;26(3):166‑72.
Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA Neurol. 1 juin 2020;77(6):683‑90.
Takayama A, Takeshima T, Nakashima Y, Yoshidomi T, Nagamine T, Kotani K. A Comparison of Methods to Count Breathing Frequency. Respir Care. mai 2019;64(5):555‑63.
Park SB, Khattar D. Tachypnea. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cité 7 avr 2023]. Disponible sur: http://www.ncbi.nlm.nih.gov/books/NBK541062/
Vandenberg O, Martiny D, Rochas O, van Belkum A, Kozlakidis Z. Considerations for diagnostic COVID-19 tests. Nat Rev Microbiol. mars 2021;19(3):171‑83.
Carpenter CR, Mudd PA, West CP, Wilber E, Wilber ST. Diagnosing COVID-19 in the Emergency Department: A Scoping Review of Clinical Examinations, Laboratory Tests, Imaging Accuracy, and Biases. Acad Emerg Med. août 2020;27(8):653‑70.
Armitage R, Nellums LB. Antibiotic prescribing in general practice during COVID-19. Lancet Infect Dis. juin 2021;21(6):e144.
Langford BJ, So M, Raybardhan S, Leung V, Soucy JPR, Westwood D, et al. Antibiotic prescribing in patients with COVID-19: rapid review and meta-analysis. Clin Microbiol Infect. avr 2021;27(4):520‑31.
Echeverría-Esnal D, Martin-Ontiyuelo C, Navarrete-Rouco ME, De-Antonio Cuscó M, Ferrández O, Horcajada JP, et al. Azithromycin in the treatment of COVID-19: a review. Expert Rev Anti Infect Ther. févr 2021;19(2):147‑63.
Fournier C, Clerc P. La construction d’une organisation territoriale des acteurs de soins primaires face à l’épidémie de Covid-19 : apports d’une étude de cas à l’échelle d’un canton. Revue francophone sur la santé et les territoires [Internet]. 11 mars 2021 [cité 7 avr 2023]; Disponible sur: https://journals.openedition.org/rfst/869
Dutour M, Kirchhoff A, Janssen C, Meleze S, Chevalier H, Levy-Amon S, et al. Family medicine practitioners’ stress during the COVID-19 pandemic: a cross-sectional survey. BMC Fam Pract. 14 févr 2021;22(1):36.
Menon V, Padhy SK, Pattnaik JI. Stigma and Aggression Against Health Care Workers in India Amidst COVID-19 Times: Possible Drivers and Mitigation Strategies. Indian J Psychol Med. juill 2020;42(4):400‑1.
Nogrady B. « I hope you die »: how the COVID pandemic unleashed attacks on scientists. Nature. oct 2021;598(7880):250‑3.
Grol R, Wensing M. Implementation of quality assurance and medical audit: general practitioners’ perceived obstacles and requirements. Br J Gen Pract. oct 1995;45(399):548‑52.
Arvidsson E, Dahlin S, Anell A. Conditions and barriers for quality improvement work: a qualitative study of how professionals and health centre managers experience audit and feedback practices in Swedish primary care. BMC Fam Pract. 14 juin 2021;22(1):113.
Arnaud G. 290 Quality circle prescribing improvement program. Qual Saf Health Care. 1 avr 2010;19(Suppl 1):A23‑4.
CNOM. ATLAS PACA. 2018

No competing interests reported.

Supplementarytable1.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Evaluation of the management of COVID-19 patients by general practitioners in France during the pandemic: how were best practices recommendations implemented?

Status:

Version 1

Abstract

Figures

Key Message

BACKGROUND

MATERIALS AND METHODS

RESULTS

DISCUSSION

Study strengths and limitations

METHOD

CONCLUSION

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1