Experiences, challenges and perspectives for ensuring end-of-life patient care: A national online survey with general practitioners in Germany.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic is posing major challenges for health care systems. In Germany, one such challenge has been that adequate palliative care for the severely ill and dying (with and without COVID-19), as well as their loved ones, has not been available at all times and in all settings., the pandemic has underlined the significance of the contribution of general practitioners (GPs) to the care of severely ill and dying patients. OBJECTIVES: To describe GPs' experiences, challenges and perspectives with respect to end-of-life care during the first peak of the pandemic (spring 2020) in Germany. MATERIALS AND METHODS: In November and December 2020, a link to an Unipark online survey was sent to GPs registered on nationwide distribution lists. RESULTS: In total, 410 GPs responded; 61.5% indicated that the quality of their patients' end-of-life care was maintained throughout the pandemic, 36.8% reported a decrease in quality compared to pre-pandemic times. Of the GPs who made home visits to severely ill and dying patients, 61.4% reported a stable number of visits, 28.5% reported fewer visits. 62.7% of the GPs reported increased telephone contact and reduced personal contact with patients; 36.1% offered video consultations in lieu of face-to-face contact. The GPs reported that relatives were restricted (48.5%) or prohibited from visiting (33.4%) patients in nursing homes. They observed a fear of loneliness among patients in nursing homes (91.9%), private homes (87.3%) and hospitals (86.1%). CONCLUSIONS: The present work provides insights into the pandemic management of GPs and supports the development of a national strategy for palliative care during a pandemic. To effectively address end-of-life care, GPs and palliative care specialists should be involved in COVID-19 task forces on micro, meso and macro levels of health care.

Acceptance of Telerheumatology by Rheumatologists and General Practitioners in Germany: Nationwide Cross-sectional Survey Study.

BACKGROUND: The worldwide burden of musculoskeletal diseases is increasing. The number of newly registered rheumatologists has stagnated. Primary care, which takes up a key role in early detection of rheumatic disease, is working at full capacity. COVID-19 and its containment impede rheumatological treatment. Telemedicine in rheumatology (telerheumatology) could support rheumatologists and general practitioners. OBJECTIVE: The goal of this study was to investigate acceptance and preferences related to the use of telerheumatology care among German rheumatologists and general practitioners. METHODS: A nationwide, cross-sectional, self-completed, paper-based survey on telerheumatology care was conducted among outpatient rheumatologists and general practitioners during the pre-COVID-19 period. RESULTS: A total of 73.3% (349/476) of survey participants rated their knowledge of telemedicine as unsatisfactory, poor, or very poor. The majority of survey participants (358/480, 74.6%) answered that they do not currently use telemedicine, although 62.3% (291/467) would like to. Barriers to the implementation of telemedicine include the purchase of technology equipment (182/292, 62.3%), administration (181/292, 62.0%), and poor reimbursement (156/292, 53.4%). A total of 69.6% (117/168) of the surveyed physicians reckoned that telemedicine could be used in rheumatology. Surveyed physicians would prefer to use telemedicine to communicate directly with other physicians (370/455, 81.3%) than to communicate with patients (213/455, 46.8%). Among treatment phases, 64.4% (291/452) of participants would choose to use telemedicine during follow-up. Half of the participants would choose telecounseling as a specific approach to improve rheumatology care (91/170, 53.5%). CONCLUSIONS: Before COVID-19 appeared, our results indicated generally low use but high acceptance of the implementation of telerheumatology among physicians. Participants indicated that the lack of a structural framework was a barrier to the effective implementation of telerheumatology. Training courses should be introduced to address the limited knowledge on the part of physicians in the use of telemedicine. More research into telerheumatology is required. This includes large-scale randomized controlled trials, economic analyses, and the exploration of user preferences.

The hydroxychloroquine debate: a therapeutic dilemma for general practitioners.

France has been at the epicenter of the worldwide debate about hydroxychloroquine, as the main advocacy for its use to treat COVID-19 comes from a research unit led by Didier Raoult in Marseille. Among a national panel of 2940 general practitioners, we found that physicians in the areas most strongly affected by the epidemic or closest to the epicenter of the controversy reported that the hydroxychloroquine debate had made it difficult for them to deal with patients' treatment requests. Their adherence to official recommendations was also lower. It will be necessary to examine the conditions producing so strong a conflict.

Family medicine practitioners' stress during the COVID-19 pandemic: a cross-sectional survey.

BACKGROUND: The COVID-19 pandemic has shaken the world in early 2020. In France, General Practitioners (GPs) were not involved in the care organization's decision-making process before and during the first wave of the COVID-19 pandemic. This omission could have generated stress for GPs. We aimed first to estimate the self-perception of stress as defined by the 10-item Perceived Stress Score (PSS-10), at the beginning of the pandemic in France, among GPs from the Auvergne-Rhône-Alpes, a french administrative area severely impacted by COVID-19. Second, we aimed to identify factors associated with a self-perceived stress (PSS-10 ≥ 27) among socio-demographic characteristics of GPs, their access to reliable information and to personal protective equipment during the pandemic, and their exposure to well established psychosocial risk at work. METHODS: We conducted an online cross-sectional survey between 8th April and 10th May 2020. The self-perception of stress was evaluated using the PSS-10, so to see the proportion of "not stressed" (≤20), "borderline" (21 ≤ PSS-10 ≤ 26), and "stressed" (≥27) GPs. The agreement to 31 positive assertions related to possible sources of stress identified by the scientific study committee was measured using a 10-point numeric scale. In complete cases, factors associated with stress (PSS-10 ≥ 27) were investigated using logistic regression, adjusted on gender, age and practice location. A supplementary analysis of the verbatims was made. RESULTS: Overall, 898 individual answers were collected, of which 879 were complete. A total of 437 GPs (49%) were stressed (PSS-10 ≥ 27), and 283 GPs (32%) had a very high level of stress (PSS-10 ≥ 30). Self-perceived stress was associated with multiple components, and involved classic psychosocial risk factors such as emotional requirements. However, in this context of health crisis, the primary source of stress was the diversity and quantity of information from diverse sources (614 GPs (69%, OR = 2.21, 95%CI [1.40-3.50], p < 0.001). Analysis of verbatims revealed that GPs felt isolated in a hospital-based model. CONCLUSION: The first wave of the pandemic was a source of stress for GPs. The diversity and quantity of information received from the health authorities were among the main sources of stress.

Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study.

BACKGROUND: To reduce contagion of COVID-19, in March 2020 UK general practices implemented predominantly remote consulting via telephone, video, or online consultation platforms. AIM: To investigate the rapid implementation of remote consulting and explore impact over the initial months of the COVID-19 pandemic. DESIGN AND SETTING: Mixed-methods study in 21 general practices in Bristol, North Somerset and South Gloucestershire. METHOD: Longitudinal observational quantitative analysis compared volume and type of consultation in April to July 2020 with April to July 2019. Negative binomial models were used to identify if changes differed among different groups of patients. Qualitative data from 87 longitudinal interviews with practice staff in four rounds investigated practices' experience of the move to remote consulting, challenges faced, and solutions. A thematic analysis utilised Normalisation Process Theory. RESULTS: There was universal consensus that remote consulting was necessary. This drove a rapid change to 90% remote GP consulting (46% for nurses) by April 2020. Consultation rates reduced in April to July 2020 compared to 2019; GPs and nurses maintained a focus on older patients, shielding patients, and patients with poor mental health. Telephone consulting was sufficient for many patient problems, video consulting was used more rarely, and was less essential as lockdown eased. SMS-messaging increased more than three-fold. GPs were concerned about increased clinical risk and some had difficulties setting thresholds for seeing patients face-to-face as lockdown eased. CONCLUSION: The shift to remote consulting was successful and a focus maintained on vulnerable patients. It was driven by the imperative to reduce contagion and may have risks; post-pandemic, the model will need adjustment.

How GPs adapted their practices and organisations at the beginning of COVID-19 outbreak: a French national observational survey.

OBJECTIVES: To describe how general practitioners (GPs) adapted their practices to secure and maintain access to care in the epidemic phase. A secondary objective was to explore if GPs' individual characteristics and type of practice determined their adaptation. DESIGN: Observational study using an online questionnaire. Organisational changes were measured by a main question and detailed in two specific outcomes. To identify which GPs' characteristics impacted organisational changes, successive multivariate logistic modelling was performed. First, we identified the GPs' characteristics related to organisational changes with a univariate analysis. Then, we tested the adjusted associations between this variable and the following GPs' characteristics: age, gender and type of practice. SETTING: The questionnaire was administered online between 14 March and 21 March 2020. Practitioners were recruited by email using the contact lists of different French scientific GP societies. PARTICIPANTS: The target population was GPs currently practising in France (n=46 056). We obtained a total of 7481 responses. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: Proportion of GPs who adapted their practice. Secondary outcome: GPs' characteristics related to organisational changes. RESULTS: Among the 7481 responses, 5425 were complete and were analysed. 3849 GPs (70.9%) changed their activity, 3605 GPs (66.5%) increased remote consultations and 2315 GPs (42.7%) created a specific pathway for probable patients with COVID-19. Among the 3849 GPs (70.9%) who changed their practice, 3306 (91.7%) gave more answers by phone, 996 (27.6%) by email and 1105 (30.7%) increased the use of video consultations. GPs working in multi-professional group practices were more likely to have changed their activity since the beginning of the epidemic wave than GPs working in mono-professional group or single medical practices (adjusted OR: 1.32, 95% CI 1.12 to 1.56, p=0.001). CONCLUSIONS: French GPs adapted their practices regarding access to care for patients in the context of the COVID-19 epidemic. This adaptation was higher in multi-professional group practices.

SARS-CoV-2 and the nose: Risks and implications for primary care.

BACKGROUND: General practitioners (GPs) have some of the highest rates of mortality from COVID-19 among healthcare workers. SARS-CoV-2 has unique properties that place GPs at particular risk. OBJECTIVE: The aim of this article is to discuss the nose-related features of SARS-CoV-2 that place GPs at risk, and to make recommendations pertinent to the safety and protection of primary healthcare physicians. DISCUSSION: The highest viral load of SARS-CoV-2 is in the nose and nasopharynx. It is often highest early in the illness, before the development of symptoms. Further, SARS-CoV-2 replicates and continues to shed in the nasopharynx long after the virus is no longer detectable in the lower respiratory tract. This places any physician performing examinations on, or procedures involving, the upper respiratory tract at risk for contracting COVID-19. New-onset hyposmia and dysgeusia are indicators for COVID-19 and should be included in screening protocols.

Perspectives of physicians in general and ophthalmologists in particular about restarting services post-COVID-19 lockdown.

PURPOSE: To assess the perspectives of physicians in general and ophthalmologists in particular about restarting elective out-patient (OP) and operating (OT) services after relaxation of lockdown for COVID-19. METHODS: An online survey, containing 31 questions, was conducted among medical doctors using a secure Google forms link. The survey was open for 48 hours from 16th-18th April 2020. RESULTS: Responses were received from 556 physicians (including 266 ophthalmologists). About a third (n = 205) wanted to start OP immediately after lockdown. In OP, mask of any kind for patient (60.8%), 3-ply for assistants (52.7%) and N95 for doctors (72.7%) were most common preferences. In OP, 31.5% and 46.6% felt full PPE and gloves alone were sufficient respectively. Ophthalmologists were more likely to start immediately after lockdown compared to other specialists (P = 0.004). Among 299 surgeons, an almost equal number (27%) wanted to start routine OT services immediately and 2 weeks post lockdown. A large majority (76.9%) would mandate COVID-19 tests before elective surgeries. In OT, 34.1% wanted N95 for surgical team and 3-ply for patient, 23.4% wanted 3-ply masks for everyone. 40.5% felt additional personal protective equipment (PPE) is not required and 33.1% felt that full PPE is required for everyone in OT. Ophthalmic surgeons preferred 3-ply masks and were less inclined to use full PPE (P < 0.001). CONCLUSION: Perspectives of doctors vary, especially with regarding to timing of restarting services and precautions to be taken in the OT. Ophthalmologists may tend to err on the side of taking lesser stringent precautions when restarting services post lockdown.