Background
Primary care is the first line of defense for the health care system during a pandemic. General practitioners (GPs) work with other health care professionals, allowing cohesion in the health care system and protecting patients and communities [
1].
The COVID-19 pandemic has exposed gaps and areas of need in health systems worldwide [
2]. According to the World Health Organization (WHO), primary care plays a major role in the COVID-19 response [
3]. GPs play a crucial role in the struggle against the pandemic as the first point of contact for possibly infected patients and are responsible for the short- and long-term follow-up care of most COVID-19 patients [
1]. In addition to their role in monitoring COVID-19 patients, GPs have a relevant function in the screening and monitoring of patients with other infectious respiratory diseases, such as influenza. Moreover, despite COVID-19 vaccination, simultaneous outbreaks of COVID-19 and flu might overwhelm health systems [
4]. By performing early diagnoses and differentiating patients with respiratory symptoms from those with COVID-19 or influenza, GPs reduce the demand for hospital services and the economic burden in health care. The arrival of the influenza season increases the need for prevention, diagnosis, management, and capacity across health care centers. Influenza leads to substantial direct and indirect health care burdens, which vary depending on the health status of the infected individual and the treatment setting [
5]. A careful approach is needed to prevent health services from being overwhelmed by a surge in demand that could exceed capacity. Point-of-care (POC) testing presents new possibilities for the management of influenza patients presenting to health care providers with acute respiratory symptoms [
6]. Following Schols et al., the international definition of POC testing is testing to support clinical decision-making that is performed by a qualified member of the practice staff near the patient and on any part of the patient’s body or its derivatives during or very close to the time of consultation to help the patient and physician decide upon the most suitable approach; the testing results should be known at the time of clinical decision-making [
7]. Accuracy rates of POC tests are approximately 80% for identifying COVID-19 infections [
8]. Hence, improving POC testing, including both molecular and rapid antigen testing, can potentially support GPs in quickly identifying infectious and noninfectious respiratory diseases (e.g., COVID-19 and flu), inform patient triaging, and improve clinical management [
9].
Although the role of primary care and GPs in health emergencies such as COVID-19 and flu is well known, different studies have revealed gaps involving primary care in pandemic preparedness and response planning [
10]. Kierkegaard et al. performed a survey among GPs in England that identified that GPs’ knowledge of POC testing influences their degree of trust, uncertainty, and perception of the risk of POC testing. Moreover, in this study, GPs expressed concerns about funding, occupational exposure, and workload in providing POC testing [
9].
To successfully manage the current COVID-19 crisis and new future pandemics, we need to understand the impact and challenges faced by GPs in Spain. In this study, we aimed to investigate the challenges encountered and solutions implemented by GPs when they faced SARS-CoV-2 and influenza patients in Spanish primary health care centers and to understand the training needs from both diagnosis and treatment perspectives.
Discussion
This study describes the current situation in primary care regarding the diagnosis and treatment of respiratory diseases through the perspective of 451 GPs from 15 autonomous communities (regions) in Spain.
GPs are placed at the center of the health care system since they have a vital role in emergencies [
1]. They can easily assess and manage infectious diseases such as seasonal influenza [
11] and have widely recognized involvement in pandemic preparedness [
12]. Indeed, this study showed that less than 10% of patients diagnosed either with COVID-19 or flu with moderate to severe risk (with comorbidities) were referred to hospitals by most GPs. This is in accordance with other studies that showed that access to a GP is associated with lower emergency department use [
13]. In contrast, patients without a GP are more likely to go to the emergency department and have a higher proportion of nonurgent consultations [
13].
Even so, GPs experience many challenges in fulfilling their role [
1]. Particularly, as the pandemic decelerates, COVID-19-related complications must be addressed alongside robust control of influenza infections to avoid outbreaks that can lead to increased bed occupancy in hospitals and considerable financial implications [
14]. Therefore, better approaches to sustain primary care services need to be considered.
This survey showed that not all GPs had infection containment measures at their primary care center (79%) to treat patients with respiratory symptoms. Unfortunately, this number may be lower as the pandemic ends and media interest in the prevention of respiratory diseases decreases. Most of the GPs (95%) had access to COVID-19 antigen tests, 81% to PCR, and 66% to COVID-19 serology tests. A possible explanation for these results is that POC antigen tests are authorized by the WHO and are particularly useful in case PCR results are not available in a timely manner or in case of an overwhelmed health care system [
15], which can happen in Spain. A total of 27% of GPs responded that they had access to influenza diagnostic tests, and only 18.3% had access to diagnostic tests against RSV. For influenza, accurate and rapid molecular test platforms have become available in recent years, with a substantial impact on reducing nosocomial transmission, reducing the use of routine blood tests, blood cultures, and chest radiography by 20%, 18%, and 19%, respectively, and improving patient flow by adopting better infection control measures [
16‐
18]. However, the survey demonstrated that the clinical diagnosis of viruses with public health impacts, such as influenza and RSV, continues to present a challenge for most physicians in Spain and needs to be better integrated into primary care [
19,
20]. In response to this, sentinel syndromic surveillance systems will be set up in Spain for influenza, RSV, and SARS-CoV-2; this will involve the provision of new testing pathways, the use of PCR tests rather than antigenic tests, the reestablishment of regional networks, and the establishments of new networks. Finally, only 57% of GPs responded that they had access to chest radiography, and an even smaller percentage responded that they had access to CRP tests (Fig.
1), which can have critical implications. Chest radiography is an important diagnostic method for evaluation of the airways, pulmonary parenchyma and vessels, mediastinum, heart, pleura and chest wall that can help to ameliorate patient management, as shown by Speets et al. [
21]. On the other hand, CRP levels that are positively correlated with the severity of different infections have been recently described as a good predictor of COVID-19 severity [
22]. Not only can CRP levels predict COVID-19-associated severe pneumonia early [
23], but they were also shown to be elevated in patients with a poor COVID-19 prognosis, in patients who dies from COVID-19-related causes, and in patients with additional COVID-19-related radiological lesions and tissue damage [
22,
23].
POC testing enables GPs to make more trustworthy decisions and to perform quicker interventions, increasing efficiency (e.g., improving the quality of antibiotic prescriptions and reducing the number of prescriptions) and consequently benefiting morbidity and mortality rates [
7,
24]. Although 81% of the GPs reported that they had instant access to POC tests, the above results showed a lack of access to some of the most important tests (Fig.
1), which can indicate that the POC concept is not very well understood among GPs. This may be due to the rapid emergence and evolution of POC tests in the last few years, particularly following the COVID-19 pandemic [
25].
The survey further demonstrated a high frequency of rapid COVID-19 self-tests performed by patients prior to consultation, highlighting their high availability at local pharmacies as a way to support Spanish primary care. However, the timing from diagnosis to results can still be an issue, as 2% of GPs reported a period of 2 to 5 days to have the results for a COVID-19 diagnosis (Fig.
2). A worse scenario was observed for influenza and RSV detection, with only 20 and 11% of the GPs having the diagnostic results on the same day, respectively.
Kierkegaard et al. showed that GPs’ knowledge of POC tests influences their degree of confidence in POC test use [
9]. Here, 85% of the participants were considered to have satisfactory knowledge about vaccines and diagnostic tests (Fig.
3). The results showed that 65% and 57% of the GPs considered that antiviral prescriptions against COVID-19 and flu, respectively, were an effective treatment for patients in primary care. In contrast, more than 50% of GPs reported having poor knowledge of antivirals and monoclonal antibodies against SARS-CoV-2 or influenza infection. These treatments given at an early stage of the infection can substantially reduce the risk of hospitalization and death among high-risk patients [
26]. Therefore, facilitating better training in diagnostic techniques for Spanish GPs could be an effective approach to improving the treatment of patients with respiratory infections in primary care. In addition, further analysis should be performed to underpin major barriers to more efficient testing and develop future guidelines, such as the reinforcement of POC testing in highly populated regions to decentralize testing from hospitals, appropriate training for all health care providers, not only GPs, and the establishment of testing regulations (e.g., POC testing in combination with previous self-testing only for high-risk patients, elderly individuals, and health care professionals). Moreover, an additional measure to reduce the economic burden may rely on investing in diagnostic tests that can detect various infections all at once (e.g., the FilmArray® Respiratory Panel) [
27].
The postpandemic health system in Spain faces an enormous challenge in reforming the organization of the national health system to respond to patients’ health needs. However, this can only be achieved by strengthening primary health care and improving the relationship with hospitals/emergency rooms to guarantee adequate conditions for GP performance [
28]. In this survey, only 21% of primary care doctors declared that they had an excellent/good relationship with emergency or hospital care providers. To improve this interaction, the Spanish government recently announced the creation of a Public Health Agency. By preparing efficient plans for alerts, risks, and current or emerging threats, this governmental agency will perform crucial roles such as public health surveillance, preparation and response to future emergencies, advice and evaluation assessment of international public health policies, and health risk communication to better respond to societal health care needs and possibly reinforce POC testing strategies [
29]. Moreover, the Spanish government recently approved 172 million euros to finance the Action Plan for Primary and Community Care 2022–2023. The investment will certainly increase the resolution capacity in primary care and allow the acquisition of equipment, as well as optimize administrative processes and promote the quality of care [
30].
Although the number of respondents was high (451 GPs, the largest number in a study on primary care in Spain), this study presents some limitations. The present study examined a convenient sample from a limited list of all registered general practitioners in IO foundations and 3 Spanish societies. However, the sample represented solely 1% of the GPs in Spain [
31]. Additionally, the level of knowledge of each GP about tests and treatments for respiratory diseases was underexplored and may not have represented the overall knowledge of the GP population. Additionally, the survey questions were highly subjective, and future efforts should be considered to adopt a more objective questionnaire (e.g., years of experience with diagnostic techniques; how many tests performed per day). Another caveat of this study is that in the timeline during which the questionnaire was open (2 months), several aspects related to the COVID-19 pandemic situation changed (e.g., changes in the number of positive COVID-19 patients), which could have introduced some bias to the results. Finally, in terms of the percentage of patients referred to hospitals, there was no information regarding the disposition rate from the emergency department. Future studies should include the number of patients referred together with the number of patients admitted vs. sent home.
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