What questions are priority areas for primary care during the COVID-19 pandemic? A rapid question generation and prioritisation exercise

May 1, 2020

Tamsin Newlove-Delgado, Emma Cockcroft, Richard Byng, Lorna Burns, Kristin Liabo

On behalf of the Oxford COVID-19 Evidence Service Team
Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences,
University of Oxford

And

NIHR Applied Research Centre South West Peninsula (PenARC)
Universities of Exeter and Plymouth

Correspondence to t.newlove-delgado@exeter.ac.uk

BACKGROUND
General practice has been asked to reorganise care to reduce the rate of spread, optimise use of critical care beds and ensure high quality care for those choosing not to be admitted. Ongoing work with primary care colleagues from across the South West to develop pathways for the management of Covid-19 suggested a number of uncertainties around this reorganisation, particularly around how triage is managed and considerations around specific groups, such as the more frail.

Working with the Centre for Evidence Based Medicine, a team from the NIHR South West Peninsula Applied Research Collaboration (PenARC) set out to undertake a rapid scope and prioritisation of the “burning questions” which were emerging, with the intention of feeding these into guideline/consensus development and rapid evidence review if needed. We used Twitter, email distribution lists and GP WhatsApp groups to gather unstructured questions. Using a simplified pathway of Covid-19 assessment and triage in primary care, we used an online survey link to ask respondents to identify their uncertainties or questions at each stage, with follow up prompts around areas such as treatment escalation plans, shared decision making, and remote assessment. This was supplemented by longer discussions with local GPs and with comments captured from an accompanying live discussion paper.  Uncertainties identified in this process were then grouped into overlapping areas and re-structured into a question format. In a final stage, we launched a second brief survey using Twitter to ask respondents to prioritise the seven main question areas identified.

QUESTIONS
In order of priority, here are the questions identified in the exercise:

1. What are the optimal screening questions at triage in terms of function, breathing and change in status? (Are there questions that should be prioritised with higher prognostic value? What combination of current status vs. change in status is most useful?)
2. What are the potential harms of community management with a SaO2 of 88-93%? What can we tell patients about this?
3. When conducting telephone or other remote assessment, what parameters (e.g. heart rate, respiratory rate and temperature) would trigger the need for face-to-face assessment at a Hub or elsewhere? Following from this:
   1. What parameters would then trigger the need for a discussion with the hospital around admission?
   2. How do different measures work together and how do parameters for assessment/admission differ with co-morbidities?
   3. What is the prognostic value of these measures both alone and in combination? In particular, if SaO2 are 93-96% (i.e. just above threshold), what are the other factors which might determine need for admission?
   4. Following hub / emergency department face-face assessment, what prognostic data are helpful for patients and doctors to make shared decision about admission? Is there useful specific prognostic data for certain groups (e.g. those who are frail)? What figures are available on outcomes for those cared for at home, or on general wards, or on ICU?
4. What information should be provided to patients to assist decision making? (linking to the question above about prognostic data)
5. Can real-time data about the local situation in terms of cases and outcomes help inform decisions about care planning and admission? Does rapid feedback to primary care about what happens to patients referred to hospital change decision-making?
6. What is the optimal guidance for fluid and nutrition intake during community management of Covid-19? How can this best be implemented? (Is this the same guidance as for Flu, or is there Covid-19 specific guidance? What is the guidance for exercise and rest? )
7. How best to have advanced care planning conversations in this climate? Are there any tools which can optimise having these conversations remotely?

CONCLUSIONS

• This process highlighted questions and uncertainties about triage, remote assessment, advanced care planning, and how to approach shared decision making around admission in the current context of Covid-19.
• The questions we have identified reflect the priorities and information needs of practitioners. They are intended to feed into reviews and guidance and consensus development, but they do not necessarily equate to a gap in the literature.
• There may already be relevant evidence available, given the recent proliferation of Covid-19 related reviews and guidelines being registered, in progress, and completed. Careful checking is therefore advised before starting any new reviews of these questions, to avoid duplication and research waste.

End.

Disclaimer:  the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.

AUTHORS
Tamsin Newlove-Delgado is an honorary consultant in Public Health Medicine and Senior Clinical Lecturer at the University of Exeter Medical School
Emma Cockcroft is a Research Fellow in the Patient and Public Involvement team within the NIHR Applied Research Centre South West Peninsula (PenARC), based at the University of Exeter
Richard Byng is a General Practitioner, and is Professor of Primary Care Research at the University of Plymouth and Deputy Director of PenARC
Kristin Liabo is Senior Research Fellow with the PenARC Patient and Public Involvement Team at the University of Exeter Medical School
Lorna Burns is a Lecturer in Evidence Based Healthcare at the University of Plymouth