SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic is having an unprecedented impact on global health and economics. Australian GPs are on the frontline and forced to make decisions in a medical landscape where the parameters for testing are changing daily and many patients are now opting for telehealth consultations.
In the Medcast Webinar on October 20, delivered by physicians at the forefront of clinical aspects of diagnosis, testing and treatment of COVID-19, five recommendations were explored through the lens of Australia Pandemic Guidance for Health Professionals put out by Choosing Wisely Australia.
Choosing Wisely Australia is the local arm of an international initiative designed to reduce the volume of low value tests, treatments and procedures in Australian health care. It recently developed five recommendations for health professionals in response to the COVID-1 pandemic, comprising:
- DO encourage patients to seek usual care for new or existing medical conditions
- DO use health resources judiciously in accordance with guidelines
- DO test and manage patients with COVID-19 according to evidence-based guidelines
- DO consider telehealth as an option, where appropriate, to reduce risk of exposure to COVID-19 and to increase accessibility
- DO discuss goals of care with patients, especially those with limited life expectancy, in accordance with relevant Choosing Wisely recommendations.
Each of the five recommendations was explored during the webinar in the context of general practice.
DO encourage patients to seek usual care for new or existing medical conditions
The early stages of the pandemic led to a well-documented and significant drop in general practice patient numbers. Data shows that the drop in patient numbers was more pronounced in urban areas and in the most affluent quartile of practices. A webinar poll confirmed that, despite the introduction and familiarity with telehealth, over half the participants reported that they continue to see fewer patients than pre-pandemic. There have been concerns raised about the impact of patients not attending their GP for usual care, including the potential for deterioration of chronic disease and delay in serious diagnoses like cancer. The evidence around the safety of continuing usual care of patients being treated with ACE inhibitors and angiotensin receptor blockers, inhaled corticosteroids and immunosuppressives was also discussed.
DO use health resources judiciously in accordance with guidelines
This section of the webinar dealt with the use of personal protective equipment (PPE), as well as infection prevention and control in general practice. The majority (74%) of webinar participants confirmed that they were wearing masks for the care of routine, non-suspect COVID-19 patients. The role of masks as part of the ‘hierarchy of controls’ (hand hygiene, physical distancing, cough/sneeze etiquette and avoiding unnecessary travel) was discussed, as was the lack of evidence supporting the routine use of P2 over standard surgical masks.
DO test and manage patients with COVID-19 according to evidence-based guidelines
The National COVID-19 Clinical Evidence Taskforce guidance was heavily referenced in discussion of the testing and treatment of patients with COVID-19. There was coverage of the current understanding of frequency of presenting symptoms, testing criteria, how to correctly take a deep nasal swab, when to test, and management of mild disease in the community. The current understanding of pharmacotherapy was presented, with the strong recommendation not to use disease modifying drugs like hydroxychloroquine and dexamethasone in the community setting. The progress on vaccine development was also discussed, with the best estimation being that a vaccine is likely to be available late 2021.
DO consider telehealth as an option, where appropriate, to reduce risk of exposure to COVID-19 and to increase accessibility
A poll demonstrated that a large proportion of participants are using telehealth, with 62% conducting more than 25% of all consultations in this manner. This was consistent with national data, which showed that in April 2020, one third of all GP consultations were telehealth, with 96% of these being conducted by phone. The approach to a remote assessment of patients with suspected COVID-19 in primary care was discussed, including important red flag symptoms, the critical need for safety netting and the criteria for a face to face review.
DO discuss goals of care with patients, especially those with limited life expectancy, in accordance with relevant Choosing Wisely recommendations
Lastly, the important role of the GP to discuss end of life care with their elderly patients or those at higher risk was covered referring to existing Choosing Wisely recommendations on goals of care and advanced care directives.
There are a number of excellent resources for further information, including:
This webinar was extremely useful in bringing GPs and health professionals up-to-date with current treatment and it can be accessed here, on demand.