Only just over half of patients referred to the CRC due to COVID-19 symptoms were given a clinical diagnosis of possible or probable COVID-19. Presence of cough, dyspnoea and pyrexia were associated with a higher odds of being clinically diagnosed with COVID-19 in the absence of confirmatory testing. This is unsurprising given that these were highlighted as key symptoms of COVID-19 early on during the pandemic. By contrast, hypoxia was not associated with suspicion of COVID-19, which is inconsistent with the prominence of lower oxygen saturations in clinical guidelines. Patients with suspected COVID-19 were more likely to be prescribed antibiotics and steroids, neither or which are supported by clinical guidelines. This may in part be due to clinical uncertainty early on in the pandemic or may reflect a heuristic of wanting to intervene in these patients, especially since they were less likely to be referred to hospital. The relatively high prevalence of COPD in this patient population may also have contributed to this finding.
Only a minority of patients referred to the CRC were referred to secondary care and this was more likely among those who were objectively more severely ill (i.e. had a higher NEWS2). Older patients, those with tachypnoea, hypoxia, tachycardia, diabetes and shortness of breath had a significantly higher odds of being referred to secondary care following clinical assessment. However, patients with a clinical diagnosis of COVID-19 were less likely to be referred, which may have been due to a perceived lack of therapeutic options in secondary care.
81.7% of patients with moderate severity illness (where referral to secondary care should be considered) were managed in the community along with 59% of patients in the highest severity category. There was, therefore, a discrepancy between the judgement of clinicians and the recommended referral thresholds from national protocols. This may be because the severity of illness was under-recognised by clinicians, or that the clinical risk assessment of severity differed from the thresholds recommended in the protocols. Alternatively, the option of hospital referral may have been offered to patients with moderate-to-severe illness, but community management was agreed upon through shared decision making. At the time, here was considerable fear about hospitalisation, which may have influenced patient preferences on location of care; and clinicians may have preferred managing patients in the community due to concerns around overwhelming secondary care. Finally, patients managed in the community will have been given safety-netting advice including when to attend secondary care, however we were unable to identify patients who subsequently attended secondary care in the same period of illness.
Despite major restructuring of primary care during the pandemic,(12, 13) little is known about service usage and characteristics of patients with COVID-19 in the community. The Birmingham CRC was established to cope with a worst-case scenario of up to 500 patients/day,(14) but in practice the busiest week saw fewer than 90 patients assessed. However, the system was designed to allow a dynamic response to demand in order to reduce waste and optimise resources. There was no evidence from the geographical spread of referrals that certain areas of the region were under-represented even though patients did need to arrange their own transport to attend the CRC. The spectrum of socioeconomic deprivation among patients who attended the CRC also suggests that the service was used equitably across the Birmingham population.
Comparisons with existing research
There are no comparable studies investigating how patients with suspected COVID-19 are assessed and triaged in primary care setting.
We found that 66% of patients with suspected COVID-19 were female. Other studies in hospital and primary care settings found a male predominance.(15–19) This may reflect differences in health-seeking behaviour, where males are less likely to access primary care, as well as the spectrum of illness severity with men potentially presenting with more severe disease directly to secondary care.
The International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) described UK patients admitted to hospital.(15) Only 28.2% of patients with suspected COVID-19 at the CRC were 60 years or older compared with 72.7% of those in the ISARIC study. Older age has clearly emerged as one of the most important risk factors for severe COVID-19,(17, 19) which correlates with our findings.
The proportion of patients presenting with symptoms of cough and shortness of breath at the CRC were comparable to those presenting to secondary care(15) although patients with suspected COVID-19 assessed at the CRC were less likely to report fever (44% at the CRC vs 72%).
When the same database was used to analyse pre-pandemic face-to-face out-of-hours consultations a similar sex and socioeconomic deprivation distribution was found, but the patients were younger than those seen at the CRC (mean age 40.6 years versus 49.6 respectively).(20) Referral rates were higher in the CRC (8.5% vs 14.0% respectively) and patients assessed at the CRC were generally more unwell with the proportion of patients with a NEWS2 of ≥5 being 3.1% at the CRC compared with 2.0% in standard out-of-hours care and the respective proportions of those with a NEWS2 of 0 or 1 was 77.5% and 65.9%. This is consistent with the differential referral rates to secondary care.
Strengths and limitations
This is the first study to describe the characteristics of patients referred to a COVID-19 primary care referral centre and how guidance for escalation of care was applied in a rapidly adapting primary care system. It was not possible to link this data with diagnostic testing for COVID-19 so conclusions can only be drawn based on clinical suspicion of infection, which represents the reality of current UK general practice. Further outcomes for patients either referred into hospital or advised to self-manage at home are not available in this dataset so we were unable to comment on the clinical consequences of referral decisions. Finally, patients were triaged by a primary care clinician before referral to the CRC, and we did not have data on severely ill patients with COVID-19 who were identified at this stage and advised to attend secondary care or those advised to self-manage at home without being referred to the CRC.
Implications for practice, policy and research
Utilisation of the CRC was less than anticipated, which highlights the importance of a flexible primary care system capable of escalating and de-escalating its response in a dynamic pandemic situation. Our findings also highlight that primary care CRCs should be prepared to receive a high proportion of patients with non-COVID-19 diagnoses, even with prior clinical triage.
We also have identified discrepancies between clinical guidelines for COVID-19 and observed practice. However, whether guidelines should better reflect the abilities of clinicians to assess and manage risk, or whether clinicians should more stringently apply guidelines is difficult to ascertain from available data. Further iteration and validation of clinical guidelines should be considered.
Finally, there is still a need to better understand the natural history of COVID-19 in the community. Further studies investigating the physiology and outcomes of patients managed in the community would improve our ability to meet the needs of this large public health challenge.