https://orcid.org/0000-0002-7396-2839
?Mathematical formulae have been encoded as MathML and are displayed in this HTML version using MathJax in order to improve their display. Uncheck the box to turn MathJax off. This feature requires Javascript. Click on a formula to zoom.Abstract
Background
Most symptomatic SARS-CoV-2 infections produce mild to moderate symptoms. Although most patients are managed in the outpatient setting, little is known about the effect of general practitioners’ (GP) management strategies on the outcomes of COVID-19 outpatients in Italy.
Objectives
Describe the management of Italian GPs of SARS-CoV-2 infected adult patients and explore whether GP active care and monitoring are associated with reducing hospitalisation and death.
Methods
Retrospective observational study of SARS-CoV-2 infected adult outpatients managed by GPs in Modena (Italy) from March 2020 to April 2021. Information on management and monitoring strategies, patients’ socio-demographic characteristics, comorbidities, and outcomes (hospitalisation and death due to COVID-19) were retrieved through an electronic medical record review and analysed descriptively and through multiple logistic regression.
Results
Out of the 5340 patients from 46 GPs included in the study, 3014 (56%) received remote monitoring, and 840 (16%) had at least one home visit. More than 85% of severe or critical patients were actively monitored (73% daily) and 52% were visited at home. Changes over time in patients’ therapeutic management were observed in concordance with the guidelines’ release. Active daily remote monitoring and home visits were strongly associated with reduced hospitalisation rate (OR 0.52, 95% CI 0.33–0.80 and OR 0.50, 95% CI 0.33–0.78 respectively).
Conclusion
GPs effectively managed an increasing number of outpatients during the first waves of the pandemic. Active monitoring and home visits were associated with reduced hospitalisation in COVID-19 outpatients.
KEY MESSAGES
This practice-based research network study from Northern Italy demonstrates the importance of primary care management of patients with COVID-19.
GPs effectively treated a large - and increasing - number of patients outside the hospital.
Active monitoring and home visits by GPs were associated with fewer hospital admissions for COVID-19.
Introduction
Since February 2020, the Coronavirus disease 2019 (COVID-19) [Citation1], challenged the Italian healthcare system heavily [Citation2]. Patients with COVID-19 may have a wide range of clinical manifestations [Citation3]. In most cases, however, patients develop a mild airway infection and therefore are commonly managed in the context of primary care (PC) by General Practitioners (GPs) [Citation4]. In Italy, healthcare is provided through the National Health Service (NHS), in which GPs are responsible for providing free-of-charge care for most acute and chronic conditions.
Italian GPs faced several challenges and difficulties managing patients during the first wave of the COVID-19 pandemic [Citation5]. The lack of personal protective equipment [Citation6,Citation7], and the absence of specific management guidelines impacted their capacity to provide care and led to widespread infections among these professionals, causing many fatalities [Citation8,Citation9].
Support for GPs was provided mainly by the GP-Out-of-Hour (OoH) service and by COVID-19 special units of continuity care (USCA-Unità Speciali di Continuità Assistenziale). These new working units were dedicated to home visits and initial assessment of infected patients [Citation10].
To date, little is known about the management strategies used by Italian GPs for SARS-CoV-2 patients and their impact on COVID-19-related hospitalisations and mortality. First, this study aimed to describe the clinical characteristics of infected patients and the management strategies used by their GPs during the first and subsequent waves of the pandemic. Second, it aimed to explore the association between active monitoring by GPs and COVID-19-related hospitalisations and mortality in adult patients in the Province of Modena (Emilia-Romagna, Italy).
Methods
Study design
The MAGMA study is a retrospective cohort study of SARS-CoV-2 positive subjects based on the review of electronic medical records (EMRs) provided by 46 GPs of the Province of Modena (Italy). See the acknowledgement section for insights on the name MAGMA chosen for this study.
Recruitment of GPs and selection of study subjects
Between March and April 2021, all GPs practising in the province of Modena (n = 462) were invited via e-mail to attend a study presentation webinar. During the webinar, GPs were asked to collaborate on the study. They were eligible if they recorded patient data using the software MILLEWIN®.
Participating GPs (n = 46) were provided with Structured Query Language (SQL) to perform EMR data extraction independently. SQL-based data extraction is routinely used by GPs in the local health service of Modena for audit purposes. Nevertheless, prior to the study, GPs received additional training on data wrangling to standardise activities and improve data quality. Data was checked for completeness and consistency by each GP, who manually added information on the severity of the disease and the monitoring strategies. We included in the analysis patients with a positive SARS-CoV-2 real-time polymerase chain reaction test performed between 01/03/2020 and 30/04/2021.
Residents in nursing homes were also included, as they are commonly managed by GPs. Patients who tested positive during a hospital stay were excluded.
Variables
Exposure
The exposure of interest was the monitoring strategy adopted by each GP as follows. For remote (telephone) monitoring, 4 options were possible: (a) no monitoring, (b) passive monitoring (i.e. monitoring performed only upon the patient’s request); (c) irregular active monitoring (not daily); and (d) active daily or twice daily monitoring. There were also 4 options for home visits: (a) no home visits, (b) only USCA/OoH service visit; (c) only GP visit, or (d) both USCA/OoH service and GP visit. These options were then grouped into a summary variable to describe the overall GP monitoring strategy as follows: (a) none or low-level monitoring (patients with no monitoring, passive monitoring, or irregular active monitoring); (b) only active daily or twice daily remote monitoring; or (c) home visits (patients receiving at least one home visit, regardless remote monitoring).
Covariables
The patient’s socio-demographic characteristics, lifestyle and clinical features were collected: age, gender, number of comorbidities, severe obesity (BMI > 35), smoking habits, place of residence (home/nursing home), socio-economic deprivation (personal, social, or economic difficulties known by GP) (details of variable categories in ), and any use of COVID-19 related therapies (). COVID-19 disease severity (asymptomatic, mild, moderate, severe or critical) was classified according to the United States National Institutes of Health Guidelines (NIH) ( and ) [Citation11]. Finally, a binary variable was created to identify the infection period: first wave (from March to May 2020) or subsequent waves (June 2020 to April 2021).
Outcomes
The primary outcomes were COVID-19-related hospital admissions (yes/no) and COVID-19-related deaths (yes/no). Outcome-related variables were automatically registered in the patient’s electronic medical record. A complete description of the variables and their level definitions, the data sources and possible sources of bias are provided as Supplementary Material.
Statistical analysis
Categorical variables were summarised by absolute and relative frequencies. Mean and Standard Deviation (SD) or median and interquartile range (IQR) were used to summarise continuous variables according to their distribution. Pearson’s chi-square test or Fisher’s exact test was used to compare categorical variables. T-student test or Mann–Whitney U-test was used to analyse numeric variables depending on their distribution. Multiple logistic regression models were built to explore the association of GPs´ monitoring strategies on hospitalisation or death due to COVID-19. The summary variable ‘GP monitoring strategy’ was used as the primary exposure variable in the model. To control for potential confounders and to evaluate their role, covariates were also included in the model. Associations are reported as adjusted odds ratios (aOR) and 95% confidence intervals (95% CI). SPSS Statistics®, version 27[Citation12] and Excel®, version 16.0, were used to perform the analyses.
This study was reported according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [Citation13].
Results
Characteristics of enrolled GPs
A total of 46 GPs (10% of all GPs in Modena) agreed to participate. They were younger, predominantly female, working in an urban setting and group practices. Enrolled GPs served a population of 64,763 people, with an average of 1408 (399) patients each. Patients´ list sizes and age distributions were similar in participating and non-participating GPs ().
Table 1. Characteristics of General Practitioners (GPs) in the province of Modena (Italy) in 2020 stratified by GPs enrolled in the MAGMA study compared to non-participating GPs.
Characteristics of patients
Data on 5340 infected patients were collected. Patients´ characteristics are reported in . GPs’ workload was significantly higher during the subsequent waves of COVID-19 pandemics, during which 5042 subjects (versus the 298 patients of the first wave) were managed, accounting for 94% of the entire sample. These patients were significantly younger, less socio-economic deprived, with fewer pre-existing comorbidities, and with a lower severity degree of the disease than those managed in the first pandemic wave.
Table 2. General and clinical characteristics stratified by the period of infection of patients with SARS-CoV-2 infection followed by general practitioners in Modena’s province (Italy) from March 2020 to April 2021.
Pharmacological strategies
Overall, 1413 (27%) patients received no pharmacological treatment. Significant prescription changes in in the subsequent waves over the first one were observed (). Antibiotics, corticosteroids, low molecular weight heparin (LMWH) and oxygen were prescribed more frequently in patients with pneumonia (NIH stage 2 or above), with significantly increased use during the subsequent waves. Anti-inflammatory drugs (NSAIDs) were more commonly prescribed in NIH stages 1 and 2 and their use increased in the successive waves while paracetamol showed a decreasing trend.
Table 3. General practitioners’ pharmacological strategies stratified by COVID-19 disease severity and by period of infection of patients with SARS-CoV-2 infection followed by general practitioners in Modena’s province (Italy) from March 2020 to April 2021.
Monitoring strategies
Overall, 3014 (56%) patients received remote monitoring, either irregularly (9%), daily (24%) or twice daily (6%) (). Remote monitoring significantly decreased in subsequent waves; however, a similar prevalence of active monitoring in more severe patients was observed during the first and next waves, with more than 80% of stage 3 or 4 patients actively contacted by their GP ().
Table 4. General practitioners’ monitoring strategies stratified by COVID-19 disease severity and by period of infection of patients with SARS-CoV-2 infection followed by general practitioners in Modena’s province (Italy) from March 2020 to April 2021.
shows a stable monthly percentage of active daily remote monitoring of pneumonia patients (more than 55%, dark line) over time, even with the increasing number of SARS-CoV-2 cases and consequent GP workload during the subsequent waves (coloured bars).
Figure 1. Absolute number of SARS-CoV-2 infected patients per month stratified by disease severity (coloured bars) managed by general practitioners (GP) in Modena’s province (Italy) from March 2020 to April 2021 in relation to the percentage of patients with pneumonia (NIH ≥ Moderate illness) who received GP’s active daily remote monitoring (dark line). NIH: US National Institute of Health.
Overall, 840 patients (16%) were visited at home. Their proportion significantly increased with the increase of disease severity and in the subsequent pandemic waves ().
A similar trend was observed for the variable summarising the overall GP monitoring strategies.
Hospitalisation and death for COVID-19
Overall, 521 patients (10%) were hospitalised (), with a significant reduction between the first and following waves (respectively 27% and 9%; p < .001). In the subsequent waves, the hospitalisation rate was lower regardless of the disease stage, as reported in .
Table 5. COVID-19 related outcomes (hospitalisation and death) stratified by COVID-19 disease severity and by period of infection of patients with SARS-CoV-2 infection followed by general practitioners in Modena’s province (Italy) from March 2020 to April 2021.
Most hospital admissions concerned patients with the severe or critical disease (463, 89%), over 70 years (54%) or with at least one comorbidity (68%).
Overall, we observed 114 deaths (2%) due to COVID-19. Deaths were more frequent during the first wave than in the subsequent ones (respectively 9% vs 2%; p < .001) and occurred mainly in stage 4 (109 deaths, 96%). However, the mortality rate in critically ill patients decreased significantly in the subsequent waves compared to the first wave ().
Deaths occurred more frequently in older patients (mean ± SD: 82 ± 10 years), in those with 2 or more comorbidities (60%) and in males (56%). GPs managed twenty-seven deaths (24%) in an outpatient setting: 12 occurred at home upon the patient’s or caregiver’s request and 15 in nursing homes.
GP monitoring strategies and hospitalisation and death due to COVID-19
As shown in , daily remote monitored or home-visited patients were half less likely to be hospitalised compared with non-monitored patients (aOR:0.52, and aOR: 0.50). A higher probability of hospitalisation was observed in older age, socio-economic deprivation, in patients with two or more comorbidities, and increasing COVID-19 illness severity. Living in a nursing home was associated with a significant reduction in the probability of hospitalisation. Mortality was not influenced by active daily monitoring or home visits. Death due to COVID-19 was associated with older age, infection in the first pandemic wave, living in a nursing home, having one or more comorbidities and increasing COVID-19 illness severity.
Table 6. Multiple Logistic Regression models of factors that influence the probability of hospitalisation and death for COVID-19 in patients with SARS-CoV-2 infection followed by general practitioners in Modena’s province (Italy) from March 2020 to April 2021.
Discussion
Main findings
This is the first study to describe the management strategies of GPs in a northern province of Italy in caring for SARS-CoV-2 infected patients. More than 85% of patients with the severe or critical disease were remotely monitored, 73% daily, and 52% received a home evaluation. In the subsequent waves, despite the exponential increase of COVID-19 cases to be managed, GPs increased the percentage of patients they could monitor via telephone or at home. In the following waves of the pandemic, the use of LMWH and oxygen increased in more severely ill patients, whereas the use of NSAIDs increased in the case of milder disease. As to the effects of GPs´ monitoring strategies, our analysis suggests that patients who get actively monitored or are home-visited are half less likely to be hospitalised than non-monitored patients.
Strengths and limitations
Our study has several strengths. First, we included a large sample of patients obtained thanks to the broad collaboration of local GPs [Citation14]. Second, our data source, the GPs EMR is widely considered a valuable source of information to conduct clinical research also considering the experience of GPs with this method of data extraction in Modena [Citation15]. Third, this is one of the few studies in Italy describing how GPs responded to the current pandemic.
The main limitation is the retrospective nature of our study, not allowing us to establish causality. Second, we had no information on the timing of therapy or GP monitoring. This limited insights into patients’ management and disease pathways. Third, GPs participated voluntarily, so that, selection bias may affect generalisability. The differences observed between MAGMA GPs and those who did not may affect our results’ generalisability in the Province of Modena. Unfortunately, the lack of data on GP’s characteristics in Italy does not allow us to compare our GP sample nationally. Nevertheless, the characteristics of SARS-CoV-2 infected patients in terms of age, sex and clinical features in the first and subsequent waves reflect national data [Citation16], so we believe that our findings’ significance is still valid.
Interpretation and perspectives
During the first wave shortage of diagnostic tests [Citation17], reserved for severe cases produced a selection of the infected population with different characteristics (older patients, with more comorbidities, with a higher hospitalisation and mortality rate) compared to subsequent waves [Citation17,Citation18]. Hospitalisation rate and deaths, as well, appear similar to those observed in another Italian study [Citation19].
Further, therapeutic and monitoring strategies vary significantly between the first and next waves, consistently with the improved knowledge on the management of COVID-19 and the publication of guidelines from the Ministry of Health and the Italian regulatory agency (AIFA) [Citation20,Citation21]. Compared with the study conducted by Crisafulli et al. in southern Italy, our data showed an overall lower use of antibiotics (28% vs 52%), steroids (13% vs 36%) and oxygen (4% vs 7%) and a comparable use of heparin (16%) [Citation19]. Also previous studies showed that GPs in northern Italy tend to prescribe less medications than in the south of the country, probably due to physicians’ attitudes [Citation22–25]. In Italy, primary care was delivered in part by the GPs, and in part by the OoH/USCA service [Citation26]. On the one hand this may limit the comparability of GPs’ management strategies we described herewith those other countries. On the other hand it represents an opportunity to learn from this different approach [Citation27]. In any case, data on the clinical pathway of COVID-19 patients in primary care is lacking, both at national and international levels, making it difficult to quantify the contribution of primary care to the pandemic response and compare different strategies. This calls for further and more extensive studies of how GPs responded to the pandemic and what we can learn from this [Citation28].
Implications
Our study shows the benefits of proactive and integrated territorial management (both for remote monitoring and for home visits) on COVID-19 hospitalisation and the results are consistent with current literature [Citation29]. Russo et al. showed a 70% decrease in hospitalisation in elderly patients from Northern Italy who were actively contacted by GPs during the infection compared non-contacted patients [Citation30]. Effects on mortality rate do not appear so clear. Several factors, often unrelated to GPs’ monitoring, are potentially associated with patients’ death. The absence of explicit evidence of an impact on health outcomes, as mortality of remote patient monitoring, was described by a recent systematic review [Citation29].
Potential protective effects of the different remote monitoring strategies, in place of or in addition to the in-person visits, need to be further investigated to draw guidelines to effectively relieve hospital pressure and costs.
GPs ability to adjust quickly in the face of a new pandemic may prove effective in helping the management of this and future epidemics. In these contexts, it is warranted that networks of primary care physicians and independent primary care practice-based research are strengthened, as they could promptly provide the much-needed evidence to implement rational patient management policies.
Conclusion
Our findings described how GP responded to the first waves of the pandemic and suggest that active monitoring of COVID-19 outpatients performed by primary care physicians may reduce hospitalisations substantially.
Ethical approval
All procedures performed in studies involving human participants were per the ethical standards of the regional ethics committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The MAGMA study was approved by the local ethics committee Area Vasta Emilia Nord with the protocol number: on 21/07/2021 with protocol AOU 0022392/21.
Supplemental Material
Download MS Word (27.9 KB)Acknowledgment
The pandemic exploded like a volcano, of which we have so far mainly observed lava (hospitalisations, deaths) and smoke (lack of knowledge, fake news); the ‘MAGMA Study’ aimed to evidence the magma: the submerged and hidden work of thousands of primary care front-line health professionals, and is dedicated to them. A special thanks goes to the members of the MAGMA Group; without your generosity and commitment to the profession of Family Medicine this study couldn’t have been possible: Maria Angela Acerbi, Claudio Andreoli, Mimmo Andreoli, Maria Rosa Bandieri, Francesco Bellelli, Chiara Bernabei, Monica Bevini, Maria Grazia Bonesi, Francesca Borsari, Paola Calzolari, Manfredo Campolieti, Emanuele Carnevale, Claudio Cavalieri, Simone Cernesi, Federica Collioli, Rita Morena Covizzi, Maria Rotonda D’Alterio, Daniela Dareggi, Roberto De Gesu, Laura Ermini, Gaetano Feltri, Nicoletta Fratti, Marinella Galletti, Manuela Gatto, Patrizia Ghirardini, Roberta Gilioli, Paola Grandi, Monica Lorenzini, Patrizia Lori, Sara Lucenti, Davide Luppi, Lisa Marcucci, Maria Marino, Chiara Moretti, Silvia Morisi, Maria, Claudia Polastri, Ilaria Pollacci, Francesca Riva, Carlo Riccò, Vanna Rinaldi, Alessandra Romani, Lanfranco Rossi, Lara Rovesta, Alberto Scaglioni, Marina Scarpa, Elisa Stefani. The MAGMA Group thanks Marco Saletti for the technical help writing the SQL query. Finally we would like to thank the reviewers and the editorial team for their comments with which helped us improve the quality and clarity of this manuscript.
Disclosure statement
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Data availability statement
The article’s data will be shared after a reasonable request to the corresponding author.
Additional information
Funding
References
- Ren L-L, Wang Y-M, Wu Z-Q, et al. Identification of a novel coronavirus causing severe pneumonia in human: a descriptive study. Chin Med J. 2020;133(9):1015–1024.
- Task force COVID-19 del Dipartimento Malattie Infettive e Servizio di Informatica. Dati della sorveglianza integrata COVID-19 in italia. [COVID-19 integrated surveillance data in Italy] [Internet]. 2022; [cited 2022 Feb 16]. Available from: https://www.epicentro.iss.it/coronavirus/sars-cov-2-dashboard
- The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Wkly. 2020;2:113–122.
- Dunlop C, Howe A, Li D, et al. The coronavirus outbreak: the central role of primary care in emergency preparedness and response. BJGP Open. 2020;4(1):bjgpopen20X101041.
- Kurotschka PK, Serafini A, Demontis M, et al. General practitioners’ experiences during the first phase of the COVID-19 pandemic in Italy: a critical incident technique study. Front Public Health. 2021;9:623904.
- Toselli M, Palazzi I, Lambertini M, et al. Teachings after COVID-19 outbreak from a survey of family physicians. J Am Board Fam Med. 2021;34:S222–S224.
- Fiorino G, Colombo M, Natale C, et al. Clinician education and adoption of preventive measures for COVID-19: a survey of a convenience sample of general practitioners in Lombardy, Italy. Ann Intern Med. 2020;173(5):405–407.
- Lapolla P, Mingoli A, Lee R. Deaths from COVID-19 in healthcare workers in Italy-What can we learn? Infect Control Hosp Epidemiol. 2021;42(3):364–365.
- Modenese A, Gobba F. Increased risk of COVID-19-Related deaths among general practitioners in Italy. Healthcare. 2020;8(2):155.
- Presidenza del Consiglio dei Ministri. Ulteriori disposizioni attuative del decreto-legge 23 febbraio 2020, n. 6, recante misure urgenti in materia di contenimento e gestione dell’emergenza epidemiologica da COVID-19, applicabili sull’intero territorio nazionale. [Presidential decree on urgent matters regarding the containment and the management of COVID-19 epidemiological emergency] [Internet]. Rome: Gazzetta Ufficiale della Repubblica Italiana; 2020 [cited 2021 April 9]. Available from: https://www.gazzettaufficiale.it/eli/id/2020/03/09/20A01558/sg.
- Clinical Spectrum [Internet]. COVID-19 treatment guidelines. [cited 2021 Apr 9]. Available from: https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum/
- IBM Corp. IBM SPSS statistics for windows, version 27.0. Armonk (NY): IBM Corp; 2021 [cited 2022 Jan 19]. Available from: https://www.ibm.com/it-it/analytics/spss-statistics-software.
- von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;370(9596):1453–1457.
- ISTAT. Bilancio demografico anno 2021 [Demografic balance year 2021]. Demografie in Cifre. 2021 [cited 2022 Feb 16]. Available from: https://demo.istat.it/.
- Shephard E, Stapley S, Hamilton W. The use of electronic databases in primary care research. Fam Pract. 2011;28(4):352–354.
- Task force COVID-19 del Dipartimento Malattie Infettive e Servizio di Informatica. Epidemia COVID-19. Aggiornamento nazionale: 2 marzo 2022. [COVID-19 epidemic. National update: March, 2nd 2022]. Rome: Istituto Superiore di Sanità; 2022.
- ISTAT, Ministero della Salute. Primi risultati dell’indagine di sieroprevalenza sul SARS-CoV-2. [Prelimirary results of seroprevalence testing on SARS-CoV-2 in Italy] [Internet]. 2020 [cited 2022 Feb 16]. Available from: https://www.istat.it/it/files/2020/08/ReportPrimiRisultatiIndagineSiero.pdf
- Salmaso S, Zambri F, Renzi M, et al. Interrompere le catene di trasmissione di COVID-19 in italia: indagine tra i dipartimenti di prevenzione. [Stopping the COVID-19 transmission chains in Italy: a survey among the prevention departments] [Internet]. E&P Repository. 2020; [cited 2022 May 16]. Available from: https://repo.epiprev.it/index.php/2020/07/21/interrompere-le-catene-di-trasmissione-di-covid-19-in-italia-indagine-tra-i-dipartimenti-di-prevenzione/
- Crisafulli S, Ientile V, L’Abbate L, et al. COVID-19 patient management in outpatient setting: a population-based study from Southern Italy. JCM. 2021;11(1):51.
- Di Filippo A, Ambrosino F, Gallinella F, et al. L’uso dei farmaci durante la pandemia di covid-19 in Italia. [Pharmacological treatment during the COVID-19 pandemic in Italy]. Recenti Prog Med. 2021;112:338–342.
- Agenzia Italiana del Farmaco (AIFA). Management principles of covid-19 cases in home setting. [Internet]. Rome: AIFA; 2020 [cited 2022 Feb 16]. Available from: https://www.aifa.gov.it/documents/20142/1123276/SOC_territoriale_EN_09.12.2020.pdf/34923ad9-a8f0-958f-45c6-95ab2f9d3ced.
- Osservatorio Nazionale sull’impiego dei Medicinali. L’uso degli antibiotici in italia. Rapporto nazionale 2020. [Antibiotic prescriprion and usage in Italy. National report 2020.] [Internet]. Agenzia Italiana Del Farmaco (AIFA); 2022 [cited 2022 Feb 16]. Available from: https://www.aifa.gov.it/-/l-uso-degli-antibiotici-in-italia-rapporto-nazionale-anno-2020
- Mazzaglia G, Caputi AP, Rossi A, et al. Exploring patient- and doctor-related variables associated with antibiotic prescribing for respiratory infections in primary care. Eur J Clin Pharmacol. 2003;59(8-9):651–657.
- Kurotschka PK, Serafini A, Massari M, et al. Broad spectrum project: factors determining the quality of antibiotic use in primary care: an observational study protocol from Italy. BMJ Open. 2020;10(7):e038843.
- Parisi G, Clavenna A. Costruire evidenze contesto-specifiche per combattere l’antibiotico-resistenza: il ruolo della ricerca in medicina generale. [Building context-specific evidences to tacle antimicrobial resistance: the role of research in general practice]. Recenti Prog Med. 2020;111:351–353.
- Wanat M, Hoste M, Gobat N, et al. Transformation of primary care during the COVID-19 pandemic: experiences of healthcare professionals in eight European countries. Br J Gen Pract. 2021;71(709):e634–e642.
- Menéndez Orenga M, Arribas Mayordomo M, Gasser P, et al. COVID suspected patients in primary care in Madrid at the beginning of first wave: Clinical characteristics and healthcare assistance. Rev Esp Salud Publica. 2022;96:e202202018.
- Ares-Blanco S, Astier-Peña MP, Gómez-Bravo R, et al. El papel de la atención primaria en la pandemia COVID-19: una mirada hacia europa. [The role of primary care during COVID-19 pandemic: a European overview]. Aten Primaria. 2021;53(8):102134. Spain
- Alboksmaty A, Beaney T, Elkin S, et al. Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review. Lancet Digit Health. 2022;4(4):e279–e289.
- Russo AG, Faccini M, Bergamaschi W, et al. Strategy to reduce adverse health outcomes in subjects highly vulnerable to COVID-19: results from a population-based study in Northern Italy. BMJ Open. 2021;11(3):e046044.