Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: A real-time observational study.

BACKGROUND: During the COVID-19 pandemic, general practitioners worldwide re-organise care in very different ways because of the lack of evidence-based protocols.
OBJECTIVE: This paper describes the organisation and the characteristics of consultations in Belgian out-of-hours primary care during five weekends at the peak of a COVID-19 outbreak and compares it to a similar period in 2019.
METHODS: Real-time observational study using pseudonymised routine clinical data extracted out of reports from home visits, telephone- and physical consultations (iCAREdata). Nine general practice cooperatives (GPCs) participated covering a population of 1 513 523.
RESULTS: All GPCs rapidly re-organised care in order to handle the outbreak and provide a safe working environment. The average consultation rate was 222 per 100 000 citizens per weekend. These consultations were handled by telephone alone in 40% (N = 6293). A diagnosis at risk of COVID-19 was registered in 6692 (43%) consultations,. Out of 5311 physical consultations, 1460 were at risk of COVID-19 of which 443 (30%) did not receive prior telephone consultation to estimate this risk. Compared to 2019, the workload initially increased due to telephone consultations but afterwards declined drastically. The physical consultation rate declined by 45% with a marked decline in diagnoses unrelated to COVID-19.
CONCLUSIONS: General practitioners can rapidly re-organise out-of-hours care to handle patient flows during a COVID-19 outbreak. Forty percent of the out-of-hours primary care contacts are handled by telephone consultations alone. We recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care. The demand for physical consultations declined drastically provoking questions about patient's safety for care unrelated to COVID-19.

Introduction

Novel coronavirus disease 2019 (COVID-19) provoked by SARS-CoV-2 is a spreading threat and its clinical and epidemiological characteristics are still being documented. [1, 2] The current COVID-19 pandemic puts extreme stress on healthcare organisation. In several countries including China, Italy, Brazil, Spain and certain parts of the United-States, the demand for emergency and intensive care exceeded the available resources.

Almost all countries are struggling to tackle this pandemic in different ways including different strategies for primary care. [3] in the UK roughly 75% of patients is seen remotely, in the USA primary care offices are capable of managing patient flows across home, clinic, hospital, and post-acute care [4], Columbia uses a very similar approach with primary care as a gate keeper [5] and finally, Australia has decided to unprecedented level of support for the primary care system. [6]

On 2020/04/20 Belgian health authorities reported a total number of 39 983 infections, 13362 hospitalisations and 5 828 deaths (including 3028 suspected case in homes for the aged). The peak of the current outbreak was situated at the beginning of April, a partial lockdown was initiated on march 13. [7] All patients presenting with symptoms of acute respiratory infection were considered as suspected cases as tests were not available in primary care services. These patients needed to stay at home in self-isolation during at least seven days. [8] The government’s recommendation to always call a doctor before going to a practice or ED was omnipresent in the media.

All chronic care both inside and outside hospitals had been suspended and emergency plans had been activated in order to increase the number of beds available in intensive and emergency care. This might have led to delayed access to hospital care and consequently increased morbidity and mortality unrelated to COVID-19. [9, 10]

Almost all Belgians are member of the mandatory healthcare insurance. Emergency Departments (EDs) and General Practitioners (GPs) are freely accessible, they are paid by a fee-for-service system. Patients pay 18% of their healthcare expenditures themselves. [11] Every ED in Belgium needs to give appropriate care to anyone entering the service regardless of citizenship, legal status or ability to pay.

In many European countries, out-of-hours primary care is increasingly organised in large-scale General Practitioners Cooperatives (GPCs). As a bottom-up response these GPCs have adapted to the COVID-19 pandemic. [12] The COVID-19 pandemic has a substantial impact on primary care consultations. [13] In order to prevent infection of patients and healthcare professionals, a shift from in-person to remote consulting by telephone or video is occurring. [14] Before the pandemic, remote consultations were neither reimbursed nor deontologically allowed. Employees in Belgium unable to work due to medical problems need a medical certificate and for this reason have to see a medical doctor. During the COVID-19 pandemic, doctors are allowed to deliver it after a telephone consultation.

During office hours, the organisation of GP-practices in Belgium is very diverse making rapid research difficult. During weekends, the organisation of care is much more uniform due to the existence of GPCs. Using the iCAREdata database containing routine data in out-of-hours care in Belgium, quick analysis of all contacts at selected GPCs is possible. [15, 16] In this paper we assess the characteristics of GPC consultations. We compare these characteristics to a reference period in 2019 and describe the organisational changes the GPCs made.

Methods

This study was approved by the Ethics Committee of the Antwerp University Hospital (reference 20/14/170). The boards of all participating GPCs gave consent; individual patient consent was waived because we only used pseudonymised data.

We included 9 GPCs out of the 13 GPCs connected to iCAREdata. They all use the same software (Mediris 2.4®). One GPC was excluded because it is located within an ED which is not the focus of this study; three GPCs were excluded because the quality of data was insufficient. The included GPCs cover an average population of 168 169 citizens each (range 85 870–251 000) and have an average of 192 member GPs (range 100–380). In total they cover a population of 1 513 523 citizens and 1730 GPs (including trainees). All GPs having a practice in a community covered by a GPC are obliged to work approximately one shift a month in that GPC. The studied GPCs are all located in the Dutch speaking part of Belgium (Flanders) and cover 23% of the Flemish population. For the historical reference period in 2019, four additional GPCs were excluded because they did not yet deliver reliable data.

All included GPCs filled in an e-mail questionnaire about their organisation in order to understand the data collected. This questionnaire covered the following subjects: location of possible COVID-19 consultations, number of citizens covered by the GPC, number of active GPs covered by the GPC, starting date of specific COVID-19 care, profile and tasks of call takers, availability of consultations without appointment, organisation of telephone consultations and collaboration with surrounding EDs. The first author called the manager or a board member of all GPCs to verify the collected information.

Clinical data registered during home visits, telephone- and physical consultations were collected during five weekends (Friday 7 pm to Monday 8 am) and one bank holiday (Easter Monday) in 2020 and 2019.

During a telephone consultation, the software allows the GP to electronically prescribe drugs, deliver medical certificates and refer to an ED or the patient’s own GP. GPs are obliged to fill in a diagnosis using a Belgian list of clinical labels linked to the International Catalogue of Primary Care (ICPC-2). This list was extended with four labels related to COVID-19 based on SNOMED-CT concepts: confirmed case, suspected case, case with close contact to confirmed case and fear of COVID-19 without clinical suspicion. Because not all GPs were aware of the existence of these labels some have used other diagnostic labels or just a symptom as a diagnosis instead. The authors SM and VV independently rated all labels used in this study as at risk for COVID-19 or not. All labels concerning a diagnosis of respiratory tract infections or a symptom in a list of the most common COVID-19 symptoms (fever, cough, myalgia, fatigue, expectorations, conjunctival congestion, diarrhoea, loss of smell and taste and dyspnoea) were rated as at risk. [17-19]

All data were automatically available in iCAREdata: a research database on out-of-hours primary care. iCAREdata uses the pseudonymised Belgian national number as a unique identifier making it possible to link several consultations (even at different GPCs) to one patient but automatically excluding patients without such a number. [15] It contains most of the data fields from the software used in the GPCs.

Data was analysed using JMP 14®. Pearson chi-square testing was used for all comparisons in categorical variables. A two sample student’s t-test was used to compare the means of age between the consultation types and the historical reference group.

Results

Organisation of COVID-19 care

See Fig 1 for a schematic overview of the organisation of the GPCs during a COVID-19 outbreak. Seven GPCs reorganised their entire care paths immediately after the start of the Belgian lock-down; the other two made this switch one week later at the start of this study. They all provide staff with personal protective equipment and clean rooms for physical examination of patients at risk for COVID-19 called Corona Units, located outside of the sites for regular care. Due to the structure of the iCAREdata database it was not yet possible to make a distinction between the consultations by site.

Fig 1

Organisational model during a COVID-19 outbreak of the nine included General Practice Cooperatives.

*in five included General Practice Cooperatives the call takers make this differentiation. In four included General Practice Cooperatives, the general practitioners make it themselves. In those GPCs, a telephone consultation within the regular patient flow can result in a referral to the infectious patient flow. PPE: Personal Protective Equipment.

Patients have to call prior to presentation at the GPC, including those presenting themselves spontaneously at the GPC. A call taker registers the administrative data. In two GPCs, the call takers refer selected patients directly to the ED (using a local triage protocol [20]) while all other GPCs do not perform any kind of triage. In five GPCS, call takers differentiate the patients between an infectious patient flow (suspected COVID-19) and a regular patient flow (no suspicion of COVID-19)) by checking the most common COVID-19 symptoms (fever, dyspnoea, coughing, sneezing, running nose, throat ache and feeling unwell). In the other four GPCs, the GP makes this differentiation based upon personal opinion. Within the infectious patient flow, all GPCs perform a thorough telephone consultation, when needed the GP will refer patients to a home visit with PPE, a physical consultation at the corona unit or referral to the ED. Within the regular patient flow, four GPCs perform a telephone consultation on all patients after which the GP decides upon the following care. In the other five GPCs, the call taker gives an appointment for home visit or physical consultation at a regular care site.

Characteristics of GP consultations

We included 15655 consultations by 12096 unique patients during five weekends in 2020, 8942 (57%) of these were telephone consultations of which 6293 (70%) could be handled by telephone alone. The 2019 reference group contains 7571 physical consultations.

See Table 1 for characteristics of the consultations. In 2020, for 6692 (43%) consultations a diagnosis at risk of COVID-19 was registered. This rate declined from 2055 (58%) in the first weekend to 533 (27%) in the final weekend. The most common diagnoses at risk of COVID-19 were: suspected case of COVID-19 (N = 3131, 47%), unspecified viral infection (N = 618, 9%), fever (N = 602, 9%), acute upper respiratory tract infection (N = 546, 8%) and coughing (N = 417, 6%). During 1438 (9%) consultations a medical certificate for employees was delivered. This proportion was higher in the first weekend (N = 422, 12%) and lower in the final weekend (N = 153, 8%, p<0,001). The GPs referred 868 patients (6%) to the ED. For patients with a diagnosis at risk of COVID-19, the referral rate to the ED for telephone consultations was lower (N = 96, 2%) whereas it was higher during physical consultations (N = 141, 10%, p<0,001) and home visits (N = 51, 15%, p<0,001). For 969 (6%) of the patients follow-up by the own GP was recommended.

Table 1

Characteristics of included consultations*.

	All consultations reference period 2019 (n = 7571)	All consultations 2020 (n = 15655)	Telephone consultations (n = 8924)	Physical consultations (n = 5311)	Home visits (n = 1420)
Female	4102 (54%)	8671 (55%)	4894 (55%)	2921 (55%)	856 (60%)
Age (years): mean	Mean: 38	Mean: 43	Mean:41	Mean:39	Mean:74
Age (years): SD	28	25	24	22	21
Suspected case COVID-19	N/A	6692 (43%)	4894 (55%)	1460 (27%)	338 (24%)
Medical certificate for employees delivered	1200 (16%)*	1438 (9%)	759 (9%)	662 (12%)	17 (1%)*
Follow-up by own GP	365 (5%)*	969 (6%)	652 (7%)	260 (5%)	57 (4%)*
Referral to ED	481 (6%)*	868 (6%)	212 (2%)	496 (9%)	160 (11%)*

SD: Standard Deviation, N/A: not applicable

*: all p-values < = 0,001

The average consultation rate was 222 per 100 000 citizens per weekend. The first two weekends had a similar workload but the third and fifth had a lower workload due to a decrease in the number of all types of consultations (see Table 2). Because it contains Eastern Monday, the small increase in the fourth weekend does not relate to an increased workload. Compared to 2019, the total amount of consultations in 2020 (data available for five GPCs) increased with 40% exclusively due to the arise of telephone consultations. The amount of physical consultations decreased by 45% and even more in the final weekend.

Table 2

Number of consultations per 100 000 citizens during a COVID-19 outbreak in 2020 and a reference period in 2019.

	All consultations	Telephone consultations	Physical consultations	Home visits
20-24/03/2020	235	148	69	18
27-30/03/2020	240	149	70	20
03-06/04/2020	192	107	66	19
10-13/04/2020	239	120	94	24
17-20/04/2020	129	66	52	12
Average per weekend 2020 (all GPCs)	222	118	70	19
Average per weekend 2020 (GPCs with data in 2019 only)	244	138	82	23
Average per weekend 2019 reference group	174	0*	148	26

*: Before the pandemic, remote consultations were neither reimbursed nor deontologically allowed

Among the patients who underwent a physical consultation, 2226 (42%) had a prior telephone consultation by a GP. Among the patients with a diagnose at risk for COVID-19 this was significantly more: 1027 (70%, p<0,001) had a prior telephone consultation. However,433 (30%) patients only spoke with a call taker. Before a home visit, 423 (30%) had a prior telephone consultation, again significantly more (N = 209, 62%, p<0,001) in case of a diagnosis suspected of COVID-19.

Changes in the demand for care

See Table 3 for an overview of the changes in the rate of physical consultations by diagnosis (ICPC chapter). There was a small increase of consultations for psychological (including fear of COVID-19) and cardiovascular diagnoses whereas there was a marked decrease in the amount of physical consultations for respiratory, ophthalmological, digestive and ear-related diagnoses.

Table 3

Shift in diagnostic categories of patients in primary out of hours care during a COVID-19 outbreak (all ICPC-chapters with >50 cases).

ICPC-chapter	2019 (n)	2019 (per 100 000 citizens)	2020 (n)	2020 (per 100 000 citizens)	Change (%)
General	720	83	402	46	-44
Digestive	646	52	361	24	-54
Eye	138	11	79	5	-53
Ear	246	20	91	6	-69
Circulatory	60	5	80	5	10
Musculoskeletal	401	32	313	21	-36
Neurological	91	7	66	4	-40
Psychological	56	4	82	5	21
Respiratory	1106	88	567	37	-58
Skin	437	35	416	27	-21
Urology	138	11	116	8	-31

ICPC: International Catalogue of Primary Care

Discussion

This study proves it is possible to rapidly collect reliable data about the characteristics of primary out-of-hours care. GPCs changed their way of working rapidly and profoundly almost immediately after the start of the Belgian lock-down. The participating GPCs made an impressing shift from no telephone consultations to half of all contacts being delivered by telephone. This organisational change is very similar to the yet unstudied response in other countries worldwide. [4-6]

At the start of the study half of the primary out-of-hours care was COVID-19 related. The GPs handled the vast majority of the patients themselves with a combination of telephone and physical consultations while referring 6% to secondary care. The demand for work certificates caused an additional increase in consultations.

Of the patients who had a diagnosis at risk for COVID-19 after a physical consultation, 30% did not have a prior telephone consultation (they only had a brief contact with a call taker). Given the fact that all GPCs state that within the infectious patient flow all patients get a GP telephone consultation first, most likely the majority of them have been seen within the regular flow. Possibly, a minority of these patients did get another type of COVID-19 risk assessment not registered in the software: prior consultation outside of the GPC (patient’s own GP working in the weekend or specialist). This proportion of patients suspected of COVID-19 physically seen without prior telephone consultation is high and indicates a risk for the GPs working in the regular patient flow, as they do not wear personal protective equipment. Awaiting validated triage guidelines we recommend to give a telephone consultation to all patients and not to rely on call takers to differentiate between infectious and regular care.

During the study, the total workload decreased drastically: from a workload much higher as in 2019, entirely due to telephone consultations, to a total workload much lower than in 2019. One explanation is the reduced demand of information as citizens get more accustomed to the partial lock-down. Another is the reduced demand for medical certificates related to work. Finally it might be related to the outbreak itself as the number of hospitalisations followed a similar decline with a one week delay. These reasons however do not explain the halving of the demand for physical consultations. This is surely a direct or indirect effect of the outbreak as this demand has steadily gone up for many years. An indirect effect might be due to the lock-down: a decline in infections and accidents can be expected. The more pronounced decline of ophthalmological and digestive diagnoses might be due to the reduced amount of other infections caused by the lock-down.

Another indirect effect is the fear of patients to consult a medical service as described in Italy. [10] The decline in physical consultations is most pronounced for respiratory, ophthalmological, digestive and ear-related diagnoses probably also due to a combination of decreased infections and fear of consulting. The decline in respiratory diagnosis can be explained by the trend to handle these patients by telephone. This reduction in care unrelated to COVID-19 is an important finding because it might be correlated to increased morbidity and mortality.

The strength of this study lies in the large number of included consultations and the speed of reporting. This study has got several limitations: it only describes what happens but does not allow for any conclusions about the outcomes, efficacy or safety of these consultations. We have no data regarding the length of the (telephone) consultations or the deployment of additional staff. For telephone consultations, safety was already an issue before the COVID-19 pandemic. [21] During the study period, ambulatory testing patients for SARS-CoV-2 in primary care was not allowed in Belgium so the proportion of truly infected patients remains unknown. Rapid changes in the organisation of the GPCs reduced data quality: some consultations might not have been registered correctly and there might be small differences in organisation among the participating GPCs. We were unable to see which patients were in the infectious or the regular patient flow. The data fields for referral (to the own GP or the ED) are not compulsory to complete a report and thus prone to under registration.

This paper does not allow to make any predictions based upon this data. Because COVID-19 patients typically deteriorate one week after the first symptoms [22], the stress on the primary care system might be a predictor for overcrowding in the hospitals in the near future. Further study into the significance of the decline in regular care is needed as this might indicate a safety problem. When implementing new strategies to limit COVID-19, close attention should be given to its side effects on regular care.

The successful implementation of telephone consultations opens new possibilities for the post COVID-19 era but should be studied more profoundly, especially regarding patient’s safety. We recommend longer follow-up studies within different healthcare systems and not restricted to out-of-hours care. The current study provides some arguments in favour of a primary care first model with remote consultations but more aspects such as financial consequences, total work burden, proportion of truly infected patients, morbidity and mortality should be studied.

Conclusions

Belgian GPs have been able to rapidly re-organise care in order to handle a COVID-19 outbreak and provide a safe working environment. Initially half of the GP’s consultations during out-of-hours care were related to COVID-19 leading to an increased work load followed by a workload below the normal average after five weeks. This provokes questions about patient’s safety for care unrelated to COVID-19. GPs handled 40% of all out-of-hours consultations by telephone alone. Among the patients with a diagnosis at risk of COVID-19, 30% had a physical consultation without a prior telephone consultation to detect this risk. This implies a risk for unprotected staff providing care for possibly infected patients.

STROBE statement—checklist of items that should be included in reports of cross-sectional studies.

(DOCX)

Click here for additional data file.

(PDF)

Click here for additional data file.

(PDF)

Click here for additional data file.

15 Jun 2020

PONE-D-20-15141

Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study

PLOS ONE

Dear Dr. Morreel,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 30 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for including your competing interests statement; "I have read the journal's policy and the

authors of this manuscript have the following

competing interests:All authors have completed the ICMJE uniform disclosure form and declare: Stefan Morreel is an unpaid Board member of one of the participating General Practice Cooperatives and is paid by the Belgian ministry of help to coordinate the response of this cooperative to the COVID-19 pandemic. Veronique Verhoeven has participated at the same GPC by handling telephone calls in a fee-for-service model. All authors are board members of iCAREdata as part of their academic position, the database used in this study. "

Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests).  If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf.

Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The study's strength lies in the massive data that allows health care system and policy makers to understand more about the nature of out-of-hours primary care during COVID19. However the data is limited in the sense that it only provides a descriptive analysis and lacking in in-depth discussion about how this data might have larger consequences to changing health care system in Belgium during pandemic, and compared with other countries' out-of-hours primary care. I suggest to expand the analysis to make connection to the larger/global implication.

Reviewer #2: The authors present an interesting case study on out-of-hours primary care in Belgium during the COVID-19 pandemic. Overall, the paper is well-written, but a proper copyediting should be performed before publication. I have a few remarks that authors should address in a revised version:

Page 5 (Sec Methods): how are the other 77% of the Flemish population covered? It seems to be quite a large number of GPs per centre, are they all on duty in shifts? Do they otherwise work full time as GPs and cover the same population?

Page 7 / Fig 1: the representation and explanation of the process during the pandemic should be clearer. All patients are advised to call first? What happens to those who just show up? It is stated on page 10, for example, that 30% did not have a telephone consultation. Please explain in more detail how you differentiate triage from consultation. How and when where patients informed about the new process?

Do you have time stamps / durations for the call handling and different consultation types? Did the durations differ in the two years? Are telephone consultations significantly faster than physical consultations? What was the staff utilisation in the two periods?

Page 8 (Sec Characteristics, first paragraph): What were the remaining 3%?

Page 10, Table 2: Why weren’t there any telephone consultations last year? Was it not possible to call the centre before the pandemic? Was everyone seen who called the centre?

Page 10, Table 2: could you provide some numbers on the pandemic for the 5 weeks you studied to get a better idea about the situation in Belgium during that time? From the news we got the impression that Belgium was hit comparatively hard by the virus.

Page 10, last sentence: do you have any explanation why ear-related diagnoses are on the list of those with the highest decline? From my experience, I would have imagined something like back pain or headaches etc. to be on that list.

From your findings, would you conclude that the centres should keep telephone consultations as an option even after COVID-19? Can you make conclusions based on your findings and your data?

Can you make any remarks on other European countries that also provide out-of-hours care by GPs like Germany? Did you find any papers or comments on that? Would you say that the care process should be transferable to other countries and would you suggest to use it?

I am missing an outlook at the end of the paper. What should follow-up research study? How can the results be used in future research?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

25 Jun 2020

We thank the reviewers for their generous comments on the manuscript and have edited the manuscript accordingly. For your convenience we have made a table with the suggestions of the reviewers and our adaptations/comments in the rebuttal letter.

Change competing interests statement We have added the suggestion to the cover letter. For clarity we have also copied our data availability statement to the cover letter.

Lacking in in-depth discussion about how this data might have larger consequences to changing health care system in Belgium during pandemic This suggestion is similar to more specific critics of the second reviewer so we have commented those

Page 5 (Sec Methods): how are the other 77% of the Flemish population covered? It seems to be quite a large number of GPs per centre, are they all on duty in shifts? Do they otherwise work full time as GPs and cover the same population? We have added the requested information. We have clarified that the studied GPCs cover 23% of the Flemish population. The remaining 77% is covered by GPCs we could not include or have the old system of rota groups for on call duties. We believe adding information about the large amount of included GPs would make the methodology section to long but provide it here for your interest: Belgium has got a rather large amount of GPs per capita and the included GPCs have a lot of part-time working GPs and trainees because of the proximity of two academic departments. GPs with a chronic illness or above 65 years of age are not obliged to work in the GPCs, all the others are.

Page 7 / Fig 1: the representation and explanation of the process during the pandemic should be clearer. All patients are advised to call first? We have entirely rewritten this paragraph and simplified Fig 1. It is now more clear that all patients need to call (but some will only speak with a call taker).

It is stated on page 10, for example, that 30% did not have a telephone consultation. We clarified this statement: 433 (30%) only spoke with a call taker

Please explain in more detail how you differentiate triage from consultation. New sentence: “In two GPCs, the call takers refer selected patients directly to the ED (using a local triage protocol) while all other GPCs do not perform any kind of triage.”

How and when where patients informed about the new process? Added to the introduction: The government’s recommendation to always call a doctor prior to going to a practice or ED was omnipresent in the media.

Do you have time stamps / durations for the call handling and different consultation types? Did the durations differ in the two years? Are telephone consultations significantly faster than physical consultations? We do not have this data, added to limitations.

What was the staff utilisation in the two periods? The GPCs definitely increased their staff (GPs and call takers/receptionists) but we do not have data proving this, neither was it part of our questionnaire. We have added this to the limitations.

Page 8 (Sec Characteristics, first paragraph): What were the remaining 3%? There is not remaining 3%, we have clarified this sentence.

Page 10, Table 2: Why weren’t there any telephone consultations last year? Was it not possible to call the centre before the pandemic? Was everyone seen who called the centre? Added to the introduction and to the footnote of this table: “Before the pandemic, remote consultations were neither reimbursed nor deontologically allowed.”

Page 10, Table 2: could you provide some numbers on the pandemic for the 5 weeks you studied to get a better idea about the situation in Belgium during that time? From the news we got the impression that Belgium was hit comparatively hard by the virus. We have extended the epidemiological information in the introduction. Belgium surely was hit hard but we have chosen not to compare these data to other countries or regions because Belgium is one of the few countries including many suspected cases to the total number of cases. Currently there are no peer reviewed publications available about the comparison of the burden of this pandemic to individual countries or regions. It would be more correct to compare Belgium to New-York or Northern Italy then to compare the numbers to bigger countries.

Page 10, last sentence: do you have any explanation why ear-related diagnoses are on the list of those with the highest decline? From my experience, I would have imagined something like back pain or headaches etc. to be on that list. There was a decline for back pain (included in the ICPC-chapter Musculoskeletal) and headache (chapter Neurological) but similar to the overall decline so we do not discuss them separately.

Added to the discussion: “The more pronounced decline of ophthalmological and digestive diagnoses is probably due to the reduced amount of other infections caused by the lock-down.”

From your findings, would you conclude that the centres should keep telephone consultations as an option even after COVID-19? Can you make conclusions based on your findings and your data? Our data do not allow for definitive conclusions but are an interesting starting point. Added to discussion: “The successful implementation of telephone consultations opens new possibilities for the post COVID-19 era but should be studied more profoundly, especially regarding patient’s safety.”

Can you make any remarks on other European countries that also provide out-of-hours care by GPs like Germany? Did you find any papers or comments on that? Would you say that the care process should be transferable to other countries and would you suggest to use it? We have entirely rewritten the first paragraph of the Discussion with additional references. This study alone does not allow for a recommendation on the transfer of this care process to other countries although is surely brings in one argument.

I am missing an outlook at the end of the paper. What should follow-up research study? How can the results be used in future research? Such an outlook has been added to the final paragraph of the discussion.

We hope that the manuscript is now suitable for publication in Plos One.

Sincerely,

The authors

Submitted filename: Rebuttal letter.docx

Click here for additional data file.

20 Jul 2020

PONE-D-20-15141R1

Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study

PLOS ONE

Dear Dr. Morreel,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 03 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

1. In order to provide a more complete information to our readers on the topic, we would like to emphasize the importance to cross referencing very recent material on the same topic published in "PLoS ONE ". Therefore, it would be highly appreciated if you would check the contents published in the last two years of "PLoS ONE" (https://journals.plos.org/plosone/) and add all material relevant to your article to the reference list.

2. add “Clinical features and short-term outcomes of 102 patients with corona virus disease 2019 in Wuhan, China. Clinical Infectious Diseases.” in the revision text

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: I think the authors did a good job revising the manuscript. I just have a few minor comments:

- The information and references about other countries that were added to the discussion might be better moved to the intro section as part of the relevant literature.

- The last sentence of the added outlook should be revised.

- The paper needs final proofreading.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

27 Jul 2020

Dear editor,

We thank the reviewers for their additional comments on the manuscript and have edited the manuscript accordingly. We believe this paper is now ready for publication and will contribute to the wide diversity of knowledge about COVID-19 distributed by PLoS ONE as it is the first study within the COVID-19 collection with a primary care perspective. For your convenience we have made a table with the suggestions of the reviewers and our adaptations/comments.

Comment Our adaptation and/or comment

In order to provide a more complete information to our readers on the topic, we would like to emphasize the importance to cross referencing very recent material on the same topic published in "PLoS ONE ". We have added a recent PLoS ONE study to the Methodology section (Grant MC, Geoghegan L, Arbyn M, et al. The prevalence of symptoms in 24,410 adults infected by the novel coronavirus (SARS-CoV-2; COVID-19): A systematic review and meta-analysis of 148 studies from 9 countries. PLoS One. 2020;15(6):e0234765. Published 2020 Jun 23. doi:10.1371/journal.pone.0234765)

Editor: add “Clinical features and short-term outcomes of 102 patients with corona virus disease 2019 in Wuhan, China. Clinical Infectious Diseases.” in the revision text We have added this reference to the introduction

The information and references about other countries that were added to the discussion might be better moved to the intro section as part of the relevant literature. We have moved this paragraph as requested

The last sentence of the added outlook should be revised. This sentence was indeed incomplete and has been corrected

The paper needs final proofreading. We have proofread the entire article and made some improvements here and there

We hope that the manuscript is now suitable for publication in Plos One.

Sincerely,

The authors

Submitted filename: Second Rebuttal letter.docx

Click here for additional data file.

31 Jul 2020

Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study

PONE-D-20-15141R2

Dear Dr. Morreel,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

4 Aug 2020

PONE-D-20-15141R2

Organisation and characteristics of out-of-hours primary care during a COVID-19 outbreak: a real-time observational study

Dear Dr. Morreel:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Wen-Jun Tu

Academic Editor

PLOS ONE