Primary care response to COVID-19 in Italy: pearls and pitfalls

By Andrea Canini, Executive Board Member of the European Forum for Primary Care

The Pearls

To date, Italy has been one of the most affected countries by Covid-19 pandemic. With a population of 60 million people, the country has faced an unprecedented health challenge, that resulted in variable outcomes according to the different regions. As we transition to this new year, it is a helpful example to look back upon and consider the strategies taken to tackle Covid-19.
 
Primary health care has been key in the effort to confront this challenge.  In order to better understand the primary care strategy drafted for the management of the Covid-19 emergency at a national level and the pearls and pitfalls that emerged in its implementation by region, one must first understand the structure of the Italian National Health System (SSN: Sistema Nazionale Sanitario). With the 2001 reform of the Italian Constitution, it was provided that the general objectives and fundamental principles of health protection and promotion are to be defined at a governmental level, whereas the organization, financing and delivery of health services is to be carried out at a regional level ¹. In a nutshell, health is mainly administered on a regional basis, and this had a significant impact on the Covid-19 preparedness and response. Regions such as Emilia-Romagna and Tuscany, that had strong primary care and community services, showed a faster and better-structured response to Covid-19 emergency, if compared to other regions such as Lombardy, that faced a considerable disinvestment in community services in favor of a more hospital-centered approach.
 
Indeed, it was the 20th of February when the young anesthetist Annalisa Palamara diagnosed the first case of Covid-19 in Italy and in Europe, and approximately one month later, by the 26th of March, Covid-19 Special Units of Primary Care (USCA) were already put in place and operative in the Emilia-Romagna region. This is particularly impressive considering the time required to open up new health services in the pre-pandemic period. The creation of this new service definitely improved the management of Covid-19 cases in the community and outside the hospital.
 
But what are the USCA? The USCA are the operational extension of family doctors fighting Covid-19 and supporting suspect Covid-19 patients. If during phone triage, the GP elicits the presence of fever or other compatible symptoms, or if an already-diagnosed Covid-19 patient requires a follow up visit, they can call on the USCA service. On the other side of the phone there will be a young doctor, most likely a family medicine specialist or resident, to assist with the case. There are two fundamental reasons why USCA were created:

1. Provide timely hospital referral for suspected and confirmed Covid-19 patients. During the first phase of the pandemic, we frequently saw extremely late presentations of cases to emergency rooms, often in a compromised state. This was due to fear in the population regarding hospital admissions and because of the difficulty in obtaining appropriate care in the community.
2. Ensure health professionals have sufficient PPE.We can all easily remember the chaos related to the provision—or lack— of PPE during the first phase of the pandemic. Unfortunately, given the large number of general practitioners (GPs)—over 40,000 operating throughout Italy— providing each one of them with the optimal PPE for every visit was not—and still is not—a feasible option due to the short supplies globally².  As a result, a decision to “verticalize” care for Covid-19 patients was made and the USCA were created.  One positive consequence of this decision was the preservation and protection of GPs, a population largely consisting of senior professionals (Italy has one of the the oldest GP workforces, with 43% of them age 55 or older), as well as promoting young professionals through the Covid-19-specific services. This was a critical move: Covid-19-related mortality was substantial among GPs, suffering more than a hundred deaths in their ranks by early April.

In the city of Bologna (390,000 inhabitants), where I currently work, there are two USCA located in two different Community Health Centers, each one with 4-5 doctors working from 8am - 8 pm. The main tasks and functions of the Covid-19 Special Units of Primary Care are:

Telephone triage and assessment: a call to the USCA Service is made by the referring GP and the case is then assessed by the USCA doctor, who can then arrange a home visit depending on the severity of the case. Currently, almost every visit is executed within 24 hours and for urgent cases within 3-4 hours. After the visit, the doctor contacts the referring GP to give immediate feedback and sends a digital report.

Home care: this represents the core activity of the USCA.  For each visit, the doctor is provided with containers for clean and contaminated waste disposal, PPE and medical equipment such as a digital thermometer, oximeter, stethoscope etc. When visiting a new suspect case, a nasopharyngeal swab is performed at home after the general examination and sent to the lab.

Regular medical care at Covid-19 hotels: at the beginning of the pandemic, some tourist hotels were converted into Covid-19 hotels, to host people with housing problems, socially fragile patients, and to quarantine people coming from high-risk countries. The Covid-19 hotels are generally nurse-led, and USCA doctors are activated in case of need. 

The Pitfalls

If we look to the Italian case from a constructive viewpoint, there are some lessons to learn that can be relevant for other countries, summarized as follows:

1. Covid-19 is as political as it is medical

Despite the likelihood that the USCA service would improve the care of Covid-19 cases at the community level, its implementation was hampered in some regions and the time it took to institute the service differed significantly from place to place ³. This was due to the fact that health is largely managed at the regional level as part of a strategy of decentralization of the Italian National Health Service, and thus also reflected pre-existing inequalities between regions ⁴. Even when faced with a national and global emergency like Covid-19, one must take into account the wider political and public health environment. As different regions undertook very different political and public health decisions over the last decade, it led to large variations in response and outcomes related to Covid-19. As an example, Lombardy, the richest region in the country, which underwent a process of privatization of the regional healthcare system leading to a parallel disinvestment in primary care faced severe and dramatic shortcomings in the pandemic response ^5 6. On the other hand, other regions like Emilia-Romagna, which were historically more assertive in the implementation of community services and primary care, are dealing better and faster with Covid-19 preparedness and response.

2. Primary care is not basic care 

To provide excellent care, primary care services must be equipped, staffed and managed with proper resources.  As the medical literature has demonstrated, with consistent initial investment in primary care, returns in the medium and long term can overcome the expenses ^7 8 9. This is once again evident in Covid-19 management. Since April, USCA medical teams have been requesting ultrasounds and blood gas analyzers be included within their kits of home care equipment, as these tools can be easily used in assessments at home and can provide useful diagnostic support, especially for moderate severity cases. With such tools, unnecessary referrals to the ED could potentially be avoided. There is an urgent need to streamline and organize diagnostic “fast-tracks” that could lead to better triage and referral systems and thus reduce the pressure on emergency rooms. This assertion becomes even more cogent as the epidemic curve has risen once again and hospital bed availability started to decrease. 

3. Rediscovering comprehensiveness and coordination in primary care

The Italian response to Covid-19 is showing us how interconnected and interdependent a good primary care system should be. The strenuous work of family doctors and nurses cannot be fully effective if not connected to the wider work of public health experts, social services and community organizations, just to name a few key actors. From the 1970s on, we have observed a progressive verticalization of primary care services, which remains evident in the pandemic response. If we are really to provide health for all, address the broader determinants of health and counteract the inverse care law, we really need a close, regular, horizontal collaboration between all the actors involved in the complex process of care. Such a management approach is not yet in place, but must represent a fundamental feature of the primary health care system of tomorrow.
 
In 2017, together with a group of young primary care professionals, we launched a public campaign to renew Italian primary health care called “2018 PHC: Now or Never.” A few months ago we published our “Libro Azzurro” (i.e. “The Blue Book), a manifesto where we advocate for a revolution of the Italian PHC System, divided into 12 concrete proposals.¹⁰  We hope this new advocacy effort will provide synergy to the coordinated efforts of the many young professionals and older GPs who have taken on much of the burden of the frontline response to Covid-19 in Italy, and deserve a better primary health care system on the other side of this crisis.

References

1. Toth F. Health Care Regionalization in Italy. Conference Paper: 23rd World Congress of Political Science Montréal. Panel: Comparative Health Care Federalism: Competition and Collaboration in Multistate Systems. 2014
2. Burki T. Global shortage of personal protective equipment. Lancet Infect Dis. 2020;20(7):785-786. doi:10.1016/S1473-3099(20)30501-6
3. Alta Scuola di Economia e Management dei Sistemi Sanitari. Analisi dei modelli organizzativi di risposta al Covid-19. Instant REPORT#17. 2020
4. Caruso, Enza, and Nerina Dirindin. ‘Health Care and Fiscal Federalism: Paradoxes of Recent Reforms in Italy.’ Politica Economica 28 (2): 169-96. 2012
5. Brenna E. Quasi-market and cost-containment in Beveridge systems: the Lombardy model of Italy. Health Policy. 2011 Dec;103(2-3):209-18. doi: 10.1016/j.healthpol.2011.10.003. Epub 2011 Oct 24. PMID: 22030307.
6. Usuelli M. The Lombardy region of Italy launches the first investigative COVID-19 commission. Lancet. 2020 Nov 14;396(10262):e86-e87. doi: 10.1016/S0140-6736(20)32154-1. Epub 2020 Oct 15. PMID: 33069278; PMCID: PMC7561338.
7. Mendes, Eugênio Vilaça. O cuidado das condições crônicas na atenção primária à saúde: o imperativo da consolidação da estratégia da saúde da família. / Eugênio Vilaça Mendes. Brasília: Organização Pan-Americana da Saúde, 2012.512 p.: il.ISBN: 978-85-7967-078-7
8. ME Kruk, D Porignon, PC Rockers, W Van Lerberghe. The contribution of primary care to health and health systems in low- and middle-income countries: a critical review of major primary care initiatives. Soc Sci Med, 70 (2010), pp. 904-911
9. J Macinko, B Starfield, T Erinosho. The impact of primary health care on population health in low-and middle-income countries. J Ambul Care Manage, 32 (2009), pp. 150-171
10. https://2018phc.wordpress.com/verso-il-libro-azzurro/