Evaluation of patient characteristics, management and outcomes for COVID-19 at district hospitals in the Western Cape, South Africa: descriptive observational study.

OBJECTIVES: To describe the characteristics, clinical management and outcomes of patients with COVID-19 at district hospitals. DESIGN: A descriptive observational cross-sectional study. SETTING: District hospitals (4 in metro and 4 in rural health services) in the Western Cape, South Africa. District hospitals were small (<150 beds) and led by family physicians. PARTICIPANTS: All patients who presented to the hospitals' emergency centre and who tested positive for COVID-19 between March and June 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: Source of referral, presenting symptoms, demographics, comorbidities, clinical assessment and management, laboratory turnaround time, clinical outcomes, factors related to mortality, length of stay and location. RESULTS: 1376 patients (73.9% metro, 26.1% rural). Mean age 46.3 years (SD 16.3), 58.5% females. The majority were self-referred (71%) and had comorbidities (67%): hypertension (41%), type 2 diabetes (25%), HIV (14%) and overweight/obesity (19%). Assessment of COVID-19 was mild (49%), moderate (18%) and severe (24%). Test turnaround time (median 3.0 days (IQR 2.0-5.0 days)) was longer than length of stay (median 2.0 day (IQR 2.0-3.0)). The most common treatment was oxygen (41%) and only 0.8% were intubated and ventilated. Overall mortality was 11%. Most were discharged home (60%) and only 9% transferred to higher levels of care. Increasing age (OR 1.06 (95% CI 1.04 to 1.07)), male (OR 2.02 (95% CI 1.37 to 2.98)), overweight/obesity (OR 1.58 (95% CI 1.02 to 2.46)), type 2 diabetes (OR 1.84 (95% CI 1.24 to 2.73)), HIV (OR 3.41 (95% CI 2.06 to 5.65)), chronic kidney disease (OR 5.16 (95% CI 2.82 to 9.43)) were significantly linked with mortality (p<0.05). Pulmonary diseases (tuberculosis (TB), asthma, chronic obstructive pulmonary disease, post-TB structural lung disease) were not associated with increased mortality. CONCLUSION: District hospitals supported primary care and shielded tertiary hospitals. Patients had high levels of comorbidities and similar clinical pictures to that reported elsewhere. Most patients were treated as people under investigation. Mortality was comparable to similar settings and risk factors identified.

How well do public sector primary care providers function as medical generalists in Cape Town: a descriptive survey.

BACKGROUND: Effective primary health care requires a workforce of competent medical generalists. In South Africa nurses are the main primary care providers, supported by doctors. Medical generalists should practice person-centred care for patients of all ages, with a wide variety of undifferentiated conditions and should support continuity and co-ordination of care. The aim of this study was to assess the ability of primary care providers to function as medical generalists in the Tygerberg sub-district of the Cape Town Metropole. METHODS: A randomly selected adult consultation was audio-recorded from each primary care provider in the sub-district. A validated local assessment tool based on the Calgary-Cambridge guide was used to score 16 skills from each consultation. Consultations were also coded for reasons for encounter, diagnoses and complexity. The coders inter- and intra-rater reliability was evaluated. Analysis described the consultation skills and compared doctors with nurses. RESULTS: 45 practitioners participated (response rate 85%) with 20 nurses and 25 doctors. Nurses were older and more experienced than the doctors. Doctors saw more complicated patients. Good inter- and intra-rater reliability was shown for the coder with an intra-class correlation coefficient of 0.84 (95% CI 0.045-0.996) and 0.99 (95% CI 0.984-0.998) respectively. The overall median consultation score was 25.0% (IQR 18.8-34.4). The median consultation score for nurses was 21.6% (95% CL 16.7-28.1) and for doctors was 26.7% (95% CL 23.3-34.4) (p = 0.17). There was no difference in score with the complexity of the consultation. Ten of the 16 skills were not performed in more than half of the consultations. Six of the 16 skills were partly or fully performed in more than half of the consultations and these included the more biomedical skills. CONCLUSION: Practitioners did not demonstrate a person-centred approach to the consultation and lacked many of the skills required of a medical generalist. Doctors and nurses were not significantly different. Improving medical generalism may require attention to how access to care is organised as well as to training programmes.