A bit of a cough, tired, not very resilient – is that already Long-COVID? Perceptions and experiences of GPs with Long COVID in year three of the pandemic. A qualitative study in Austria.

A bit of a cough, tired, not very resilient – is that already Long-COVID? Perceptions and experiences of GPs with Long COVID in year three of the pandemic. 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Perceptions and experiences of GPs with Long COVID in year three of the pandemic. A qualitative study in Austria. Silvia Wojczewski, Mira Mayrhofer, Nathalie Szabo, Kathryn Hoffmann This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3523586/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background: COVID-19 is a new multisectoral healthcare challenge. This study contributes to research on long COVID. It aims at understanding experiences, knowledge, attitudes and (information) needs that GPs have in relation to long COVID and how these evolved since the beginning of the COVID-19 pandemic. Methods: The study used an exploratory qualitative research design. It investigated infection protection, infrastructure, framework conditions and the treatment of patients during the COVID-19 pandemic in Austria through semistructured interviews. A total of 30 semistructured interviews with GPs in different primary care settings (single practices, group practices, primary care centres) were conducted between February and July 2022. For this study, the questions relating to long COVID were analysed. The data were analysed using the qualitative content analysis software Atlas.ti. Results: This is the first study that empirically investigated long-COVID management by GPs in a country with a Bismarck healthcare model in place. All GPs indicated having experience with long COVID. In cities, GPs tended to have slightly better networks with specialists, and GPs, especially in more rural places, would need much more support. The GPs who already worked in teams tended to find the management of COVID-19 easier. The symptoms that the physicians described as Long-Covid symptoms correspond to those described in the international literature, but it is unclear whether postCovid syndromes such PostExertinal-Malaise, autonomic dysfunction such as postural tachycardia syndrome or Mast-Cell-Overactivation-Syndrom (MCAS), and cognitive dysfunction are also recognized and correctly classified since they were never mentioned. The treatment of the patients is basically described as an enormous challenge and frustrating if the treatment does not yield significantly improved health. With this problem, the GPs feel left alone. GPs lacked information and contact information about specific health personnel or contact points that were familiar with postinfectious syndromes. Such facilities are urgently needed. Conclusion: COVID-19 will continue to preoccupy our health care systems for a long time to come, as new variants without prevention strategies will continue to produce new patients. Therefore, it is not a question of if but when good support for GPs and adequate care pathways for people with COVID-19 will be implemented. Post-COVID-19 syndrome postacute sequelae of SARS-CoV-2 infection PACS postinfectious disease primary health care semistructured interviews post-COVID condition family physician family medicine Figures Figure 1 Figure 2 Introduction After the COVID-19 pandemic, there is a new global health challenge to tackle: long COVID. Long-COVID describes a multisystemic illness present 30 or more days after a COVID-19 infection [ 1 ]. The term has been coined by patients and is the one that is most widely used. Other more medically accurate terms to designate the chronic condition have emerged, such as “postacute sequelae of SARS-CoV-2 infection (PASC)” or the definition the NICE rapid guideline used since December 2020: It differentiates between ongoing symptomatic COVID-19 and “post COVID-19 syndrome”, which describes signs and symptoms that develop during or after an infection consistent with SARS-CoV-2, continue for more than 12 weeks and are not explained by an alternative diagnosis [ 2 ]. Similarly, the WHO formulated their definition in October 2021 [ 3 ]. More than 200 symptoms have been reported by patients thus far, yet the most commonly reported are fatigue, shortness of breath, headache, cognitive dysfunction, muscle aches, palpitations, chest pain, dizziness and sleep disturbance [ 4 – 6 ]. The illness can have a strong negative impact on quality of life, with patients indicating little or no improvement in long-term COVID symptoms as long as two years after their initial COVID-19 infection [ 7 – 13 ]. The percentage of people affected by long COVID globally varies, yet studies imply that at least 10% of people who were infected with COVID-19 develop long COVID symptoms or 3% of the overall population [ 4 , 14 , 15 ]. COVID-19 is a major new multisectoral healthcare challenge, and thus far, it is not known what impact it will continue to have. This is also because there are no reliable data on long-COVID prevalence in the different COVID-19 subvariants. There are studies showing that long-COVID cases and symptoms vary by wave and that there have been more cases in the first waves due to no or low vaccination. However, new studies with cohorts in the USA, UK and the Netherlands show that there might be a higher risk of developing long-term COVID symptoms after reinfections with COVID-19 [ 14 – 16 ]. There are other cases of postinfectious diseases causing long-term symptoms, such as post-SARS. However, there are also many similarities with other medically understudied conditions, such as ME/CFS (which a subgroup of long-COVID patients with PEM - postpost-exertional malaise develops). Much could be learned from including these medical conditions in comparative research [ 17 , 18 ]. Symptoms affect many different organs and physiological pathways, can be interrelated and all need to be studied more profoundly. The symptoms can be clustered into systems: they can affect neurological and cognitive, cardiovascular, gastrointestinal, dermatological and respiratory/pulmonary systems [ 4 , 5 , 14 – 16 , 19 ]. Impacts can also be on the reproductive system with effects, for example, on menstruation, yet sex-specific pathophysiology has to be studied in more detail. To date, different pathways are being explored to understand the mechanisms underlying long COVID: for example, organ damage in targeted tissue, a persistent virus reservoir, reactivation of Epstein‒Barr or herpes viruses, autoimmunity or mast cell activation [ 14 , 15 ]. Most patients with self-reported long COVID were not hospitalized due to their SARS-CoV-2 infection and only had mild symptoms of the infection itself. New studies indicate that people at higher risk are women, people aged 35 to 69, socioeconomically deprived people, people working in social care, people belonging to ethnic minorities, and people with other activity-limiting illnesses [ 4 , 19 , 20 ]. Studies also found that long COVID impacts children of all ages [ 4 , 9 , 14 , 21 ]. The WHO recommends three aspects for managing COVID-19 that can also be applied to long COVID-19: “multidisciplinary rehabilitation teams, continuity and coordination of care and people-centred care as well as shared decision-making” (4:38). The Expert Panel on effective ways of investing in health from the European Commission (EXPH) further recommends that long COVID should be coordinated by the primary care sector. GPs have a central role in diagnosing, managing and coordinating diagnosis and treatment with other primary healthcare personnel as well as medical specialists for postinfectious diseases. However, to guarantee the quality and continuity of care, the challenges for primary health care should be well documented and addressed. Long-COVID and the Austrian health care system By the end of June 2023, there will be approximately 6.08 million cases of documented SARS-CoV-2 infections, and 22.500 people will die from COVID-related causes in Austria [ 22 ]. Only 56% of the Austrian population received the full immunization (three doses), which is low compared to other European countries, such as Spain or Portugal. Among European countries, sociodemographic factors in Austria impacted COVID-19 cases and death numbers more than in other countries [ 23 , 24 ]. Single or group practices of GPs and very few primary healthcare centers (PVEs), where different primary health care professions work together, are the first contact point for COVID-19 as well as long-COVID-19 patients. During the COVID-19 pandemic, GPs and primary care workers at first had a difficult time adapting to the pandemic challenges because they were partly left alone from the government, which focused primarily on the hospital setting and its challenges. However, after a difficult beginning with lack of equipment and information, they mostly adapted quickly [ 25 , 26 ]. In Austria, physicians in the ambulatory sector are mainly self-employed and can either work with a contract with the public social health insurance system ( Kassenärztin/-arzt ) or open a private practice ( Wahlärztin/-arzt ). In the first case, patient costs are almost entirely covered by social insurance (patients have a social insurance card (e-card) that they have to show at the appointment), and in the latter case, patients must pay for the services and are only partly refunded by social insurance. The predominant payment scheme is fee-for-service, which leads to high patient frequencies and short consultation rates. Since the end of 2021/2022, in Austria, there have been very few specific long-COVID outpatient clinics. However, most of them specialize in mono-specialty aspects, such as pulmonary or neurological aspects, which are not useful in the treatment of complex postinfectious syndromes, where the medical knowledge of several disciplines is needed. As a result, they are closing again. No specific medical contact point for postinfectious diseases has been established. A webpage of Long-Covid Austria as well as the Austrian Society of ME/CFS where one can find information on where to seek help managed by patient initiatives and several rehabilitation spots have been created for Long-Covid patients, however exclusively for Long-Covid patients without PEM with one or two exceptions. Thus, long-COVID patients are usually directed towards their family physician who is responsible for managing and coordinating long-COVID – referring to specialists and laboratories for tests as well as referring to several other health professionals for treatment, such as physio-, ergo- or psychotherapists, dieticiants and others. Therefore, the Austrian Society of General Practice (Österreichische Gesellschaft für Allgemein- und Familienmedizin, ÖGAM) worked out an S1 Long-Covid guideline together with seven other Austrian medical societies that was published in December 2021[ 20 ] and has been updated in 2023 [ 19 ]. It is directed towards primary health services in Austria and is supposed to be a helpful and practical tool that is also available via an easy-to-use webtool . This study will contribute to research on long COVID. It aims to understand the experiences, knowledge, attitudes and (information) needs that GPs have in relation to long COVID and how these evolved since the beginning of the COVID-19 pandemic in 2020. The study is particularly interested in understanding the challenges that long COVID has for the primary health care system and how to best address them. Methods This study was conducted in the framework of the Austrian research project “Cov-FIT”. It used an exploratory qualitative research design. The study investigated infection protection, infrastructure, framework conditions and the treatment of people with and without infectious diseases during the COVID-19 pandemic in family doctor primary care in Austria through semistructured interviews. It was conducted according to the SRQR checklist. The checklist has been added as supplement 1 (S1). Participant recruitment and data collection A total of 30 semistructured interviews with GPs in different primary care settings (single practices, group practices, primary care centres) in Austria were conducted between February and July 2022. All GPs had a contract with social insurance companies and were thus public practices and not private. Physicians were recruited through the Austrian Society of General Practice (ÖGAM) via e-mail information and newsletters and through the research network of the Department of Health Services Research in Primary Care at the Medical University of Vienna (now Department of Primary Care Medicine). Of the 1350 physicians approached, 34 expressed their interest by email. They were contacted by telephone or e-mail. After a description of the topic and an introduction by the research team, their consent to participate in a qualitative interview was obtained. Of these, 4 were lost to follow-up due to time constraints, and 30 returned the consent form and demographic short questionnaire. An interview date was then arranged. Interviews were conducted in person, by telephone or via WebEx. The interviews were recorded using an audiorecorder or the WebEx tool. The duration of the interviews ranged from 26 minutes to 1 hour and 25 minutes. The average length was 56 minutes. None of the respondents dropped out during the interview. It was always a one-to-one setting. No interview was discontinued or repeated. The interviews were conducted by three interviewers, two of whom are coauthors (MM, NS), and the other is mentioned in the acknowledgements. The interview guide was based on the six research questions found in the supplementary material (S2). However, the order of the questions was modified after initial experience acquired through the interviews and subquestions were added. Research questions and interview guide For the research questions of this paper, the research questions regarding Long-COVID were considered relevant (Fig. 1). The other topics will be explored in separate publications. Data analysis The 30 interviews were transcribed verbatim using Tucan software (contract, data protection agreement and data security agreement were concluded). The data were analysed using qualitative content analysis [ 27 ]. The interviews were coded inductively by two researchers independently (SW and MM) and analysed along the research questions using the qualitative content analysis software atlas.ti to ensure reliable and repeatable analysis of the material. The codes were discussed together, and a code book was developed with code names, descriptions, and categories. Relevant quotes from the material were directly cited. A demographic short questionnaire (Supplement S3) was statistically analysed to describe the sample descriptively and to analyse similarities and differences between the primary care organizational forms. Results A total of 30 GPs participated in the study. Participants were recruited from eight of the nine Austrian provinces (all except Salzburg) (Table 1 ). The gender distribution was well balanced, and we included all three types of general practice in Austria. Details are given in Table 1 . Table 1 Interview partners Variable Subvariable N All County Burgenland Carinthia Lower Austria Upper Austria Salzburg Styria Tyrol Vienna Vorarlberg 30 3 1 4 2 0 4 1 13 2 Sex Female Male 15 15 Type of practice Single-handed (1 GP) Group-practice (2 + GPs) PVE 11 11 8 Experiences with and attitudes towards Long-COVID During the interviews on managing COVID in their daily work, the GPs almost never (except for one Interview partner, I12) talked about long COVID without being explicitly asked about it. However, all GPs indicated having experience with long COVID. The range of how often it occurred did vary greatly, although, from a few cases a week or month to patients with long-COVID symptoms on a daily basis. One physician assumed that it occurred in “20 to 25% of all those having had a COVID-19 infection” (I22), and another guessed it was 10% (I23). One-fifth of all interview partners indicated that long COVID-19 occurred only very little. Only rarely. Thinking about it now it was approximately 4 or 5 patients who suffered that much with Long-Covid that I sent them to Medical Specialists. That is not much. (I10) Not every day, but I see long COVID approximately 2–3 times per week. (I20) Only one (I25) indicated that s/he had no case of long COVID in her/his practice, although she/he actually mentions symptoms defined as long COVID in the context of her patients. I don´t think I have real COVID-19 patients. However, I see a lot of patients who truly do suffer over many weeks. A bit of a cough, tired, not very resilient. I am not sure if that can be classified as long already, but people who have a longer healing process. (I25) However, the citation already indicates one of the biggest problems in dealing with long COVID: many of the interviewed GPs had varying understandings of what long COVID was and how long the symptoms were supposed to last to diagnose the patient with long COVID. Some already spoke of long COVID when there were symptoms for approximately four weeks, others guessed six weeks, and others supposed it was eight weeks. Most importantly, almost all GPs took long COVID very seriously because they had seen severe cases of long COVID, and they tried to treat it in a wide variety of ways, usually a combination of physiological and psychological treatment. Some were very proactive and indicated searching for much information on long COVID. Many named the important support of the ÖGAM (Austrian Society for General Practice and Family Medicine), which formulated a guideline on long COVID. Most GPs explained that they took much time to manage their long-COVID patients. They were trying to help in many different ways. How do you deal with it? I am there for my patients all the time, they can come whenever they need and we discuss it over and over. Another point is assessing where further diagnostics are needed. (I24) Only a few (3/30 or 10 percent) downplayed long COVID by saying that they had some patients who believed or pretended to have long COVID, although they did not or by stressing that it was mostly psychosomatic (1) and due to other causes and not due to a COVID infection. Patients who believed they had Long-Covid were patients who suffered from mobbing or burn out before and now believed to have Long-Covid, two GPs argued. It is important to note that even those who were sceptical indicated that they did have a few patients – at least one – who were suffering from “real” COVID-19. Strangely enough, the usual suspects all have long COVID now. Before they had a burn-out or a bullying problem, now they have Long-Covid. There are a few who are truly suffering, yes, thank God there are few. (I11) It is a bit complicated with the Long-Covid patients. Sometimes it is difficult to estimate is it Long-COVID or is the person pretending. It is not always easy to determine where the problem lies. (I27) They are coming with the diagnosis already, “I have Long-COVID” (laughs). They had been to the AKH (university hospital in Vienna) or to an outpatient clinic or whereever. I have a bit of a problem with Long-COVID because I don’t know. It is a bit like chronic fatigue syndrome. (I9) Diagnosing Long-Covid How did the GPs diagnose long COVID, and what were the challenges of diagnosing long COVID at the time of the interviews? It is a very complicated matter, the people are weak, the people are depressed, the people are desperate, the people have the feeling that nobody truly understands or takes them seriously with their problems and the whole thing has a strong psychological layer and we find it very difficult to somehow classify them diagnostically in our existing diagnostic scheme. We do 100 blood tests, 99 of which, except for the vitamin D, are somehow normal, so how do we deal with the situation? (I1) The citation from the GP above illustrates what many interview partners explained in the interviews. Many felt it was very difficult to diagnose COVID-19 because it was always a mix of different factors, and those were different from case to case. It was mostly a combination of physical and psychological aspects yet the biggest problem was that the standard tests to check for the physiological problems (e.g. lung or heart function, neurological functions) hardly brought any results. The GPs often lamented that there were no clear diagnostic parameters and that it was difficult for them to deal with long-COVID or potential long-COVID patients. “There is not truly a lab value” (I1), “You can only diagnose it through thorough case history” (I2), “It is not measurable or tangible” (I3), “It is not tangible yet the people are not well.” (I10) Regarding problems with regard to long-COVID health provision, many indicated that there was not enough space for rehabilitation available and that the waiting times in specific long-COVID outpatient clinics were very long (up to six months at this point in time). Other problems that were mentioned were that the treatment with Vitamin C infusions and other treatments were not refunded from the social insurance, but the patient had to pay privately, and that sometimes there were problems with the social insurance in relation to sick-leaves: as many sick-leaves for Long-COVID had a longer duration, it happened that social insurance would end the sick-leaves automatically and the GP would have to call the insurance to change that again. A few physicians said that the guideline from the ÖGAM was too long (approximately 50 pages) and that it was not applicable for a GP to go through 50 pages every time they suspected COVID-19. Another problem was that at the time of the interviews, the definition of long COVID was not clear to many physicians. Additionally, the difference between post-COVID and long COVID was not clear for some and was often used synonymously. Nonetheless, the physicians spontaneously named a wide range of symptoms as a basis for applying a long-COVID diagnosis (oder in frequency of mentions) (Fig. 2). Other physicians, however, relied on parameters from the blood count, but which ones were not explicitly mentioned except for saying they made a large blood count. The majority of GPs said that they would not diagnose COVID-19 only by themselves but that it was a cooperation between different professions. Only one GP mentioned that it was him/her only who provided treatment because s/he was in a very rural place with no access to other medical specialties. Most interview partners indicated that when they had a patient where they suspected Long-Covid, they would send the patient to different specialists to do a medical checkup. Many also indicated that they would work with psychologists or psychotherapists to check the mental health aspects of the patient because depression was also a symptom of long COVID, and many patients also had problems dealing with the new and problematic situation that long COVID produced for them. Doctors from rural areas sometimes mentioned that there was a lack of capacity in specialist care. Some specifically indicated that they used the questionnaire from the ÖGAM (Austrian Society for General Practice and Family Medicine) to help with the long-COVID diagnosis (4/30). Other GPs said they would record the case history and, according to the results, send their patients to respective specialists. Some, especially those who work in PVE or cooperate closely with other medical professions in their practice, stressed that they diagnosed COVID-19 together within their teams. Mostly it is tiredness, lower resilience in the sense that there's often a bit of shortness of breath and cardiac symptoms, so if that is the case, then I arrange for a corresponding specialist examination,... Yes, but I have to say that nothing has truly come out for the patients I'm treating. (I10) The problem the physician (I10) mentioned in the above citation is a common problem among the interviewed physicians: In many cases, the GPs would send their patients to pulmonologists or cardiologists, but there were no significant results from the specialist examinations. This was also one reason for some GPs to wait slightly longer before sending their patients to specialists. One other physician, for example, stressed that their job as a GP was to talk extensively with patients and to accompany the patients through the process. Many physicians reported that in the case of long COVID, it was the patients who came to the physician with the assumption to have long COVID. Most physicians were fine with that proactive behavior; only two indicated that it was a problem and explained that they were the ones who did the diagnosis and not the patients themselves. When people come to my practice and say they have long COVID, I send them away. I make the diagnosis not them. (I11) On the other hand, some GPs also wished for more adequate information to be circulated via the media in order for people to know more about it. One GP (I25) spoke about the important role and responsibility of different media outlets for informing about long COVID and about informing about the effects that a COVID-19 infection can have on a person. For example, it was normal to feel weak for some weeks after an infection. The GP felt that the media could provide more and better information about COVID-19. It would help the GPs to have better informed patients. Treatment/Therapy of Long-Covid How do GPs treat long COVID? The GPs often stressed that they made a very individual therapy plan according to the symptoms of the patient because each patient with COVID-19 had different symptoms. As physiological treatment methods, the following were mentioned : infusions (especially vitamin C, then zinc), vitamin D substitution and special long-COVID rehabilitation are the most commonly mentioned, together with physiotherapy. The importance of the rehabilitation possibilities - some where the patient could go during the day or even part time rehab/part time work and others where the patient would go to a rehab for a few weeks - was often mentioned as one of the most efficient treatments, and at the same time, it was stressed that more places were needed in order for less waiting times. Other treatments that GPs mentioned were lung spray, Vitamin C in drug form, giving Covid-19 vaccine for those who have no vaccine yet, Cortisone, antihistamine, massages, and electrolytes. As psychological treatment, they named fewer things than the physiological treatments : long COVID-19 groups, psychotherapy, seeing a social worker, going to a psychiatric clinic/prescribing drugs against depression. In addition to the abovementioned treatments, which many GPs said were often not enough, many saw that their role was a lot about raising awareness, talking and accompanying and motivating the patients as well as prescribing sick leaves. The important thing is to give the people a vision, how their life will be different – because it will be different for someone with long COVID – but how they can still manage to have a certain quality of life and help them learn to deal with it. (I13) […] However, of course, they are desperate; when a young father sits in front of you and says, "I'm taking care of my two little children then I have to lie down and I just cannot do anything anymore.“ [...] Then, you cannot do much more than sit with them for a long time, somehow persuade them to take the time, telling them that it affects many, that it will most likely get better again and just try to find a place for them for rehabilitation. On the one hand, this is time-consuming, and on the other hand, I have to say that it truly gets to me.” (I16) From the last citation of participant I16, we learn that the support of long-COVID patients can be difficult for GPs. Often, the patients are desperate, and it is difficult for the GP to handle the situation, as the major problem is that there is not a single treatment for COVID-19 that helps, but it is a time-intensive and very individual treatment that can be emotionally stressful for both the patient and the GP. Support (needs) What was striking about the answer of if the GPs would wish for more support in the case of Long-COVID was that the answers were very diverse. Some said they had a very good support network around them, and others said they had no support and had to search for all information on the topic by themselves. GPs in the city tended to have more access to resources such as specialists and rehabilitation; on the other hand, there were also other regions that were more rural, such as Vorarlberg in the very western part of Austria, where GPs also seemed to be well connected. In other regions, it seemed to be lower, for example, in Corinthia. The knowledge of where to find support seemed to be very diverse among GPs: We did not truly get support. However, I would say that family physicians are used to that. (I21) We have our information from the ÖGAM, and there are already trainings on Long-COVID. I believe every colleague has to look out for it and be active. There are offers for example the Billroth Gesellschaft, the Wiener Gesellschaft für Allgemeinmedizin has a training on Long-Covid for example, it is even online, hybrid. (I2) Support for the GPs The work of ÖGAM (Austrian Society for General Practice and Family Medicine) was mentioned several times as helpful and supportive with regard to the topic of long COVID. Both its guidelines on the diagnosis of COVID-19 and the training offered in the field were mentioned positively. However, it was mentioned that the guidelines were very extensive, which limited their practicability in the everyday work of general practitioners. It was also mentioned that the ÖGAM was facilitating the research on Long-Covid by giving an overview of recent studies in the field and providing summaries. To read existing studies and summarize and interpret. That is work that is done for me (by the ÖGAM). (I24) The outpatient clinic for Long-Covid in Vienna was mentioned a few times as very useful with the negative additional info that there were already long waiting times. A few GPs explained that they did not need any support and that they did the research themselves. One GP I30) spoke of a tool for clearing the long-COVID diagnosis that had been promised by the Austrian Medical Association Ärztekammer but which s/he was still waiting for. Apparently there is a system (from the Ärztekammer) to get refunded for Long-Covid diagnostics, but I have never seen that tool or I have not found it thus far. (I30) Discussion Overall, this study provides insight into the experience, lessons learned, and challenges of GPs in the public health system with an emerging disease from which an increasing number of people are and will be affected. This is the first study that empirically investigates long-COVID management by GPs in a country with a Bismarck healthcare model in place (based on social insurance contributions). The study shows that even in year three of the COVID-19 pandemic, there are still many challenges to attend to, and support has to be scaled up everywhere. In addition, there are regional differences regarding long-term COVID support. In cities, GPs tend to have slightly better networks with specialists; for example, in Corinthia, GPs, especially in more rural places, would need much more support. The GPs who already worked in teams tended to find the management of COVID-19 easier. Frequency and definition Physicians' reporting of how many long-COVID patients they saw varied from 20–25% of COVID-19-infected patients to hardly any patients with long-COVID. This leads immediately to an important issue, the definition of long COVID. At the beginning of 2022, when the study was conducted, the NICE and WHO definitions were already in place but obviously not very well known. However, even the two definitions of the WHO [ 28 – 30 ] and NICE [ 2 , 31 ] differ in nuances from each other. This gap is fundamentally a challenge for science with respect to long COVID, but of course, particularly in regard to diagnostics, diagnosis and coding/recording of diagnoses [ 4 ]. Reviews of the incidence of long COVID from this period concluded an incidence of 10–35% in mildly ill persons [ 32 ]. Later reviews continue to suggest an overall incidence of 10–30% of all SARS-CoV-2-infected persons when vaccinated beforehand [ 14 , 15 ]. The risk appears to be reduced in the fully vaccinated and for the Omicron variant, but probably not for neurological symptoms [ 33 , 34 ]. The fact that some GPs stated that they saw only a few long-COVID patients may be because the symptoms described by the patients were not related to the postviral context of the GPs [ 35 ]. Symptoms and diagnostics Most primary care physicians interviewed stated that they took COVID-19 seriously because they had seen severe courses of COVID-19 and therefore knew what COVID-19 could do to the human body. The symptoms that the physicians described and listed as long-COVID symptoms corresponded very closely to those described in the international literature [ 14 ]. However, the question arises whether post-COVID syndromes such as the now known PostExertinal-Malaise (PEM) [ 14 , 15 , 17 , 36 ], autonomic dysfunction such as postural tachycardia syndrome (POTS) [ 37 – 39 ] or Mast-Cell-Overactivation-Syndrom (MCAS) [ 40 , 41 ], and cognitive dysfunction [ 10 , 42 ] are also recognized and correctly classified, since they were never mentioned by the GPs. In particular, these can hardly be detected by standard diagnostic methods [ 36 ]. Specific examinations are often not yet known or not paid for by health insurance companies or not yet available [ 18 ]. To date, postinfectious syndromes such as post-COVID syndrome have received little attention in medicine. ME/CFS, as the most severe course of a postinfectious syndrome, has been a neglected disease since 1969, when it was recognized by the WHO. Long-COVID could highly benefit from research on the diagnosis and treatment of, for example, ME/CFS, as many symptoms overlap, and it would also be important to transmit this knowledge in long-COVID educational activities for primary health professions. Additionally, ME/CFS is particularly interesting in terms of patient involvement, as many patients are very active in raising awareness and in self-help online groups [ 8 , 14 , 17 ]. In particular, the differentiation of psychiatric diseases such as depression or burnout syndrome was difficult for the GPs because existing tools were either not yet known (e.g., PEM questionnaire [ 43 ] or Schellong test) or fast to perform official biomarkers are still missing [ 14 , 15 ]. In addition, it must also be taken into account that SARS-CoV-2 can simultaneously lead to the occurrence of long COVID with PEM and to a worsening of, for example, latently existing depression, and this must both be recognized and not mixed in terms of further treatment steps. Until diagnostic tests are well developed, it will remain a challenge to fully differentiate long COVID from other diseases that have symptom overlap [ 14 , 36 , 44 ]. Patients often bring up this diagnosis by themselves. Most physicians feel fine with this; however, some physicians are ambivalent or negative about it. Interestingly, GPs who are offended by patients bringing up the possible diagnosis by themselves are also more skeptical about COVID-19 as a condition in general. There are studies indicating that people who already belong to marginalized groups in general have more difficulties being taken seriously by healthcare workers [ 45 , 46 ]. There is a danger of stigma and double stigma: of being stigmatized because the illness is not taken seriously and in addition the person is not taken seriously because s/he belongs to a marginalized group (e.g., ethnic or sexual minority, socioeconomically deprived). Therefore, it is even more important for COVID-19 patients to find an empathic, understanding GP who understands the needs of the person [ 35 ]. Further education programmes should therefore also include the objective to counter possible long-COVID stigma. Health workers should be aware of that stigma, as it can impact how (much) COVID-19 patients seek help in the health system and how they are being treated [ 4 , 35 ]. Several studies suggest that patients lack empathy and compassion from their GPs and that marginalized people are seeking less help in the public health system for fear of being discriminated against and not being taken seriously [ 47 – 50 ]. Our study shows that adequate training for health workers on long COVID is indeed important; however, what we understood through the study is that further education trainings, even if they exist, are only taken up by some GPs. Hence, it would be important to disseminate information and trainings widely and try out different channels of information to target a large array of health workers. A study among physiotherapists in Austria, for example, found that most physiotherapy students wished for an adaptation of academic curricula due to the pandemic and resulting long COVID to be able to adequately treat it [ 51 ]. In line with the challenges described above, diagnosis is described by the interviewees across the board as time-consuming. In addition, there is a lack of support from specialists and specific contact points, such as long-COVID outpatient clinics, where postinfectious syndromes such as long-COVID can be further cared for. Specialist appointments for clarification of possible organ damage are very difficult to obtain and only with long waiting times, and the few public long-COVID outpatient clinics already had waiting times of 6–12 months in the first half of 2022. These problems are also known in other countries [ 52 ]. In contrast, physicians described the Austrian guideline on Long-Covid of the ÖGAM very positively and supportively. However, the time issue was also addressed here. Consultation time in a public Austrian general practitioner's office averages five minutes, which does not fit well with the occurrence of a new complex disease, especially without rapid biomarkers and causal therapies. Treatment and support In terms of treatment, physicians communicated to their patients the prevailing information at the time that most symptoms would go away on their own after a few weeks or at least a few months. In addition, an increasing number of studies have shown that approximately 20–30% of affected patients still have symptoms after two years [ 7 – 13 ]. Some studies even show that in approximately 5% of infected patients, the symptoms have even worsened after two years [ 12 , 13 , 16 , 53 ]. Due to the symptoms described in the Dutch study, which tend to worsen, as well as the main symptoms still existing after two years, it is reasonable to assume that the affected persons are mainly persons with long COVID with PEM, which is now also referred to as post-COVID syndrome of the ME/CFS type [ 17 ]. The primary care physicians see above all the great burden on the patients, especially with regard to their ability to work, the loss of quality of life and the increasing functional limitations in everyday life. Not being able to help adequately is also described by the GPs as very stressful. With this problem, the GPs feel left alone. GPs in the city tended to have more access to resources, especially to medical specialists. However, in general, we found that regardless of whether they were in urban or rural places, the GPs tended to be better equipped to handle long-COVID patients when they already worked in teams with different health professions (e.g., in PVEs). It is important to note that in the first half of 2022, which is when the interviews took place, there were no official recommendations of suitable therapy attempts for COVID-19. GPs often attempt to alleviate the disease by means of additional administration through dietary supplements. This approach, as is now known, is probably not wrong, as studies on dietary supplements, especially Vit C, coenzyme Q10 and probiotica, indicate [ 54 – 58 ]. Additionally, antihistamines [ 14 , 15 , 17 , 19 , 20 ] might be of benefit for mast cell activation syndrome (MCAS) as well as electrolytes for POTS. Social support as well as psychotherapy [ 59 ] to be better able to deal with the burden of the disease are now known to be effective for certain long-COVID symptoms. However, what we know as of today is that the recommendation of exercise therapy without the knowledge of PEM in long COVID can be potentially damaging. When PEM is present, it is of high importance to stabilize the condition of the patent with pacing first; otherwise, the patient runs the risk of deteriorating her/his condition. In terms of therapy, GPs also lacked contact and knowledge about specific health personnel familiar with postinfectious syndromes and who could initiate off-label therapy trials or would have access to ongoing therapy studies. The few existing public long-COVID outpatient clinics were mostly affiliated with specific medical specialties, such as cardiology, pulmonology, or neurology. As a result, patients with long COVID could usually not be comprehensively helped here either, since the diagnostic options were limited to only one specialty, but postinfectious syndromes must be considered and treated across disciplines. It would therefore be of the utmost importance to create specific and multidisciplinary medical contact points for postinfectious syndromes, in which both medical staff and health and social professionals work on site, telemedically and through home visits. This is where primary care physicians could refer patients when a refractory postinfectious syndrome such as long COVID is diagnosed. The same applies to rehabilitation offers. Many GPs explained in the interviews that it was rehabilitation offers that were the most effective against COVID-19 (without PEM). Public funding for both specific outpatient clinics and rehabilitation possibilities should be increased to reduce the burden on both the patients and primary health care settings. Referral to outpatient assessments and clinics has been recommended in several countries [ 60 ]. Strengths and limitations This is the first qualitative study investigating the experiences and needs of GPs regarding long COVID-19 in a country with a Bismarck health care system. As the aim of the study was to gain an in-depth understanding of the experiences of GPs with long COVID, a qualitative study was the right choice. However, a representative quantitative survey on the experiences and needs of GPs in relation to long COVID would be important as a further study – especially given that in our sample – although only a few – they were GPs who did not take long COVID seriously. With a larger sample, it would become clearer how many GPs would potentially need more information on long COVID to treat their patients correctly. Furthermore, the study includes interviews in all Austrian regions except for one, all organizational forms in which GPs work in Austria (single-practice, group practice, and primary care facility (PVE) as well as a gender balance of interview partners. One limitation of the data collection is that it took place in the first half of 2022 – during the Omicron BA1 and 2 COVID-19 waves when cases in Austria were extremely high and the workload for GPs was disproportionately high as well. Therefore, it is possible that the GPs who participated in the study were already quite interested in the topic of long COVID and generally engaged in research activities. On the other hand, the themes of the interviews were not limited to COVID-19 and were related to the management of the pandemic in general. Therefore, it also spoke to GPs who were not particularly interested in the topic of Long-COVID. Another limitation is that when the study took place, knowledge on long COVID in Austria was still relatively scarce, with the ÖGAM guidelines coming out in December 2021. However, there have not been considerable changes between 2022 and 2023, and many aspects are still unclear in terms of diagnosis and treatment. Conclusion COVID-19 will continue to preoccupy our health care systems for a long time to come, as new variants without prevention strategies will continue to produce new patients. Therefore, it is not a question of if, but when and how good care pathways for people with COVID-19 will be implemented and when primary care physicians as first contact for diagnostics and care will be adequately equipped. Diagnostic tools, payment schemes other than fee-for service and adequate training are needed, as well as specific points of contact for patients with postinfectious syndromes, including ME/CFS (including multidisciplinary teams, telemedicine, home visits) and patient-centred rehabilitation, with a focus on PEM. Training for healthcare workers should be disseminated in various ways and channels to reach many or most GPs who seem to have diverse support needs. The most important aspect in addition to diagnosis and treatment, however, should be to prevent any new cases. Abbreviations EXPH – Expert Panel on effective ways of investing in health GP – General practitioner ME/CFS – Myalgic encephalomyelitis/chronic fatigue syndrome NICE – National Institute for Health and Care Excellence ÖGAM – Österreichische Gesellschaft für Allgemeinmedizin PASC – Postacute Sequelae of SARS-CoV-2 Infection PVE – Primärversorgungseinheit POTS – Postural Tachycardia Syndrome PEM – Post Exertional Malaise WHO – World Health Organization Declarations Ethics approval and consent to participate The research team guarantees that the project was conducted in accordance with the Declaration of Helsinki (1964) and all subsequent updates of the Declaration. The team is responsible for ensuring that the project is conducted in accordance with the European Commission's "Guidelines of Good Clinical Practice", national requirements and the requirements of the Medical University of Vienna. All study protocols were approved by the Ethics Committee from the Medical University of Vienna; a positive vote for the study from the Ethics Committee of the Medical University of Vienna is available (EC no.: 1491/2021). For all interviews, a written informed consent form and a written agreement to maintain anonymity and data protection were signed by the participants after they were informed in detail about the study. Consent for publication Not applicable Availability of data and materials The data collected and analysed during the current study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests. Funding The CovFIT study was funded by the scientic-medical fund of the mayor of the capital of Vienna. The funding authority had no influence in the conception, design, analysis and interpretation of the study and related data and had no inuence in the writing of this publication. Authors' contributions The research study conceptualized KH. MM and NS conducted the research. The article was conceptualized by SW and KH. Data were formally analysed by SW and MM. The original draft was written by SW and KH. Review and editing were conducted by SW with MM, NS and KH. All authors agreed on the final version of the manuscript. Acknowledgements We would like to thank Constanze Teuschl for support in the recruitment and interviewing of some of the participants. Authors information S Wojczewski is a postdoctoral researcher at the Department of Primary Care Medicine at the Medical University of Vienna, Austria. She holds a PhD in Social and Cultural Anthropology from the University of Lausanne. M Mayrhofer is a postdoctoral researcher at the Department of Primary Care Medicine at the Medical University of Vienna, Vienna, Austria. She holds a PhD in journalism and communication studies and is manager of a primary care centre in Vienna, Austria. N Szabo is a student of law with a focus on medical aspects of the legal process. In addition, she has been assisting the Department of Primary Care Medicine in conducting studies for some time and has thus gained good knowledge and practice in qualitative research. K Hoffmann has a full professorship in Primary Care Medicine and chairs the Department of Primary Care Medicine at the Medical University of Vienna, Austria. Additionally, she is MD, Master of Public Health and General Practitioner. References NICE, COVID-19 rapid guideline: managing the long-term effects of COVID-19 , National Institute for Health and Care Excellence (NICE), Editor. 2022. NICE, COVID-19 rapid guideline: managing the long-term effects of COVID-19 , Guidelines, Editor. 2020, National Institute for Health and Care Excellence (NICE): London. Soriano, J.B., et al., A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis, 2022. 22 (4): p. e102-e107. 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Sustain Cities Soc, 2020. 62 : p. 102418. Moshammer, H., M. Poteser, and L. Weitensfelder, COVID-19: Regional Differences in Austria. Int J Environ Res Public Health, 2022. 19 (3). Schaffler-Schaden, D., et al., COVI-Prim Longitudinal Survey: Experiences of Primary Care Physicians During the Early Phase of the COVID-19 Pandemic. Front Med (Lausanne), 2022. 9 : p. 761283. Siebenhofer, A., et al., COVI-Prim survey: Challenges for Austrian and German general practitioners during initial phase of COVID-19. PLoS One, 2021. 16 (6): p. e0251736. Mayring, P. Qualitative content analysis: Demarcation, varieties, developments . in Forum: Qualitative Social Research . 2019. Freie Universität Berlin. Soriano, J.B., et al., A clinical case definition of post-COVID-19 condition by a Delphi consensus. The Lancet Infectious Diseases, 2022. 22 (4): p. e102-e107. WHO A clinical case definition of post COVID-19 condition by a Delphi consensus . World Health Organization. 2021. WHO, Clinical management of COVID-19: living guideline . World Health Organization. 2023. NICE, COVID-19 rapid guideline: managing the long- term effects of COVID-19 , N.I.f.H.a.C. Excellence, Editor. 2022. van Kessel, S.A.M., et al., Post acute and long-COVID-19 symptoms in patients with mild diseases: a systematic review. Family Practice, 2021. 39 (1): p. 159-167. Percze, A.R., et al., Fatigue, sleepiness and sleep quality are SARS-CoV-2 variant independent in patients with long COVID symptoms. Inflammopharmacology, 2023. Taquet, M., et al., Neurological and psychiatric risk trajectories after SARS-CoV-2 infection: an analysis of 2-year retrospective cohort studies including 1 284 437 patients. The Lancet Psychiatry, 2022. 9 (10): p. 815-827. Kingstone, T., et al., Finding the 'right' GP: a qualitative study of the experiences of people with long-COVID. BJGP Open, 2020. 4 (5): p. bjgpopen20X101143. Iwasaki, A. and D. Putrino, Why we need a deeper understanding of the pathophysiology of long COVID. Lancet Infect Dis, 2023. 23 (4): p. 393-395. Blitshteyn, S., et al., Multi‐disciplinary collaborative consensus guidance statement on the assessment and treatment of autonomic dysfunction in patients with post‐acute sequelae of SARS‐CoV‐2 infection (PASC). PM&R, 2022. 14 (10): p. 1270-1291. El-Rhermoul, F.-Z., et al., Autoimmunity in Long Covid and POTS. Oxford Open Immunology, 2023. 4 (1): p. iqad002. Fedorowski, A. and R. Sutton, Autonomic dysfunction and postural orthostatic tachycardia syndrome in postacute COVID-19 syndrome. Nature Reviews Cardiology, 2023. 20 (5): p. 281-282. Weinstock, L.B., et al., Mast cell activation symptoms are prevalent in Long-COVID. International Journal of Infectious Diseases, 2021. 112 : p. 217-226. Wechsler, J.B., et al., Mast cell activation is associated with post‐acute COVID‐19 syndrome. Allergy, 2022. 77 (4): p. 1288. Zhou, T., et al., Internal tremors and vibrations in long COVID: a cross-sectional study. medRxiv, 2023: p. 2023.06.19.23291598. Cotler, J., et al., A brief questionnaire to assess postexertional malaise. Diagnostics, 2018. 8 (3): p. 66. Morgan, J., Long COVID? What is that? The Lancet Respiratory Medicine, 2023. 11 (6): p. 515-517. Nyblade, L., et al., Stigma in health facilities: why it matters and how we can change it. BMC Medicine, 2019. 17 (1): p. 25. Henderson, C., et al., Mental health-related stigma in health care and mental health-care settings. The Lancet Psychiatry, 2014. 1 (6): p. 467-482. Buja, A., et al., Why do patients change their general practitioner? Suggestions on corrective actions. Irish Journal of Medical Science, 2011. 180 (1): p. 149-154. Luras, H., The association between patient shortage and patient satisfaction with general practitioners. Scandinavian Journal of Primary Health Care, 2007. 25 (3): p. 133-139. McManimen, S.L., M.L. Sunnquist, and L.A. Jason, Deconstructing postexertional malaise: An exploratory factor analysis. J Health Psychol, 2019. 24 (2): p. 188-198. Froehlich, L., et al., Causal attributions and perceived stigma for myalgic encephalomyelitis/chronic fatigue syndrome. Journal of Health Psychology, 2022. 27 (10): p. 2291-2304. Scheiber, B., et al., Post-COVID-19 Rehabilitation: Perception and Experience of Austrian Physiotherapists and Physiotherapy Students. Int J Environ Res Public Health, 2021. 18 (16). Macpherson, K., et al., Experiences of living with long COVID and of accessing healthcare services: a qualitative systematic review. BMJ Open, 2022. 12 (1): p. e050979. Ballouz, T., et al., Recovery and symptom trajectories up to two years after SARS-CoV-2 infection: population based, longitudinal cohort study. Bmj, 2023. 381 : p. e074425. Naureen, Z., et al., Proposal of a food supplement for the management of post-COVID syndrome. Eur Rev Med Pharmacol Sci, 2021. 25 (1 Suppl): p. 67-73. Castro-Marrero, J., et al., Does Coenzyme Q10 Plus Selenium Supplementation Ameliorate Clinical Outcomes by Modulating Oxidative Stress and Inflammation in Individuals with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome? Antioxid Redox Signal, 2022. 36 (10-12): p. 729-739. Barletta, M.A., et al., Coenzyme Q10 + alpha lipoic acid for chronic COVID syndrome. Clin Exp Med, 2023. 23 (3): p. 667-678. Vollbracht, C. and K. Kraft, Feasibility of Vitamin C in the Treatment of Post Viral Fatigue with Focus on Long COVID, Based on a Systematic Review of IV Vitamin C on Fatigue. Nutrients, 2021. 13 (4). Rathi, A., S.B. Jadhav, and N. Shah, A Randomized Controlled Trial of the Efficacy of Systemic Enzymes and Probiotics in the Resolution of Post-COVID Fatigue. Medicines (Basel), 2021. 8 (9). Grande, T., et al., The Role of Psychotherapy in the Care of Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Medicina (Kaunas), 2023. 59 (4). Wolf, S. and J. Erdos, Long COVID care pathways: a systematic review. 2021. Footnotes https://www.longcovidaustria.at/wichtige-anlaufstellen-fuer-betroffene/ (20.08.2023 https://www.kl.ac.at/de/allgemeine-gesundheitsstudien/long-covid-leitlinie (24.08.2023) Additional Declarations No competing interests reported. Supplementary Files S1SRQRchecklist190923.docx S2Interviewguideenglishgerman190923.docx S3Shortdemographicquestionnaire190923.docx Cite Share Download PDF Status: Published Journal Publication published 07 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 05 Sep, 2024 Reviews received at journal 04 Sep, 2024 Reviewers agreed at journal 06 Aug, 2024 Reviews received at journal 09 Nov, 2023 Reviewers agreed at journal 27 Oct, 2023 Reviewers invited by journal 25 Oct, 2023 Editor assigned by journal 25 Oct, 2023 Editor invited by journal 20 Sep, 2023 Submission checks completed at journal 20 Sep, 2023 First submitted to journal 29 Aug, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Perceptions and experiences of GPs with Long COVID in year three of the pandemic. A qualitative study in Austria.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAfter the COVID-19 pandemic, there is a new global health challenge to tackle: long COVID. Long-COVID describes a multisystemic illness present 30 or more days after a COVID-19 infection [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The term has been coined by patients and is the one that is most widely used. Other more medically accurate terms to designate the chronic condition have emerged, such as \u0026ldquo;postacute sequelae of SARS-CoV-2 infection (PASC)\u0026rdquo; or the definition the NICE rapid guideline used since December 2020: It differentiates between ongoing symptomatic COVID-19 and \u0026ldquo;post COVID-19 syndrome\u0026rdquo;, which describes signs and symptoms that develop during or after an infection consistent with SARS-CoV-2, continue for more than 12 weeks and are not explained by an alternative diagnosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Similarly, the WHO formulated their definition in October 2021 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. More than 200 symptoms have been reported by patients thus far, yet the most commonly reported are fatigue, shortness of breath, headache, cognitive dysfunction, muscle aches, palpitations, chest pain, dizziness and sleep disturbance [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The illness can have a strong negative impact on quality of life, with patients indicating little or no improvement in long-term COVID symptoms as long as two years after their initial COVID-19 infection [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The percentage of people affected by long COVID globally varies, yet studies imply that at least 10% of people who were infected with COVID-19 develop long COVID symptoms or 3% of the overall population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. COVID-19 is a major new multisectoral healthcare challenge, and thus far, it is not known what impact it will continue to have. This is also because there are no reliable data on long-COVID prevalence in the different COVID-19 subvariants. There are studies showing that long-COVID cases and symptoms vary by wave and that there have been more cases in the first waves due to no or low vaccination. However, new studies with cohorts in the USA, UK and the Netherlands show that there might be a higher risk of developing long-term COVID symptoms after reinfections with COVID-19 [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. There are other cases of postinfectious diseases causing long-term symptoms, such as post-SARS. However, there are also many similarities with other medically understudied conditions, such as ME/CFS (which a subgroup of long-COVID patients with PEM - postpost-exertional malaise develops). Much could be learned from including these medical conditions in comparative research [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSymptoms affect many different organs and physiological pathways, can be interrelated and all need to be studied more profoundly. The symptoms can be clustered into systems: they can affect neurological and cognitive, cardiovascular, gastrointestinal, dermatological and respiratory/pulmonary systems [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Impacts can also be on the reproductive system with effects, for example, on menstruation, yet sex-specific pathophysiology has to be studied in more detail. To date, different pathways are being explored to understand the mechanisms underlying long COVID: for example, organ damage in targeted tissue, a persistent virus reservoir, reactivation of Epstein‒Barr or herpes viruses, autoimmunity or mast cell activation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Most patients with self-reported long COVID were not hospitalized due to their SARS-CoV-2 infection and only had mild symptoms of the infection itself. New studies indicate that people at higher risk are women, people aged 35 to 69, socioeconomically deprived people, people working in social care, people belonging to ethnic minorities, and people with other activity-limiting illnesses [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Studies also found that long COVID impacts children of all ages [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe WHO recommends three aspects for managing COVID-19 that can also be applied to long COVID-19: \u0026ldquo;multidisciplinary rehabilitation teams, continuity and coordination of care and people-centred care as well as shared decision-making\u0026rdquo; (4:38). The Expert Panel on effective ways of investing in health from the European Commission (EXPH) further recommends that long COVID should be coordinated by the primary care sector. GPs have a central role in diagnosing, managing and coordinating diagnosis and treatment with other primary healthcare personnel as well as medical specialists for postinfectious diseases. However, to guarantee the quality and continuity of care, the challenges for primary health care should be well documented and addressed.\u003c/p\u003e\n\u003ch3\u003eLong-COVID and the Austrian health care system\u003c/h3\u003e\n\u003cp\u003eBy the end of June 2023, there will be approximately 6.08\u0026nbsp;million cases of documented SARS-CoV-2 infections, and 22.500 people will die from COVID-related causes in Austria [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Only 56% of the Austrian population received the full immunization (three doses), which is low compared to other European countries, such as Spain or Portugal. Among European countries, sociodemographic factors in Austria impacted COVID-19 cases and death numbers more than in other countries [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSingle or group practices of GPs and very few primary healthcare centers (PVEs), where different primary health care professions work together, are the first contact point for COVID-19 as well as long-COVID-19 patients. During the COVID-19 pandemic, GPs and primary care workers at first had a difficult time adapting to the pandemic challenges because they were partly left alone from the government, which focused primarily on the hospital setting and its challenges. However, after a difficult beginning with lack of equipment and information, they mostly adapted quickly [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In Austria, physicians in the ambulatory sector are mainly self-employed and can either work with a contract with the public social health insurance system (\u003cem\u003eKassen\u0026auml;rztin/-arzt\u003c/em\u003e) or open a private practice (\u003cem\u003eWahl\u0026auml;rztin/-arzt\u003c/em\u003e). In the first case, patient costs are almost entirely covered by social insurance (patients have a social insurance card (e-card) that they have to show at the appointment), and in the latter case, patients must pay for the services and are only partly refunded by social insurance. The predominant payment scheme is fee-for-service, which leads to high patient frequencies and short consultation rates.\u003c/p\u003e \u003cp\u003eSince the end of 2021/2022, in Austria, there have been very few specific long-COVID outpatient clinics. However, most of them specialize in mono-specialty aspects, such as pulmonary or neurological aspects, which are not useful in the treatment of complex postinfectious syndromes, where the medical knowledge of several disciplines is needed. As a result, they are closing again. No specific medical contact point for postinfectious diseases has been established. A webpage of Long-Covid Austria as well as the Austrian Society of ME/CFS where one can find information on where to seek help managed by patient initiatives\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e and several rehabilitation spots have been created for Long-Covid patients, however exclusively for Long-Covid patients without PEM with one or two exceptions. Thus, long-COVID patients are usually directed towards their family physician who is responsible for managing and coordinating long-COVID \u0026ndash; referring to specialists and laboratories for tests as well as referring to several other health professionals for treatment, such as physio-, ergo- or psychotherapists, dieticiants and others.\u003c/p\u003e \u003cp\u003eTherefore, the Austrian Society of General Practice (\u0026Ouml;sterreichische Gesellschaft f\u0026uuml;r Allgemein- und Familienmedizin, \u0026Ouml;GAM) worked out an S1 Long-Covid guideline together with seven other Austrian medical societies that was published in December 2021[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and has been updated in 2023 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It is directed towards primary health services in Austria and is supposed to be a helpful and practical tool that is also available via an easy-to-use webtool\u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eThis study will contribute to research on long COVID. It aims to understand the experiences, knowledge, attitudes and (information) needs that GPs have in relation to long COVID and how these evolved since the beginning of the COVID-19 pandemic in 2020. The study is particularly interested in understanding the challenges that long COVID has for the primary health care system and how to best address them.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was conducted in the framework of the Austrian research project \u0026ldquo;Cov-FIT\u0026rdquo;. It used an exploratory qualitative research design. The study investigated infection protection, infrastructure, framework conditions and the treatment of people with and without infectious diseases during the COVID-19 pandemic in family doctor primary care in Austria through semistructured interviews. It was conducted according to the SRQR checklist. The checklist has been added as supplement 1 (S1).\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003eParticipant recruitment and data collection\u003c/h2\u003e\n \u003cp\u003eA total of 30 semistructured interviews with GPs in different primary care settings (single practices, group practices, primary care centres) in Austria were conducted between February and July 2022. All GPs had a contract with social insurance companies and were thus public practices and not private. Physicians were recruited through the Austrian Society of General Practice (\u0026Ouml;GAM) via e-mail information and newsletters and through the research network of the Department of Health Services Research in Primary Care at the Medical University of Vienna (now Department of Primary Care Medicine). Of the 1350 physicians approached, 34 expressed their interest by email. They were contacted by telephone or e-mail. After a description of the topic and an introduction by the research team, their consent to participate in a qualitative interview was obtained. Of these, 4 were lost to follow-up due to time constraints, and 30 returned the consent form and demographic short questionnaire. An interview date was then arranged.\u003c/p\u003e\n \u003cp\u003eInterviews were conducted in person, by telephone or via WebEx. The interviews were recorded using an audiorecorder or the WebEx tool. The duration of the interviews ranged from 26 minutes to 1 hour and 25 minutes. The average length was 56 minutes. None of the respondents dropped out during the interview. It was always a one-to-one setting. No interview was discontinued or repeated. The interviews were conducted by three interviewers, two of whom are coauthors (MM, NS), and the other is mentioned in the acknowledgements. The interview guide was based on the six research questions found in the supplementary material (S2). However, the order of the questions was modified after initial experience acquired through the interviews and subquestions were added.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003eResearch questions and interview guide\u003c/h2\u003e\n \u003cp\u003eFor the research questions of this paper, the research questions regarding Long-COVID were considered relevant (Fig. 1). The other topics will be explored in separate publications.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eThe 30 interviews were transcribed verbatim using Tucan software (contract, data protection agreement and data security agreement were concluded). The data were analysed using qualitative content analysis [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. The interviews were coded inductively by two researchers independently (SW and MM) and analysed along the research questions using the qualitative content analysis software atlas.ti to ensure reliable and repeatable analysis of the material. The codes were discussed together, and a code book was developed with code names, descriptions, and categories. Relevant quotes from the material were directly cited. A demographic short questionnaire (Supplement S3) was statistically analysed to describe the sample descriptively and to analyse similarities and differences between the primary care organizational forms.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 30 GPs participated in the study. Participants were recruited from eight of the nine Austrian provinces (all except Salzburg) (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The gender distribution was well balanced, and we included all three types of general practice in Austria. Details are given in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eInterview partners\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSubvariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eN\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll\u003c/p\u003e\n \u003cp\u003eCounty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBurgenland\u003c/p\u003e\n \u003cp\u003eCarinthia\u003c/p\u003e\n \u003cp\u003eLower Austria\u003c/p\u003e\n \u003cp\u003eUpper Austria\u003c/p\u003e\n \u003cp\u003eSalzburg\u003c/p\u003e\n \u003cp\u003eStyria\u003c/p\u003e\n \u003cp\u003eTyrol\u003c/p\u003e\n \u003cp\u003eVienna\u003c/p\u003e\n \u003cp\u003eVorarlberg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eType of practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSingle-handed (1 GP)\u003c/p\u003e\n \u003cp\u003eGroup-practice (2\u0026thinsp;+\u0026thinsp;GPs)\u003c/p\u003e\n \u003cp\u003ePVE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eExperiences with and attitudes towards Long-COVID\u003c/h2\u003e\n \u003cp\u003eDuring the interviews on managing COVID in their daily work, the GPs almost never (except for one Interview partner, I12) talked about long COVID without being explicitly asked about it. However, all GPs indicated having experience with long COVID. The range of how often it occurred did vary greatly, although, from a few cases a week or month to patients with long-COVID symptoms on a daily basis. One physician assumed that it occurred in \u0026ldquo;20 to 25% of all those having had a COVID-19 infection\u0026rdquo; (I22), and another guessed it was 10% (I23). One-fifth of all interview partners indicated that long COVID-19 occurred only very little.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eOnly rarely. Thinking about it now it was approximately 4 or 5 patients who suffered that much with Long-Covid that I sent them to Medical Specialists. That is not much. (I10)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eNot every day, but I see long COVID approximately 2\u0026ndash;3 times per week. (I20)\u003c/h3\u003e\n\u003cp\u003eOnly one (I25) indicated that s/he had no case of long COVID in her/his practice, although she/he actually mentions symptoms defined as long COVID in the context of her patients.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eI don\u0026acute;t think I have real COVID-19 patients. However, I see a lot of patients who truly do suffer over many weeks. A bit of a cough, tired, not very resilient. I am not sure if that can be classified as long already, but people who have a longer healing process. (I25)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eHowever, the citation already indicates one of the biggest problems in dealing with long COVID: many of the interviewed GPs had varying understandings of what long COVID was and how long the symptoms were supposed to last to diagnose the patient with long COVID. Some already spoke of long COVID when there were symptoms for approximately four weeks, others guessed six weeks, and others supposed it was eight weeks. Most importantly, almost all GPs took long COVID very seriously because they had seen severe cases of long COVID, and they tried to treat it in a wide variety of ways, usually a combination of physiological and psychological treatment. Some were very proactive and indicated searching for much information on long COVID. Many named the important support of the \u0026Ouml;GAM (Austrian Society for General Practice and Family Medicine), which formulated a guideline on long COVID. Most GPs explained that they took much time to manage their long-COVID patients. They were trying to help in many different ways.\u003c/p\u003e\n\u003ch3\u003eHow do you deal with it?\u003c/h3\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eI am there for my patients all the time, they can come whenever they need and we discuss it over and over. Another point is assessing where further diagnostics are needed. (I24)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cp\u003eOnly a few (3/30 or 10 percent) downplayed long COVID by saying that they had some patients who believed or pretended to have long COVID, although they did not or by stressing that it was mostly psychosomatic (1) and due to other causes and not due to a COVID infection. Patients who believed they had Long-Covid were patients who suffered from mobbing or burn out before and now believed to have Long-Covid, two GPs argued. It is important to note that even those who were sceptical indicated that they did have a few patients \u0026ndash; at least one \u0026ndash; who were suffering from \u0026ldquo;real\u0026rdquo; COVID-19.\u003c/p\u003e\n\u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eStrangely enough, the usual suspects all have long COVID now. Before they had a burn-out or a bullying problem, now they have Long-Covid. There are a few who are truly suffering, yes, thank God there are few. (I11)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eIt is a bit complicated with the Long-Covid patients. Sometimes it is difficult to estimate is it Long-COVID or is the person pretending. It is not always easy to determine where the problem lies. (I27)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eThey are coming with the diagnosis already, \u0026ldquo;I have Long-COVID\u0026rdquo; (laughs). They had been to the AKH (university hospital in Vienna) or to an outpatient clinic or whereever. I have a bit of a problem with Long-COVID because I don\u0026rsquo;t know. It is a bit like chronic fatigue syndrome. (I9)\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eDiagnosing Long-Covid\u003c/h2\u003e\n \u003cp\u003eHow did the GPs diagnose long COVID, and what were the challenges of diagnosing long COVID at the time of the interviews?\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eIt is a very complicated matter, the people are weak, the people are depressed, the people are desperate, the people have the feeling that nobody truly understands or takes them seriously with their problems and the whole thing has a strong psychological layer and we find it very difficult to somehow classify them diagnostically in our existing diagnostic scheme. We do 100 blood tests, 99 of which, except for the vitamin D, are somehow normal, so how do we deal with the situation? (I1)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe citation from the GP above illustrates what many interview partners explained in the interviews. Many felt it was very difficult to diagnose COVID-19 because it was always a mix of different factors, and those were different from case to case. It was mostly a combination of physical and psychological aspects yet the biggest problem was that the standard tests to check for the physiological problems (e.g. lung or heart function, neurological functions) hardly brought any results. The GPs often lamented that there were no clear diagnostic parameters and that it was difficult for them to deal with long-COVID or potential long-COVID patients.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There is not truly a lab value\u0026rdquo;\u003c/em\u003e (I1),\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You can only diagnose it through thorough case history\u0026rdquo;\u003c/em\u003e (I2),\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It is not measurable or tangible\u0026rdquo;\u003c/em\u003e (I3),\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It is not tangible yet the people are not well.\u0026rdquo;\u003c/em\u003e (I10)\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eRegarding problems with regard to long-COVID health provision, many indicated that there was not enough space for rehabilitation available and that the waiting times in specific long-COVID outpatient clinics were very long (up to six months at this point in time). Other problems that were mentioned were that the treatment with Vitamin C infusions and other treatments were not refunded from the social insurance, but the patient had to pay privately, and that sometimes there were problems with the social insurance in relation to sick-leaves: as many sick-leaves for Long-COVID had a longer duration, it happened that social insurance would end the sick-leaves automatically and the GP would have to call the insurance to change that again. A few physicians said that the guideline from the \u0026Ouml;GAM was too long (approximately 50 pages) and that it was not applicable for a GP to go through 50 pages every time they suspected COVID-19. Another problem was that at the time of the interviews, the definition of long COVID was not clear to many physicians. Additionally, the difference between post-COVID and long COVID was not clear for some and was often used synonymously.\u003c/p\u003e\n \u003cp\u003eNonetheless, the physicians spontaneously named a wide range of symptoms as a basis for applying a long-COVID diagnosis (oder in frequency of mentions) (Fig. 2).\u003c/p\u003e\n \u003cp\u003eOther physicians, however, relied on parameters from the blood count, but which ones were not explicitly mentioned except for saying they made a large blood count.\u003c/p\u003e\n \u003cp\u003eThe majority of GPs said that they would not diagnose COVID-19 only by themselves but that it was a cooperation between different professions. Only one GP mentioned that it was him/her only who provided treatment because s/he was in a very rural place with no access to other medical specialties. Most interview partners indicated that when they had a patient where they suspected Long-Covid, they would send the patient to different specialists to do a medical checkup. Many also indicated that they would work with psychologists or psychotherapists to check the mental health aspects of the patient because depression was also a symptom of long COVID, and many patients also had problems dealing with the new and problematic situation that long COVID produced for them. Doctors from rural areas sometimes mentioned that there was a lack of capacity in specialist care. Some specifically indicated that they used the questionnaire from the \u0026Ouml;GAM (Austrian Society for General Practice and Family Medicine) to help with the long-COVID diagnosis (4/30). Other GPs said they would record the case history and, according to the results, send their patients to respective specialists. Some, especially those who work in PVE or cooperate closely with other medical professions in their practice, stressed that they diagnosed COVID-19 together within their teams.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eMostly it is tiredness, lower resilience in the sense that there\u0026apos;s often a bit of shortness of breath and cardiac symptoms, so if that is the case, then I arrange for a corresponding specialist examination,... Yes, but I have to say that nothing has truly come out for the patients I\u0026apos;m treating. (I10)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe problem the physician (I10) mentioned in the above citation is a common problem among the interviewed physicians: In many cases, the GPs would send their patients to pulmonologists or cardiologists, but there were no significant results from the specialist examinations. This was also one reason for some GPs to wait slightly longer before sending their patients to specialists.\u003c/p\u003e\n \u003cp\u003eOne other physician, for example, stressed that their job as a GP was to talk extensively with patients and to accompany the patients through the process. Many physicians reported that in the case of long COVID, it was the patients who came to the physician with the assumption to have long COVID. Most physicians were fine with that proactive behavior; only two indicated that it was a problem and explained that they were the ones who did the diagnosis and not the patients themselves.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eWhen people come to my practice and say they have long COVID, I send them away. I make the diagnosis not them. (I11)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eOn the other hand, some GPs also wished for more adequate information to be circulated via the media in order for people to know more about it. One GP (I25) spoke about the important role and responsibility of different media outlets for informing about long COVID and about informing about the effects that a COVID-19 infection can have on a person. For example, it was normal to feel weak for some weeks after an infection. The GP felt that the media could provide more and better information about COVID-19. It would help the GPs to have better informed patients.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eTreatment/Therapy of Long-Covid\u003c/h2\u003e\n \u003cp\u003eHow do GPs treat long COVID? The GPs often stressed that they made a very individual therapy plan according to the symptoms of the patient because each patient with COVID-19 had different symptoms.\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAs physiological treatment methods, the following were mentioned\u003c/span\u003e: infusions (especially vitamin C, then zinc), vitamin D substitution and special long-COVID rehabilitation are the most commonly mentioned, together with physiotherapy. The importance of the rehabilitation possibilities - some where the patient could go during the day or even part time rehab/part time work and others where the patient would go to a rehab for a few weeks - was often mentioned as one of the most efficient treatments, and at the same time, it was stressed that more places were needed in order for less waiting times. Other treatments that GPs mentioned were lung spray, Vitamin C in drug form, giving Covid-19 vaccine for those who have no vaccine yet, Cortisone, antihistamine, massages, and electrolytes.\u003c/p\u003e\n \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAs psychological treatment, they named fewer things than the physiological treatments\u003c/span\u003e: long COVID-19 groups, psychotherapy, seeing a social worker, going to a psychiatric clinic/prescribing drugs against depression.\u003c/p\u003e\n \u003cp\u003eIn addition to the abovementioned treatments, which many GPs said were often not enough, many saw that their role was a lot about raising awareness, talking and accompanying and motivating the patients as well as prescribing sick leaves.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eThe important thing is to give the people a vision, how their life will be different \u0026ndash; because it will be different for someone with long COVID \u0026ndash; but how they can still manage to have a certain quality of life and help them learn to deal with it. (I13)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;[\u0026hellip;] However, of course, they are desperate; when a young father sits in front of you and says, \u0026quot;I\u0026apos;m taking care of my two little children then I have to lie down and I just cannot do anything anymore.\u0026ldquo; [...] Then, you cannot do much more than sit with them for a long time, somehow persuade them to take the time, telling them that it affects many, that it will most likely get better again and just try to find a place for them for rehabilitation. On the one hand, this is time-consuming, and on the other hand, I have to say that it truly gets to me.\u0026rdquo; (I16)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eFrom the last citation of participant I16, we learn that the support of long-COVID patients can be difficult for GPs. Often, the patients are desperate, and it is difficult for the GP to handle the situation, as the major problem is that there is not \u003cem\u003ea\u003c/em\u003e single treatment for COVID-19 that helps, but it is a time-intensive and very individual treatment that can be emotionally stressful for both the patient and the GP.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eSupport (needs)\u003c/h2\u003e\n \u003cp\u003eWhat was striking about the answer of if the GPs would wish for more support in the case of Long-COVID was that the answers were very diverse. Some said they had a very good support network around them, and others said they had no support and had to search for all information on the topic by themselves. GPs in the city tended to have more access to resources such as specialists and rehabilitation; on the other hand, there were also other regions that were more rural, such as Vorarlberg in the very western part of Austria, where GPs also seemed to be well connected. In other regions, it seemed to be lower, for example, in Corinthia. The knowledge of where to find support seemed to be very diverse among GPs:\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eWe did not truly get support. However, I would say that family physicians are used to that. (I21)\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eWe have our information from the \u0026Ouml;GAM, and there are already trainings on Long-COVID. I believe every colleague has to look out for it and be active. There are offers for example the Billroth Gesellschaft, the Wiener Gesellschaft f\u0026uuml;r Allgemeinmedizin has a training on Long-Covid for example, it is even online, hybrid. (I2)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eSupport for the GPs\u003c/h2\u003e\n \u003cp\u003eThe work of \u0026Ouml;GAM (Austrian Society for General Practice and Family Medicine) was mentioned several times as helpful and supportive with regard to the topic of long COVID. Both its guidelines on the diagnosis of COVID-19 and the training offered in the field were mentioned positively. However, it was mentioned that the guidelines were very extensive, which limited their practicability in the everyday work of general practitioners. It was also mentioned that the \u0026Ouml;GAM was facilitating the research on Long-Covid by giving an overview of recent studies in the field and providing summaries.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eTo read existing studies and summarize and interpret. That is work that is done for me (by the \u0026Ouml;GAM). (I24)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003eThe outpatient clinic for Long-Covid in Vienna was mentioned a few times as very useful with the negative additional info that there were already long waiting times. A few GPs explained that they did not need any support and that they did the research themselves. One GP I30) spoke of a tool for clearing the long-COVID diagnosis that had been promised by the Austrian Medical Association \u003cem\u003e\u0026Auml;rztekammer\u003c/em\u003e but which s/he was still waiting for.\u003c/p\u003e\n \u003cdiv class=\"BlockQuote\"\u003e\n \u003cp\u003e\u003cem\u003eApparently there is a system (from the \u0026Auml;rztekammer) to get refunded for Long-Covid diagnostics, but I have never seen that tool or I have not found it thus far. (I30)\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOverall, this study provides insight into the experience, lessons learned, and challenges of GPs in the public health system with an emerging disease from which an increasing number of people are and will be affected. This is the first study that empirically investigates long-COVID management by GPs in a country with a Bismarck healthcare model in place (based on social insurance contributions). The study shows that even in year three of the COVID-19 pandemic, there are still many challenges to attend to, and support has to be scaled up everywhere. In addition, there are regional differences regarding long-term COVID support. In cities, GPs tend to have slightly better networks with specialists; for example, in Corinthia, GPs, especially in more rural places, would need much more support. The GPs who already worked in teams tended to find the management of COVID-19 easier.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eFrequency and definition\u003c/h2\u003e \u003cp\u003ePhysicians' reporting of how many long-COVID patients they saw varied from 20\u0026ndash;25% of COVID-19-infected patients to hardly any patients with long-COVID. This leads immediately to an important issue, the definition of long COVID. At the beginning of 2022, when the study was conducted, the NICE and WHO definitions were already in place but obviously not very well known. However, even the two definitions of the WHO [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and NICE [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] differ in nuances from each other. This gap is fundamentally a challenge for science with respect to long COVID, but of course, particularly in regard to diagnostics, diagnosis and coding/recording of diagnoses [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Reviews of the incidence of long COVID from this period concluded an incidence of 10\u0026ndash;35% in mildly ill persons [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Later reviews continue to suggest an overall incidence of 10\u0026ndash;30% of all SARS-CoV-2-infected persons when vaccinated beforehand [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The risk appears to be reduced in the fully vaccinated and for the Omicron variant, but probably not for neurological symptoms [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The fact that some GPs stated that they saw only a few long-COVID patients may be because the symptoms described by the patients were not related to the postviral context of the GPs [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSymptoms and diagnostics\u003c/h2\u003e \u003cp\u003eMost primary care physicians interviewed stated that they took COVID-19 seriously because they had seen severe courses of COVID-19 and therefore knew what COVID-19 could do to the human body. The symptoms that the physicians described and listed as long-COVID symptoms corresponded very closely to those described in the international literature [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, the question arises whether post-COVID syndromes such as the now known PostExertinal-Malaise (PEM) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], autonomic dysfunction such as postural tachycardia syndrome (POTS) [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] or Mast-Cell-Overactivation-Syndrom (MCAS) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], and cognitive dysfunction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] are also recognized and correctly classified, since they were never mentioned by the GPs. In particular, these can hardly be detected by standard diagnostic methods [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Specific examinations are often not yet known or not paid for by health insurance companies or not yet available [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To date, postinfectious syndromes such as post-COVID syndrome have received little attention in medicine. ME/CFS, as the most severe course of a postinfectious syndrome, has been a neglected disease since 1969, when it was recognized by the WHO. Long-COVID could highly benefit from research on the diagnosis and treatment of, for example, ME/CFS, as many symptoms overlap, and it would also be important to transmit this knowledge in long-COVID educational activities for primary health professions. Additionally, ME/CFS is particularly interesting in terms of patient involvement, as many patients are very active in raising awareness and in self-help online groups [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn particular, the differentiation of psychiatric diseases such as depression or burnout syndrome was difficult for the GPs because existing tools were either not yet known (e.g., PEM questionnaire [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] or Schellong test) or fast to perform official biomarkers are still missing [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In addition, it must also be taken into account that SARS-CoV-2 can simultaneously lead to the occurrence of long COVID with PEM and to a worsening of, for example, latently existing depression, and this must both be recognized and not mixed in terms of further treatment steps. Until diagnostic tests are well developed, it will remain a challenge to fully differentiate long COVID from other diseases that have symptom overlap [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatients often bring up this diagnosis by themselves. Most physicians feel fine with this; however, some physicians are ambivalent or negative about it. Interestingly, GPs who are offended by patients bringing up the possible diagnosis by themselves are also more skeptical about COVID-19 as a condition in general. There are studies indicating that people who already belong to marginalized groups in general have more difficulties being taken seriously by healthcare workers [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. There is a danger of stigma and double stigma: of being stigmatized because the illness is not taken seriously and in addition the person is not taken seriously because s/he belongs to a marginalized group (e.g., ethnic or sexual minority, socioeconomically deprived). Therefore, it is even more important for COVID-19 patients to find an empathic, understanding GP who understands the needs of the person [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Further education programmes should therefore also include the objective to counter possible long-COVID stigma. Health workers should be aware of that stigma, as it can impact how (much) COVID-19 patients seek help in the health system and how they are being treated [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Several studies suggest that patients lack empathy and compassion from their GPs and that marginalized people are seeking less help in the public health system for fear of being discriminated against and not being taken seriously [\u003cspan additionalcitationids=\"CR48 CR49\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Our study shows that adequate training for health workers on long COVID is indeed important; however, what we understood through the study is that further education trainings, even if they exist, are only taken up by some GPs. Hence, it would be important to disseminate information and trainings widely and try out different channels of information to target a large array of health workers. A study among physiotherapists in Austria, for example, found that most physiotherapy students wished for an adaptation of academic curricula due to the pandemic and resulting long COVID to be able to adequately treat it [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with the challenges described above, diagnosis is described by the interviewees across the board as time-consuming. In addition, there is a lack of support from specialists and specific contact points, such as long-COVID outpatient clinics, where postinfectious syndromes such as long-COVID can be further cared for. Specialist appointments for clarification of possible organ damage are very difficult to obtain and only with long waiting times, and the few public long-COVID outpatient clinics already had waiting times of 6\u0026ndash;12 months in the first half of 2022. These problems are also known in other countries [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. In contrast, physicians described the Austrian guideline on Long-Covid of the \u0026Ouml;GAM very positively and supportively. However, the time issue was also addressed here. Consultation time in a public Austrian general practitioner's office averages five minutes, which does not fit well with the occurrence of a new complex disease, especially without rapid biomarkers and causal therapies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTreatment and support\u003c/h2\u003e \u003cp\u003eIn terms of treatment, physicians communicated to their patients the prevailing information at the time that most symptoms would go away on their own after a few weeks or at least a few months. In addition, an increasing number of studies have shown that approximately 20\u0026ndash;30% of affected patients still have symptoms after two years [\u003cspan additionalcitationids=\"CR8 CR9 CR10 CR11 CR12\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Some studies even show that in approximately 5% of infected patients, the symptoms have even worsened after two years [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Due to the symptoms described in the Dutch study, which tend to worsen, as well as the main symptoms still existing after two years, it is reasonable to assume that the affected persons are mainly persons with long COVID with PEM, which is now also referred to as post-COVID syndrome of the ME/CFS type [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe primary care physicians see above all the great burden on the patients, especially with regard to their ability to work, the loss of quality of life and the increasing functional limitations in everyday life. Not being able to help adequately is also described by the GPs as very stressful. With this problem, the GPs feel left alone. GPs in the city tended to have more access to resources, especially to medical specialists. However, in general, we found that regardless of whether they were in urban or rural places, the GPs tended to be better equipped to handle long-COVID patients when they already worked in teams with different health professions (e.g., in PVEs).\u003c/p\u003e \u003cp\u003eIt is important to note that in the first half of 2022, which is when the interviews took place, there were no official recommendations of suitable therapy attempts for COVID-19. GPs often attempt to alleviate the disease by means of additional administration through dietary supplements. This approach, as is now known, is probably not wrong, as studies on dietary supplements, especially Vit C, coenzyme Q10 and probiotica, indicate [\u003cspan additionalcitationids=\"CR55 CR56 CR57\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Additionally, antihistamines [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] might be of benefit for mast cell activation syndrome (MCAS) as well as electrolytes for POTS. Social support as well as psychotherapy [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e] to be better able to deal with the burden of the disease are now known to be effective for certain long-COVID symptoms. However, what we know as of today is that the recommendation of exercise therapy without the knowledge of PEM in long COVID can be potentially damaging. When PEM is present, it is of high importance to stabilize the condition of the patent with pacing first; otherwise, the patient runs the risk of deteriorating her/his condition.\u003c/p\u003e \u003cp\u003eIn terms of therapy, GPs also lacked contact and knowledge about specific health personnel familiar with postinfectious syndromes and who could initiate off-label therapy trials or would have access to ongoing therapy studies. The few existing public long-COVID outpatient clinics were mostly affiliated with specific medical specialties, such as cardiology, pulmonology, or neurology. As a result, patients with long COVID could usually not be comprehensively helped here either, since the diagnostic options were limited to only one specialty, but postinfectious syndromes must be considered and treated across disciplines. It would therefore be of the utmost importance to create specific and multidisciplinary medical contact points for postinfectious syndromes, in which both medical staff and health and social professionals work on site, telemedically and through home visits. This is where primary care physicians could refer patients when a refractory postinfectious syndrome such as long COVID is diagnosed.\u003c/p\u003e \u003cp\u003eThe same applies to rehabilitation offers. Many GPs explained in the interviews that it was rehabilitation offers that were the most effective against COVID-19 (without PEM). Public funding for both specific outpatient clinics and rehabilitation possibilities should be increased to reduce the burden on both the patients and primary health care settings. Referral to outpatient assessments and clinics has been recommended in several countries [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis is the first qualitative study investigating the experiences and needs of GPs regarding long COVID-19 in a country with a Bismarck health care system. As the aim of the study was to gain an in-depth understanding of the experiences of GPs with long COVID, a qualitative study was the right choice. However, a representative quantitative survey on the experiences and needs of GPs in relation to long COVID would be important as a further study \u0026ndash; especially given that in our sample \u0026ndash; although only a few \u0026ndash; they were GPs who did not take long COVID seriously. With a larger sample, it would become clearer how many GPs would potentially need more information on long COVID to treat their patients correctly. Furthermore, the study includes interviews in all Austrian regions except for one, all organizational forms in which GPs work in Austria (single-practice, group practice, and primary care facility (PVE) as well as a gender balance of interview partners. One limitation of the data collection is that it took place in the first half of 2022 \u0026ndash; during the Omicron BA1 and 2 COVID-19 waves when cases in Austria were extremely high and the workload for GPs was disproportionately high as well. Therefore, it is possible that the GPs who participated in the study were already quite interested in the topic of long COVID and generally engaged in research activities. On the other hand, the themes of the interviews were not limited to COVID-19 and were related to the management of the pandemic in general. Therefore, it also spoke to GPs who were not particularly interested in the topic of Long-COVID. Another limitation is that when the study took place, knowledge on long COVID in Austria was still relatively scarce, with the \u0026Ouml;GAM guidelines coming out in December 2021. However, there have not been considerable changes between 2022 and 2023, and many aspects are still unclear in terms of diagnosis and treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCOVID-19 will continue to preoccupy our health care systems for a long time to come, as new variants without prevention strategies will continue to produce new patients. Therefore, it is not a question of if, but when and how good care pathways for people with COVID-19 will be implemented and when primary care physicians as first contact for diagnostics and care will be adequately equipped. Diagnostic tools, payment schemes other than fee-for service and adequate training are needed, as well as specific points of contact for patients with postinfectious syndromes, including ME/CFS (including multidisciplinary teams, telemedicine, home visits) and patient-centred rehabilitation, with a focus on PEM. Training for healthcare workers should be disseminated in various ways and channels to reach many or most GPs who seem to have diverse support needs. The most important aspect in addition to diagnosis and treatment, however, should be to prevent any new cases.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEXPH – Expert Panel on effective ways of investing in health\u003c/p\u003e\n\u003cp\u003eGP – General practitioner\u003c/p\u003e\n\u003cp\u003eME/CFS – Myalgic encephalomyelitis/chronic fatigue syndrome\u003c/p\u003e\n\u003cp\u003eNICE – National Institute for Health and Care Excellence\u003c/p\u003e\n\u003cp\u003eÖGAM – Österreichische Gesellschaft für Allgemeinmedizin\u003c/p\u003e\n\u003cp\u003ePASC – Postacute Sequelae of SARS-CoV-2 Infection\u003c/p\u003e\n\u003cp\u003ePVE – Primärversorgungseinheit\u003c/p\u003e\n\u003cp\u003ePOTS – Postural Tachycardia Syndrome\u003c/p\u003e\n\u003cp\u003ePEM – Post Exertional Malaise\u003c/p\u003e\n\u003cp\u003eWHO – World Health Organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research team guarantees that the project was conducted in accordance with the Declaration of Helsinki (1964) and all subsequent updates of the Declaration. The team is responsible for ensuring that the project is conducted in accordance with the European Commission's \"Guidelines of Good Clinical Practice\", national requirements and the requirements of the Medical University of Vienna. All study protocols were approved by the Ethics Committee from the Medical University of Vienna; a positive vote for the study from the Ethics Committee of the Medical University of Vienna is available (EC no.: 1491/2021).\u003c/p\u003e\n\u003cp\u003eFor all interviews, a written informed consent form and a written agreement to maintain anonymity and data protection were signed by the participants after they were informed in detail about the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data collected and analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CovFIT study was funded by the scientic-medical fund of the mayor of the capital of Vienna. The funding authority had no influence in the conception, design, analysis and interpretation of the study and related data and had no inuence in the writing of this publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research study conceptualized KH. MM and NS conducted the research. The article was conceptualized by SW and KH. Data were formally analysed by SW and MM. The original draft was written by SW and KH. Review and editing were conducted by SW with MM, NS and KH. All authors agreed on the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Constanze Teuschl for support in the recruitment and interviewing of some of the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS Wojczewski is a postdoctoral researcher at the Department of Primary Care Medicine at the Medical University of Vienna, Austria. She holds a PhD in Social and Cultural Anthropology from the University of Lausanne.\u003c/p\u003e\n\u003cp\u003eM Mayrhofer is a postdoctoral researcher at the Department of Primary Care Medicine at the Medical University of Vienna, Vienna, Austria. She holds a PhD in journalism and communication studies and is manager of a primary care centre in Vienna, Austria.\u003c/p\u003e\n\u003cp\u003eN Szabo is a student of law with a focus on medical aspects of the legal process. In addition, she has been assisting the Department of Primary Care Medicine in conducting studies for some time and has thus gained good knowledge and practice in qualitative research.\u003c/p\u003e\n\u003cp\u003eK Hoffmann has a full professorship in Primary Care Medicine and chairs the Department of Primary Care Medicine at the Medical University of Vienna, Austria. Additionally, she is MD, Master of Public Health and General Practitioner.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNICE, \u003cem\u003eCOVID-19 rapid guideline: managing the long-term effects of COVID-19\u003c/em\u003e, National Institute for Health and Care Excellence (NICE), Editor. 2022.\u003c/li\u003e\n \u003cli\u003eNICE, \u003cem\u003eCOVID-19 rapid guideline: managing the long-term effects of COVID-19\u003c/em\u003e, Guidelines, Editor. 2020, National Institute for Health and Care Excellence (NICE): London.\u003c/li\u003e\n \u003cli\u003eSoriano, J.B., et al., \u003cem\u003eA clinical case definition of post-COVID-19 condition by a Delphi consensus.\u003c/em\u003e Lancet Infect Dis, 2022. \u003cstrong\u003e22\u003c/strong\u003e(4): p. e102-e107.\u003c/li\u003e\n \u003cli\u003eEXPH, \u003cem\u003eFacing the impact of postCovid-19 condition (Long COVID) on health systems\u003c/em\u003e. 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Kraft, \u003cem\u003eFeasibility of Vitamin C in the Treatment of Post Viral Fatigue with Focus on Long COVID, Based on a Systematic Review of IV Vitamin C on Fatigue.\u003c/em\u003e Nutrients, 2021. \u003cstrong\u003e13\u003c/strong\u003e(4).\u003c/li\u003e\n \u003cli\u003eRathi, A., S.B. Jadhav, and N. Shah, \u003cem\u003eA Randomized Controlled Trial of the Efficacy of Systemic Enzymes and Probiotics in the Resolution of Post-COVID Fatigue.\u003c/em\u003e Medicines (Basel), 2021. \u003cstrong\u003e8\u003c/strong\u003e(9).\u003c/li\u003e\n \u003cli\u003eGrande, T., et al., \u003cem\u003eThe Role of Psychotherapy in the Care of Patients with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.\u003c/em\u003e Medicina (Kaunas), 2023. \u003cstrong\u003e59\u003c/strong\u003e(4).\u003c/li\u003e\n \u003cli\u003eWolf, S. and J. Erdos, \u003cem\u003eLong COVID care pathways: a systematic review.\u003c/em\u003e 2021.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.longcovidaustria.at/wichtige-anlaufstellen-fuer-betroffene/\u003c/span\u003e\u003cspan address=\"https://www.longcovidaustria.at/wichtige-anlaufstellen-fuer-betroffene/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (20.08.2023\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kl.ac.at/de/allgemeine-gesundheitsstudien/long-covid-leitlinie\u003c/span\u003e\u003cspan address=\"https://www.kl.ac.at/de/allgemeine-gesundheitsstudien/long-covid-leitlinie\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (24.08.2023)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Post-COVID-19 syndrome, postacute sequelae of SARS-CoV-2 infection, PACS, postinfectious disease, primary health care, semistructured interviews, post-COVID condition, family physician, family medicine","lastPublishedDoi":"10.21203/rs.3.rs-3523586/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3523586/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/u\u003e COVID-19 is a new multisectoral healthcare challenge. This study contributes to research on long COVID. It aims at understanding experiences, knowledge, attitudes and (information) needs that GPs have in relation to long COVID and how these evolved since the beginning of the COVID-19 pandemic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eThe study used an exploratory qualitative research design. It investigated infection protection, infrastructure, framework conditions and the treatment of patients during the COVID-19 pandemic in Austria through semistructured interviews. A total of 30 semistructured interviews with GPs in different primary care settings (single practices, group practices, primary care centres) were conducted between February and July 2022. For this study, the questions relating to long COVID were analysed. The data were analysed using the qualitative content analysis software Atlas.ti.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/u\u003e This is the first study that empirically investigated long-COVID management by GPs in a country with a Bismarck healthcare model in place. All GPs indicated having experience with long COVID. In cities, GPs tended to have slightly better networks with specialists, and GPs, especially in more rural places, would need much more support. The GPs who already worked in teams tended to find the management of COVID-19 easier. The symptoms that the physicians described as Long-Covid symptoms correspond to those described in the international literature, but it is unclear whether postCovid syndromes such PostExertinal-Malaise, autonomic dysfunction such as postural tachycardia syndrome or Mast-Cell-Overactivation-Syndrom (MCAS), and cognitive dysfunction are also recognized and correctly classified since they were never mentioned. The treatment of the patients is basically described as an enormous challenge and frustrating if the treatment does not yield significantly improved health. With this problem, the GPs feel left alone. GPs lacked information and contact information about specific health personnel or contact points that were familiar with postinfectious syndromes. Such facilities are urgently needed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/u\u003e\u003cstrong\u003e \u003c/strong\u003eCOVID-19 will continue to preoccupy our health care systems for a long time to come, as new variants without prevention strategies will continue to produce new patients. Therefore, it is not a question of if but when good support for GPs and adequate care pathways for people with COVID-19 will be implemented.\u003c/p\u003e","manuscriptTitle":"A bit of a cough, tired, not very resilient – is that already Long-COVID? Perceptions and experiences of GPs with Long COVID in year three of the pandemic. A qualitative study in Austria.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-11 18:25:40","doi":"10.21203/rs.3.rs-3523586/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-05T13:55:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-04T15:04:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180587170332839588641944006782516036976","date":"2024-08-06T06:04:41+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-09T15:08:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2ed8e7cd-ddcf-48c6-b8db-9a5974a5164a","date":"2023-10-27T11:53:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-10-25T10:56:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-10-25T08:52:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-09-20T04:23:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-09-20T04:21:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2023-08-29T12:29:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"10a08489-f768-4ea0-99e4-69885d9429b8","owner":[],"postedDate":"January 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-11T16:09:04+00:00","versionOfRecord":{"articleIdentity":"rs-3523586","link":"https://doi.org/10.1186/s12889-024-20475-z","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-11-07 15:58:13","publishedOnDateReadable":"November 7th, 2024"},"versionCreatedAt":"2024-01-11 18:25:40","video":"","vorDoi":"10.1186/s12889-024-20475-z","vorDoiUrl":"https://doi.org/10.1186/s12889-024-20475-z","workflowStages":[]},"version":"v1","identity":"rs-3523586","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3523586","identity":"rs-3523586","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}