Lingering Impact of COVID-19, Preventive Care Considerations, and US Health System Challenges

COVID-19/Post-COVID-19

COVID-19 has not yet left us. We had hoped, but COVID-19 lingers. Several articles illustrate the good, the bad, and the ugly for patients and practices. COVID-19 was expensive. Researchers count the cost, not just in dollars, but in lives and emotional well-being of patients and clinicians.

Substantial costs and health issues continue far beyond an initial COVID-19 illness, as verified by the work of Khan et al.¹ The costs are staggering. Pandemic-related loneliness can be deadly, as discussed in a reflection named “Friendship as Medicine,”² which notes “loneliness is the new smoking,” referencing The National Academies of Sciences, Engineering, and Medicine (NASEM) report on the topic.

The pandemic’s impact on medical practices was tremendous. In a 2022 Virginia state-wide study, there were increases in practices owned by health systems (25% vs 43%, P < .0001) compared with 2018.³ How much of this resulted from practice stresses is unclear. Yet, practices reporting any major stressor also increased from 34% to 53% (P < .0001) in the same time frame. Further, a Council of Academic Family Medicine’s Educational Research Alliance (CERA) survey⁴ of clinicians within the allied organizations elucidates the extent and amount of family physician distress as a result of the COVID-19 pandemic. Cook et al⁵ provide interesting electronic health record (EHR) data from the OCHIN multistate network of 18 community-based clinics from before the pandemic and over the next 4 years. There were multiple changes in types of patients and in-person versus telehealth visits, in primary care versus mental health visits, and number of visits. The influence of available staff as a possible factor was not reported. Not only were there many aspects to the stress, the clinicians’ resulting plans for change—and the frequency of those plans—are also quite distressing for the future of the public’s health.

Some practices also report successes in COVID-19 responses. One Department of Family and Community Medicine had high rates of COVID-19 vaccination among patients with immunocompromising diagnoses (mostly solid-tumor cancers or HIV) with 2/3 receiving ≥ 3 vaccine doses. (Of note, 1 of the authors is an investigator in a trial of vaccines.) However, disparities remained within the sample.⁶ A rural family medicine office⁷ shares how it increased the colon cancer screening rate of their patients despite the pandemic. A family medicine residency program also reports how it responded to⁸ increases in behavioral health needs during the pandemic.

Prevention

In a reminder to clinicians, Yogendran et al⁹ report a lack of completed interventions for women at high risk for breast cancer who could benefit from intensified mammography screening or chemoprophylaxis. Embedded in the article is a lesson on which women are considered at high risk. Further, Jarvis and colleagues¹⁰ remind us that we should not assume that women have high confidence in the ability of mammograms to detect cancer, in their review of the factors associated with lower confidence in mammograms.

Many patients eligible for breast cancer screening should also get lung cancer screening, but do not. Participants from multiple health care systems in one state provided input on lung cancer screening implementation, noting multiple barriers, such as a lack of office coordination and difficulties for patients accessing the screening financially or geographically.¹¹

Within one school district, about a quarter of the students failed their preparticipation sports examinations, primarily for 1 of 2 reasons yet the follow-up was unknown.¹² What happens to these students? Do they end up not participating in sports?

While advance care planning may not seem like a typical preventive care item, perhaps it should be, as it is designed to meet patient desires and prevent end-of-life emotional turmoil for individuals and others important to them. Roberts et al¹³ trialed an online version of Advance Care Planning and found some patients appreciate the opportunity and will use it. The authors provide a summary of the patients’ preferences for location and type of care and note some differences by self-reported race. Of note, this computer program is proprietary, and this is the initial reporting of its potential.

Lucas et al¹⁴ highlight a problem for which the goal should be prevention—the original identification of wheezing in young children and the number who develop asthma over time. Some who did not have wheezing did develop wheezing asthma after age 4. This work also highlights the large number of children who develop asthma. The study was completed through the ADVANCE Clinical Research Network and included more than 70,000 patients from US Community Health Centers. The article’s topic raises another question: how can the development of asthma be prevented? What is the difference for those who wheeze at a young age and do not develop asthma and those that do? One thought is that environmental improvements and changes in animal exposure both internal and external to the home could make a difference.

Dai et al¹⁵ tackle the complexities of identifying and studying the impacts of physician continuity of care on preventable hospitalizations and costs, using the Virginia all-payers claim database for patients of all ages. The authors distinguish physician continuity of care from patient continuity of care, a more common measure.

Increasingly, practices are screening patients for social risk factors. De Marchis et al¹⁶ report the experience with regular social risk factor screening at community health centers based on surveys and interviews. The results suggest what could enhance these processes and potentially improve outcomes for patients.

US Health System Cost Issues–Medicare Advantage & Pharmaceutical Benefit Managers

Two articles examine problems in the US health system related to Medicare Advantage (MA) and Pharmaceutical Benefit Managers (PBMs). The current MA carve-out private plans include risk-based plans.¹⁷ The editors suspect that this type of health insurance does not feel like an “advantage” to many family physicians who care for patients enrolled in Medicare Advantage due to low reimbursement, nor to the high number of patients disenrolling, with denials or limited networks being major complaints. Adashi and colleagues¹⁸ also provide a thorough update on current status of PBMs, another type of entity enabled by federal laws, with limited national competition (only 3 national PBMs), while associated with increasing pharmaceutical costs.

Self- and Prescribed Treatments for Physical or Mental Pain

Addressing pain is a major part of practice for family medicine clinicians. For example, low back pain is common and often vexing to both patients and clinicians. Joyce et al¹⁹ reviewed low back pain management by primary care physicians, considering severity and consistency with guidelines.

Cannabis is increasingly a pain management option for patients. Ford et al²⁰ investigated patient experiences in Washington State, a state that has legalized recreational cannabis. Their report includes information on the type of cannabis products were used, frequency of use, and concurrent tobacco use. Further, an interesting aspect of the results is the perception of the usefulness of cannabis in relationship to the person’s reason for use.

An updated review of guidelines, systematic reviews, clinical trials, and/or observational studies of perinatal depression covers much literature to provide clinicians with important helpful information on recognition and treatment.²¹ Appropriate treatment needs to account for the health of both the mother and child.

Clinical Practice and Personnel

Given that behavioral health training is required, integrated behavioral health (IBH) in family medicine residency sites was investigated by Filipi et al.²² Using a multi-method approach, this study highlighted a lack of standardization in training or collaboration. Participants concurrently agreed on critical elements for sustainability.

Music is often used by individuals to improve their emotional health. Schoonover et al²³ extend the benefits in an article on the feasibility of an innovative use of virtual music therapy for substance use disorders by the authors that elicited patient perceptions as well as outcome measures of the music therapy program for SUD in a community health center. Feasibility was measured by implementation measures, attendance, and use of technology. Mood scores, substance use, and craving were measured before and after the intervention.

With support from the American Medical Association (AMA) Practice Transformation Initiative, O’Connell et al²⁴ illuminate the reasons why some family physicians continue, and some leave, practice.

The employment of physician assistants and nurse practitioners in family medicine is both very common and of high interest. Carek et al²⁵ present the results of a survey of Family Medicine Chairs concerning the employment of physician assistants and nurse practitioners within their departments. More than half of the departments reported they employed 1 or more types of advanced care providers, primarily to provide patient care and specifically to fill in gaps in access. The authors provide other intriguing details and thoughts.