Pandemic threatens primary care for long term conditions

British Medical Journal (2020)

Patients, healthcare staff, and policy makers are now recognising that the fluctuating health needs of populations will require changes in how primary healthcare is delivered beyond the covid-19 pandemic. Any changes should aim to maximise the capacity and effectiveness of primary care but must also ensure that health inequalities are narrowed not widened, such as the ethnic disparities in infection and mortality seen with covid-19. Several areas should be considered.

Are the needs of people with multiple long-term conditions being met?

Rolewicz L and Scobie S (2020)

Analysis found concerning levels of unmet need among patients with two or more long-term health conditions. People with five or more conditions were least likely to have their needs met, either in their last consultation or from local services. Covid-19 has exacerbated the challenges already faced by people with multiple long-term conditions, from increased burden of illness and mortality from Covid-19 directly, as well as from reduced access to their usual service.

Early insight into the impacts of COVID-19 on care for people with long-term conditions

The Health Foundation (May 2020)

There is much more variation in the proportion of people who decided not to risk accessing care on account of the disease; this number is higher for patients with diabetes (27%), heart disease (28%) and mental health illness (30%).

Supporting people with long-term conditions (LTCs) during national emergencies

• Evidence relating to LTC management during medical emergencies, such as the current COVID-19 pandemic, is mainly focused on the direct impact of infection on people living with LTCs

• There is limited evidence on the indirect effects of pandemics on LTCs, mainly relating to changes in healthcare provision. Evidence from natural disasters is more prevalent, but may be limited in its generalisability.

• The evidence we do have suggests LTCs are at risk of neglect during pandemics and national emergencies. Diabetes and cardiovascular disease have been particular focuses for research, but whether this is because these are the conditions most affected is not clear. Older adults and people living in deprived communities may be particularly at risk.

• Suggestions for mitigation of indirect risks include coordination, communication, patient education, and continuity planning.

• Practitioners may consider ways of proactively identifying those patients with LTC most at risk of sub-optimal management to ensure their necessary care is maintained.

What conditions could we prioritise in the primary care setting to reduce non-COVID-related admissions to hospital?

This rapid review has established that targeted interventions for influenza, COPD, CHF, diabetes, UTI and cellulitis across England, Spain and Australia to support primary care management will assist to reduce preventable admissions where possible.

Are guidelines for monitoring chronic disease in primary care evidence based?

British Medical Journal (2019)

• Current UK guidelines for monitoring type 2 diabetes, chronic kidney disease, and hypertension are largely based on expert opinion, but robust evidence for optimal monitoring strategies and testing intervals is lacking

• Guideline recommendations should feed into, rather than override, discussions with patients that incorporate their values and preferences

• Unnecessary testing in primary care can lead to false positive and false negative results, increased workload for clinicians, and increased costs for the health service

• Patients and healthcare professionals should be aware of these uncertainties when making shared decisions about chronic disease monitoring

What methods are being used to create an evidence base on the use of laboratory tests to monitor long-term conditions in primary care?

Family Practice, Volume 37, Issue 6, December 2020, Pages 845–853

• Optimal testing for chronic diseases is an area of uncertainty in primary care.

• The uncertainty causes unwarranted variation in test ordering among GP practices.

• We identified gaps in research on determining the optimal frequency of testing.

• Optimal testing strategies improve patient outcomes and reduce patient harms.

• To optimize testing strategies, high-level evidence is needed.

Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic

NEJM catalyst – Innovations in Care Delivery, Vol. No. | May 4, 2020

Health systems have adopted telemedicine with remarkable speed not only for Covid-19– related care, but also for chronic disease management. But without proactive efforts to ensure equity, the current wide-scale implementation of telemedicine may increase disparities in health care access for vulnerable populations with limited digital literacy or access, such as rural residents, racial/ethnic minorities, older adults, and those with low income, limited health literacy, or limited English proficiency. To ensure that the current telemedicine implementation does not exacerbate health disparities, the authors propose four key actions for clinicians and health system leaders: (1) proactively explore potential disparities in telemedicine access, (2) develop solutions to mitigate barriers to digital literacy and the resources needed for engagement in video visits, (3) remove health system–created barriers to accessing video visits, and (4) advocate for policies and infrastructure that facilitate equitable telemedicine access. Without taking these actions now, health care systems risk creating telemedicine programs that exclude vulnerable populations.

Technology and innovation for long-term health conditions

The Kings Fund, August 2020

Case studies illustrate the potential of digital technology to transform care, particularly through empowering patients, supporting stronger therapeutic relationships and effective team working across professional boundaries, and creating networks and communities to support patients.

Building the House of Care for people with long-term conditions

British Journal of General Practice 2016; 66 (645)

The House of Care (HoC) is a framework for a coordinated service model that enables patients with long-term conditions (LTCs) and clinicians to work together to determine and shape the support needed to enable them to live well with their condition.