The Pandemic’s Agenda

• coronavirus
• pandemic
• COVID-19
• telehealth
• diabetes
• research
• family medicine
• primary care

We are now about 2 years into the COVID-19 pandemic and although great progress has been made with vaccines, medical management, and public health response, globally between 5 and 10 thousand people are still dying from COVID-19 every day. Family medicine health services delivery has changed dramatically and continues to evolve in response to the pandemic. In this issue of Annals of Family Medicine, we are publishing a collection of original research articles focused on assessing the impact of the pandemic in family medicine.

Sisó-Almirall et al estimated the impact of the pandemic on new diagnoses of common chronic conditions such as hypertension and diabetes in primary care.¹ Using data from a cohort of almost 90,000 patients of 3 primary care centers in Spain and comparing pandemic incidence rates to rates during the 3 years prior to the pandemic, authors showed an astonishing reduction of incident diagnosis. For many chronic conditions, only about 50% to 60% of expected new cases were detected. This corresponds to the 41% drop in face-to-face visits for chronic disease detection and likely represents missed opportunities to intervene early in the course of a disease rather than an actual decrease in disease incidence. These undiagnosed cases will eventually present at more advanced stages with less favorable outcomes and will further increase the demand on our already depleted health care infrastructure.

Although much has been written about the impact of the rapid transition to telehealth on physicians and care teams, the impact on patients and their family members is less apparent. In a survey of caregivers of older adult patients, Raj et al asked caregivers about their experiences with telehealth.² Caregivers who were colocated with the patient could assist with the technical set up for visits. However, most caregivers were not colocated with patients and although telehealth visits facilitated remote caregiver participation, the technical challenges were more difficult to overcome.

Ha et al describe a program of targeted outreach by 1 family medicine residency team to increase vaccination rates among their patients.³ Using publicly available vaccination rate data, the team identified communities with low vaccination rates, reviewed medical charts for patients in those communities to identify unvaccinated patients, and then reached out by telephone to provide information and appointments for vaccinations. Their efforts paid off with 39% of those identified as unvaccinated ultimately receiving vaccinations. Leveraging the trusting relationship between the family medicine team and their patients to increase vaccination rates is resource intensive and not every outreach will be successful. However, every incrementally vaccinated community member reduces the risk of COVID-19 transmission, illness, and death in these vulnerable communities.

With all available resources devoted to responding to the crisis, it has been difficult to conduct rigorous research that documents the impact of COVID-19. Many researchers have been pulled away from their research efforts to staff escalating clinical efforts. Research projects have had to be shut down or modified to protect both patients and research staff. When schools were shut down and children were learning from home, childcare responsibilities also played a role in slowing research efforts. Wright et al examined the gender differences in manuscript submission rates in this journal before and during the pandemic and found that while women and men both increased their submissions, the increase for men was larger.⁴

Family medicine practice is intense, leaving little time or energy for connecting with the family medicine community outside of clinic walls. This experience of isolation may have been exacerbated by the pandemic for many. However, a team of investigators in Oregon developed a virtual extension program, COVID-19 Extension for Community Healthcare Outcomes (COVID-19 ECHO), to support primary care teams in the community. Using text data from the extensive chat box comments that clinicians used to communicate with each other during the 11-session COVID-19 ECHO telementoring program, Steeves-Reece et al identified common themes related to clinician needs during the pandemic. In addition to seeking reliable information and practical tools related to COVID-19 response, clinicians expressed a need for support and connection.⁵

In a qualitative study, Kelly et al found that staff members in a primary care clinics pulled together to respond to the acute reorganization in response to the pandemic. Staff contributed by learning new skills and taking on new roles during the early months of the pandemic. Uncertainty about job security was a major source of stress for some as clinical access was limited. For some, the increased demands and the uncertainty were experienced as an additional source of stress contributing to burnout.

This collection in Annals of COVID-19 impact articles presents some concerning data about the impact of COVID-19 on primary care above and beyond the direct impact of the virus on the health of patients and health care teams. Collateral damage related to care for chronic diseases, the isolation experienced by clinicians in the outpatient primary care setting, and the gender disparity of the impact on academic careers are concerning trends that call for action. The rapid changes such as the increase in telehealth have left little time for reflection or optimization. Research, innovation, and evaluation efforts will play a critical role in guiding policy and practice as we navigate a world with COVID-19.

• Received for publication December 3, 2021.
• Accepted for publication December 2021.

• © 2022 Annals of Family Medicine, Inc.