NEJM Op-Ed: Physician Experts Urge the Reinvention of Routine Preventive Care During COVID-19
Does routine preventive care need to be revamped, in the context of the current COVID-19 pandemic? Yes, say two physician leaders in Boston who are connected to the Harvard Medical School. Daniel M. Horn, M.D. and Jennifer S. Haas, M.D. on August 12 published a Perspective piece in The New England Journal of Medicine online, entitled “COVID-19 and the Mandate to Redefine Preventive Care,” in which they argue that a wholly new approach is needed to providing adult preventive care.
Daniel M. Horn, M.D. is director of population health and quality in the Division of General Internal Medicine at Massachusetts General Hospital, associate medical director of the Massachusetts General Physician Organization, and an instructor at Harvard Medical School. Jennifer S. Haas, M.D., M.S.P.H., is associate physician at Brigham and Women’s Hospital and a professor of medicine at Harvard Medical School.
Drs. Horn and Haas begin by stating that, “As the U.S. health care system defines the new normal for ambulatory care in the Covid-19 era, it needs a new approach to providing routine preventive care for adults. Concerns about contagion, competing demands, and shortages of personal protective equipment may limit preventive care visits — most commonly the ‘routine annual exam’ and the Medicare Annual Wellness Visit. But given that routine physical examinations have been shown to have limited clinical value, we believe health care organizations should take this opportunity to advance alternative systems for promoting evidence-based prevention. Failure to do so will sustain or worsen the long-standing disparities in health that have been underscored by the pandemic,” they insist.
“Before Covid-19, many primary care clinicians believed that annual exams did not optimally make use of their skills,” the physicians write. “The visit often became an exercise in checking off regulatory boxes, performing a head-to-toe physical exam for which there is no evidence of benefit, and ordering “routine” lab tests, many of which also lack supporting evidence. Yet many clinicians value these exams as a time for establishing or maintaining relationships with patients and reviewing the results of and rationale for key preventive screening tests recommended (with a grade A or B) by the U.S. Preventive Services Task Force (USPSTF) — a list that is 25 items long and growing. There are troubling disparities, however, in use of these evidence-based preventive services according to race, ethnicity, and socioeconomic status.3 Since use of annual exams is more common among White people than Black people and increases with household income, such exams won’t help address disparities in the delivery of preventive services.4 So we are faced with a long and growing list of evidence-based preventive services to deliver to a broad population but a low-efficiency, low-efficacy mechanism for doing so. And the pandemic has revealed the clear and pressing need for a revamped approach.”
Given all of that, Horn and Haas say, “We believe the U.S. health care system should embrace this moment as an opportunity to shift the locus of preventive care from face-to-face annual exams to a strategy that focuses on population health: clinical registries that readily identify all preventive services for which a patient is due; annual prevention kits for patients that facilitate widespread deployment of home-based testing, shared decision making, and self-scheduling of preventive screening tests and procedures in more convenient and approachable community settings; and robust community-based strategies involving navigators to overcome health disparities in underserved populations.”
The doctors propose a three-step solution to the current situation; and it involves the leveraging of healthcare data at its core. The three steps:
Ø First, develop “a robust, real-time clinical preventive care registry that allows tracking of care needs asynchronously from visits.”
Ø Second, “build the infrastructure for an annual “prevention kit” received by every patient. The kit should consist of a language-appropriate, culturally sensitive package that addresses all indicated USPSTF grade A and B preventive services as indicated by the clinical prevention registry. Point-of-care tests should be included to allow preventive care to happen from patients’ homes; these could include fecal immunochemical testing, glycated hemoglobin and lipid testing, and perhaps soon, self-sampling of human papilloma virus for cervical cancer screening. QR code links to standardized electronic questionnaires should be included for depression screening, tobacco and alcohol use, and personalized risk assessment for common conditions such as breast cancer and cardiovascular disease.”
Ø And third, “create specific programs to address the known disparities in preventive care within a given population. There is a rich body of literature supporting the effectiveness of community-based patient navigators in closing gaps in cancer-screening rates affecting underserved patients.”
The doctors note that “These navigators facilitate patients’ preventive care by using proactive outreach and motivational interviewing and by accompanying patients to procedures such as colonoscopies. Navigators are also well suited to systematically screening for and facilitating access to community-based resources for addressing social determinants of health. In addition, they can connect patients with community-based campaigns to promote prevention, such as screening vans. Though navigation programs cannot eliminate key social determinants of poor health, such as poverty, educational barriers, food insecurity, and racism, they can help make access to evidence-based preventive services more equitable.”
