Pressure on primary care is expected to intensify with long-term COVID

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As the number of patients with COVID-19 problems persists, much of the diagnosis and management of symptoms will fall to primary care, experts say.

Dr. Russ Phillips

“They could reach 5% to 10% who still have symptoms at 12 weeks. These numbers are higher when it comes to patients who had been hospitalized with COVID-19,” said Russ Phillips, MD, director of the Va. say the Primary Care Center at Harvard Medical School in Boston, Massachusetts Medscape Medical News.

A recent one to study of the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente Georgia found that among 3171 adult patients not hospitalized with COVID-19, 69% had one or more outpatient visits 28 to 180 days after diagnosis. Two-thirds had a visit to obtain a new primary diagnosis and approximately one-third had a new specialized visit. Diagnoses of symptoms include cough, difficulty breathing, chest or throat pain, and fatigue.

These visits have occurred while cases of acute COVID continue to occur, and there has been an increase in patients returning to primary care after avoiding it as the pandemic escalated. For these patients, the delay in seeking care has often led to a worsening of chronic conditions.

Phillips noted a deficiency in primary care that will need to be addressed with regard to long-term COVID: “We do not have good systems for tracking patients and their symptoms over time.”

Long-COVID will require this type of care, but current payment systems do not allow patients to be proactively reached for follow-up over time, he noted.

“We do a good job of identifying these problems for the patients who come in, but they’re the ones we don’t care about anymore,” he said.

Phillips provided examples of the type of management plans needed to improve outcomes in patients with long-term COVID. In anticoagulation clinics, patients receiving anticoagulants are closely monitored and, in mental health care, patients with anticoagulation depression they are linked to social workers and are monitored regularly.

“Around COVID, these management plans are in their infancy,” he said.

John Brooks, MD, medical director of the CDC’s COVID-19 response, he declared at a congressional hearing in late April, which will publish an interim guideline on long-term COVID protocols in primary care. He also noted that the CDC is working closely with the Centers for Medicare & Medicaid Services to develop medical coding for long-term COVID.

Meanwhile, Phillips said, one of the strategies is for patients to automatically monitor their condition and transmit the results to primary care physicians electronically.

As an example, Phillips described a patient with long COVID who was receiving supplemental oxygen and who wanted to resume her exercise regimen.

He checked his own oxygen saturation levels before and during exercise and reported them every few days through the patient portal.

“Very slowly we were able to reduce his oxygen and increase his ability to exercise until he no longer needed oxygen and could return to his usual activities of daily living,” he said.

Professional nurses, social workers and other members of the non-health care team can be increasingly relied upon to provide care to patients with long-term COVID, he said.

In addition, telecare, which will currently be reimbursed in the same way as face-to-face visits, allows for easier access to visit patients, he said.

You need empathy and listening

Sabrina Assoumou, MD, MPH, assistant professor of medicine at Boston University School of Medicine, Boston, Massachusetts, said Medscape Medical News that it will be crucial to address health disparities as long-term COVID cases increase.

Dra. Sabrina Assoumou

COVID disproportionately affects communities of color and it is logical that this will also be the case for long COVID, he said. Workforce diversification will be vital, as the diagnosis may depend on how a doctor listens to patients as they describe their symptoms, Assoumou continued, whose primary care practice focuses on HIV patients.

Symptoms of long COVID are vague, he explained, and include brain fog, fatigue, and shortness of breath, and the diagnosis takes longer in many conditions.

Assoumou said some people never took COVID screening tests and never received any diagnosis, although they are now experiencing extended effects.

“Long-COVID will force us to go back to the basics, like really listening to our patients,” he said. “We definitely need to be more empathetic.”

There is not yet a large influx

Charles Vega, MD, clinical professor of family medicine in health sciences at the University of California, Irvine, said he is skeptical that the primary care system will be overwhelmed by long COVID cases.

Dr. Charles Vega

Vega is a family physician who works at the largest safety net clinic in Orange County, California. About 90% of its patients are LatinX, a population disproportionately burdened by COVID, but it has not seen an increase in long COVID cases.

He said this may be because patients know there is no long-term treatment for COVID. They are well connected through online forums like Body Politic COVID-19 Support group and you may not feel the need to see a doctor.

“They didn’t find scientists [long-COVID], it was the patients who developed this disease model themselves, “he said.” This is where most of the shared data is “.

However, for patients with long-term COVID who need care, primary care is the best home for them, Vega said.

He said the most common symptoms he sees are fatigue and poor activity tolerance. “They put air in the bathroom,” he said.

The most difficult symptom is dyspnea, he said. Patients describe that they have no breath, but it is not bad enough to qualify for supplemental oxygen.

“Being out of breath is a pretty desperate thing and it harms the quality of life,” he said.

Most patients describe general malaise.

Care for a long COVID requires medical care and mental health care, Vega notes. Primary care is already set up to examine and coordinate care with the right provider.

“I think there is a role for specialists, but primary care needs to be addressed,” he said.

Phillips, Assoumou and Vega do not report relevant financial relationships. Vega regularly contributes to Medscape.

Marcia Frellick is a Chicago-based freelance journalist. She has previously written for the Chicago Tribune and and was editor of the Chicago Sun-Times, the Cincinnati Enquirer and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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