COVID 19 Missed Opportunities (Part 2)

In part one of our COVID 19 conversation we talked about the large number of patients that could have potentially been saved from death or hospitalization if curative therapy had been applied correctly. To recap, curative therapy arose very early in the pandemic, however, after large efforts to implement, evidence support that most of the 2022 mortality surges comprised patients that did not receive or were never offered these therapies. In this section of our conversation, we'll look at what are some of the potential causes of such widespread failure and what ways we can prevent these problems from every happening again.

Root Causes

What are the root causes of these failures?  Intuitively, we can categorize the problem as two shortcomings:  1) lack of public awareness of treatment options, 2) lack of physician awareness of treatment developments.    

Lack of Physician Awareness

Figure 1 illustrates the typical structure of healthcare delivery.  Medical literature, state policies, and professional guidelines form practices recommendations.  Physicians are then tasked with collecting and digesting this knowledge.  Lastly, patients are the recipient of recommended care practices through their interaction with a physician.  This model has been the traditional model of health care for close to a century.

Figure 2. Representation of typical healthcare structure. Information is distributed from authoritative sources through physicians and ultimately to patients. The X represents the occurrence of single point failure in the process with either access to a physician, or lack of physician knowledge, interrupts the flow of best care to the patient.

This model is robust in everyday practice as it allows patients to also seek specialty physician consultation or second opinions for matters in which patient’s are not comfortable with their care or in which physicians are admittedly not knowledgeable about a disease state.

In the COVID 19 crisis, however, this model was not sufficient for two reasons.  One is the severe time limitation that effective care demanded.  Effective treatment demanded quick referral within days of symptoms.  Patient’s that could not access their physicians in a timely manner would not be made aware in time.  Secondly, a physician that is not knowledgeable about care development would not have time to refer to specialty opinion such as infectious disease specialist or pulmonologist in the time-window required.  Additionally, patients would not have sufficient time to seek second opinion.

What must also be noted is that physicians have very little uniformity in channels of communication.  Most professional guidelines are published electronically, however, without membership to society or email subscription, physicians are not guaranteed to be aware of new developments.  Physicians are not mandatorily required to join professional societies such as the Texas Medical Association or the local physician organization.  Additionally, state health declarations may not be realized without a proactive provider, actively surveilling medical websites or publications.   Many breakthroughs in treatment are scattered amongst dozens of medical journals each publishing regularly, for which a physician may not have subscriptions. 

Also additionally, physicians are not historically required to update treatment knowledge until certification renewals every few years.  This is in stark contrast to the rapidly evolving treatment strategies of COVID 19 in which guidelines were updated sometimes multiple times per month.

COVID 19s treatment required a time-dependent response and an awareness of rapidly evolving treatments.  The knowledge of treatment recommendations has no guaranteed recognition.  The thousands of cases the state encountered in 2021 can be viewed a repeated ‘single point failures’ recurring repetitively across multiple physician patient encounters.

Lack of Public Awareness

The lack of public awareness compounded provider unawareness.  A high-profile case of MOAB treatments occurred when the former President of the United States received monoclonal therapy after contracting COVID 19 October 2020.  The public could not distinguish its effectiveness from the other therapies administered or the coincidence of an incidentally mild case.  The development of an outstanding treatment went unnoticed by the public.

Additionally, numerous other national headlines and controversies monopolized public attention.  Vaccine mandates, mask mandates, a Presidential election, civil unrest, and early 2021 historic freeze all dominated public attention.  Additionally, skepticism over media reliability prompted many to discard traditional news outlets for their information.  This contributed to treatment breakthroughs going largely unnoticed.  Because of COVID19 novelty in comparison to familiar diseases, the public was unfamiliar with novel treatment options and reliant on physicians to convey recommended care.

SOLUTIONS

The deficiencies above can be addressed to yield improved strategy in future pandemic and can be aimed at the deficiencies separately: 1) efforts to increase physician awareness and 2) efforts to increase public awareness.  Figure 2 illustrates two potential solutions.

Figure 2. Representation of a potential state emergency information strategy. In addition to the traditional healthcare structure, further efforts at redundancy are present. (1) Emergency measures by the state toward public service announcements, radio, social media campaigns, and advertisement will supplement public awareness. (2) The creation of an emergency communication announcement system to distribute public health information directly to physicians reliably.

Step 1: Creation of a public awareness mass media campaign

To increase public awareness of treatments in the event of important state health action, the Department of State Health should consider mass media campaigns and public service announcements.  For example, in the creation of the regional infusion centers, radio, YouTube social medical, and television ads are produced to distribute out the information to the public at large.  This would serve as a more robust communication structure in which patient awareness is redundant to physician awareness.  Informed patients will help to remedy the single-point failures that an uninformed physician represent.

Step 2: Creation of a robust emergency announcement system to physicians

We suggest creating an emergency physician broadcast system to serve as a uniform and robust communication channel to practicing physicians in the state.  Physicians will be registered through their Texas Medical Licensing.  The system would require each physician to provide a valid email, as well as updated cell phone to receive direct messaging from the state health departments on important public health threats and developments.  For example, updates to the opening of the infusion centers would be texted directly to physician cell phones and emails with links for more information. 

This system would only be accessible in stages by state officials.  In minor threats, such as monkey pox, the department of state health would email announcements from the department to physicians.  In severe health emergencies as declared by the Governor, a system of text will be used to ensure additional reliability. 

We believe that these measures would create a more robust information structure in cases of public health emergencies when traditional healthcare structures are insufficient. 

CONCLUSION

Historically, public health threats emerge every 3-6 years.  SARS 1 (2003), Swine Flu (2009), Middle Eastern Respiratory Syndrome (2012), Ebola (2015), and COVID 19 (2019) are all examples.  In future threats of contagion, we must have an informed citizenry and healthcare providers to prevent unnecessary loss of life.  Health care authorities and physician organizations will need start robust discourse and establish root cause analysis to look at the public health deficiencies revealed by COVID 19. 

Efforts to improve our future response require more reliable flows of information.  Information bottlenecks and single point failures will need to be removed.  Efforts to establish reliable information distribution to physicians to ensure updated knowledge will be necessary.  For those that have already suffered severe illness, irreversible lung damage, or lost loved ones from the 2021 COVID 19, no future strategy can reconcile their loss.  However, it is our obligation to learn from our experiences and work to ensure no future opportunities to save lives are missed.   

Cheers

Benjamin J. Blow, M.D.