Managing measles better (and cheaper) with family physician home visits

After many years of near absence, measles is back, and public health is scrambling to control its spread, especially when patients attend for health care. Measles is highly contagious, with the virus aerosols hanging in the air for hours. The guidelines in various provinces require that patients, primarily children, be isolated in special rooms, preferably with separate negative pressure ventilation. The trouble is that initially measles looks like many other viral infections, so many children must be managed this way until assessed.

When examining and caring for patients suspected to have measles, staff are required to wear protective equipment: N95 masks, face shields and protective clothing. The ritual of donning and removing this gear takes time and contributes to the “contaminated” waste that must be disposed of. After the room is used, it must be kept vacant until the air has been fully exchanged, which may take two hours or more. Even an infected patient entering an emergency department or clinic is enough to infect susceptible people. To prevent such transmission, special negative-pressure rooms for such infections should open directly to the outside. But these rooms are costly, and only a few are available in each emergency department. The financial, social and environmental cost of such care is enormous, and disruptive to already overstressed emergency care, even when these patients are not sick enough to need inpatient care.

There is a better way: family physicians can do it.

The last case of measles I saw was 44 years ago – the day my first son was born. That Saturday morning, I was a young family physician on call for our practice group; on a house call, I saw the 8-year-old daughter of a local pharmacist. Both the parents and I had measles as children, so we knew we were immune. We did not have nor need protective equipment. The girl was sick and needed to be observed sequentially to ensure she was not developing complications or deteriorating and needing admission to hospital. She was isolated at home, and my colleague visited over the next few days to check on her as she recovered.

Back then, medical students and family physicians in training were taught that these childhood infectious diseases were best managed at home to minimize moving sick children and keep them out of hospitals or clinics where they might easily infect others. However, few Canadian family physicians, pediatricians, or primary care nurse practitioners now perform house calls, since they take extra time, and the fees for doing so are so low that it is no longer economically viable. Consequently, the default option is for suspected measles patients to go to the emergency department, which is very costly for the health-care system and for families. An emergency visit with physician costs more than $300.

Public health plans for infectious diseases in Canada appear to be developed without recognition of the potential role of family practice, resulting in a reliance on hospital care even when it is inappropriate. This was demonstrated during the first phase of the COVID epidemic, when community physicians were left mainly to their own devices to buy protective equipment of uncertain quality at inflated prices rather than being assisted as part of the health-care workforce. Many shut down, so their patients crowded into hospitals.

It is time to rethink how to incorporate the primary care workforce into the care of these new epidemics. If a higher fee were paid for house calls to patients with suspected measles (or another similar infectious disease), many family physicians would be willing to relearn the skills associated with this part of their practice.

This would alleviate the strain on emergency departments that care for children, which are already overburdened with work that requires their specialized skills and equipment. A home visit by an immunized physician would minimize the risk of measles transmission to the wide range of staff and be safer for the many children with immune deficiencies who must attend hospitals for their medical issues.

Considering the cost of building and maintaining hospital structures, the problems of infection control and the pay of emergency department staff, a family physician fee of $250 would be a bargain and likely to change practice patterns. It would also take stress off parents who need not take their sick child to the hospital, especially those who rely on public transport.

Since measles is resurging, and the low immunization rates suggest this epidemic will last for a few years, it is time to rethink our strategies for care. We need to re-integrate family medicine into the public health care system, at least for the 60 per cent of patients who have Family Physicians. A focus on measles could be the first step: Others may follow.