A second-year medical student participates in a study examining the correlation between patient loneliness and lack of primary care visits. The findings underscore the need for investments in research on social determinants of health and value-based medicine.
A recent study, conducted in part by one of Privia’s own physicians, Dr. Alex Krist, and researchers at Virginia Commonwealth University School of Medicine, including Dr. Sebastian Tong, took a novel approach to examining the possible link between two factors that aren’t typically thought to influence one another: chronic disease and loneliness in primary care patients. As a second-year medical student at VCU, I joined this study last summer and conducted surveys to gauge the loneliness of hundreds of primary care patients. The ultimate goal of the study was to understand a fundamental question integral to the value-based movement in healthcare: how can we get closer to ensuring access and adherence to primary care?
You might be wondering why loneliness was chosen as the primary focal point of this study. In the original IRB proposal, Dr. Tong cites a couple of studies that help understand this decision. The first study shows that loneliness is not only widely prevalent among the elderly (a finding already well-studied and shown to be associated with negative health outcomes) but it’s also highly prevalent among young adults. A second population-based study shows high levels of social isolation and loneliness in people with disabilities, addiction issues, and those with chronic health issues. These studies established the need for more research on causes of loneliness.
So, how did we measure something as arbitrary as loneliness for the purposes of our study? It turns out were able to do so with pretty good accuracy using the UCLA Three Item screening test (our survey is depicted in image 1).
With hundreds of surveys in hand, I spent my 2017 summer at different primary care clinics in Richmond, Virginia, and the surrounding area to survey respondents on measures of loneliness. One thing that became immediately apparent was that not everyone I spoke with was overflowing with enthusiasm to take a survey attempting to quantify just how lonely they were. Nonetheless, after a couple months of persistence, I had gathered over 700 completed responses.
This means, if you’re a primary care physician, more than one in five people walking into your office are lonely — yet PCPs don’t routinely screen for loneliness.
From our findings, a few crucial points stood out. First, 22 percent of participants recorded a ‘high loneliness’ score based on the Three Item survey. This means, if you’re a primary care physician, more than one in five people walking into your office are lonely — yet PCPs don’t routinely screen for loneliness.
Second, there was a significant and positive association between the loneliness classification and the number of days with poor physical or mental health, the number of visits to the primary care office, the number of hospitalizations, and the number of emergency room or urgent care visits (all p values for these statistics were less than 0.0001). This set of results is pretty tough to ignore; lonely people tend to be less healthy. Third, and in my opinion most important, loneliness classifications were also significantly different based on respondent health classifications (p-value less than 0.0001). Fifty-three percent of respondents in poor health reported high loneliness. This confirms our initial suspicion that healthy people are not generally lonely and people in poor health have high rates of loneliness (to the tune of greater than 50 percent)
The takeaway here is complex. On one hand, it is clear to see that there is an evident association between loneliness and poor health, but every doctor and researcher knows that correlation does not imply causation. In other words, is loneliness the cause of poor health, or is it the other way around? My best guess is that it’s a little bit of both.
Either way, the next step involves further research into cause and effect as well as identification of specific co-morbidities associated with loneliness. Our specific study is still ongoing, with data from other areas of study in the United States, still pouring in. The ultimate goal, as Dr. Tong and Dr. Krist would tell you, is to eventually have loneliness be a part of every primary care physician’s routine review of systems. If this goal is reached, we believe that some chronic diseases can be avoided and the impact of value-based care will be maximized.
If I learned anything from this project, it would have to be that loneliness can come in many forms, and patients who seem to have it all together can sometimes be the loneliest, so it never hurts to ask. In an age where efficiency is paramount and physicians are encouraged to see as many patients as possible, this study warns that we might be missing what’s right in front of our faces. Instead of rewarding the physician that sees five patients an hour, maybe we should reward the physician who prevents the patient from ever having to be seen in the first place—isn’t that what value-based care is all about? Perhaps the solution is just to slow down and listen; maybe then we would find that prevention is really the purest form of efficiency.