Check back often as we continue to post timely updates on COVID-19.
Don’t miss other important issues facing hospitalists. Battling the other epidemic: opioids
October 23, 2020
Studies don’t find clear benefit with tocilizumab
Observational studies have backed the efficacy of the monoclonal antibody tocilizumab to help patients with severe covid. However, a trio of randomized studies published in JAMA Internal Medicine doesn’t deliver a solid endorsement. The first study, which was conducted in the U.S., did find an association between early use of tocilizumab (within two days of ICU admission) and lower risk of in-hospital mortality. But the authors warned of unmeasured confounding. The next trial, this one from Italy, randomized patients with covid pneumonia to tocilizumab or standard care and found no clinical benefit. The third study was done in France, randomizing covid patients with moderate to severe pneumonia to tocilizumab or standard care. While the intervention group had lower risk of death or need for high-flow oxygen or ventilation at day 14 (24% vs. 36%), neither group at day 28 had a mortality advantage. An editorialist writes that he’ll wait for more compelling randomized data. Otherwise, “findings do not support the routine use of tocilizumab for COVID-19 in most settings.” In other news on therapeutics, the FDA has given final approval to remdesivir, which will be marketed under the brand name Veklury.
CDC redefines “close contact”
If you’ve been counting on spending fewer than 15 minutes at a stretch with covid patients so you don’t get infected, the CDC this week upended that strategy. Instead, the agency detailed a case in MMWR in which a corrections officer had a series of encounters, each lasting only a minute or less, with asymptomatic inmates waiting for covid test results. While the inmates weren’t wearing masks, the corrections officer was wearing one as well as goggles and gloves—but he still tested positive within eight days. The CDC has now expanded its definition of “close contact” to include anyone who spends 15 minutes or more as a cumulative total with infected patients over a 24-hour period. The distance cited for transmission is still six feet or less.
Why the hate for DOs?
The high profile given Sean Conley, DO, the president’s physician, in the wake of the president’s covid diagnosis, had this unintended and ill-informed consequence: It produced a lot of disparaging remarks about doctors who train in osteopathic medicine. Apparently, many members of the media and the public mistakenly believe that DOs aren’t fully qualified, licensed physicians. In response, the American Osteopathic Association pushed back, targeting media figures and social media as well as connecting reporters to prominent DOs. The association also urged its members to advocate for osteopathic practitioners and for accurate information. In a commentary published by KevinMD, two prominent hospitalists both DOs—likewise rallied support for their colleagues. “(W)hen someone challenges the validity of a legitimate medical degree,” wrote Joshua Lenchus, DO, and Bradley Flansbaum, DO, MPH, “the entire house of medicine is under attack.”
October 22, 2020
Inpatient admissions are still down
Are admissions back to normal in your hospital? Authors from Sound Physicians teamed up with those from the Dartmouth Institute for Health Policy and Clinical Practice to look at admissions data from more than 200 hospitals across 36 states. Their study, which was published in Health Affairs, compared patient characteristics, diagnoses and mortality between February-July 2020 vs. the same period last year—and they found that admissions by April 2020 were down almost in half. Even months later, however, admissions were close to 20% lower. Why? This spring’s drop was due to patients avoiding hospitals for fear of becoming infected. As for the persistent decline, some studies have pointed to a sharp decrease in air pollution resulting from the shutdown, which could reduce respiratory infections, and masking and social distancing probably did the same. “Alternatively,” the authors write, “the ‘missing’ non-COVID-19 hospital admissions could have resulted in elevated out-of hospital deaths.” Their results also suggest that minority and low-income patients this spring ran into barriers to care access. In a New York Times commentary, a Boston surgeon mentions the Health Affairs study and notes that, in her hospital at least, “more than seven months into the pandemic, there are still no lines of patients in the halls.”
October 21, 2020
Caseloads rise, but mortality may be on the decline
Two preprint studies that have now reportedly been peer reviewed find that mortality rates from covid are falling, at least from their highs this spring. In the first study, researchers analyzed biweekly death rates among 5,000 hospitalized patients
between March and June in one New York City health system. They found that mortality fell from a high of 26% to just under 8%, about a 70% decrease. The second study; was conducted in the U.K. and looked at death rates from covid in ICUs, also between March and June. That analysis found that mortality likewise dropped 20 percentage points. That trend, the authors write, isn’t due to changing patient characteristics, and it persists after adjusting for demographics and comorbidities. This trend remains after adjustment for patient demographics and comorbidities suggesting this improvement is not due to changing patient characteristics.
October 19, 2020
Why have trials been halted?
Headlines last week contained some alarming news: Johnson & Johnson has put its vaccine trial—which encompasses more than 60,000 people—on hold due to an unexplained illness, while Eli Lilly has halted its trial to test an antibody. (AstraZeneca’s vaccine trial has been on hold since last month.) While not being specific about the issues that brought the trials to a halt, the FDA commissioner has said the holds were put in place “to identify safety issues.” According to Fierce Pharma coverage, Johnson & Johnson executives say such halts aren’t unusual in large trials and that they plan to complete their trial enrollment on schedule within two or three months. In other research news, the NIH is launching a trial to test the efficacy of three immunomodulators in hospitalized covid patients. The phase 3 trial will enroll about 2,100 patients and test infliximab, abatecept and the experimental ceniciviroc. All the patients in that trial will also receive remdesivir.
Studies: More links found between blood type, covid severity
Two new studies add to suggestions that blood type may be associated with both covid susceptibility and severity. Danish researchers publishing this month in Blood Advances found that patients with type O blood had less risk of developing covid, although differences in blood type weren’t linked to increased risk of being hospitalized with covid or of mortality. The study found that 38% of patients in blood group O vs. 42% in a reference population. Another smaller study, also published by Blood Advances, reported a link between blood type and disease severity. That trial, done by Canadian researchers, found blood types A or AB associated with a higher risk of being ventilated and of needing continuous renal replacement therapy or prolonged stays in an ICU. The authors collected data from six Vancouver hospitals this spring.
October 16, 2020
U.S. cases on the rise
Bad news on the case curve for covid: The Washington Post reports that the number of single-day cases in the U.S. hit their highest level since late July yesterday, surpassing 64,000 new cases. There’s also been a 23% increase in new cases over the past two weeks while over the past week, the U.S. has averaged more than 53,000 new cases a day, with uncontrolled outbreaks in the upper Midwest and Mountain states. Meanwhile, the Northeast is seeing resurgence (as is Europe) and the number of hospitalizations in the U.S. is rising. This month, average death rates are running at about 700 per day. A JAMA research letter finds that covid patients in the U.S. are dying at unparalleled rates compared to other developed countries. The study compared covid and all-cause mortality rates in the U.S. to those in 18 other countries. On average, the death rate here is 50% higher, running 85% higher than in Germany and Israel and close to 30% higher than in Sweden.
The U.S. posts its first reinfection
A patient in Nevada appears to be the first documented case of covid reinfection in North America, with positive tests first in April and then in June. Reporting in The Lancet Infectious Diseases, the authors say that genomic analysis of the samples revealed significant differences, suggesting two separate infections. The patient was 25 years old and had more severe symptoms the second time around. “Previous exposure to SARS-CoV-2 might not guarantee total immunity in all cases,” the authors write, saying that everyone should take identical precautions, even if they have previously been infected. So far, there have been only a handful of cases of reinfection worldwide, although there have been close to 39 million infections. Researchers note that the issue of reinfections has implications for the application and development of vaccines.
October 13, 2020
NIH updates its covid treatment guidelines
The NIH recently updated its covid treatment guidelines, outlining therapeutic recommendations according to disease severity. For hospitalized patients receiving supplemental oxygen (but not high-flow or ventilation), for instance, the guidelines recommend remdesivir alone or in combination with dexamethasone. However, the guidance advises against using dexamethasone in patients not receiving supplemental oxygen. The updated guidelines also include special considerations for covid patients with HIV and for patients with persistent symptoms after their acute recovery. Among those symptoms: covid brain fog, cognitive impairment that affects patients’ function and their ability to work.
The $16 trillion pandemic
Two Harvard economists have put a price tag on what the coronavirus pandemic may cost the U.S.: $16 trillion, which translates to about $200,000 per every American family of four. Publishing in JAMA, the authors write that the pandemic is “the greatest threat to prosperity and well-being the US has encountered since the Great Depression.” Their projected total costs include $7.6 trillion in lost work output during the next 10 years. And based on current mortality figures, the authors note that an additional 250,000 Americans may die from the virus within the next year; they estimate the value of expected premature deaths due to the virus at $4.4 trillion. That’s in addition to the costs related to long-term complications of many survivors and the mental health burden of those not directly infected. On the other side of the ledger, the authors point to the immense potential social and economic value of policies to reduce virus spread, writing that “increased investment in testing and contact tracing could have economic benefits that are at least 30 times greater than the estimated costs of the investment.” The authors also recommend that the government rethink its role in the pandemic response, making public health infrastructure and services as much of a spending priority as acute treatment.
October 12, 2020
More evidence that remdesivir speeds up recovery (* updated Oct. 16th)
A randomized trial of remdesivir that enrolled more than 1,000 patients finds that the antiviral seems to hasten recovery, cutting about five days off the time that patients need to recover. In a study conducted at 60 trial sites around the world and sponsored by the NIH, patients given remdesivir recovered in a median of 10 days vs. 15 for those given placebo or saline, with the greatest benefit found in patients receiving low-flow oxygen. However, remdesivir did not appear to reduce patients’ mortality odds or needing to be ventilated. The authors point out that remdesivir continues to be tested with immune modifiers and with other antivirals. “(C)ombination approaches are needed,” they write, “to continue to improve outcomes in patients with Covid-19.”
**The WHO yesterday released non-peer-reviewed results of an international study on remdesivir, as well as other repurposed drugs, enrolling more than 11,000 patients across 30 countries. That study concluded that remdesivir didn’t lower covid mortality.
October 9, 2020
How Arizona squashed its curve
A covid tracking site maintained by public health officials finds that more than 40 states have either uncontrolled spread or are trending poorly in terms of coronavirus cases. (Only Maine and Vermont are trending better.) But an early release of MMWR from the CDC details how Arizona was able to mitigate its summer surge that peaked in late June, turning around a 151% increase in daily cases that occurred after the state’s stay-at-home orders were lifted. The mitigation strategies outlined in the article should come as no surprise: implementation and enforcement of mask-wearing via county and city mandates; limiting public events and closing bars, gyms, movie theaters and water parks; scaling back in-dining capacity to 50%; and encouraging non-essential workers to stay at home. According to the reports, the state’s seven-day moving average of daily cases subsequently fell 75%.
Close to one-in-four covid patients in the ICU throws clots
While doctors have known for months that coronavirus promotes clotting, a meta-analysis provides some percentages for clotting among hospitalized covid patients. Nor surprisingly, the risk for developing clots is highest among ICU patients. The review of more than 60 studies found an overall VTE prevalence of 14%, with 8% of VTEs occurring outside the ICU among patients with mild-to-moderate disease and 23% among patients in the ICU. As for PEs, rates were 4% in non-ICU patients and 14% among the critically ill. The authors call for more research on thromboprophylaxis strategies to improve VTE prevention, and the studies included in the analysis covered about 28,000 patients. Results were published last month in Research and Practice in Thrombosis and Haemostasis.
Monoclonal cocktails, convalescent plasma and remdesivir
Physicians step—or get pulled—into the political fray
With the president hospitalized last weekend for covid, several articles discussed “VIP syndrome” (see here and here), where doctors feel pressured to deviate from standard care for prominent or celebrity patients. The president’s personal physician came under fire for issuing vague details about the president’s use of supplemental oxygen, his X-ray findings and the timeline when he first tested positive. Reports also came out this week that physicians who treated the president at Walter Reed last year during a still mysterious episode were asked to sign non-disclosure agreements, which more than one refused to do. Given the heated run-up to the election, at least one doctor is wondering about the ethics of discussing politics with patients: Are such discussions always taboo, or does he have an obligation to raise political issues that affect patients’ health and health care?
October 8, 2020
NEJM slams national leaders as “dangerously incompetent”
For the first time in the journal’s 208-year history, the editors of the New England Journal of Medicine yesterday stepped squarely into the national political fray. While they stopped short of explicitly endorsing Vice President Joe Biden for president, the editorial they penned claimed that, “We have failed at almost every step” in terms of the U.S. response to the pandemic. The editorial laid the blame for that failure on our current national political leaders, saying those leaders have squandered America’s scientific advantages. As for specific failures, the editors cited inadequate testing nationwide, with testing rates per infected person in the U.S. being lower than in Kazakhstan; inconsistent isolation measures and “lackadaisical” social distancing rules; and the politicization of wearing masks, an impasse the current administration has helped create. “(O)ur current political leaders have demonstrated that they are dangerously incompetent,” the editorial concludes. “We should not abet them and enable the deaths of thousands more Americans by allowing them to keep their jobs.” Last month, the editors of Scientific American likewise broke that mold, backing a presidential candidate—Biden—for the first time in its 175-year history.
October 7, 2020
Covid’s hard neurologic hit
Two new studies zero in on the neurologic impact of covid among hospitalized patients. A prospective observational study of close to 4,500 patients hospitalized with covid in New York City finds that 14% developed a new neurological disorder. That development, according to research published in Neurology, came a median of two days after symptom onset and was associated with an increased risk of in-hospital mortality and of lower odds of hospital discharge. The most common diagnoses: toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%) and hypoxic/ischemic injury (1.4%). Another study—this one in the Annals of Clinical and Translational Neurology—looked at neurologic manifestations in more than 500 covid patients hospitalized in Chicago. Among those patients, more than 80% had some neurologic manifestation ranging from myalgias (45%) and headaches (38%) to encephalopathy (32%). The authors found an association between encephalopathy and both worse functional outcome and 30-day mortality.
Hospital data wars may be heating up
The HHS yesterday announced that it is sending hospitals notices about what the department requires in terms of daily covid reporting. Those notices come with this warning: Hospitals that don’t comply with those requirements risk being tossed out of the Medicare and Medicaid programs. According to the announcement, hospitals have 14 weeks to toe the line, with hospitals expected to report daily on a host of covid-related factors including their number of covid deaths, hospitalizations and ICU patients. In addition, CDC officials say that hospitals must also now start reporting on flu cases. The CMS released its final rule on daily data reporting requirements for hospitals in August.
October 5, 2020
Regeneron’s monoclonal cocktail in the spotlight
Hospitalized with covid, President Trump has received at least three treatments: dexamethasone, remdesivir and an experimental monoclonal antibody cocktail being tested by Regeneron, its manufacturer. The company released a press release with preliminary data about the cocktail only last Tuesday. According to that analysis, the combination (dubbed REGN-COV2) reduced viral load and alleviated symptoms in non-hospitalized patients. The first 275 patients enrolled in the trial were randomized to either a one-time high-dose infusion (8 grams, which is what the president received), a low-dose infusion (2.4 grams) or placebo. All enrolled patients were being treated as outpatients. The New York Times reports that Regeneron and Eli Lilly are “the furthest along” among a host of companies and researchers seeking to develop monoclonal antibodies to treat covid.
Study: Plasma antibodies wane within a few months
Findings published in the journal Blood indicate that covid antibodies in blood plasma begin to decline within three months. While experts are still trying to determine the role of convalescent plasma in covid treatment, a press release put out by the American Society of Hematology notes that, according to the research, donors should have their plasma collected as soon as possible after their recovery. The study, which was done by researchers in Quebec, followed 15 patients who recovered from covid and whose disease ranged from mild to severe. Each patient donated plasma between four and nine times. Half of their detectable antibodies decreased within 21 days, while all 15 showed decreased antibodies at 88 days. In addition to encouraging patients to donate plasma soon after recovery, the authors note that donor plasma should be checked for antibodies before being administered.
October 2, 2020
Home health rebounds, but not SNFs
Given the big drop in inpatient volumes during the shutdown, it’s no surprise that discharges to SNFs and to home health agencies likewise took a major hit. Now, however, an analysis finds that home health is bouncing back but that discharges to SNFs remain well below 2019 levels among Medicare fee-for-service beneficiaries. The report, which was released by health care consulting firm Avalere Health, found that the number of discharges to SNFs remains about 25% lower than before the pandemic, while home health agencies actually had close to 5% more business this June than in June 2019. As for why discharges to SNFs aren’t keeping pace with home health, the report underscores the negative impact covid has had on institutional settings. “(S)ome post-acute providers,” the report states, “may not experience a full return in volume for the remainder of 2020 and into 2021.”
October 1, 2020
Don’t let your guard (or mask) down in the hospital
Boston’s Brigham and Women’s Hospital has gone public with what it says is a nosocomial outbreak of covid that has so far affected 12 patients and 33 hospital employees. The hospital is now testing every inpatient every three days in addition to testing all patients on admission, and MedPage Today reports that the cluster may eventually include more than 650 people. Among contributing factors cited: Staff not maintaining appropriate physical distancing, particularly while they were unmasked and eating together. A hospital press release also noted that many patients weren’t masked during staff interactions and that some providers didn’t consistently use eye protection. The hospital believes the outbreak has been contained within two units, which have been closed for deep cleaning and HVAC inspections, and it is changing seating capacity in breakrooms and workrooms.
Among diabetic patients, sitagliptin linked to lower mortality
A small retrospective study from Italy finds an association between adding sitagliptin to insulin for covid patients with type 2 diabetes and significantly lower mortality. Publishing their results in Diabetes Care, the authors compared 169 covid patients receiving sitagliptin along with insulin to 169 diabetic patients given insulin alone. In the sitagliptin group, the authors found mortality of 18% vs. 37% in the insulin-only arm. The use of sitagliptin was also linked to less risk of mechanical ventilation and to fewer ICU admissions. An analysis of U.K. registry data published in August in The Lancet Diabetes & Endocrinology found a mortality rate of around 30% among covid patients with diabetes.
September 30, 2020
Anticoagulation: Small RCT gives nod to therapeutic dosing
An anticoagulation study in Brazil enrolled only 20 covid patients, 10 each in both the therapeutic- and prophylactic-dosing arm. And three patients on the therapeutic dose died within 28 days vs. only one in the prophylactic arm, although study authors say that difference wasn’t statistically significant. But in their study, which was published by Thrombosis Research, researchers found that therapeutic dosing with enoxaparin improved respiration in patients with severe covid. Higher dosing also led to four times as many patients being weaned from a ventilator and to more ventilator-free days. While none of the patients had major bleeds, more patients in the high-dose group had minor bleeding. News coverage calls the study the first randomized controlled trial on covid anticoagulation and points out that more than 20 trials are now looking into optimal anticoagulation levels in outpatients, inpatients and those in the ICU.
Covid hospital at home proves safe, effective
Denver Health has launched a Virtual Hospital at Home program, one that has allowed the health system to safely monitor more than 200 low-acuity covid patients in their homes without dedicating observation or inpatient resources. Researchers in a letter published in Infection Control & Hospital Epidemiology pointed out that the program was designed for confirmed or suspected covid patients who had at least one risk factor for possible complications but who did not meet admission criteria. Fewer than 14% of the patients enrolled in the program ended up needed higher-level care, with more than one-third of those (39%) being admitted. The lead authors told HealthLeaders that the key to the program’s success was frequent communication, with doctors and nurses checking in with patients via phone at least twice a day and monitoring patients’ pulse, temperature, blood pressure and pulse oximetry. Also important: working with the state’s Medicaid program and Medicare Advantage plans to secure payment.
September 29, 2020
Prominent physicians protest political influence in public health
As concerns about the politicization of health care during a pandemic reach a fever pitch, physicians and medical organizations last week responded with blistering criticism of what they see as the administration’s attempt to politically manipulate the response to coronavirus.
The issue received new attention last week when FDA officials proposed a new rule that would require vaccine makers to wait at least two months after the last administration of their vaccine before they could seek an emergency use authorization from the agency. While the move was backed by physicians including the head of the government’s covid vaccine development program, President Trump said the proposal appeared “political” and threatened that he might not approve it.
Two groups of scientists warned of “alarming” levels of political interference. In statements, scientists at the National Academy of Sciences and the National Academy of Medicine said that political interference “undermines the credibility of public health agencies and the public’s confidence in them when we need it most.” The statement came the day after the President threatened to veto the FDA’s new rules for releasing a covid vaccine.
A viewpoint piece in the JAMA Network looked at the issue of political interference in the CDC’s weekly MMWR reports, which have reportedly been subject to review and revisions from political appointees. The authors call on officials at the CDC and HHS to affirm the agencies’ commitment to science and to strengthen measures to keep MMWR free from political influence in the future.
JAMA Editor-in-Chief Howard Bauchner, MD, hosted a video chat that discussed the implications of even the appearance of political meddling in the work of agencies like the FDA and the CDC. Two public health experts joined Dr. Bauchner to discuss why the reputation of these agencies matters, and how it can encourage members of the public to get a covid vaccine once it is approved. The discussion comes after the HHS secretary earlier this month claimed that he, not the FDA, has the authority to sign new rules on food, medicines and other products.
September 28, 2020
Health care workers: Who’s getting infected?
New CDC data on which health care workers are most likely to become infected come as no surprise: Nurses account for 30% of all covid infections among health care workers, even though they comprise only 15% of the health care workforce. Moreover, two-thirds of infections involved staff working in residential and nursing homes, according to the most recent MMWR. Even staff not providing direct patient care are at considerable risk; the CDC analysis found that 19% of cases were among administrative staff and environmental service workers. Experts believe the count is probably under-estimated. As for protecting medical workers once a safe vaccine is available, panelists told an HHS committee last week that there wouldn’t be enough vaccine initially to cover all front-line health care workers, first responders and nursing home residents. Instead, decisions would need to be made about which groups should have priority.
Risk-scoring tool can help manage hospitalized patients
U.K. researchers say they have developed and validated the most accurate mortality risk-stratification tool to date that can to used to divide covid patients into different management groups. The 4C Mortality Score includes eight variables that are available on admission: age, sex, number of comorbidities, respiratory rate, peripheral oxygen saturation, consciousness level, urea level and C-reactive protein, with points assigned for each variable. Patients scoring as low risk were found to have only a 1.2% mortality rate, while those in the highest-scoring risk group had 62% mortality. The authors points out that patients found to be at low risk may need only outpatient management, while those at intermediate risk could be monitored on the wards. The tool was derived from data from more than 35,000 patients across 260 hospitals in England, Scotland and Wales.
September 25, 2020
Red blood cell changes may pinpoint mortality risk
Researchers have found an association between elevated red blood cell distribution width (RDW) and higher mortality risk in covid patients. Publishing in JAMA Network Open, the authors looked at more than 1,600 covid patients admitted across four hospitals in Boston, defining elevated RDW as greater than 14.5%. An elevated RDW at admission was associated with statistically significant mortality risk (31% vs. 11%), while patients with an elevated RDW at admission were over six times more likely to die within 48 hours (4.9% vs. .8%). “RDW is routinely measured,” the authors wrote, “and may be helpful for prioritizing patients for early, aggressive intervention and managing local hospital resource use.”
Can clinical trials bounce back from covid?
While the pandemic caused inpatient volumes to dry up, another medical enterprise also stalled and may have a hard time bouncing back: clinical trials testing new (noncovid) drugs. Fierce Biotech reports that clinical trial enrollment came to a standstill from March to May. Across 300,000 global clinical trial sites, 28,000 sites are currently suspended, with phase 2 and 3 trials particularly hard hit. According to a report from one clinical trial firm, 125 trials typically complete enrollment every month, but that figure dropped to only 70 in August. Given the economic uncertainty caused by the pandemic and the high cost of clinical development, industry leaders expect biopharma to face significant financial challenges next year.
September 24, 2020
Hospital finances: trouble ahead for for-profit hospitals?
Despite recent news that hospital finances are showing signs of stabilizing, a new report from Moody’s expects for-profit hospitals to see a financial decline over the next 12-18 months as relief funds from the CARES Act start to run out. The analysis says that as surgical procedures migrate outside of hospitals and growing numbers of patients move to lower-paying payers like Medicaid, for-profit hospitals will find their finances stretched thin. Complicating matters is the fact that hospitals also need to spend extra money on PPE like masks, gowns and screening technology. A FierceHealthcare report notes that because not all of the $175 billion that was allocated to health care as part of the CARES Act has been dispersed, those funds could help these hospitals.
September 23, 2020
Most KN95 masks don’t meet U.S. standards
A report from the safety organization ECRI says that 60%-70% of KN95 masks don’t filter 95% of aerosol particulates, failing to live up to their name and U.S. standards. According to Fierce Healthcare, ECRI tested nearly 200 masks that lacked NIOSH certification from 15 manufacturers that provide masks for large health systems. The organization notes that over the last six months, U.S. health care organizations have purchased hundreds of thousands of masks from Chinese companies.
Report: a look at hospitals’ finances during covid
A look at the operations of 275 hospitals during six months of the pandemic gives a snapshot of the financial impact covid is having on health care. The report, from the data company Strata Decision Technology, found that covid inpatients in the top seven DRGs had a 20% higher length of stay than noncovid patients with the same DRGs, which it says justifies increase reimbursement. The report also noted that inpatient procedures and surgeries are still down 19% when compared to 2019, and that the biggest comeback in inpatient services has occurred in medical, not surgical, service lines. Emergency room care, which dropped by 50% during the peak of the pandemic, is still down 25%. The report also says that while outpatient visits were down 56% at the start of the pandemic, they’re now down only 1.5% during the last 30 days. Strata collected the data from hospitals using its data analysis platform, which is used by 1,000 hospitals and health systems.
September 21, 2020
One in 7 covid infections occur in health care workers
New data from the World Health Organization show that worldwide, one in seven covid cases, or 14% of total cases, are health care workers. In some countries, the group says, that number goes as high as 35%. WHO officials say they can’t be sure if health care workers are being infected at work or in their communities, but they called on health care organizations to give frontline medical workers protective equipment. In related news, OSHA last week cited and fined hospitals and healthcare systems in New Jersey and Louisiana for failing to give their employees appropriate PPE during the pandemic. The fines said that the health systems failed to provide properly fitted respirator masks and protective gowns to employees. (In one case, employees had to use gowns that had been previously used by someone else.)
CDC changes course on testing asymptomatic people who have been exposed
The CDC late last week said that people who had been exposed to covid but are asymptomatic should be tested, reversing a policy shift it issued in late August. The agency had originally recommended testing for asymptomatic people with exposure, but on August 24 the agency altered its recommendation, saying those individuals didn’t necessarily need a test. The reversal was applauded by groups like the Infectious Diseases Society of America, which in a statement talked about the “return to a science-based testing guidance. News reports say that the CDC changed its testing recommendations in August over the objections of agency scientists.
September 18, 2020
When vacationers don’t go home, who cares for them?
One unanticipated side effect of covid: Vacationers and second-home owners are thinking of staying at the beach, the mountains or some other get-away instead of returning home to more densely populated urban and suburban areas. As a result, hospitals and health care organizations in those areas are being swamped with a wave of new patients. A Kaiser Health News article says that for now, hospitals and clinics in towns from the Hamptons to the Rocky Mountains have benefited from a new pool of patients as they try to bring in more revenue. Many are worried that with the approach of flu season and a possible rebound in covid rates, however, that they’ll be overwhelmed by spikes in volume that they usually experience only in peak season and around the holidays.
Technology helping hospitals tap into new markets
Hospital volumes are recovering from the lows of the covid pandemic, but even as they show signs of bouncing back, hospitals are learning to continue with telehealth initiatives to keep seeing patients. One report from the American Hospital Association’s annual meeting, held virtually this week, looks at some of the ways hospitals are handling patient reluctance to come to the hospital. A report released by TransUnion Health care says that while inpatient volumes at U.S. hospitals are 8% below pre-covid levels, emergency department visits are down 25%. Hospitals are relying on messages about the safety measures they’re taking to protect patient health, but they’re also continuing to ramp up telehealth initiatives that many accelerated during the pandemic. One report from Healthcare Dive says that hospitals are scaling down their physical footprints and giving patients more virtual options. Hospitals reported that patient satisfaction with telehealth is good, and that telehealth is allowing them to connect with patients who would not have come to the hospital.
September 16, 2020
AMA releases two new codes to bill for covid care
The AMA has published two new codes physicians can use when billing for patient care that involves covid. CPT code 99072 can be used to bill for additional supplies and extra staff time spent staying safe when caring for covid patients. A new lab testing code (86413) can be used for lab tests that provide quantitative measurements of covid antibodies. Both codes went into effect last week and are scheduled to remain in place until the end of the covid pandemic.
September 15, 2020
Masks during covid: shortages, evidence and conspiracy theories
While much of the talk about covid has recently focused on what the public thinks about the vaccines that are being developed, the role of a much lower-tech tool—masks—is still the topic of considerable discussion.
Why mask shortages still persist. More than six months into the pandemic, there’s still a shortage of masks and other PPE in hospitals and medical organizations. Coverage from the Associated Press says that because health care providers have been re-using masks for so long from patient to patient and from shift to shift, it’s difficult to say just how many masks the U.S. health care system needs. And retooling manufacturing facilities to increase mask production is challenging, companies say, because it can take up to a year of preparation. Manufacturers are afraid that by the time they start to increase production, the pandemic will be fading, and they won’t be able to recoup their investments. After the H1N1 pandemic in 2009, demand for N95 masks crashed, leaving manufacturers without a market for their increased supply.
The evidence behind masks. What kind of evidence backs up the effectiveness of masks? According to an article in NEJM Journal Watch by hospitalist Neil Winawer, MD, studies looking at the ability of masks to prevent respiratory diseases like covid are “sparse,” particularly when it comes to using masks to specifically prevent covid (as opposed to other respiratory diseases) in community settings. But the review also says that using masks “makes sense” and points to data that show there may not be a big advantage of using N95 masks instead of surgical masks to prevent covid in community settings. (Data show that in health care settings, N95s are more effective.) And in a point that will be of interest to health care providers, the review notes that no study has evaluated the effectiveness of N95 or surgical masks that are reused.
Can masks reduce the severity of covid? There may not be many randomized, controlled trials looking at masks to prevent covid, but a New England Journal of Medicine article says that epidemiologic investigations in the wake of various pandemics provide strong evidence that masking helps control transmission of the virus. The article also looks at the notion of viral pathogenesis, which says that the severity of disease is related to the viral inoculum that a person receives. The theory is that face masks can filter out droplets containing the virus, thereby reducing the inoculum that an exposed person inhales. The researchers hypothesize that masks could increase the number of asymptomatic infections, something they say is borne out by data from an Argentinian cruise ship. A WebMD article says that while experts emphasize that masks should in no way be considered a replacement for a vaccine, they note that masks still have a big role to play in containing the pandemic by reducing transmission rates and the severity of illness.
Who’s opposing masks? A Medscape article looks at groups opposed to mask wearing and the reasons they give for their opposition to masks. Groups like Million Unmasked Patriots, which have thousands of members, cite concerns that masks obstruct oxygen flow and make children sick from breathing in bacteria. The article also notes that anti-maskers have a lot in common with anti-vaxxers, including their reliance on theories that the pandemic is not real and is instead a creation of people like Anthony Fauci, MD, and Bill Gates. Anti-mask demonstrations around the county have drawn support from anti-vaxxers and incorporated anti-vaxxer messages. Hospitalist Vineet Aurora, MD, co-authored a piece on Kevin MD about the intersection of anti-maskers and anti-vaxxers.
September 14, 2020
A vaccination expert talks about the process of developing a covid vaccine
With AstraZeneca set to resume its covid vaccine trial after a brief setback last week and Pfizer announcing that it will expand the third phase of its trial of a covid vaccine, the race is once again on to develop a covid vaccine. That also means there’s more talk about whether a vaccine can be released sometime this year—and possibly before the election. In an in-depth interview published by Medscape, vaccine expert Paul Offit, MD, talks about the worry of many people that covid vaccines are being rushed through the development process and might not be safe and/or effective. Dr. Offit says that because the vaccines are given in two doses a month apart, it’s unlikely that enough research data will be available to release a vaccine before the end of the year. Dr. Offit, who sits on an FDA advisory committee that will meet in late October to make recommendations about the progress of covid vaccines, also talks about the role of data safety monitoring boards in reviewing and approving vaccines. The interview, which is available as a text article and video, offers some interesting insight into the vaccine development process.
What will convince Americans to get a covid vaccine?
With the public nervous about the development of a covid vaccine, researchers are looking at the most effective ways to convince Americans to actually get a vaccine once one or more are released. A new study on what kinds of messages get through the doubt and mistrust that many people feel about vaccines finds that personal stories do the best in persuading people to get vaccinated, while messages about societal responsibility may actually drive down vaccination rates. In the study, ads featuring stories about real people, like a healthy young person who died from covid, resulted in an additional 5% of people saying they would likely get the vaccine. Messages explaining the benefit of community protection, on the other hand, actually reduced by 1% the number of people who said they would get a vaccine. Researchers say there’s a 69% chance that community benefit messages would create a negative backlash.
September 11, 2020
NIH and pharma reaffirm safety protocols
Testifying before a Senate subcommittee, NIH Director Francis Collins, MD, said that any decisions about the development of a covid vaccine will be based or science or he “will have no part of it.” Surgeon General Jerome Adams, MD, who was testifying at the same hearing, also insisted that “there will be no shortcuts” in the development of a covid vaccine. Finally, the revelation that the AstraZeneca trial of a covid vaccine was temporarily shut down because a subject experienced neurological symptoms was held up as evidence that the development process is following safety protocols. The CEO of AstraZeneca is reported to have said that the trial had been stopped previously in July after another subject experienced neurological symptoms. He also said that a “vaccine that nobody wants to take is not very useful.”
Using robocalls to connect with patients post-discharge
By using robocalls to connect with 80% of its patients post-discharge, Chicago’s Rush University Medical Center has been able to reduce its inpatient readmissions by 6%. According to coverage in HealthLeaders, the academic center started using automatic calls in 2018 after other efforts to reach patients after discharge were unsuccessful. Before patients are discharged, Rush staff tell patients that they’ll receive a robocall and give the name of the service so patients will accept the call. Patients respond to questions by pressing numbers on their phones’ keypads. Nurses triage the responses and get back in touch with patients who are having problems. The article says that by helping identify challenges patients experience after discharge, the system has also improved its covid discharge process.
September 9, 2020
Pharma companies vow to put science above politics when creating a covid vaccine
Nine pharmaceutical companies have banded together to sign a statement indicating they will not put politics ahead of science when it comes to creating and releasing a covid vaccine. The statement said the companies will release a vaccine only after going through large, high-quality clinical trials. A New York Times article notes that goal of the letter was to instill public confidence in the science behind the development of a covid vaccine. Critics of President Trump worry that he’ll prematurely release a covid vaccine to help with his re-election chances. The nine companies did not rule out seeking an emergency use authorization from the FDA, which could allow a vaccine to be released before all of the standard phases of clinical research were complete.
Will primary care survive the financial impact of covid?
A new survey found that 20% of primary care physicians were considering leaving primary care because of the financial fallout of covid, and 13% were unsure of their futures in medicine. The survey, which was conducted by the Larry A. Green Center and Primary Care Collaborative, also found that in August, 2% of primary care practices had closed and another 2% were considering bankruptcy. According to coverage from FierceHealthcare, 21% of the physicians surveyed have had layoffs or furloughs, 28% have seen a revenue drop of 30%-50%, and 24% have shut down quality initiatives that started before the pandemic.
September 8, 2020
Covid fatality rate for seniors 2.5 times higher than for influenza
Researchers studying seniors in Indiana found that the death rate from covid increases with age in older Americans and is 2.5 times higher than the rate for seasonal influenza. According to an article in Annals of Internal Medicine, researchers estimated that among noninstitutionalized residents of Indiana 12 and older, the fatality rate from covid was 0.26%. For people 60 and older, that rate jumped to 1.71%. By comparison, fatality rates for seasonal influenza among seniors is 0.8%. Researchers also found that the mortality rate is also three times higher for nonwhite people.
Saliva test for covid gets high marks from new study
A saliva test for covid developed at Yale Hospital may outperform the nasal swabs that many people find uncomfortable. A letter published by the New England Journal of Medicine described testing 70 patients who had already tested positive for covid. They found at one to five days after diagnosis, 81% of the saliva test samples were positive. By comparison, 71% of the nasal swabs came back positive.
September 4, 2020
Is a covid vaccine coming to the U.S. this fall?
An announcement from the CDC is raising concerns that the development of a covid vaccine is being influenced by politics. Last week, the agency asked states to prepare to expedite applications for vaccine distribution facilities so they can be operational by Nov. 1. The CDC noted that a vaccine or vaccines will either be approved by the FDA or authorized by an emergency use provision. Anthony Fauci, MD, explained in an interview with Kaiser Health News that a covid vaccine could be available this year if clinical trials produce “overwhelmingly positive results.” While two trials of 30,000 volunteers are ongoing, Dr. Fauci said that an independent board could end the trials weeks early if the interim results are either overwhelmingly positive or negative.
Steroids get boost from WHO, but there’s a warning
The World Health Organization this week released a meta-analysis of seven trials that found that giving steroids to inpatients with covid reduced the risk of death by one-third. Experts say that the study makes steroids the only therapy shown to improve the odds of survival for critically ill covid patients. Another study in JHM found that while patients with a markedly elevated CRP may benefit from glucocorticoid treatment, the therapy may harm patients with lower CRP. Researchers from Montefiore Medical Center found that treating covid patients with steroids within 48 hours of admission didn’t produce an association between early use and benefits in terms of lower mortality or fewer intubations. However, patients with an initial CRP of 20 mg/dL or more had significantly reduced risk of mortality or ventilation, while early steroid treatment in patients with a CRP of less than 10 mg/dL was linked to significantly higher risk.
U.S. hospitals say “not yet” to convalescent plasma
Up to 45 hospitals around the country may ignore a decision by the FDA granting emergency use of plasma from recovered covid patients to treat the disease. According to an article in HealthLeaders, dozens of hospitals are instead considering collaborating in a randomized, controlled trial—but avoiding or minimizing the use of convalescent plasma. The FDA last week granted emergency authorization to the use of convalescent plasma, but the decision raised concerns that the agency was caving to pressure from the Trump administration. A NIH panel said that the therapy should not be considered the standard of care until clinical trials provide more data. A trial of convalescent plasma is being sponsored by Vanderbilt University Medical Center.
Nurses say that mask shortages still a big problem
A survey of more than 20,000 nurses finds that more than two-thirds of nurses are being forced to reuse N-95 masks and that 58% are having to reuse them for five days or more. The survey found that overall, 62% of nurses feel unsafe reusing masks. Nursing leaders say the data are disturbing because they show that more nurses say they are reusing masks than when similar questions were asked in May. One respondent said that the nurses on her unit at a large hospital in Texas are still using the same five masks they were given back in March.
Are you being shunned because of covid?
A survey of Americans and Canadians found that one-third of respondents avoid health care workers because of fears about getting covid, and that one-quarter think the rights of health care personnel should be restricted to protect others. (Thirty-one percent believe that health care workers who treat covid patients should be separated from their families.) The data, which were reported in the Journal of Anxiety Disorders, found that one-third of respondents did not want to be around health care workers, while 32% thought that people who worked in hospitals likely have the virus.
September 2, 2020
Who will be first in line for the covid vaccine?
As the drugmaker AstraZeneca begins to enroll 30,000 subjects in a phase 3 trial of its covid-19 vaccine candidate (AZD1222), an advisory group has recommended that the first covid vaccines should go to frontline health care workers and first responders. The National Academies of Sciences, Engineering and Medicine recommends that after the initial “jumpstart phase,” people at the greatest risk of severe health outcomes from the virus and older adults living in long-term care facilities should be the next in line to receive the vaccine. While the report estimates that latter group accounts for 15% of the U.S. population, the first batch of covid vaccine will likely cover only about 5% of the population. The second phase of the vaccine is expected to cover 30%-35% of the U.S. population. The report recommends that during phase 2, priority access to the vaccine be given to critical risk workers at high risk of exposure (people working in meat processing plants and grocery stores).
Health care workers being shunned because of covid?
A shocking new study of Americans and Canadians finds that one-third of respondents avoid health care workers because of fears about getting covid and that one-quarter believe that the rights of health care personnel should be restricted to protect others. (Thirty-one percent believe that health care workers who treat covid patients should be separated from their families.) According to a report from Medscape, researchers from the University of British Columbia in Vancouver expected some avoidance of health care personnel, but they were surprised by the data. The data, which were reported in the Journal of Anxiety Disorders, found that one-third of respondents did not want to be around health care workers, while 32% thought that people who worked in hospitals probably had the virus. The study also found that even members of the public who participated in nightly shows of public support for health care personnel were just as likely to stigmatize those workers. CDC data show that 89% of covid cases did not occur in health care workers.
September 1, 2020
Remdesivir gets expanded approval from FDA
On Friday, the FDA expanded its emergency use authorization for the drug remdesivir. The expanded approval now covers the inpatient treatment of all adults and children with covid, regardless of the severity of their disease. The previous authorization initiated in May approved the drug for severe covid, which included patients with low blood oxygen levels and individuals who needed mechanical ventilation. The decision was based in part on the results of an open-label trial conducted by Gilead, the manufacturer of remdesivir.
Is covid going undetected in health care workers?
A new study indicates that covid testing may be missing the disease in front line health care workers. CDC data analyzing more than 3,000 health care workers found that 6% tested positive for covid antibodies, but almost one-third of those individuals did not recall feeling symptoms of the disease. Half didn’t suspect ever having the infection, and two-thirds didn’t have a positive test for covid. The presence of antibodies was lower in people who said they always wore a face mask while caring for patients (6%) compared to those who did not (9%).
Covid will be the third leading cause of death in 2020
The National Safety Council last week said that covid is on track to become the third leading cause of death in the US this year, behind only heart disease and cancer. That would make the virus more deadly than preventable deaths, a category that includes drug overdoses, car crashes and falls. Covid deaths in 2020 (more than 170,000) have already surpassed preventable deaths in 2018 (167,000), the last year for which data are available.
Today’s Hospitalist has been reporting on covid-19 since January 2020. Click here for earlier updates.