For more recent updates on covid-19 and how it has affected the health care industry and hospitalists, click here: Special report: Covid-19.
November 30, 2020
No good news in revised CDC forecasts
It remains to be seen if a Thanksgiving surge of cases materializes. But the CDC has crunched more than two dozen models to come up with a revised forecast for new cases in four weeks. During the week ending Dec. 19, the CDC predicts there will be between 1.1 million and 2.5 million new cases. (The Web site includes links to state and county forecasts as well.) The models used in the national forecast make different assumptions about social distancing measures. As for deaths, the CDC’s forecast relies on three dozen different models. The agency’s prediction: Covid deaths will rise over the next three weeks, with between 10,400 and 21,400 deaths the week of Dec. 19. That week, the overall death toll in the U.S., according to the CDC, will total between 294,000 and 321,000.
CMS moves to boost hospital capacity
In response to rising numbers of covid hospitalizations, the CMS has signed off on a number of relaxed regulations, all designed to increase hospital capacity. The CMS is expanding its Hospitals Without Walls program to make it easier for facilities to establish hospital at home capability to treat patients with 60 different conditions outside the hospital. Participating hospitals must have screening protocols and at-home needs assessment, and patients may be admitted only from EDs or hospital beds. Patients first need to be evaluated in person by a physician, and either RNs or paramedics must provide two in-person visits daily. (Hospitals that want to participate should file a waiver request <a href=https://qualitynet.cms.gov/acute-hospital-care-at-home >here</a>.) The CMS also announced more flexible regulations for ambulatory surgery centers, allowing them to be temporarily certified as hospitals and to provide care to patients for 24 hours or longer.
November 25, 2020
Plenty of ventilators, not enough clinicians to operate them
While hospitals were desperate to find ventilators in the spring, the national supply now seems OK. Instead, the problem is finding enough pulmonologists, respiratory therapists and clinicians with critical care experience to operate them. The New York Times reports that device manufacturers in the U.S. have produced more than 200,000 ventilators since the spring, with 155,000 of them going to the National Strategic Stockpile. Meanwhile, doctors have been using other methods to get oxygen to hospitalized patients. But now, hospitals are again strained, particularly in rural areas that don’t have ICU personnel. Currently, there are only 37,400 intensivists in the country, and close to half of the nation’s hospitals have none on staff; even in hospitals with ICU staff, that staff is burning out. In other staffing news, more than 900 staff members at Mayo Clinic’s Midwestern facilities have been infected with covid—within the last two weeks. That’s close to a third of all Mayo staff members who have become infected since the beginning of the pandemic. MedPage Today reports more than 90% of those infections were contracted in the community.
Controversy over remdesivir
While it is now routinely used in hospitals to treat covid patients, remdesivir is not getting the WHO’s endorsement. Last week, the global health organization recommended against using remdesivir in hospitalized patients, saying evidence doesn’t uncover any mortality or outcomes benefits. Many infectious disease experts, however, back the drug’s use, saying it may improve some patients’ clinical course, especially when used early in the disease. The IDSA this week released revised guidelines that advised using remdesivir in hospitalized patients with severe disease. The guidelines also recommended against routine use of the two monoclonal antibodies the FDA recently issued EUAs for. The guidance did note that those therapies may be appropriate for patients at higher risk of covid complications.
The link between viral load and mortality
New research from the University of Washington published in Open Forum Infectious Diseases adds to evidence of an association between viral load on admission and patients’ odds of 30-day mortality. The retrospective study of more than 180 patients found that those with a high covid viral load on admission (a cycle threshold of less than 22) had more than a four-fold greater risk of dying within 30 days. The research also found that patients who were IgG seropositive had less risk of mortality, although those findings weren’t significant—which may be due, the authors noted, to the small sample size. “Our work illustrates,” they wrote, “the importance of quantitative virologic and serological testing for SARSCoV-2 infection.”
November 24, 2020
And then there were three
AstraZeneca yesterday announced that its vaccine candidate, one developed with Oxford University, was up to 90% effective, based on interim results of phase 3 trials. But the 90% rate was based on administering first a half-dose, then a full dose; when two full doses were used, the vaccine was only 62% effective. STAT reports that the U.S. trial for AstraZeneca is testing two full doses—but that regimen may soon change. This makes AstraZeneca’s the third vaccine candidate, after Pfizer-BioNTech and Moderna, to publish trial results within the last two weeks. According to reports, AstraZeneca-Oxford’s has some advantages: For one, it’s expected to be cheaper at about $2.50 a dose, while Pfizer’s may cost about $20 per dose and Moderna’s between $15 and $25. Also, it can be stored in refrigerators; Moderna’s can remain in regular refrigerator temperatures for only 30 days (otherwise, it needs to be frozen), while the Pfizer-BioNTech vaccine needs ultra-low temperatures.
Death rates are falling
Covid deaths are the rise, but at least a higher proportion of patients are surviving the disease. Experts say that falling mortality rates are due to better understanding of the disease and its potential treatments, as well as to younger patients now becoming infected vs. more older patients earlier this year. However, one factor that’s contributed to improved mortality rates is hospitals not being as inundated as they were in the spring with covid patients—an advantage that’s now evaporating. According to one analysis, the mortality rate among hospitalized covid patients fell from 11.4% in March to below 5% in June and 3.7% in September. The same analysis also found length of stay also dropping, from 10.5 days to 4.6. A recent JHM analysis based on data from three New York academic centers found that their adjusted covid mortality fell from 25.6% in March to 7.6% in August.
November 23, 2020
New treatment options
It may become known as the Trump cocktail: The FDA this weekend issued an emergency use authorization for the monoclonal antibody combination—casirivimab plus imdevimab—that the president received last month after his covid diagnosis. The treatment is not authorized for hospitalized patients or those who need supplemental oxygen. Instead, it’s intended for patients with mild to moderate disease who are at high risk of developing severe disease, including those age 65 and older. The IV antibody has been authorized for patients 12 and older who weigh at least 40 kg. The Hill reports that the combo’s manufacturer, Regeneron, believes 80,000 doses will be available by the end of this month and 300,000 by the end of January. The FDA also issued an EUA for this combination: baricitinib, an oral janus kinase inhibitor, and remdesivir. This treatment is authorized for hospitalized patients age 2 and older who need supplemental oxygen, invasive ventilation or ECMO. In a randomized trial of 1,000 hospitalized patients, patients taking that combo (vs. remdesivir plus placebo) had a shorter time to recovery and less risk of mortality or need of mechanical ventilation within 29 days.
You’re in a distinct minority
Plenty of articles have described shortages of PPE, ventilators and ICU beds. Now, as the latest covid surge bears down nationwide, new attention is being paid to another resource in short supply: inpatient physicians with experience treating hospitalized patients. UPenn researchers analyzed 2017 Medicare fee-for-service billing data on close to 600,000 physicians. They found 45% of physicians had billed hospital visits while 7% had billed for critical care. (Those billing for ED visits were excluded from the analysis.) However, many—17% for hospital visits, 43% for critical care visits—performed 50 or fewer of those visits that year. Two of the same researchers published an analysis in Healthcare that looked at regional physician workforce estimates in conjunction with predicted peak covid hospital volumes. In an article those authors wrote for STAT News, they write that 35 states may face a shortage of inpatient physicians with recent experience treating hospitalized patients. Hospitals anticipating a shortage, they write, should implement training protocol to help prepare doctors who aren’t hospitalists to work in the hospital. A UPenn brief synthesizing both studies is available here.
November 20, 2020
Considering “contingency” and “crisis standards”
As the country surpasses 250,000 covid deaths, The Atlantic reports what many of you already know: Hospitals are either at capacity, experiencing staffing shortages or both. Currently, more than one-in-five hospitals (22%) across the country expects to be short-staffed. That rises to 35% in Arkansas, Missouri, North Dakota, New Mexico, Oklahoma, South Carolina, Virginia and Wisconsin, with all indications that the number of covid hospitalizations is accelerating and will continue to rise. In an article in The New Yorker, a New York-based hospitalist writes that hospital leaders in Utah are considering new standards of care. One, the contingency standard, will take effect when ICUs are overwhelmed and clinicians from other specialties need to treat those patients. The second is the “crisis standard,” where hospitals need to ration ICU care. As part of those decisions, clinicians will weigh patients’ comorbidities and give preferential treatment to younger patients and those who are pregnant. Already, rural hospitals in the Midwest and Plains states are finding few transfer options. That’s because the larger hospitals they typically transfer to are either full themselves or are understaffed due to infections. For one critical access hospital in Kansas, the only large hospital it can transfer patients to now is six hours away.
Data reveal only modest cardiovascular complications
The first results of analyses done on the covid registry maintained by the American Heart Association delivers this good news: Hospitalized covid patients are having fewer cardiovascular complications than researchers expected to find. However, the results also underscore the high risk among minorities and patients who are obese. The database includes information on more than 22,000 patients, with data supplied by more than 100 hospitals and academic centers. What the analyses found: Eight percent of hospitalized covid patients had a composite rate of CV death, stroke, MI, heart failure and shock, with atrial fibrillation being reported in 8% as well. Less than 4% had DVT, PE or MI, while fewer than 2% of patients had stroke or new heart failure. Meanwhile, myocarditis was found in 0.3%. However, 43% of hospitalized covid patients were obese, a differential seen especially in patients age 50 and under. While African-Americans make up just over 10% of the population, they represented 26% of cases and 24% of deaths. Hispanics, who make up only 9% of the census, accounted for 33% of cases and 29% of deaths. The AHA is inviting researchers to submit research proposals to use the nationwide covid dataset. The deadline for proposals is Wednesday, Dec. 2.
Getting together for Thanksgiving?
If you’re planning an in-person Thanksgiving with friends and family, here’s the CDC’s advice: Don’t. The safest way to spend the holiday, according to the CDC, is with members of your own household only. If you do host people who don’t live with you, limit their number and eat outdoors, in addition to masking and physical distancing. If you’re going to someone else’s home, bring your own food, drinks, plates and utensils—and if you are planning to travel, you should already be in quarantine. One Mississippi newspaper went with this headline: “After Big Thanksgiving Dinners, Plan Small Christmas Funerals, Health Experts Warn.” A survey done by Ohio State Wexner Medical Center finds that almost 40% of people are planning to attend events with more than 10 people over the holidays; a third of them didn’t intend to ask guests to wear masks. And Georgia Tech has devised a real-time, interactive Web site that allows you to gauge your risk of being with infected people at events. (Find the related study in Nature Human Behaviour here.) Put in the estimated number of people at the event and click on the county where it’s being held, and you’ll see your risk of being with at least one covid-positive person.
November 18, 2020
Rural hospitals are running out of transfer options
As hospitals throughout the Midwest and Plains states become overwhelmed, Fierce Healthcare reports rural hospitals that typically transfer out patients who need higher level and critical care now find dwindling options. That’s because the larger hospitals they transfer to are either full themselves or have lost staff due to infections or quarantines. As a possible solution, some rural hospitals are considering working together to designate some facilities as covid-only hospitals while others would treat only non-covid patients. For one critical access hospital in Kansas mentioned in the article, the only large hospital it can still transfer patients to is six hours away.
More good news on vaccines
It’s another big week for vaccine news. On Monday, biotech Moderna announced (via a press release) that its mRNA vaccine candidate shows an efficacy rate of better than 94%. The company is also stressing this feature: Unlike the Pfizer-BioNTech candidate, which needs to be stored at ultra-cold temperatures, Moderna’s is stable for up to 30 days in a normal refrigerator. Pfizer-BioNTech came back today with its own announcement, saying its data indicate a 95% efficacy as well and that the two companies plan to apply for an FDA EUA within a matter of days. According to the announcement, the Pfizer-BioNTech data includes two months of follow-up. While the news and the two vaccines’ safety profiles are encouraging, it’s still unknown when either candidate (or any of the others being developed) would be available. STAT News reports that the FDA is expected to issue EUAs, which would allow some vaccine to be distributed to front-line workers and patients at high risk for severe disease before the end of the year. General distribution would have to wait until next spring.
The most hopeful answer yet to the question of how long immunity lasts after being infected with coronavirus comes in a new preprint. According to New York Times coverage, the new data are also the most comprehensive. In the study, researchers recruited close to 200 patients who’d recovered from covid; the majority had mild disease and weren’t hospitalized. Researchers analyzed subjects’ blood samples, some for eight months, and they found four immune components: antibodies, B cells and two types of T cells. While antibodies were durable, the T cells decayed only slightly over those months—and the B cells actually multiplied, a result the authors can’t explain. While a small number of recruited subjects were found to not have long-term immunity, that may have been a function of how little virus they were exposed to.
November 16, 2020
Philly-area nurses contemplate a strike
Two thousand-plus nurses in southeastern Pennsylvania may strike this week, citing their hospitals’ “unsafe staffing that seriously undermines patient safety” during the pandemic. Nurses at one Philadelphia-area hospital avoided a strike with a new contract that boosted pay and staffing levels. In North Dakota, the lack of hospital capacity is so constrained that the governor proposed allowing health care workers who’ve tested positive to continue working with covid patients; the state’s nurses association rejected that proposal. The Washington Post reports that the lack of hospital capacity is especially dire in the upper Midwest and Plains states, which lead the country in both covid deaths and new cases. That’s a preview, experts say, of what the rest of the country can expect over the next several weeks. Already, critical access hospitals in the region that want to transfer out critically ill patients can’t find anywhere to send them. An article in The Atlantic points out that exhaustion is setting in for health care workers who’ve already worked through two waves and are now looking at something worse. While the rest of America digests election results and plans Thanksgiving, health care workers “do not have the luxury of looking away.” Iowa has run out of staffed beds, and smaller hospitals can’t attract traveling and ICU nurses, who are being lured away by higher pay in cites.
November 13, 2020
A staggering surge in coronavirus cases saw more than 150,000 new cases being reported yesterday and more than 66,000 hospitalizations. While many outbreaks in the spring were linked to nursing homes and large events, public health officials say that new cases now can be traced to small private gatherings among family and friends. States are stepping up with new restrictions, including a 10-person limit in private homes in New York, while some Oregon counties are limiting gatherings to six people. The Seattle Times reports that several big hospitals in Oregon are already limiting elective procedures in an effort to free up hospital space for an anticipated surge. Earlier this week, the incoming administration of the president-elect announced the formation of its transition covid advisory board, a group of 13 doctors, scientists and public health officials.
How safe is that gown?
The bad PPE news a month ago was that up to 70% of KN95 masks didn’t meet filtration standards, according to safety organization ECRI. Now ECRI has turned to disposable gowns and filed this report: More than half the isolation gowns it tested failed safety standards. ECRI tested more than 170 gown samples that hospitals were buying outside their regular supply chains or from international sellers. Some gowns didn’t come with a specified level of protection; of those, 52% failed even the lowest industry standard. Of the ones labeled with a protection level, half didn’t meet that stated level. MedPage Today reports that the subpar gowns failed either a splatter test, a hydrostatic pressure test or both. ECRI’s advice: Don’t buy gowns from unfamiliar suppliers. The organization also supplied a link to its Gown Testing Summary with the manufacturer and model names of the gowns tested.
Preprint: Eight-day quarantine may be as effective as two weeks
The CDC recommends that people exposed to covid quarantine for two weeks. But researchers publishing in a preprint say that an eight-day quarantine, with testing on day one as well as on day seven before leaving quarantine on day eight, is just as effective as staying in isolation for 14 days without testing. To come up with that recommendation, the authors combined data on infectivity, PCR accuracy and covid incubation periods. They also validated their strategy by testing offshore drilling company employees, who need to remain quarantined in hotels before going to a drilling site. According to coverage of the study, the findings underscore the importance of testing before ending quarantine.
November 10, 2020
Vaccine breakthrough? Plus, EUA for antibody treatment
Early trial results released yesterday from Pfizer and BioNTech indicate that the vaccine the two companies are developing has a 90%-plus efficacy a week after a second dose. Experts caution that no one knows how long the vaccine may last and that key long-term safety data still need to come in. The phase 3 trial has enrolled about 44,000 volunteers, with 39,000 having received both doses. Trial enrollees need to be observed for at least two months after their second dose, and this particular vaccine is not being tested in children. The encouraging news comes at the same time as a STAT-Harris poll shows that 60% of Americans say they are likely to get a vaccine if it cuts their risk of becoming infected by at least half. While the vaccine manufacturers haven’t yet applied for an emergency use authorization, the FDA yesterday issued an EUA for Eli Lilly’s monoclonal antibody treatment. The investigational therapy, called bamlanivimab, is being authorized to treat mild-to-moderate covid in both adult and pediatric patients (age 12 and older). An FDA press release notes that the agent is not authorized for covid patients who are hospitalized or who need oxygen therapy.
Nearly one in 10 covid patients is readmitted
As if readmissions overall weren’t bad enough, a new CDC analysis finds that 9% of all covid patients are readmitted to the same hospital within two months—and that 2% of patients had multiple readmissions. Readmission risk factors include being 65 or older; having COPD, heart failure, diabetes or chronic kidney disease; being hospitalized within three months before the index covid hospitalization; and being discharged to either a SNF or home health care. The median time from discharge to first readmission was eight days. The analysis looked at about 126,000 index hospitalizations between March and July, with about 15% of those patients dying in the hospital. According to the report, the results underscore the need for careful planning, discharge disposition and post-acute follow-up.
The ACA’s (latest) day in court
The Supreme Court today will hear arguments about the ACA, the third time the 2010 law has come up in front of the nation’s highest court. This time, in the case of California vs. Texas, the court will decide whether to uphold a lower court’s ruling that the ACA’s individual mandate—one requiring everyone to maintain health insurance—is unconstitutional, thereby invalidating the entire law, or if the insurance requirement can be considered separately from the rest of the ACA. The court’s decision will come at a time when contracting covid would be a pre-existing condition and fall under the ACA’s protection for pre-existing conditions. Should the ACA be struck down, those infected could have a hard time maintaining insurance, while an additional 20 million American could lose their health insurance.
November 9, 2020
Incoming administration names covid transition advisory board
With election results called Saturday morning, the incoming administration this morning announced the formation of its transition covid advisory board. The group of 13 doctors, scientists and public health officials will be co-chaired by Vivek Murthy, MD, a former hospitalist and surgeon general; David Kessler, MD, a former FDA commissioner; and Marcella Nunez-Smith, MD, MHS, a public health researcher. Among the advisory board’s 10 other members: UPenn’s Ezekiel Emanuel, MD, PhD; Atul Gawande, MD, MPH, of Harvard and Brigham and Women’s Hospital; Michael Osterholm, PhD, MPH, from the University of Minnesota; and Robert Rodriguez, MD, a UCSF professor who works in the ED and the ICU of two trauma centers. The panel will advise on the incoming administration’s pandemic response including vaccines, testing and contact tracing. Several panel members have counseled the incoming administration during the campaign.
Nursing home cases in hard-hit states start to surge
This weekend, AP reported that nursing home cases in states with covid surges have risen more than four-fold. That’s according to an analysis of May-October data from close to two dozen states. While resident deaths in those facilities have more than doubled over that time, weekly cases have more than quadrupled. The current administration has tried to protect nursing homes, allocating $5 billion as well as fast-test machines and PPE. But experts believe that infected staffers—pre- or asymptomatic—are bringing the infection in. While residents of nursing homes and other long-term facilities make up only 1% of the U.S. population, they account for 40% of covid deaths.
November 6, 2020
Study: Ultrasound bests X-rays in screening for covid pneumonia
Findings presented by Temple University researchers at last month’s ACEP virtual meeting indicate that portable ultrasound was more sensitive than X-ray in detecting pneumonia in patients with suspected covid. According to MedPage Today, ultrasound sensitivity in patients with possible covid was 97.6% vs. 69.9% for chest X-ray. (Specificity was lower: 33.3% with ultrasound vs. 44.4% for X-ray.) The research tracked more than 140 ED patients who all received both ultrasound and X-rays. Those at high risk or with abnormal findings then went on to have a CT scan and most were admitted, while those with negative findings were typically discharged home. The authors note that patients with possible covid at their hospital now are routinely screened with ultrasound scans, not X-rays.
CMS fines half of all hospitals
In its ninth annual round of readmission penalties, the CMS is lowering Medicare payments for almost half of all hospitals, due to excess readmissions. Retroactive to Oct. 1, Medicare will lower a year’s worth of payments to 2,545 hospitals, Kaiser Health News reports, with an average reduction of 0.69%. More than 600 hospitals will be penalized 1% or more, although the number of hospitals receiving the maximum penalty—3%—fell from 56 this past fiscal year to 39. This latest round of readmission penalties was announced despite the fact that the CMS wrote in September that it is thinking of suspending that program, given all the problems caused in hospitals by the pandemic and this spring’s suspension of elective procedures.
November 5, 2020
An horrendous milestone, and some good news on myocarditis
The number of new infections in the U.S. on Wednesday topped 100,000 for the first time, a frightening threshold–and then smashed through that record on Thursday, with more than 120,000 new cases. Those numbers are part of a seven-day average that is 108% higher than just a month ago, with more than 52,000 infected patients currently hospitalized. There is this ray of good news: Fewer covid patients than previously estimated may have myocarditis. Findings reported in Cardiovascular Pathology indicate that, among autopsies of close to 300 covid patients, the rate of heart inflammation ranged between 1.4% and 7.2%. Previously reported rates ran from 14% in athletes positive for covid to 60% in middle-aged and senior patients who recovered.d between 1.4% and 7.2%. Previously reported rates ran from 14% in athletes positive for covid to 60% in middle-aged and senior patients who recovered.
Staff exhaustion, and treacherous work for “travelers” (updated)
November 3, 2020
Where’s the hidden hospital data?
HHS continues to collect data daily from individual hospitals on everything related to covid, from the number of daily admissions to ICU capacity. But NPR now reports that the administration is no longer sharing those data with the public or researchers. Instead, the analysis of the hospital data being collected is being circulated only among “a few dozen staffers,” including those from the HHS, the CDC and the NIH. Critics say that not making those data widely available will block efforts to craft an appropriate local response and make it harder to predict which hospitals and health systems are at risk of being overwhelmed. The issue of daily hospital data has been controversial since the administration changed data collection from the CDC to HHS in July. HHS has since cracked down on hospitals that aren’t complying with daily reporting, warning that hospitals out of compliance may eventually be terminated from the Medicare and Medicaid programs.
A break room outbreak
A hospital in western Massachusetts is reporting an outbreak among 15 employees—and has noted that the cluster is probably due to staff eating together in a crowded break room. Among the infected at Holyoke Medical Center, 10 worked in the ED. The hospital has since put new capacity limits on break rooms, according to a statement from the hospital CEO. He pointed to what he called “covid fatigue,” suggesting that some staff members may be lulled into letting their guard down in terms of appropriate physical distancing and PPE. The hospital statement didn’t mention how big the break rooms are or what the new capacity threshold is.
November 2, 2020
Worst pandemic week yet
The New York Times on Friday described last week as the U.S.’ worst pandemic week yet. More than 500,000 new cases had been identified over the previous seven days, for a total of more than 9 million cases since the pandemic began, and record-breaking numbers of new cases continued over the weekend. Unlike other surges, this one isn’t confined to just a few cities or regions but is producing outbreaks around the country. As if the pandemic wasn’t overwhelming enough: U.S. hospitals are now dealing with a rash of ransomware attacks, with several hospital systems—in Pennsylvania, New York, Vermont and Oregon, among others—attacked last week. Hospitals being hacked may need to divert patients elsewhere while patients may see delays in care.
October 30, 2020
Shorter incubation period linked to more severe disease
While incubation periods show a lot of variability, new research from China concludes that clinicians should focus more attention on patients with shorter incubation periods before symptom onset. The study of 330 patients hospitalized with covid found that those with a shorter incubation period—defined as less than three days between exposure and symptom onset—were more likely to have aggravated lung involvement on CT scan than those with incubation periods of more than 10 days. While the median incubation period in the study was seven days, 17% of patients had symptoms within three days while 23% didn’t develop symptoms for more than 10 days. The study appeared in Virulence. Of note: While the authors acknowledged problems arriving at precise incubation periods, exposure times were determined via medical history—and via big data and artificial intelligence from closed-circuit televisions, smartphones, mobile payments, and high-speed rail or airplane records.
Colorado CMOs share expertise, resources, best practices
When the pandemic broke out in March. the CMOs and CCOs of seven Colorado health systems decided to band together to share best practices as well as information about their individual supply chains and staffing challenges. In a commentary they published in NEJM Catalyst, the seven CMOs write that their collaboration played a part in that state’s rapid de-escalation of infection, hospitalization and death rates. Between March and July, the seven health systems combined treated 98% of the state’s hospitalized covid patients. The physician executives met virtually for an hour every weekday and shared their hospitals’ or health systems’ dashboards on implemented policies and supply inventories and burn rates. The partnership allowed those systems to share and redeploy resources—including staff, ICU beds, ventilators and medications—to hotspots around the state
October 28, 2020
Covid surges: Can regional hospitals keep up with demand? (Updated)
The fall covid surge is here with a vengeance, as close to 70,000 new cases are being reported per day and officials in at least four states—Colorado, Texas, Massachusetts and Idaho—impose new restrictions on social gatherings, businesses and schools. With nearly 43,000 patients hospitalized around the country, regional hospitals throughout the Midwest and Plains states are being strained as rural hospitals with fewer resources keep sending patients. According to the New York Times, that strain is becoming critical in Idaho, Missouri, New Mexico and Utah, while health workers from around Texas are converging on El Paso to help with that outbreak. Research done at Vanderbilt on covid caseloads in Tennessee hospitals finds that hospitals in areas without mask mandates are seeing much higher hospitalization rates. Other findings released this week, these from the University of Kansas, found a 50% reduction in covid spread in counties in Kansas that mandate masks vs. those that don’t.
More clues on how long antibodies last (Updated)
Recent studies offer differing views on how long antibodies last in covid patients after they’re infected. One preprint out of Britain reports that antibody levels fall about 27% over a three-month period. In response, experts point out that such a reduction is normal after an infection. Another study, this one published in Nature Microbiology, had U.K. researchers following 65 covid patients for up to three months after symptom onset. They found that patients with a high-peak infective dose (ID50 of more than 10,000) maintained neutralizing antibody titers of 1,000-plus for more than 60 days, while those with lower peak infective doses had their neutralizing antibodies return almost to baseline. The findings suggest, say the authors, that people may need vaccine boosters for longer-term protection. But a third study finds that neutralizing antibodies persist for at least five months. The authors analyzed data on more than 30,000 patients with mild to moderate covid who were screened at New York’s Mount Sinai. They found that the “vast majority” had robust IgG responses, with titers remaining “relatively stable for several months.” Results were published in Science.
October 27, 2020
Can the pandemic drive creative change?
Covid’s disruptions and distress have all added up to trauma for the U.S. (and global) health workforce. Can any good come out of that? According to the authors of a recent JAMA viewpoint, the pandemic may spur posttraumatic growth, which they characterize as psychological changes achieved after going through severe adversity and accepting it as the new normal. To facilitate that growth, health care workers and organizations need to assess the impact of the pandemic, seek out role models (or best practices in groups) that have grown through their handling of the crisis, be creative when looking for new ideas and structures, emphasize altruism and connections, and deal with loss and grief. Hallmarks of that growth include stronger relationships, willingness to embrace new possibilities, improved perception of personal strength, heightened spirituality and an increased appreciation of life. “Posttraumatic growth does not minimize the seriousness and severity of what has happened,”; the authors write, “but can emerge from adversity through active management following the important process of grieving.”
October 26, 2020
Bad trends getting worse
Nothing but bad news on covid cases and hospitalizations: On both Friday and Saturday, the U.S. posted more than 83,000 new covid cases, the two highest single-day tallies since the beginning of the pandemic. As for hospitalizations, the New York Times reports that those figures have jumped 40% over the past month, rising to more than 41,000. While the overall number of hospitalizations was higher this spring, the burden of care is now falling on smaller hospitals in the Midwest and Mountain states, which have many fewer beds than urban academic centers. A modeling study released in Nature Medicine by the University of Washington’s Institute for Health Metrics and Evaluation lays out three possible scenarios for this winter. The first: States continue to ease physical distancing mandates, resulting in more than 1 million covid deaths by the end of February. The second scenario has states tightening restrictions in response to rising mortality—with more than 500,000 deaths over the same period of time. The third scenario relies on 95% of Americans wearing masks in public when their states reach a threshold of eight daily deaths per million. Under that scenario, 130,000 deaths could be prevented.
Study: No benefit found with convalescent plasma
A randomized trial testing the efficacy of convalescent plasma to treat patients with moderate covid came up empty in terms of reducing patent progression to severe covid or mortality. The trial enrolled more than 460 patients at several dozen hospitals in India. STAT reports that an earlier study, this one done at the Mayo Clinic without a control arm, did find benefit; those results were instrumental in the FDA issuing an emergency use authorization. Sources quoted by STAT note that more than 80% of the patients in the Indian trial had already developed antibodies, suggesting that they should have received convalescent plasma earlier. They also note that researchers didn’t measure antibody levels in the plasma, although later analyses of the Indian research did not find that patients given plasma with higher antibody levels fared better.
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.
August 28, 2020
CMS changes rule for hospitals to get covid bonus
Starting Sept. 1, hospitals will need laboratory proof that a patient has covid in order to get the higher payments they’ve been receiving since spring. Back in March, CMS gave hospitals a 20% boost in the MS-DRG weighting factor for treating covid patients as long as there was a clinical diagnosis. (The increased payment was created as part of the CARES Act.) But starting Sept. 1, inpatient covid claims will require a positive viral test for hospitals to be eligible for the 20% boost. Without a positive viral test, inpatient treatment for covid will not receive the 20% bump. According to an article from the National Association of Healthcare Revenue Integrity, if a viral test is performed more than 14 days before a patient is admitted, CMS will consider whether other factors in the patient’s case merit the higher payment.
Changes in rules for reporting, testing and quarantining
It’s been a busy week for rule changes when it comes to reporting, testing for and quarantining from covid.
CMS changed its reporting requirements for hospitals treating covid patients. Hospitals that don’t meet the new reporting requirements could be “terminated” from Medicare and Medicaid. The new rules require hospitals to report the number of confirmed or suspected covid patients, ICU beds occupied, and the availability of essential supplies and PPE. Hospitals protested the rules as a “heavy-handed regulatory approach” that threatens the finances of some hospitals.
The rule change came in the same week that the CDC announced that people who have recent exposure to someone with the virus but are asymptomatic do not need testing. A New York Times article says the rule change was controversial in part because so many cases of the virus can be traced back to contact with asymptomatic individuals.
The CDC also dropped its recommendation that travelers returning from areas with a high concentration of covid quarantine for 14 days.
Two surveys look at public attitudes toward covid vaccine
With the race on to create and approve a covid vaccine, two new polls shed some light on what patients—and physicians—think.
When asked about Russia’s covid vaccine, code named Sputnik V, 67% of Americans are wary of Russia’s vaccine without further proof that it works, and 56% believe that Russia hurried the vaccine to beat other countries to the finish line. While just over half of respondents are very interested in getting a covid vaccine when it becomes available, nearly half are either uninterested or unsure about whether they’ll get one.
A second survey found that more than two-thirds of Americans (69%) say they support a priority system for distributing a vaccine. Seventy-three percent said health care workers should receive top priority, 71% said seniors should get the vaccine first, and 68% said immunocompromised people should get priority. Sixty-six percent of Americans also said that U.S. citizens should receive a vaccine before doses are distributed internationally, and 69% said they are “at least somewhat likely” to get a covid vaccine as soon as it’s available.
How long will the pandemic last? Doctors weigh in
Half of U.S. physicians say the pandemic won’t be under control until June 2021. A survey of more than 3,500 American physicians found that 86% believe the covid pandemic won’t be under control until at least next year, and 49% don’t think the virus will be controlled until after June 2021. Seventy-two percent believe that patient care will suffer from delays that will affect patient health, and 75% say that patients will feel “indirect effects” of the pandemic, such as job losses that may lead to problems with health coverage. More than half of physicians said the pandemic will slash the number of independent physician practices, and 8% have already closed their practices as a result of the virus.
CDC: Covid patients should delay getting a flu shot
The CDC is suggesting that suspected or confirmed covid patients delay getting a flu vaccine to keep health care workers from getting exposed unnecessarily to the virus. Even patients over 65, who face a higher risk of hospitalization and death from influenza, should hold off on getting a flu vaccine until they meet CDC criteria for discontinuing isolation. While CDC officials said patients don’t need a negative covid test to get a flu shot, they suggested screening all patients for covid symptoms before giving a vaccine even in asymptomatic patients. Public health officials are expecting a high demand for flu vaccines this fall as the nation prepares to potentially battle two viruses at once. CDC officials emphasized that high-risk individuals facing a higher risk of covid should get a flu shot. Those groups include staff and residents of long-term care facilities, adults with underlying illnesses, Black Americans and Hispanics, and adults who are part of the critical infrastructure.
August 22, 2020
CMS boosts its inpatient covid payment
Starting Sept. 1, the CMS is hiking what it pays hospitals for treating covid in Medicare patients by 20%. But that increase comes with some strings. For one, covid patients must have a verified positive covid test within 14 days of being admitted. Further, test results have to be documented in patients’ records, and only results for viral tests (molecular or antigen), consistent with CDC guidelines, may be used. The viral test does not need to be performed by the treating hospital, and test results conducted before admission can be entered into hospital records. In the rare event that patients have results from tests performed more than 14 days before admission, the CMS will consider the augmented payment on a case-by-case basis. In other payment news, the HHS is releasing $1.4 billion to 80 pediatric hospitals around the country that have been adversely affected by coronavirus. According to Fierce Healthcare coverage, the distribution is meant to offset hospitals’ higher costs and their drop in revenue from fewer patient visits.
Convalescent plasma: The data aren’t there yet
Senior federal health officials, including Anthony Fauci, MD, have intervened to put a hold on an emergency use authorization that the FDA was about to issue for convalescent plasma. Why? According to the New York Times, the officials are concerned that the evidence backing the therapy is still too weak. That includes the results of a study done by Mayo Clinic researchers that was reported in a preprint. That study, which looked at the effect of convalescent plasma on covid mortality, did find an association between mortality benefit and transfusing convalescent plasma with higher antibody levels in hospitalized patients. Researchers also found lower mortality when patients were transfused within three days of covid diagnosis.
Obesity: a risk factor for men, younger people
A retrospective cohort study finds a striking association between BMI and mortality among covid patients, particularly in men and in patients younger than age 60. Researchers with Kaiser Permanente Southern California studied the health records of more than 6,900 covid patients. Adjusting for other comorbidities, the authors found that patients in the highest weight group (those with a BMI of 40 or more) were four times as likely to die from covid as those with normal weight. Men and those under age 60 with a high body weight ran a particularly high mortality risk. Writing that “obesity plays a profound role in risk for death,” the authors point out that the risk is not uniform across all patient populations. While “the exact mechanism is unclear,” they note, “ectopic fat and COVID-19 share a common link in the upregulation of proinflammatory, prothrombotic, and vasoconstrictive peptide hormone, ATII.”
Will the CDC once again collect hospital data?
The administration has been widely criticized for abruptly switching the task of collecting hospital covid data from the CDC last and assigning it instead to a private company contracted with HHS. But Deborah Birx, MD, a member of the administration’s coronavirus task force, this week announced that the CDC is building “a revolutionary new data system” to once again track hospital data, although she provided no timeline for when that system might go live. While the administration claimed the switch in hospital data collection was meant to streamline reporting, the new system seemed full of errors. In her remarks this week, Dr. Birx referred to the HHS’ data collection process as “interim.” The data, which hospitals are supposed to report data, give a snapshot of hospital capacity related to covid including bed availability and PPE and drug supplies.
How long will the pandemic last? Doctors weigh in
Survey results from 3,500 providers indicate that doctors don’t believe the pandemic will be under control any time soon. The survey, which was conducted by The Physicians Foundation, found that 86% of respondents don’t think the pandemic will be reined in by the beginning of next year. Just about half (49%) think it will take much longer and won’t be contained until some time after June 2021. Moreover, nearly three-quarters (72%) think coronavirus will have serious consequences for patient health because of care delays caused by the pandemic. The majority (59%) feel that opening businesses and schools too soon poses more of a health risk than social isolation, while 8% report having closed their practice due to coronavirus and 43% have reduced their staff.
Canines and coronavirus
While researchers everywhere are focused on finding faster, more accurate covid tests, those with the University of Pennsylvania veterinary school have enrolled nine dogs in a study to see if they can sniff out infected patients. The dogs are being trained to detect urine collected from hospitalized covid patients who have tested positive (with inactivated virus) vs. urine from patients with negative results. The Washington Post reports that in the experiment, the dogs have been able to identify the right sample as much as 97% of the time and that trained dogs may be able to screen as many as 250 people per hour in nursing homes, airports and businesses. Critics claim that such programs are too expensive and that the need for widespread screening for covid is too great. But by helping scientists pinpoint molecules that represent disease, dogs may aid the development of electronic sensors that could be used in clinical settings. In other news, preliminary results released by Fitbit indicate that the company’s wearable fitness trackers have been able to identify before symptoms start almost half the 1,100 users who have tested positive. The trackers pick up on subtle differences in heart and breathing rates as well as in physical activity and sleep quality.
August 19, 2020
Can your patients understand you through a mask?
How well can you communicate with your patients while wearing a mask? A report in Medpage Today reviews communication research to come up with 10 tips to get through to patients. They include re-introducing yourself to patients who don’t recognize you; making more eye contact, but without making the interaction awkward or patients uncomfortable; and using body language and hand gestures to get your point across to patients. One physician interviewed for the article said that using certain facial gestures—squinting and smirking, for example—may seem odd without a mask, but when done from behind a mask, these gestures can appeal to patients as inviting and kind.
What to do when your patients ask to be exempted from mask-wearing
How should you handle patients who refuse to wear a mask in your office, particularly those who ask you to provide a medical exception? Groups like Freedom to Breathe Agency offer medical exemption cards on their Web sites. The Department of Justice has said that such cards are fraudulent. An article from MD Edge says experts maintain that even patients with physical conditions like COPD and reactive airway disorders should wear masks and that pulmonary issues are rarely a reason to not wear a mask. One physician said that patients suffering from anxiety and conditions like PTSD might qualify for an exemption. The issue is not crystal clear for physicians, however, because CDC guidelines note that “anyone who has trouble breathing, is unconscious, incapacitated, or otherwise unable to remove the mask without assistance” should not be required to wear a mask.
August 17, 2020
Immunity for three months?
Updated guidance from the CDC doesn’t claim that people who have recovered from covid have immunity for three months. But it does say that those who have recovered don’t need to go into quarantine or be retested for three months, even if they come into close contact with someone who is actively infected. Recovered patients should be tested within three months only if they again develop symptoms that have no other apparent cause. According to the guidance, patients who have recovered do need to continue to wear a mask and practice physical distancing.
Some sick clinicians are pressured to get back to work
It’s bad enough that doctors and nurses become infected with coronavirus. But Kaiser Health News reports that some hospitals have leaned on clinicians who are out ill with covid to come back to work even if they’re experiencing symptoms. Or employers don’t extend enough sick leave, forcing sick employees to have to choose between coming back to work before it may be safe or losing pay. Another factor: the “presenteeism” that often sways health care workers to stay on the job when they don’t feel well. In a survey of close to 1,200 unionized health care workers, about one-third of those who were infected said they’d returned to work while they were still symptomatic. The CDC has issued recommendations for hospitals that are short-staffed including implementing regional transfer plans.
FDA green-lights new saliva test
The FDA this weekend issued an emergency use authorization for a saliva-based covid test, the fifth such test the FDA has authorized. According to the FDA announcement, however, this test uses a new method. Developed by the Yale School of Public Health, the new test—called SalivaDirect—does not require any special swab or collection device, nor separate nucleic acid extraction. Another plus: The test can be used with different, commonly available reagents and instruments, so it should be OK to use in most labs. Yale plans to offer the test in an open-source protocol to interested laboratories. Coverage of the emergency authorization pointed out that the test was used in a pilot with asymptomatic NBA players and staff. The FDA also noted that, because the test is self-collected, it poses lower risks to health care workers.
August 14, 2020
Yeah, it’s airborne, and it’s in your hospital
Research (in preprint form) has now established what clinicians and scientists have thought all along: that aerosols floating in the air contain covid and are contagious. Researchers from the University of Florida isolated live virus from aerosols collected between seven and 16 feet away from patients in a room in a covid ward; the patients in that room did not have aerosol-generating procedures. The New York Times reports that the room in which aerosols were collected had six air changes an hour along with filters and UV irradiation to inactivate the virus. Researchers found only 74 virus particles per liter, a level that critics point out may not be enough to infect someone. Analysts note that the research underscores the need for effective ventilation in workplaces and school classrooms. In other hospital news, researchers writing in JAMA Internal Medicine tested 29 different respirators and masks. They found that N95s sterilized with ethylene oxide still maintained more than 95% air filtration efficiency.
ECMO posts high success rate
Researchers in two Chicago centers report success with ECMO in patients with severe covid, with more than 70% of the 40 patients enrolled being discharged without any need for further oxygen. In a research letter published by JAMA Surgery, the authors write that they used a single-access, dual-stage right atrium–to-pulmonary artery cannula, which offered several advantages. Those included direct pulmonary artery flow, early mobility and support of the right side of the heart in event of right ventricular dysfunction. While the authors note that previous studies on ECMO in covid have found high mortality, theirs “demonstrates promising outcomes.” They also note that for 70% of the patients in the study, obesity was the primary preexisting condition.
Immune suppression: a matter of timing?
Dozens of trials worldwide are now targeting the immune system as clinicians try to figure out how to curb the immune overreaction—or cytokine storm—that may kill many covid patients. That’s according to an article in the New York Times Magazine, which reports on immunomodulating drugs. The ones being tested (and given to covid patients outside clinical trials) include anakinra, tocilizumab and leronlimab; this week, phase 2 study results indicated that leronlimab improved symptoms in patients with mild to moderate coronavirus. (The drug is also being tested in phase 3 trials on severe covid.) In trying to figure out a role for immunosuppression, researchers point to the RECOVERY trial, which found benefit of dexamethasone in ventilated covid patients and those receiving supplemental oxygen, but not in patients who didn’t need respiratory support. As for the timing of immunosuppressants, some academic centers are prescribing sarilumab as soon as patients’ oxygen saturation begins to fall and before they need to be admitted to the ICU. With so much attention being paid to immune response in coronavirus, researchers hope new remedies will be suggested for ARDS and sepsis as well.
CMS pilots a new payment model for rural providers
Which vaccine candidates have the most promise?
ID doctors have definite ideas about when a vaccine may be available and which vaccine may be the first approved. Reports based on survey results from InCrowd find that 45% of ID doctors in the U.S. believe the Moderna vaccine will be the first to be approved, while 41% think it will be the first available in the U.S. The vast majority (77%) of other specialists, however—ED and critical care physicians, along with PCPs and pediatricians—weren’t able to name the candidate they thought had the most promise. In the survey, ID doctors ranked the Moderna and the AstraZeneca-Oxford vaccines as potentially equally efficacious. As for when ID doctors believe a vaccine will be available, the average time cited was 11 months (mean, 10 months), with more than 80% believing a vaccine will be on the market within a year. Close to three-quarters of ID physicians believe that health care workers should be the first to receive a vaccine. The Washington Post reports that there are now 200 experimental covid vaccines, with seven in phase 3 trials.
August 12, 2020
Small practices join together to buy PPE
Faced with having to beg, borrow and reuse PPE, independent practices are banding together to buy protective gear in bulk. According to an article in Medscape, a pilot project known as Project N95 has helped 2,000 members of medical societies like ACP secure nearly 150,000 N95s and 70,000 medical gowns. On average, practices participating in the program ordered four boxes of 20 N95s and two bags of 15 gowns. The article notes that even when practices could find PPE, face masks were going for as much as $5 each, and the quality was often suspect.
How has Covid affected physician practices financially?
A new survey from Medical Economics takes a look at the financial effects of the covid pandemic on physician practices, and the news isn’t good. Just over one-quarter of surveyed practices (27%) have furloughed physicians either temporarily or permanently, and 37% don’t anticipate returning to the same overall staffing levels. Almost two thirds (59%) are looking at revenue losses of up to 40%, while 30% are looking at revenue losses of more than 40%.
One bright spot: While 47% of groups think that in-person appointments will decrease once they fully re-open, 42% think that telemedicine visits are likely to increase. Finally, just under half (49%) of practices said they had received federal assistance.
August 10, 2020
Study: Asymptomatic patients carry a high viral load
With the number of U.S. cases this weekend topping five million, new findings from South Korea show that asymptomatic patients have as much virus in their nose, lungs and throat as those with symptoms. The results also indicate that asymptomatic patients are transmitting virus for almost as long as symptomatic ones. The study, published in JAMA Internal Medicine, looked at 300 patients who had tested positive and were being isolated in a community treatment center. More than 36% were asymptomatic when they were first isolated, although 19% of those went on to develop symptoms. In related news, researchers continue to question why at least one-third of infected patients don’t develop symptoms. The Washington Post reports that the answer may have to do some patients having some degree of immunity from previous exposures to other coronaviruses.
Health care workers of color run an outsized infection risk
Research into infection rates finds that health care workers of color in the U.S. and U.K are five times more likely than the general population to test positive for coronavirus—and nearly twice as likely to be infected as their white colleagues. Published in The Lancet Public Health, the study analyzed one month’s worth of data self-reported to the Covid Symptom Study smartphone app; data submitted were from more than two million people in the general community and close to 100,000 health care workers. As for factors driving that inequity, researchers found that health care workers of color were 20% more likely to care for covid patients than white colleagues; that figure rose to 30% among black health care workers. Health care workers of color were also more likely to report using reused or inadequate PPE. In covering the study, Modern Healthcare notes that in published profiles of health care workers who’ve died of the disease, 62% are people of color.
Pharma giant steps in to boost remdesivir supplies
August 7, 2020
States band together to boost antigen test production
While death rates in the U.S. are up to more than 1,000 per day, testing rates unfortunately are dropping. An AP analysis finds that testing rates have fallen 3.6% over the past two weeks, a decrease that experts say is due to patients’ frustration with having to wait to be tested and with not getting results for days or weeks. To boost test production, seven state governors this week announced a purchasing compact, the first of its kind. The states—Virginia, Louisiana, Massachusetts, Michigan, North Carolina, Ohio and Maryland—are working with the Rockefeller Foundation and negotiating with companies to produce 3.5 million rapid antigen tests, with results ready within 30 minutes. Each state would expect 500,000 tests; however, the governors say other states and cities may join them.
Is a civil war brewing over covid research?
Researchers have published preliminary data in a preprint on convalescent plasma, looking at 12 different studies. Those included three randomized trials, five matched control trials and four case study series. The data, which encompassed more than 800 patients, suggest a mortality benefit: Patients who received plasma had a 13% mortality rate vs. 25% for those with only standard treatment. The New York Times reports, however, that solid randomized data on plasma are hard to come by. That’s because clinicians’ enthusiasm to administer convalescent plasma has stymied research efforts to try to definitively find out if it really works. Doctors who want to give patients the therapy won’t enroll them in trials, worried that patients may get only placebo. And by the time clinical trials do get off the ground, outbreaks have passed so researchers have to scramble to enroll subjects in new hotspots. With several trials in the U.S. unfinished, the NIH is urging researchers to pool their data. An article in the New York Times Magazine points out that clinicians in many academic centers who use unproven therapies and off-label drugs with covid patients are facing off against their own researchers, who want to systematically build a body of evidence instead. That tension in some hospitals, according to the article, has “opened up a civil war.”
Cancer diagnoses drop sharply
Cancer diagnoses appear to be another victim of coronavirus, according to the authors of a research letter in JAMA Network Open. Researchers looked at weekly diagnostic numbers for six cancers, comparing figures from Quest Diagnostics last year to seven weeks this March and April. The weekly number of diagnoses was cut almost in half across all six cancer types, which included breast, colorectal, lung, gastric, pancreatic and esophageal. Breast cancer diagnoses took the biggest hit with a 51.8% decrease while the smallest decline was 24.7% for pancreatic cancer. The authors chalked those drops up to patients not being screened or ignoring symptoms while in lockdown. “The delay in diagnosis,” the authors write, “will likely lead to presentation at more advanced stages and poorer clinical outcomes.”
Surges expose the dangers of understaffing
Experts have identified many factors that cause covid mortality to spike including comorbidities and social determinants of health. Writing in Health Affairs, a New York City hospitalist points to what may be another critical factor: the chronic understaffing of hospital teams. The author works in a community hospital that, like others in that metropolitan area, was overwhelmed with covid patients this spring. As Healthcare Innovation reports, the writer believes the hospitals with “the least capacity for surge staffing” may eventually be linked to the highest number of excess deaths. The outbreak, he writes, was a great object lesson in how patient safety is jeopardized as patient-to-nurse ratios increase, particularly in the ICU. With covid patients, “patient-to-(respiratory) therapist ratios are just as vital.” In terms of staffing, the pandemic revealed the inequities of resources for safety net hospitals, a condition tolerated pre-covid. “The stress test of the pandemic made such stark inequities impossible to ignore.”
#MedRacism takes down an anti-affirmative action paper
Twitter’s #medbikini pushed back against a peer-reviewed paper by vascular surgeons, which criticized trainees for such social media behavior as posting pictures of wearing swimsuits, drinking alcohol, using profanity and engaging in political activism. The paper claimed such behavior was unprofessional, and the resulting pushback led to the paper’s retraction. Now, #MedRacism has taken on an article published earlier this year by the Journal of the American Heart Association and written by a director of an electrophysiology fellowship program. In what was styled a “white paper,” the author claims that affirmative action programs for blacks and Hispanics in cardiology programs have produced “poor performance” and “disengagement.” As comments snowballed on Twitter about racial and ethnic stereotypes, the publication first released an apology, then a retraction. With many commenters questioning how the author’s views affected his fellowship program, MedPage Today reported that the author had been relieved of that directorship.
August 5, 2020
Telehealth update: popular with patients, but will payment be permanent?
As many in health care wonder if telemedicine will continue the rapid growth it has experienced during the pandemic, there have been some encouraging signs in the news over the last week.
First, President Trump has proposed permanently extending certain telehealth policies that led to the rapid growth of telehealth during the pandemic. The proposal, which was announced with reforms to rural health payment that were part of an executive order, aims to make Medicare payment permanent for certain health providers. According to a report in Politico, a more comprehensive telehealth policy would have to come from Congress.
Data from a new survey find that about 90% of respondents who have had a telehealth visit are likely to schedule another one instead of an in-person visit. Those data probably have something to do with how safe patients feel in health care settings. The survey found that only 12% of respondents felt safe in emergency rooms and urgent care centers. By comparison, 42% felt safe in grocery stores and 37% felt safe in pharmacies.
Finally, new data find that telehealth visits accounted for nearly half of all primary care visits by Medicare patients in April. The report, which was released by an office of the HHS, found that both rural and urban areas saw an increase in use in both March and April, but it also found that rural areas saw a smaller increase in March and April as a proportion of all primary care visits than urban areas.
How the gender gap can cost $90,000 (in certain practices)
A new study from Harvard Medical School found that the more male physicians are in a practice, the lower the pay for female doctors.
In non-surgical private practices with the same number of men and women, men earn 12% more than women. When staffs are 90% male, men earn 20% more. A report in Forbes says that can come out to a gender gap of $90,000 or more. That gap gets even worse at surgical practices. At surgical practices with 90% or more of men, the gap grows to 27%, which can account for a difference of nearly $150,000.
August 3, 2020
Testing: Speed counts more than sensitivity
It’s time to rethink how the U.S. is doing testing, according to Harvard’s Ashish Jha, MD. In a commentary in Time, Dr. Jha writes that, “America’s testing infrastructure is collapsing”—due largely to the heavy reliance on PCR tests, which are both slow and expensive. He proposes instead using cheap antigen tests whereby everyone in the country would spit on a specially treated piece of paper every morning. Critics of such testing point to their less-than-perfect sensitivity of perhaps only 50%—a drawback that, Dr. Jha writes, would be countered by frequent testing and rapid results. Referring to a preprint on testing sensitivity, he writes that, “(S)peed matters much more than test sensitivity in controlling a pandemic.” Across the country, patients still wait more than a week for test results, a delay that renders those results and any possibility of contact tracing useless. One privileged group that gets answers in less than a day: NBA players and staff in Orlando. They are tested daily, with the NBA spending between $115,000 and $180,000 every day on tests that deliver results in less than 24 hours. The league last week announced that it will open a free testing site at an Orlando mall that would delivered results in less than 72 hours. Federal officials this weekend warned that the pandemic in the U.S. had entered a “new phase,” one that is “extraordinarily widespread” and now threatens outbreaks in the Midwest. To combat that growing spread, they recommended taking more extreme precautions including wearing masks in homes with multiple generations or vulnerable family members.
New hospital data collection so far falling short
Last month’s switch to having hospitals report their daily covid data to a private company contracted with HHS instead of to the CDC was supposed to streamline the collection process and make information more readily available. So far, that hasn’t panned out, according to sources quoted by NPR. While the CDC reported estimates three times a week based on the data it collected, officials in charge of the new collection method first said data would be updated several times a day, then daily and now weekly. According to the HHS Protect Public Data Hub, those data were last updated July 23. The hub data, sources say, reflect anomalies and inaccuracies. On Friday, the CDC director testified to a Congressional subcommittee that the switch in data collection methods—and the CDC wasn’t involved in making that final decision—was driven by the need to know where to distribute remdesivir.
How are those back-to-school plans coming along?
A CDC report on a sleep-away camp gone wrong contains some bad news for children being able to go back to school in person. The camp, which was in session in Georgia for less than a week, required close to 600 campers and staff to provide documentation of negative testing; while staff were required to wear masks, the children—median age of 12—were not. More than three-quarters of campers and staff tested in just a few days (260) were positive. In related news, previous studies have suggested low transmissibility among children younger than age 10. But that wasn’t borne out in a research letter published online last week by JAMA Pediatrics. Researchers analyzed nasopharyngeal swabs collected in March and April around one Chicago tertiary pediatric medical center. They found that young children (age five and under) with mild to moderate covid had higher amounts of viral RNA in their nasopharynx than older children and adults. As for reopening college and universities, a study in JAMA Network Open concludes that campuses can safely reopen—if “strict behavioral interventions” can be maintained and students can be tested every two days.
July 31, 2020
What will it take to get the pandemic under control?
As the U.S. passes the 150,000 mark in coronavirus deaths, experts now say the country is in worse shape in terms of the pandemic than it was in March. How to bring it under control? That depends on the specific outbreak, according to interviews with 20 public health experts in the New York Times. Multiple epicenters have emerged, with outbreaks driven by different factors; some hotspots have been fueled by vacation travelers, while others are due to bars re-opening too soon or to residents refusing to wear masks. While some experts argue for a national lockdown, others say that stay-at-home orders should be issued only in communities that record more than 25 cases per 100,000 people. A report from the Johns Hopkins Center for Health Security calls for a national reset in pandemic response. Among the report’s suggested changes: issuing universal masking mandates, closing high-risk activities and settings in areas where hospitalizations are on the rise, and putting stay-at-home orders in place for at least two weeks in communities where health care systems are in (or approaching) crisis.
Intensivists are in short supply in more than a dozen states
There’s a shortage of testing supplies everywhere, and one-third of hospital pharmacies need more remdesivir. But a new report out of George Washington University highlights the increasing shortage of intensivists. That shortage is now severe in Arizona and Texas, according to the report, with more than 100% of the intensivists in those states already treating covid patients. Meanwhile, the supply of intensivists in 11 other states is strained, with less than 50% of them available to treat non-covid patients. Those states include Alabama, Arkansas, Florida, Idaho, Louisiana, Mississippi, Nevada, Oklahoma, South Carolina, Utah and Washington. To help manage shortages, the report notes that ICUs can employ surge-staffing models in which each intensivist, instead of caring for seven patients, treats 10. (Another surge staffing strategy: Have each critical care nurse treat three patients, not one.) But clinicians under such models run a greater risk of burnout. The SCCM has published a tiered staffing strategy to boost ICU staffing with non-ICU clinicians, including hospitalists.
Studies raise concerns of long-term cardiac damage
A new study out of Germany of relatively young covid patients (average age of 49) reports troubling results. On MRI scans taken more than two months after patients tested positive, the vast majority (78%) had abnormal cardiac findings, with the majority of them showing myocardial inflammation. Two-thirds of the patients studied had never been hospitalized, and the results were similar regardless of patients’ underlying conditions or covid severity. Another study, which looked at autopsy results, found high levels of virus in the hearts of almost two-thirds of the patients autopsied. Both studies were published in JAMA Cardiology. An editorial calls for more research to see if that high risk is confirmed. If it is, say the editorialists, the covid crisis may “shift to a new de novo incidence of heart failure and other chronic cardiovascular complications.”
First Medicare snapshot confirms racial, ethnic vulnerabilities
In the first of what the agency says will be monthly updates, the CMS has released data on the impact of coronavirus on Medicare beneficiaries. The analysis is based on claims and encounter data through June 20. Those data find a disproportionate burden of both infections and hospitalizations for black Americans, with African-Americans having 670 covid hospitalizations per 100,000 vs. 175 among white Americans. The second highest rate of hospitalizations is among American Indian/Alaskan Native Medicare populations with 505 hospitalizations per 100,000. Dual eligibles were also hospitalized at much higher rates as were patients with end-stage renal disease. In other CMS news, Medicare is implementing new procedure codes to identify the use of covid therapeutics remdesivir and convalescent plasma. The use of the new codes, according to the CMS, will allow the agency to track their use. The CMS will also now pay clinicians for counseling patients who test positive about the need for self-isolation.
The emotional stages of coronavirus
A New York hospitalist has detailed what he calls the “emotional evolution” that both covid patients and the clinicians treating them are going through. Patients, he writes in the New Yorker, often have a hard time accepting the debility they still feel weeks and months after they supposedly recover. As for physicians, the writer describes several stages of emotional response. First is excitement at treating such an unknown, along with fear about PPE shortages and anxiety over infecting family. But as sick patients overwhelm hospitals, clinicians start to feel detachment and disconnection. That desensitization can shift only if hospitals and clinicians can humanize the patients they’re treating, and he describes one New York ICU that asked family members to send in patient photos and bios to hang on IV poles. There’s also frustration with the misinformation that’s being passed around and with officials lifting restrictions too soon. “It reflects,” one of the author’s colleagues told him, “the ignorance and privilege of those who haven’t had to confront this suffering.”
July 29, 2020
Will independent practices survive the pandemic?
A new report says that more than half of independent physicians are worried about their future, stoking concerns about a coming wave of consolidation in health care.
The consulting firm McKinsey & Co. surveyed physicians before the pandemic and six weeks into it. Earlier this year, more than half of the respondents said they had no more than four weeks of cash on hand and were worried about going out of business because of covid. One-third of physicians in small, independent practices said that they thought working for a larger practice might provide them more benefits, and 26% said they were much more likely or somewhat more likely to consider partnering with a larger entity. About one-third were more likely to sell their practice, and 40% were more likely to consider employment.
An article in the New Yorker on the challenges outpatient practices are facing during the pandemic similarly questions whether many will be able to survive financially until the pandemic is gone. The author, an emergency medicine resident, talks about the challenges facing specialties like internal medicine, family medicine, pediatrics and ob/gyn because patient visits have dried up. The article points out that primary care was in crisis before the pandemic because of lackluster compensation and student loan debt, which has created a shortage of PCPs. But the pandemic has exacerbated many of those problems, and the author wonders whether doctor-patient relationships that have been severed because of the coronavirus will be able to be repaired once the pandemic is over.
Professionalism vs. sexism? Judging selfies of docs
Is it unprofessional for physicians to post on social media showing themselves with a drink in hand by the pool? An article in the Journal of Vascular Surgery–“Prevalence of unprofessional social media content among young vascular surgeons”—seems to think so. A team of three researchers condemned photos that featured “provocative posing in bikinis/swimwear” and “holding/consuming alcohol.” The article generated a fierce backlash that led to physicians around the world posting their best bikini pix. A CNN report that features pictures posted by male and female hospitalists says that the journal retracted the article and apologized. Critics say that the article targets images of women and highlights the problem of sexism in the field. The authors of the article are all men.
A look at physicians’ net worth
When it comes to the finances of physicians, the good news is that more than half are worth more than $1 million. The bad news is that physicians are seeing a 55% reduction in their revenues because of a 20-30% drop in patient volumes. That’s according to a new series of slideshows from Medscape, which drills down into the finances of different specialties. The slideshow for all physicians found that 19% of orthopedists have an average net worth of $5 million, compared to just 5% of internists. Medscape data find that the biggest sources of physician debt come from mortgages, car loans and medical school loans. Medscape has individualized slideshows for internists, family physicians, psychiatrists and cardiologists.
July 27, 2020
Pooling tests delivers rapid results in low-risk patients
Need to conserve scarce testing supplies? Clinicians at a 171-bed community hospital in upper-state New York did just that by using a pooled testing strategy. Utilizing the Cepheid GenXpert system, they pooled nasopharyngeal samples from patients at low risk of covid into groups of three; over the course of three weeks, the hospital ran 530 tests using only 179 cartridges. Only four groups came back positive, requiring 11 more cartridges to be used. The pooled strategy, which was used for all patients who were admitted or placed under observation, saved two-thirds of the cartridges that would have been used for individual testing. Importantly, the authors note that they deployed the strategy when their community had an estimated positivity rate of between 1% and 2%. “If the rate of positive tests in our community rises,” they write, “the use of pooling may need to be limited or the pool size reduced.” In related news, Fierce Biotech reports that some states are seeing delays of days or weeks in test results, rendering testing basically useless. Those states are seeking out other lab partners besides the national commercial labs, which are overwhelmed.
Covid’s long-term effects
Clinicians now treating the long-term effects of covid are sounding this alarm: Some recovering covid patients will continue having persistent symptoms, perhaps indefinitely. An MMWR study of outpatients with mild covid found that 35% still reported persistent symptoms weeks after becoming infected, including patients ages 35 and younger with no underlying health conditions. And in an interview with New York magazine, the medical director of Mount Sinai’s Center for Post-COVID Care, which now treats about 300 patients, says the predominant persistent symptom is shortness of breath, due to long-term—or permanent—lung damage. Many patients also have chest pain and chest discomfort as well as neurological symptoms, and large numbers report anxiety, depression or PTSD. “I feel,” the medical director is quoted as saying, “like the population of this is going to be very large.” European countries that were hard-hit have since launched rehab services for recovering patients.
More than half of positive pregnant women are asymptomatic
A new report from the nation’s largest OB hospitalist provider makes a case for universal hospital covid testing, at least in labor and delivery units. The report, from Ob Hospitalist, looks at 10 weeks of patients across more than 160 hospitals. Among the 200 obstetric patients who presented and tested positive, 58% were asymptomatic. A study in The Lancet Child & Adolescent Health finds that 8% of women giving birth in three New York hospitals between March and May were positive. All the positive mothers practiced hand and skin hygiene and wore masks when holding their babies, most of whom roomed with their mothers in a closed isolette. Babies were tested for two weeks and followed up at one month via telemedicine—and none of them became infected. Among the mothers, 78% were breastfeeding at one week.
July 24, 2020
What data do we need?
With hospitals submitting daily covid data to HHS instead of the CDC, HHS this week unveiled its dashboard for hospital capacity data. Called the Coronavirus Data Hub, the dashboard reports on overall confirmed cases as well as inpatient and ICU bed utilization. According to MedPage Today, an HHS official claimed the new database was more robust, collecting data from 4,500 hospitals while the former CDC database included data from only 3,000. While that official said the data would be updated regularly, he didn’t say how often. A public health group led by a former head of the CDC is calling on states to collect standardized data to be able to mount an effective defense against the virus. The group is advocating for public data on 15 data points. In addition to per capita covid hospitalization rates and seven-day moving averages, the suggested indicators include the number of tests processed within 48 hours, per capita antigen and diagnostic testing rates, rates of confirmed and probable deaths, and infection rates among health care workers. “What gets measured,” the former CDC director was quoted in STAT as saying, “can get managed.”
One in six covid patients has a thrombotic event
In a new research letter published in JAMA, NYU Langone researchers report that about 16% of covid patients at their hospital in March and April had a thrombotic event including DVT, PE, MI or stroke. Among those patients, all-cause mortality was 43% vs. 21% for patients without thromboses. Most patients received low-dose prophylaxis. A well-known anticoagulant—heparin—is also in the news: Researchers writing in Antiviral Research report that heparin binds tightly to the virus, neutralizing it before it infects healthy cells. Until a vaccine is developed, the authors say, heparin could be inhaled as an early intervention among patients who test positive but don’t yet have symptoms. The research tested three heparin variants including one without anticoagulant properties.
Actual infection rates, fading immunity
With more than 4 million cases now in the U.S., the number of hospitalizations is matching the peak rate set in April, while the daily death toll this week passed 1,000 for at least two days for the first time since early June. As for how many Americans have actually been infected, a serosurvey of 16,000 people drawn from 10 sites around the country produced these estimates: The true infection rate in the U.S. is between six and 24 times the number of reported cases, based on antibodies. Writing in JAMA, the authors—who are CDC researchers—suggest that in seven of the 10 sites, actual infection rates are 10 times higher than reported. The analysis was based on blood samples collected routinely for inpatient monitoring and cholesterol screening, and the CDC has developed an interactive dashboard with data from the 10 sites. The results indicate very large numbers of patients with mild or asymptomatic infection. As for patients with mild infections, researchers writing in NEJM note that out of 34 patients recovering from mild cases, an assessment of their antibodies found a half-life of just over 70 days. According to the authors, “the results call for caution regarding antibody-based ‘immunity passports,’ herd immunity, and perhaps vaccine durability.”
Several vaccines about to move into phase 3 trials
This week brought more encouraging news about possible vaccines. One being developed by Oxford University and AstraZeneca produced an immune response among 1,000 patients enrolled in a phase 1-2 study, with interim results published in The Lancet. While researchers reported no serious side effects, 60% of subjects had mild or moderate side effects including headache, fever and injection site reactions. Chinese researchers also published results in The Lancet of a phase 2 trial in which their vaccine also induced neutralizing antibodies. Findings indicate, however, that the vaccine works better in patients under age 55. Meanwhile, the federal administration committed to paying Pfizer $1.95 billion if it delivers 100 million doses of a vaccine it’s developing with a German biotech by the end of this year. (Last week, results published by Moderna found that its vaccine candidate also produced an immune response.) USA Today reports that, after a call went out from the NIH for volunteers for vaccine and clinical trials, more than 138,000 Americans volunteered.
Beware your teens and tweens!
Among the many unknowns about coronavirus are these: How badly do children become infected, and are they major vectors of the virus? A study done in South Korea that looked at contact tracing for close to 60,000 patients found that children under age 10 transmit the disease much less frequently than adults. But that’s not the case for those ages 10 through 19; the tweens and teens may be spreading more virus than adults. Published in the CDC’s Emerging Infectious Diseases, the authors found that, overall, 12% of household contacts in homes with infected patients contracted the virus. However, that rate rose to 19% of household contacts in homes with patients ages 10-19, the highest rate among patients broken down by age. Households with covid patients under age 10, by contrast, had the lowest rate of transmission among household contacts: 5.3%. “We showed,” they wrote, “that household transmission of SARS-CoV-2 was high if the index patient was 10–19 years of age.”
July 20, 2020
Inpatient volumes bounce back
Hospitals saw their volumes begin to rebound in June although the volume of ED visits isn’t coming back as quickly. That’s according to an analysis from TransUnion Healthcare, an analytics company, which found that inpatient volumes in June were down only 8% from pre-covid benchmarks. That represents a 75% rebound from early April. The number of ED visits, however, was still 25% below pre-covid volumes, having recovered only about 50%. The bounce-back in ED visits for low-acuity diagnoses like ear pain has been even more sluggish—a possibly good trend, a company spokesperson pointed out, if patients with lower-acuity conditions are seeking out less acute care settings. Reuters reports, however, that areas of the country with growing outbreaks are again seeing patients pull back from hospital care, while Texas has again banned non-emergency procedures. An unpublished administration report identifies 18 states in the covid “red zone,” with more than 100 new cases per 100,000 people. The document suggests that those states should revert to more stringent measures.
What’s your post-acute care strategy for covid patients?
As pandemic hotspots shift to the South and West, one problem—in addition to ongoing PPE and testing shortages—keeps cropping up: Where to discharge covid patients once they no longer need hospital care? MedPage Today reports that Florida now has 11 post-acute facilities dedicated exclusively to covid patients, a network of about 750 beds. No national data exist on how many covid patients need rehab or SNF care after being hospitalized or how many require home-based post-acute treatment. So far, it doesn’t appear as if post-acute facilities have been overrun with covid patients, in part due to fewer patients getting elective procedures. Nursing-home advocates say that facilities accepting such patients need dedicated covid units and PPE. Further, figuring out discharge strategies has been made more difficult because of testing delays, with post-acute facilities refusing to admit patients without knowing their status. The CMS has announced that it plans to send point-of-care tests to 2,000 nursing home initially and eventually to all 15,000-plus facilities in the country.
Residents ensnared in H1-B ban
The guidance seemed clear: The federal proclamation issued at the end of June barring most immigrant workers on H1-B visas notes that doctors involved in the care of covid patients are exempt. But ProPublica now reports that despite that guidance, hundreds of first-year residents from other countries weren’t able to secure visas in time to start their training this month and many teaching hospitals are now short-staffed. Consulates around the world have been slow to implement the guidance, and residents are left waiting for approvals from the departments of State and Homeland Security. As of last week, some consulates began approving visas, and a State Department Web site spelled out the exemption for covid-related health care workers and researchers.
July 13, 2020
U.S. covid death rate is again on the rise
Driven by deaths in the South and the West, the coronavirus death rate in the U.S. is rising once again. That reverses a trend that’s lasted for months in which the number of daily deaths from covid has fallen. According to an analysis from Associated Press, the seven-day rolling average for deaths per day hit 664 last Friday, up from 578 two weeks ago. Driving up those averages are covid deaths in California, Texas, Florida, Arizona, Illinois, New Jersey and South Carolina. While researchers now expect the number of deaths to rise for weeks, they believe the death rate will stop short of where it was this spring as a result of more widespread testing, mask-wearing and social distancing. Florida on Sunday scored the highest number of infections reported on a single day in any state: 15,300. That’s 3,000 more cases than were reported on any day in New York in April.
Study: Remdesivir may slash covid mortality
It’s once again medical news by press release, with actual data not yet published or peer-reviewed. But Gilead Sciences, the manufacturer of remdesivir, has announced that in a new trial of more than 1,100 patients, the antiviral was associated with a 62% lower risk of mortality. According to the announcement, the mortality rate for patients who received remdesivir was 7.6% at day 14 vs. 12.5% for patients not given the drug. Further, 74% of those on remdesivir recovered by day 14 vs. 59% of those given standard care. News coverage indicates that black patients did especially well on the treatment, while those under 65 did better on remdesivir than those 65 and older. More benefit was also seen in patients who weren’t intubated. Earlier this year, remdesivir was linked to faster time to recovery for covid patients.
Will home-schooling ever end?
As the debate over whether schools can safely open again in the fall is raging, Johns Hopkins has issued resources for reopening schools. Perhaps some encouraging news: A study published in Pediatrics suggests that children aren’t major spreaders of the infection. Looking at household contacts of 40 children infected with covid in Switzerland in March and April, researchers found that 79% of those homes had at least one adult with suspected or confirmed covid before a child exhibited symptoms. In only 8% of households was a child suspected of being the index case. An accompanying editorial argues that “serious consideration should be paid toward strategies that allow schools to remain open, even during periods of COVID-19 spread,” to minimize the developmental and social disadvantages to children of remaining out of school. The American Academy of Pediatrics has issued a statement with this clarification: While being in school benefits children, “Science should drive decision-making.”
July 10, 2020
Testing crisis: Deja vu all over again
With the U.S. passing the 3 million mark in covid cases this week, many cities and states are struggling with the same dilemma that crippled hotspots in the pandemic’s early days: a lack of testing capacity. The New York Times reports that the U.S. performed three times as many tests in June as in April. Still, one testing site in New Orleans recently ran out of tests five minutes after it opened for the day, while patients in Phoenix are waiting in their cars for eight hours to be tested. Other cities are again restricting testing to only those patients with symptoms. In addition to skyrocketing demand, officials also point to scarce testing supplies and lab backlogs as reasons for the lack of capacity. The HHS plans to open surge testing sites in three outbreak locations: Jacksonville, Fla., Baton Rouge, La., and Edinburg, Texas. Each site is designed to remain in its location between five and 12 days and to test 5,000 samples per day. As for accurate point-of-care testing that would allow patients to test themselves at home and have results in minutes, companies are working furiously. While some of the products being designed would test sputum or identify coronavirus proteins, they are all in early stages and won’t be marketed for months. One proposed solution is a pooling strategy that would combine multiple samples and test them as a group. And Atul Gawande, MD, is co-author of an HBR article on assurance testing that proposes a network of online testing marketplaces.
Coronavirus and racial inequity
The most comprehensive look yet at the first 1.5 million covid cases in the U.S. indicates that Black and Latino patients have been disproportionately affected across the country, not just in large cities. Latinos and African-Americans are three times as likely to become infected as whites in the U.S., and close to twice as likely to die. Native Americans were also much more likely to be infected than whites, as were Asian Americans, although not to as great a degree. As for the reasons behind the disparities, experts say that both Blacks and Latinos tend to have front-line jobs that can’t be done at home, take public transportation, or live in crowded or multigenerational homes. The data were released by the CDC after the New York Times filed a FOIA lawsuit for the information.
Concern grows about neurological symptoms
A study in JAMA Neurology of covid patients in two New York academic centers finds that their stroke rate was eight times greater than among patients with the flu: 1.6% vs. 0.2%. U.K. neurologists writing in Brain published details of more than 40 coronavirus patients, some of whom had only mild symptoms, who ended up with acute disseminated encephalomyelitis, nerve damage, stroke or temporary brain dysfunction. The BBC reports that a University of Pittsburgh neurologist is coordinating scientists across 17 countries who are using brain scans to monitor neurologic conditions among covid patients. According to that researcher, neurological injuries caused by the virus may “result in much greater overall disability, and possibly more death” than lung problems. And while typical covid presentations in the hospital include pneumonia, ARDS or a flu-like illness, a write-up in BMJ Postgraduate Medical Journal details emerging atypical presentations when respiratory symptoms may not be apparent. Those include silent hypoxemia; delirium; cardiovascular, GI, and hepatic symptoms; and neurologic features including encephalitis. Given that range of symptoms, the authors write, it’s important to not miss other diagnoses in patients who aren’t infected with coronavirus.
What should you stockpile?
A new survey finds that virtually all hospitals are stockpiling supplies of critical medications in preparation for covid surges this summer and fall. Health care improvement company Premier surveyed its members in June and found that 88% were building their supplies of sedatives, neuromuscular blockers and controlled substances. Among respondents, 51% reported having a safety stock that could last a month while 25% were planning to stock a two-month supply. More than 80% were also stockpiling agents for rapid intubation, while 75% were stocking vasopressors. To handle covid comorbidities and complications, hospitals are also building their supplies of inhalers and IV syringes.
The pandemic’s hit on women researchers
Research into coronavirus may be exploding, but women in medical research aren’t making the kind of gains their male colleagues are. One study, for instance, that looked at published covid papers found that lead authorships by women researchers fell 23% compared to the same publications last year. Further, an analysis in Nature of preprints also found that authorship by women researchers during the pandemic has fallen compared to that of men. Experts suspect the disparity may be driven by the need for parents—specifically mothers—to take on more child care. To ensure that women academicians aren’t penalized for a research slowdown, STAT reports that Harvard Medical School and Massachusetts General Hospital have temporarily stopped the clock for tenure-track researchers and established video presentation options for women researchers to present their work.
July 8, 2020
Is telehealth fizzling out as the pandemic rages on?
While telehealth services were booming in the early days of the covid pandemic, there are signs that interest in telemedicine may be waning. Here’s a look at recent coverage of telemedicine’s adoption:
Fewer patient visits?
While many industry experts predicted that the embrace of telemedicine seen during the pandemic would continue once covid had subsided, there are signs that the use of telemedicine has already started to decline. An article in STAT says that during the week of June 14, telemedicine was used for 8% of the number of visits that would have occurred before the pandemic. In April, the number was nearly 14%.The article says that the decline in telemedicine visits could be due to difficulties getting patients—particularly the elderly—to use technology and a lack of technical resources in smaller groups. The report notes that groups with 100-plus providers shifted almost 16% of their pre-pandemic volumes to telemedicine, compared to 8% for groups with five or fewer clinicians.
Some payers scaling back coverage
A report in Becker’s Hospital Review says that some payers are scaling back their telehealth coverage. Blue Cross Blue Shield of Texas, for example, is scaling back its expanded telehealth coverage at the end of August, and Aetna began charging patients co-pays and cost-sharing for telehealth visits in early June. The report notes that some Arizona insurers had begun to decrease telehealth coverage, but as hospital ICUs in the state have filled with covid patients, they have restored telehealth coverage.
Promise vs. reality
An article in last month’s New Yorker notes that while telehealth has the potential to improve patient care, it can be a tough sell with physicians, even those in rural areas who don’t have a lot of resources and could see a boost from the technology. The article notes that one problem is that patients who are old and poor lack the technology needed to take advantage of telehealth services. The article also looks at reimbursement issues that have slowed the adoption of telemedicine.
Fraud in telehealth
Finally, another report from Becker’s says that Medicare administrator Seema Verma noted in an interview with Business Insider that the CMS is investigating fraudulent charges for telehealth services. She noted that some providers are billing for “more visits than are humanly possible in a day.”
July 6, 2020
Researchers: It’s airborne
Close to 250 scientists from more than 30 countries have signed onto an open letter to the WHO that they plan to publish this week. Their goal: to have the WHO revise its recommendations to acknowledge that coronavirus is airborne, based on evidence described in the letter. To date, the WHO has maintained that the virus is transmitted via droplets, and it continues to state that health care workers not involved in aerosol-generating procedures are protected with only surgical masks. However, the open letter argues that the virus is airborne and can linger indoors, particularly in tight quarters with poor ventilation. As a result, people should wear masks indoors, even when they’re socially distanced, and health care workers need N95 respirators. The authors of a recent Annals opinion piece made a similar case: “Use of N95 respirators to protect HCWs should not merely be a preference or a recommendation based on availability. The data indicate that it should be the standard for all inpatient COVID-19 management.”
Remdesivir’s new price tag
Remdesivir’s manufacturer last week outlined the drug’s new pricing policy, announcing that a treatment course in hospitals would cost $3,120 for covid patients with private insurance and $2,340 for patients insured by the government. The company, Gilead Sciences, also announced that almost the entire supply of the drug through September—more than 500,000 courses—will be sold in the U.S. Advocacy groups pushed back, saying the price was too high for a drug that has so far failed to improve covid mortality, while public health officials slammed the lack of better access to the drug worldwide. The California-based company, which up to now has donated the drug, defended the sales policy, noting that case numbers are surging in the U.S. The HHS says the drug is being shipped to states with record-high cases including Arizona, California, Florida and Texas. And the authors of a JAMA viewpoint propose a lottery among states to ensure fair distribution of remdesivir, so long as the lottery is paired with registries of clinical outcomes.
Chaotic research efforts make the case for large studies
More than 1,000 clinical trials targeting covid treatment and prevention have been launched since this January. But a new STAT analysis finds that much of those efforts are chaotic and wasting valuable resources. According to the analysis, many studies are too small with no controls, and they target too few potential treatments. One out of six of those trials, for instance, was designed to test antimalarials, which have since proved to be ineffective. Experts are calling for greater research collaboration worldwide and for a national clinical trial agenda in the U.S. As for other problems getting covid research off the ground, New York’s Northwell Health is a case in point. The pandemic came and went in the greater New York area before the investigators of many of the health system’s studies could enroll enough patients. That’s a problem with covid-related research even in medical centers that sweep aside internal hurdles related to oversight and regulations.
July 1, 2020
The outlook for post-covid finances in health care is grim
As the covid pandemic continues to rage in parts of the country, estimates of the economic damage are pouring in, and the news is bad. Newest data estimate that U.S. hospitals stand to lose more than $300 billion in 2020 as a result of the pandemic. Primary care practices, by comparison, stand to lose about $67,000 per physician in revenue.
A report from the American Hospital Association says that hospitals have seen declines in their inpatient volumes of 19.5% and health systems have seen declines of 34.5%. Many hospitals don’t expect volumes to return to pre-pandemic levels until 2021 at the earliest.
A Health Affairs study says that primary care practices in the U.S. will lose just over $15 billion. Researchers emphasize that number could go higher if quarantine conditions are extended or renewed, and if reimbursement rates for telemedicine revert to pre-pandemic levels.
Finally, a report from the AMGA says that more than 40% of health systems say it will take a year for their revenues to reach pre-pandemic levels. One-fifth of health systems surveyed and nearly 40% of medical groups reported drops in revenue of more than 50%.
How is covid affecting physicians’ personal finances?
While much attention has been paid to the financial havoc covid is causing large health systems and medical practices, the pandemic is also affecting physicians’ personal finances. According to a Medscape report, primary care compensation at the beginning of 2020 averaged $243,000 and specialist compensation was $346,000. But experts in the report said that some of their physician clients have reported drops in income of 50% and had stopped saving for retirement to cover basic expenses, which are outlined in the report. A report in Fierce Healthcare says one piece of good news is that because about half of physicians surveyed said they had a net worth of between $1 million and $5 million, they have some resources to get through financial hard times.
June 29, 2020
Who’s at high risk, and what’s the real number of U.S. cases?
Two global milestones passed this weekend: More than a half-million people have died of covid worldwide, and there are now 10 million confirmed cases. Here in the U.S., an analysis of antibody tests suggests that the actual covid infection rate in this country is more than 10 times greater than what’s been reported. That’s according to the CDC, which is partnering with commercial labs to test blood samples. The current analysis is based on serology samples taken between late March and early May in six states. The CDC has also broadened its list of people at high risk for developing severe disease. Instead of pegging high risk to age, the new guidance emphasizes the risk younger patients run from underlying health conditions including having a BMI of 30 or more or diabetes. Given the number of states struggling with record hospitalization numbers, the HHS secretary this weekend warned that “the window is closing for us to take action and get this under control.”
Mayo Clinic plans to restore staff pay, end furloughs
Mayo Clinic last week announced that it was calling back furloughed staff and restoring the pay cuts it had enacted earlier this year to manage falling revenue. The health system, which is based in Rochester, Minn., had cut the hours or pay of more than 40% of its 70,000-plus employees; while physicians weren’t furloughed, they did receive a 10% pay cut. The furloughs and pay cuts were originally designed to last through this year, but they will now end mid-July. That’s thanks to a better-than-expected return of clinical practice and research as outpatient, surgical and procedural volumes continue to rise. The only pay cuts that will remain in effect for those for senior leadership.
MIT launches new preprint review
The amount of covid research has exploded, as have the non-peer-reviewed results of many of those trials. To vet the findings being published on servers like bioRxiv and medRxiv, MIT and UC Berkeley have teamed up to launch a new open access journal. Rapid Reviews Covid 19 plans to publish reviews of preprint findings to weed out misinformation and bad methodology as well as highlight important new research. The project, which has received a $350,000 grant, will tap 1,600 potential reviewers.
June 26, 2020
SXSW surge, unmet demands for testing and steroid shortages
Given climbing case numbers in Texas, the state’s governor this week halted elective procedures in four counties. Texas and Arizona are two of the hardest hit among 29 states where caseloads are on the rise, while more than a dozen public laboratories nationwide say they are struggling to meet testing demand. That problem is particularly acute in Arizona where, the New York Times reports, testing bottlenecks remain the same as they were several months ago, with labs not having enough machines or trained personnel. While national testing capacity has reached a half million per day, that doesn’t help cities and states with outbreaks that need to sharply increase testing capacity. STAT reports that hospitals now have a shortage of several injectable forms of dexamethasone, the steroid found in preliminary results to lower covid mortality. After those results were announced June 16, hospital orders for the low-cost drug rose more than 600% in three days, while the rate of orders being filled for it fell by half.
ACP recommends N95s for all covid care
Guidance on masks and respirators from national and international agencies has been controversial: While the WHO says N95s should be used only during aerosolizing procedures with covid patients, the CDC recommends using N95s for all covid care—unless supplies are limited. The ACP has now weighed in with what it calls “practice points,” looking at the effectiveness of N95s vs. surgical masks vs. cloth masks. Among its recommendations: All health care personnel in close contact with suspected or confirmed covid should use N95s, while all suspected or confirmed covid patients in health care settings should wear surgical masks. (All staff, patients and visitors not in close contact with covid patients should also wear surgical masks.) As for cloth masks, they are “not considered PPE in health care settings,” and they shouldn’t be used. The guidance defines “close contact” as being within six feet of a covid patient or handling secretions from such patients. As for extended use and re-use, the guidance says there is no available evidence. But based on nonclinical outcomes, extended N95 use is preferable to re-use.
To manage ICU capacity, think state-wide, not local
When it comes to factors that can drive up covid mortality in hotspots, the authors of a Harvard Business Review piece propose this one: overcrowding of individual ICUs. Both Germany and Italy had similar infection rates, they write, but the mortality rate in Germany was 4.7% vs. 14.5% in Italy. While there were many reasons for that disparity, one was the ability in Germany to tamp down individual ICU capacity. German hospitals were able to easily transfer critically ill patients out of crowded ICUs, thanks to a national ICU bed registry that tracks available critical care beds and ventilators and allows doctors to relocate ICU patients quickly. Trying to boost ICU capacity in individual hospitals may only increase mortality, the authors argue, as overload leads to higher provider fatigue and infections among health care workers. Instead of trying to manage individual ICU capacity, hospitals should adopt a pan-regional or pan-state management strategy instead.
Health care workers, others, exempt from new H1-B restrictions
The Trump administration this week made headlines for restricting temporary work visas. A new executive order, which took effect earlier this week and remains active through the end of the year, suspends new H-1 and H-2B, L-1, J and other visas for more than 500,000 skilled and seasonal workers. Exempt from that executive order, however, are health care workers, while other broad exemptions apply to agricultural and food industry workers. The visa suspension also does not affect the status of visa-holders already in the country. The rationale given was to protect jobs lost due to the pandemic. Earlier this year, the administration called a temporary halt to issuing new green cards.
Foundations suspend fundraisers—and research suffers
Many nonprofit foundations and disease societies are being challenged by funding shortfalls. That’s because the charity fundraisers they depend on—silent auctions, mini-marathons and galas—have dried up due to covid. Not only is foundation staff being laid off, but research grants from those nonprofits are being postponed or even canceled. That’s bad news for junior researchers who often score their first grant from a disease society or foundation. According to a source in Science, such “training wheel grants”—while they make up only 5% of national research funding—often go to young researchers for small, high-risk pilots. Scoring such support enables researchers to then go on and attract much larger, government-funded grants.
June 22, 2020
WHO reports record numbers of new daily cases
This weekend, the WHO announced the largest single-day jump in the number of covid case worldwide: more than 183,000, with Brazil setting a record for the country with the most new cases in a single day (55,000). Seven states also set records over the weekend for new daily-case numbers. Health experts say that’s not just a factor of more testing but that hospitalizations are on the rise in Arizona, Texas, Florida, and North and South Carolina. As the pandemic reaches rural areas, concerns grow about financially-strapped rural hospitals. And the Boston Globe reports that statewide data show the disproportionate burden of disease among Hispanics and black Americans. While Hispanics make up only 12% of the population in Massachusetts, they account for close to 30% of all cases, while black Americans’ positive rate in the state is more than 14% although they represent only 7% of the population.
Need to sterilize masks? Steer clear of chlorine dioxide
University of Oklahoma researchers compared mask sterilization via either hydrogen peroxide vapor or chlorine dioxide on three different types of masks: N95s, KN95s and surgical masks. Their findings: Hydrogen peroxide vapor was better than chlorine dioxide, which was found to compromise masks’ filtration efficiency. With chlorine dioxide, MedPage Today reports, the filtration efficiency of both KN95s and surgical masks fell below 50% for particles of 300 nm; with vaporized hydrogen peroxide, that efficiency remained above 95% for both N95s and KN95s. (Surgical mask efficiency was reduced after being sterilized with hydrogen peroxide vapor.) While the research looked at filtration efficiency according to aerosol particle size, the study did not look at the effects of multiple rounds of sterilization.
Antibodies may fade quickly, at least in asymptomatic patients
Do recovering patients have immunity going forward? And if they do, for how long? A letter published in Nature Medicine may provide some clues. Chinese researchers looked at the clinical features and immune responses of 37 asymptomatic patients, comparing them to an equal number of people not infected. They found that antibodies may last only two or three months—although that may not mean that patients can be re-infected. According to the New York Times, the research also found that asymptomatic patients shed virus longer than those with symptoms. A preprint article published in Nature suggests that even low antibody levels may prevent re-infection.
June 19, 2020
Racial disparities, bias and activism
Calling African-American mortality from covid “a sentinel event,” editorialists in the Journal of the American College of Cardiology write that covid’s disproportionate toll among black Americans highlights “deep-rooted U.S. health care failures.” Specific disparities exist for African-Americans in cardiovascular disease and social determinants of health, both predictors of covid infection and mortality. An NEJM piece notes that many of the decision-making tools, algorithms and formulas used in medicine end up denying black patients needed care. The consequences of adjusting lab values for kidney function according to race, for instance, gives blacks better filtration rates than whites, kicking some black patients off transplant lists. And a growing number of clinicians are taking part in direct advocacy against police brutality and racial disparities, with more than 10,000 health care workers marching in downtown Seattle for Black Lives Matter. But while the national ranks of those participating in #whitecoatsforblacklives have swelled, activism may still be uncomfortable for some in a profession taught to keep silent about political and social beliefs.
Lessons learned: How NYC’s public system managed the surge
As covid cases spike in the Sunbelt and western U.S., an analysis in Health Affairs describes how New York City’s public health system (NYC Health + Hospitals, with 11 hospitals and three field hospitals) managed the crisis there this spring. One key component: increasing ICU beds, and at its apex, the health system—which had 300 ICU beds—was treating more than 1,000 ICU patients. “Primary” ICU spaces were those that already had ICU equipment, while “flex” spaces were added in PACUs, ORs and procedural areas. The most seriously ill patients were treated in the primary spaces. As for boosting ICU staff, the system used a tiered model, with experienced staff leading those who were redeployed. The EDs also had to be extensively managed, with text-message campaigns and open public letters urging patients with mild symptoms to not come to an ED. The health system also partnered with the city’s 911 call center to set up telehealth assessments of patient symptoms. Another Health Affairs commentary describes how NYC Health + Hospitals trained 20,000 staff including close to 9,000 nurses on covid content within two months.
Dexamethasone results: Proceed with caution
In the wake of this week’s announcement that low-cost dexamethasone cut mortality in covid patients who need respiratory support, Britain’s National Health Service approved use of the steroid in all ventilated covid patients. But some experts are urging caution, pointing out that researchers in the dexamethasone trial released only a summary of their data and that those data have yet to be peer-reviewed. They also note that other optimistic studies related to covid therapies have ultimately been shot down. “(A)fter all the retractions and walk backs,” wrote Atul Gawande, MD, on Twitter, “it is unacceptable to tout study results by press release without releasing the paper.” Given the enthusiasm the preliminary results have received, the WHO clarified that the therapy is to be used only for patients with severe covid who need oxygen or ventilation, not for mild cases or for prophylaxis.
What recovery can look like for the sickest patients
In New York City, the fight against covid has switched from the ICU to recovery units where the sickest covid patients, many of whom were intubated for weeks, re-learn how to walk and to eat. Sources quoted by the New York Times say the PTSD symptoms seen in many critically ill patients seem magnified among those recovering from coronavirus as those patients stay longer in ICUs and lose more muscle. MedPage Today notes that no algorithms have been released targeting post-covid care. New York’s Mount Sinai has organized a Center for Post-COVID Care to follow up on thousands of covid patients. In the three weeks that center has been operating, 80% of the patients treated there needed a pulmonology referral while 50% needed cardiology, between 20% and 30% were referred to neurology, and many received a psychiatric referral.
Patient satisfaction becomes soaring patient appreciation
It’s unprecedented, according to the CEO and CMO of Press Ganey. In a piece in the Harvard Business Review, they write that they are used to seeing patient satisfaction scores for overall care inch up by 1% a year. Yet in just one month—this February to March—survey scores for overall care from more than 238,000 hospitalized patients rose 1.6% nationwide. That jump was eclipsed by increases in covid hotspots: a 4.3% one-month increase in Washington state and a 13.2% spike in New York. As for how surveyed patients rated physician skills, those rose 2.4% nationally, but 2.8% in Washington and 10.4% in New York, with similar hikes seen for nursing ratings, overall courtesy and responsiveness. “This is,” they write, “the survey version of their banging on pots every night.”
June 16, 2020
Study: Low-cost steroid cuts covid mortality
U.K. researchers today announced the findings of their 6,000-patient RECOVERY trial: Dexamethasone reduced deaths by one-third in ventilated covid patients and by one-fifth in those receiving supplemental oxygen. According to a statement from the study’s chief investigators, more than 2,100 patients were randomized to dexamethasone 6 mg once daily (either PO or IV) for 10 days. More than 4,300 other patients who were randomized to the control arm received only usual care. Among patients receiving usual care, 28-day mortality was 41% among ventilated patients, 25% among those requiring oxygen and 13% among those with no respiratory intervention. Among patients in the dexamethasone arm, however, researchers say that one death was prevented for every eight ventilated patients and for every 25 patients requiring oxygen alone. The study found no benefit to the therapy among patients who didn’t need respiratory support. Saying that the drug was the first found to cut covid mortality, the authors—who are working to publish full details—wrote: “The survival benefit is clear and large in those patients who are sick enough to require oxygen treatment, so dexamethasone should now become standard of care in these patients.”
FDA yanks emergency use for hydroxychloroquine
The FDA this week withdrew its emergency use order for hydroxychloroquine and chloroquine, saying the drugs were not proving effective against covid and highlighting what the agency called “serious side effects,” including cardiac adverse events. According to a top FDA official, the withdrawal was based on recent science. The FDA this week also cautioned against using hydroxychloroquine in combination with remdesivir, saying that using both could reduce remdesivir’s antiviral activity. A list of frequently asked questions from the FDA states that the agency does not recommend treating hospitalized covid patients with hydroxychloroquine outside of a clinical trial.
Childrens’ risk of infection is only half that of adults’
A new letter published in Nature Research delivers this reassuring news: Children and teenagers are only half as likely to become infected with covid as those age 20 or older. Further, even when children and teenagers do become infected, they don’t develop clinical disease or develop only mild symptoms. The authors surveyed populations in six nations. They note that among patients ages 10 to 19, only 21% develop symptoms vs. 69% of those over age 70. According to Washington Post coverage, the findings have big implications not only for re-opening schools this fall but for developing countries that have very young populations. Previous studies from China have found that children are as likely as adults to become infected.
June 12, 2020
Some states see spikes in covid hospitalizations
With all states in some phase of reopening, the number of covid cases in the U.S. has now surpassed 2 million. While 21 states have reported increases in their number of covid cases since Memorial Day, nine states are seeing their number of covid hospitalizations rise: Texas, California, Arizona, Arkansas, North and South Carolina, Oregon, Mississippi, and Utah. As hospitalizations continue to mount in Arizona, Banner Health has sounded the alarm, pointing out that half the hospitalized cases in that state are in Banner hospitals. If that trend continues, according to a health system statement, the hospitals will need to surge up to 125% bed capacity. Two preprint studies in Nature Research quantify the impact of lockdowns in different countries. The authors of one of those studies estimate that the shutdown in the U.S. prevented 60 million infections and 285 million in China, while the other preprint finds that lockdown measures in Europe may have saved more than 3 million lives.
Which respirators shouldn’t you reuse?
The FDA this week released a list of respirators it says shouldn’t be decontaminated and reused. On that list: N95s manufactured in China—banned because of issues around quality control—as well as any respirators with exhalation tubes. According to the agency, hospitals should use decontamination systems only on non-cellulose-compatible N95 respirators. The announcement reverses in part the FDA’s emergency authorizations issued earlier this year that OKed decontaminating single-use masks and respirators. HealthLeaders Media reports that the Massachusetts Nurses Association, citing safety concerns, had petitioned for the right to refuse to wear decontaminated masks and respirators. And the Pennsylvania health department has now ordered all hospitals in the state to replace any soiled or damaged respirators on request, as well as require universal masking. Responding to complaints about PPE voiced by one of Pennsylvania’s largest nursing unions, the state now requires hospitals to provide respirators to any staff providing direct care to covid patients.
Health system launches acute ventilator recovery units
Because covid patients who are ventilated for more than a week need physical therapy, a New York health system has come up with this solution: acute ventilator recovery units. Northwell Health has now launched two such units, each costing about $1 million to equip. Those units are being staffed by hospitalists, pulmonologists, respiratory and physical therapists, and nurses. Patients in the units are being weaned off ventilators while receiving physical therapy. The two units, which together have 27 beds, are intended to bridge care between the ICU and acute rehab facilities. Patients transferred to the unit must have a tracheostomy, be hemodynamically stable and be able to participate in physical therapy.
Preventing your own mental health crisis
Writing in Annals, two palliative care physicians applaud the types of resources—employee assistance programs, debriefings and counseling—that institutions have set up to address the trauma front-line clinicians are experiencing treating covid. But those approaches aren’t enough, they write, sharing what they call “a foundational set of principles” to help clinicians cope. Those include “looking past the illness” by spending a few minutes on the phone with a family member to learn something “humanizing” about the patient; fostering community, not self-isolation, to build resilience; promoting vulnerability, the opposite of all the “super-hero” characterizations; and establishing boundaries and limitations, making sure clinicians have scheduled time off that they use.
Black clinicians navigate two pandemics
The intersection of the coronavirus pandemic, with its catastrophic burden on black Americans, and the grief caused by the latest round of racist murders makes this “a time of deep sorrow for Black people.” So writes Kimberly Manning, MD, a hospitalist at Atlanta’s Grady Hospital and Emory’s associate vice chair of diversity, equity and inclusion. In a Journal of Hospital Medicine perspective, Dr. Manning describes the texts and e-mails she’s received from colleagues who realize that she, along with all African-Americans, continue to face a “far more destructive pandemic,” even as coronavirus ravages black communities. Her advice: listen more than talk, extend timely support, don’t expect the grieving to guide you in how to help and “remember that support is a verb.” The Nocturnists is handing over the mic, launching a new audio documentary series called Black Voices in Healthcare. The series host has issued an open call to black health care workers to participate.
June 10, 2020
New data show mixed picture of physicians’ finances
A new survey finds that while physicians in several major specialties have experienced drops in compensation over the past year, about one-third still say their practices are financially stronger than they were five years ago.
Data from the most recent Medical Economics survey of physicians paints a mixed picture of physicians’ compensation and finances. The survey found that in terms of compensation, specialties like internal medicine, family medicine and pediatrics all experienced declines in their incomes from 2018 to 2019. Internists reported an average income of $243,000, family physicians reported an average of $241,000, and pediatrics reported an average of $231,000.
When asked to compare the financial state of their practice five years ago, 31% of respondents said things were better, 34% said things are about the same and 35% said things were worse.
Physicians who said their practices were better off financially said factors included seeing more patients, pay-for-performance incentives and renegotiating contracts with payers. Physicians who said their practices were in worse shape blamed more time spent on uncompensated tasks and lower reimbursement from commercial payers and higher overhead.
A slideshow has more details on compensation trends by specialty, type of practice, size of practice and more.
Advocacy group aims to protect physicians who speak up about PPE
A new group has formed to protect the rights of health care professionals who voice concerns they have about PPE and other issues surrounding the covid pandemic.
There have been numerous reports during the pandemic of health care workers being fired or disciplined for complaining about the state of their PPE gear. The new group, Beacon, will try to protect the rights of health care professionals who speak out about PPE and other covid-related issues.
Beacon published a letter on social media urging hospitals to respect medical professionals who “research, write and speak” about PPE. Beacon is asking physicians and health care professionals to sign a petition demanding fair and safe treatment of physicians and nurses when it comes to discussing covid-related issues like PPE.
The group intends to help health care professionals who face retaliation by helping them get their jobs back, retain a severance package or get compensation for unfair treatment.
Physician social media ratings fall way behind lawyer ratings
A new report says that lawyers are 44% more likely than physicians to receive a five-star review on the social media platform Yelp. Put another way, lawyers are 72% less likely than a doctor to receive a one-star review.
The report, published by the health care marketing firm Vanguard, found that the average Yelp rating for a doctor is 3.5 stars compared to an average rating of 4.2 for lawyers.
An article in Physicians Practice says that a study of 35,000 physician reviews found that while 96% of unhappy patients were satisfied with the quality of care, they were unhappy with non-care issues like wait times in the office and hold times on the phone. The article looks at strategies medical practices can take to address patients’ issues with those aspects of care to boost their ratings on social media sites like Yelp.
June 8, 2020
Problems arise with recycled N95s
Given mask shortages in hit-hard facilities, many hospitals have adopted protocols to extend the use of N95s and/or re-use them after storage or cleaning. But in a new research letter, UCSF researchers outline problems they uncovered with extended use and reuse. Looking at N95s worn by 68 clinicians in their ED, the authors found a high level of fit failure (71%) among duckbill N95s compared to 28% for dome-shaped masks. Among those wearing dome-shaped masks, fit failure was linked to a higher number of shifts worn, more frequent donning and doffing, and increased hours worn. “Health systems should closely evaluate N95 fit during extended use or reuse,” the authors write, “and limit duckbill mask use if alternatives are available.”
Roundup: asymptomatic patients, neurologic symptoms
As cities and states loosen stay-at-home orders, a new Annals review makes the case for substantially broadening testing to include asymptomatic patients. Data suggest that almost half (40% to 45%) of all infections are caused by asymptomatic carriers who may transmit virus to others for more than 14 days. Given the constraints with diagnostic testing, the authors call for innovative surveillance tactics including crowdsourcing data from wearables and monitoring sewage. In other news, more than half—57%—of all covid patients admitted to two hospitals in Spain had neurologic symptoms. The retrospective observational study, which was published in Neurology, looked at data on more than 800 patients. The authors found that while neurologic symptoms were present in all covid stages including recovery, stroke and inflammatory diseases appeared in late stages. One in five patients hospitalized was found to have disordered consciousness. And in addition to age and underlying conditions, genetics may play a key role in determining who develops only mild symptoms vs. severe disease. A preprint study, for instance, links having type A blood to a 50% greater risk of needing oxygen or ventilation. Other genes may regulate immune response and trigger an overreaction.
Hospitals continue to bleed jobs
Very mixed news on health care jobs in May: It was the second straight month of negative job growth for hospitals, although dentists and outpatient offices saw the return of more than 300,000 positions. Hospitals, however, reported losing 27,000 jobs last month, which came in the wake of 127,000 jobs lost in April. And while hospitals have received billions in federal relief funds designed to tide them over, a New York Times analysis finds that many of the large health systems receiving relief funds have billions of dollars in cash reserves. Many of those same systems have also cut workers’ pay while continuing to award big bonuses to top executives.
June 5, 2020
What protests may mean for transmission
The protests against racial injustice going on across America may also fuel a surge in coronavirus cases, experts say. While many protesters can’t social distance and some don’t wear masks, the fact that they are shouting and chanting is increasing the odds of passing the virus from person to person, while fires and tear gas may also increase risk. An IDSA spokesperson noted that clinicians may want to include questions about taking part in a protest when screening possible covid patients and to “enlarge the differential” to see if patients might have inhaled tear gas or were near fires. Many hospital and medical groups, including the AMA, the American Hospital Association and the American Nurses Association, have said that police brutality is a public health issue and that racism and inequitable access to care are also driving the pandemic’s disproportionate impact on African-Americans. Across the country, while some states are seeing reduced caseloads, hospitalizations continue to rise in other states including Wisconsin and Minnesota.
Some good news (maybe) for convalescent plasma
Convalescent plasma comes up short in a new study in terms of improving outcomes for patients with either severe or life-threatening covid—but the authors did note “a signal of possible clinical benefit” among those with severe disease. Chinese researchers randomized about 100 patients to either convalescent plasma plus standard therapy or standard therapy alone. Overall, they found no significant differences between the two groups in terms of less time to clinical improvement within 28 days or in mortality or time to discharge. (Patients with severe disease included those in respiratory distress, while the group with life-threatening disease included those with organ failure or intubation.) But an editorial points out that the study was underpowered and that it makes sense that the therapy would be more effective among patients who aren’t intubated. The findings, the editorialists write, “provide an important signal of possible benefit in the subgroup of severely ill patients and suggests that high titer antibody against SARS-CoV-2 may have antiviral efficacy.” In related news, “60 Minutes” this week highlighted convalescent plasma research being done at New Jersey’s Hackensack University Medical Center in which plasma donors are being handpicked. About 20% of donors have the strongest antibody response, and researchers are testing outcomes among covid patients treated with plasma from those donors.
Covid studies are challenged, then retracted
Two well-publicized covid studies have now been retracted after a host of clinicians, researchers and statisticians penned open letters to the study authors, asking to see the data their findings were based upon. One of the studies, which appeared in The Lancet, found increased mortality risk among covid patients taking hydroxychloroquine and chloroquine, findings that led the WHO to suspend a hydroxychloroquine trial. The open letter to the authors called for independent validation of the results and pointed out research inconsistencies. (The WHO has since resumed its research.) The second trial was published in NEJM, and it reported not finding a link between ACE inhibitors/ARBs and in-hospital covid mortality. The letter targeting that study questioned the reliability of the data used. Both studies relied on the same database, and both had several of the same authors. The authors this week retracted their findings, saying that the company that compiled and analyzed the data used in both studies—Surgisphere—was not cooperating with an independent review.
CMS extends more flexibility to alternative-payment models
Throwing a lifeline to hospitals and health systems struggling with coronavirus, the administration this week outlined changes to its value-based payment model programs. Among those, as reported by FierceHealthcare: The CMS will delay the start of its direct contracting model next year and extend its Next-Gen ACO model through the end of next year. It’s also allowing participants in the BPCI Advanced program to eliminate either upside or downside risk, and it is removing the downside risk for the joint replacement comprehensive care model for all episodes through the covid emergency period. A professional association of ACOs praised the changes, saying the new options would protect ACOs from pandemic-related losses.
A primer to help keep patients—and clinicians—safe
How can clinicians in covid hotspots keep themselves and their patients safe while they deal with unprecedented demand and stress? A new AHRQ primer delves into team factors that can boost safety while treating covid patients. The authors note that fatigue and burnout as well as time constraints and the stress of dealing with new teams can all lead to misdiagnoses and adverse events. Recommendations to help reduce those risks include rapid team formation by using huddles, debriefings and checklists. And because so many new work processes have been introduced to treat covid, attention must be paid to identify “potential failure points” where mistakes are more easily made. The primer also recommends using simulation to help teams prepare and prominent signage for equipment locations, hand hygiene and PPE reminders, and restricted areas.
June 4, 2020
Survey #1: How physicians are treating covid
A new survey by Medical Economics looks at how the covid pandemic has affected physicians. The survey found that 52% of physicians have treated covid patients; 18% saw those patients in an office setting, 16% in the hospital, 19% via telehealth. Just under half of physicians (47%) say they haven’t treated any covid patients at all.
The survey found that 83% of physicians have increased their use of telehealth to treat covid. More than half of physicians (60%) say they don’t have adequate access to covid test kits, and only half think they have adequate PPE gear when treating covid patients.
Half of physicians say that they have patients who have experienced a health crisis or a deterioration in a chronic health problem that could have been prevented by routine health care. Nearly all (94%) say that some of their patients are foregoing routine and/or acute medical care because of the virus.
Survey #2: anxiety and underemployment in the age of covid
A survey by the healthcare staffing company CHG finds that covid is, not surprisingly, raising the levels of stress and burnout among physicians and PAs/NPs as it reduces their work hours and income.
Nearly three-quarters of physicians and PAs/NPs (72% ) report feeling slightly or significantly more general anxiety in their lives. Just over half (56%) are concerned that they’ll become infected themselves; 68% are worried that they’ll give the virus to a loved one.
A small number of respondents (7%) say they’ve been laid off; 6% say they’ve been furloughed. A much larger number (74%) say they’re working less because of the pandemic. Lower patient volumes are behind the reduction in work for 43% of respondents. The pause in elective care is behind fewer work hours for 26% of respondents.
Of those who were furloughed or laid off, 62% say they will file for unemployment, 57% plan to reduce expenses, and 52% say they will rely on savings. To supplement their income, about half of respondents (46%) are actively looking for new positions, 37% are working locum tenens, and 26% are finding work in telehealth.
How hospital volumes have been crushed by covid
While health care tries to come back to life as the covid pandemic shows signs of slowing, there are signs that hospitals continue to struggle.
A report by the firm Strata Decision Technology found that the number of patients who sought hospital care in March and April plummeted 55% compared to the same time frame during the previous year. And while some analysts had predicted that patient volumes might begin to pick up in May, data show that was probably not the case.
When comparing patient volume data from early April to early May, Strata found that daily ED visits were down by 23%, daily outpatient visits were down by 11%, and daily inpatient admissions were down by 8%.
Here’s a look at how individual specialties have seen their patient volumes affected by the pandemic. The following data compare patient volumes from March/April of 2020 to March/April of 2019.
- Primary knee replacements: -99%
- Lumbar/thoracic spinal fusions: -81%
- Primary hip replacements: -79%
- Diagnostic catheterizations: -65%
- Diagnostics: -60%
- Cardiology: -57%
- Breast health: -55%
- Percutaneous coronary interventions: -44%
- Cancer care: -37%
- Fracture repairs: -38%
June 1, 2020
Lockdowns cut infection rates by more than half
The stay-at-home orders issued in more than 40 states achieved their objective, slashing covid transmission by 58%. That’s according to a new study published in the American Journal of Infection Control. The authors tracked the number of confirmed cases before and after those orders took effect and found that the daily increase in community cases dropped from 12%—with the number of cases doubling every five to six days—to 5%. With a 5% daily increase, the number of covid cases instead doubled every 14 days.
Research letter: Start anticoagulants early
In a new research letter, French authors report that among 34 covid patients treated, 65% were found to have DVT on admission. Further, venous ultrasounds performed on those patients within 48 hours of ICU admission found that 79% had DVTs. Among those, 53% had bilateral thrombosis and 26% had proximal. “Despite anticoagulant prophylaxis,” the authors write in JAMA Network Open, “15% of our patients developed deep vein thrombosis only 2 days after ICU admission. Systematic anticoagulant therapy for all ICU patients with COVID-19 should be assessed.” In addition to starting anticoagulation promptly, researchers urge early detection.
New CMS waiver allows hospitals to offer SNF swing beds
One recurring problem during the pandemic: where to discharge covid patients when they no longer need hospital care but are too ill to go home. With many SNFs refusing to accept covid patients, a new CMS swing bed waiver should help. Issued last month, the waiver allows hospitals to offer patients long-term swing beds as long as patients meet criteria for SNF level of care. (The waiver does not apply to psychiatric or long-term care hospitals.) Those swing beds don’t need to be in a separate location, and hospitals must have a plan in place to discharge patients from swing beds as soon as practicable or when a SNF bed becomes available.
May 29, 2020
What will it take to bring patients back to the hospital?
Hospitals and health systems around the country are rolling out marketing efforts to convince patients it’s OK to access health care. Six of Southern California’s biggest health systems, for instance, have partnered to produce the BetterTogether.Health campaign. Using “Get Care When You Need It” as a tagline, the campaign is relying on a Web site and public service announcements with TV and radio spots, billboards, and ads in print, digital and social media. Also in California, a 150-bed community hospital is using targeted Facebook messaging to convince patients that it’s safe to come to its ED. One big part of that message: letting patients know the ED has been partitioned into separate sections for respiratory and non-respiratory patients. And in a new JAMA Internal Medicine perspective, a physician looks at how other services he is using—dry cleaners and tire and hardware stores—are building trust to convince customers to come back. The biggest challenge for hospitals, he writes, is getting a safety message out without scaring patients away. While photos of plexiglass shields at information stations will seem familiar, “published statements about the frequent testing of staff or their ritualistic gowning need careful thought, and perhaps some testing of their own.” A Kaiser Family Foundation poll found that almost half of respondents—48%—said they or a family member had delayed or postponed medical care due to the pandemic.
U.S. death toll climbs past 100,000
The U.S. on Wednesday passed this ghastly milestone: More than 100,000 Americans have now died of coronavirus in the last three months. According to the CDC, that death toll is out of close to 1.7 million cases, with more than 26% of reported cases among African-Americans. (African-Americans make up only 12% of the population.) The CDC further reports that close to 63,000 cases of covid infections are among health care workers, 294 of whom have died. However, those figures are probably under-counted because health care-personnel status was available in only 21% of total cases. Several states are seeing increases in the number of new cases and deaths including Alabama, Arkansas, California, North Carolina and Wisconsin
Start remdesivir before patients need to be intubated
The NIAID has finally released preliminary results of its much-publicized remdesivir trial. In that study, more than 1,000 patients were randomized to either remdesivir for 10 days or placebo, and those taking remdesivir had a shorter median time to recovery (11 vs. 15 days). The big takeaway: Results were significant only among patients receiving oxygen but not in those who were intubated, so use of the antiviral should begin before patients need mechanical ventilation. In a separate study, close to 400 patients with severe covid pneumonia who weren’t intubated were randomized to either five or 10 days of remdesivir, with the authors finding no significant difference in outcomes between the two groups. An editorial pointed out: Given the limited supplies of remdesivir, “priority should be given to a 5-day remdesivir regimen for patients at the early stages of severe disease” when they are on supplemental oxygen but not intubated.
Study doesn’t back theory of separate covid pneumonia phenotypes
Last month, a prominent Italian pulmonologist kicked off a big debate, suggesting in an editorial that there were two separate phenotypes of covid pneumonia, each requiring separate treatment. One presented like ARDS and benefited from standard respiratory therapy; the other was more akin to high-altitude pulmonary edema, and those patients could be harmed by standard ventilator protocols. But a new study in the Annals of the American Thoracic Society doesn’t back that concept. Instead, the authors found that the proposed characteristics of the two phenotypes weren’t mutually exclusive and that most patients showed features of both. “[T]he most reasonable approach for ICU care” for most covid patients, the authors concluded, is extrapolating data from ARDS.
Homegrown disinfection system sterilizes thousands of masks a day
An orthopedic surgeon working with several colleagues in his shop at home produced a prototype of a trellis that his health system—VCU Health in Richmond, Va.—is now using to hang and sterilize N95s with UV-C light. HealthLeaders reports that the builders originally used parts from home and tractor supply stores; once they finalized a design, machinists made the actual product. The system utilizes a UV-C light robot that was already being used to decontaminate patient rooms, and it is now sterilizing up to 12,000 N95s per day for reuse. VCU Health put together a decontamination facility on its campus that employs two dozen people. The cost: about $15,000, which doesn’t include the price of a UV-C light source. VCU Health has released a downloadable 28-page instruction manual for facilities to build their own.
May 27, 2020
Hospitals roll out the red carpet for visitors and patients
As the pandemic shows signs of waning, hospitals are beginning to welcome visitors so patients don’t have to recuperate—or die—alone. A MedPage Today article says that in New York state, 16 hospitals are taking part in a pilot project to allow visitors into the hospital. Visitors will be allowed onto units for a set amount of time and will have to wear PPE.
Hospitals are also working to make people who need care more comfortable coming to the hospital. A recent survey found that 40% of respondents planned to hold off on obtaining medical care for at least six months because of concerns about covid. A Healthcare Dive article looks at the strategies several health systems are using to encourage patients who need care to go to a hospital, from elective surgeries to mammograms and blood work. Strategies to make patients feel more comfortable include taking the temperature of patients upon arrival, providing face masks and other PPE, and procedures to keep patients socially distanced. CMS has also released guidelines for hospitals providing non-covid care.
Physician practices take steps toward re-opening
As the country tries to get back to business as normal, medical practices are taking steps toward opening up and seeing patients in-person again. A survey earlier this month by MGMA found that more than half of physicians across a range of specialties had already started seeing patients in person, and 29% said that most physicians were making on-site appointments. The survey found that many practices say they’re seeing only half of their pre-covid volumes, and many physicians are continuing to see patients via telehealth. In a second survey by the Primary Care Collaborative, more than half of primary care physicians think they’ll be overwhelmed by a backlog of health needs. MGMA has released a reopening checklist for medical practices.
A primer for billing telehealth services
Now that Medicare has announced that it will pay for telehealth visits conducted only via phone, and not just visits via video, do you know how to bill for those services? A Medscape article gives a list of the codes to use when billing for telehealth and some tips to avoid trouble. For example, Medicare don’t use the place of service 02 (telehealth), but use a tag indicating where the service would have been furnished if the visit was face-to-face.
May 22, 2020
Trends among New York City’s critically ill
Out of more than 1,100 covid patients admitted to two New York City hospitals in March and April, more than one in five—22%—became critically ill, and most of those patients (80%) needed to be ventilated for a median of 18 days. That’s according to a new prospective study published in The Lancet. By the end of April, 40% of critically ill patients had died, while another 37% were still hospitalized. Among critically ill patients, more than 80% had at least one chronic illness, with hypertension and diabetes being the most common, and 46% had obesity. Two-thirds of critically ill patients received vasopressors, 31% had renal replacement therapy and minority populations were disproportionately affected. Factors associated with in-hospital mortality were older age, chronic pulmonary disease, higher concentrations of interleukin-6 and higher D-dimers. In other clinical news, an international study of more than 96,000 hospitalized covid patients found that those given hydroxychloroquine had a significantly higher risk of death. Also, experts now warn that young adults are presenting with the same Kawasaki-like inflammatory syndrome seen in some children with covid. And a research team that uses cellphone data to track mobility and predict hotspots says that cities and states in the South that have been rapidly re-opening risk a wave of new cases within four weeks.
Great news on a potential vaccine? Not so fast
The company that announced good news this week related to its phase 1 vaccine trial saw its stock price soar. But STAT reports that vaccine experts had a very different take, pointing out that the company didn’t release enough study data to gauge how well the vaccine really performed. In the trial, 45 subjects received varying doses of the vaccine and all developed some antibodies. Eight developed neutralizing antibodies, but those patients were followed for only two weeks. Furthermore, while the company (Moderna) claimed those subjects’ antibody levels were similar to patients who’ve recovered from covid, it didn’t disclose those levels—and antibody levels in recovered patients can vary widely. The company says it plans to publish those data in a journal article.
What impact will coronavirus have on physician compensation?
Physician compensation was enjoying modest gains this year—at least until the pandemic hit. The 2020 Medscape report on physician compensation found that average annual salaries rose between October 2019 and February 2020, with primary care physicians seeing a 2.5% boost and specialists a 1.5% gain. But now, the report notes, group and private practices and specialties that perform elective procedures are at serious risk due to the pandemic. Since March, patient volumes have fallen 60% and revenues dropped 55%, with 43,000 health care workers laid off in March. One bright note: The report points out that telemedicine volume has increased more than 200%.
Implementing evidence within days, not years
It can take a decade or more to translate research findings into clinical practice. But that’s all changed with coronavirus. A new Journal of Hospital Medicine perspective tells, according to its title, “An Implementation Story,” as physicians at Baystate Health decided to no longer pursue an early intubation strategy with covid patients. To produce a new respiratory pathway, one that featured high-flow nasal cannula or noninvasive ventilation instead of early intubation, the authors sought protocols from other institutions via social media, assembled all clinical stakeholders within their institution and reached consensus within 48 hours. (The protocol also endorses early “awake” proning, which was the focus of two new JAMA research letters here and here.) It was adopted immediately after aggressive distribution of and education about the new protocol, the authors report. “This endeavor,” they write, “highlights how the COVID-19 pandemic, for all its tragedy, may represent an important era for implementation science: a time when emerging literature from a variety of sources can be implemented in days rather than years.”
Not feeling all the “hero” talk?
In the latest episode in the covid podcast series produced by The Nocturnists, a group of clinicians reflects on the narratives being told around covid and each offers his or her own. The episode, “Insomnia,” includes audio diaries from a geriatrician distressed that she didn’t pick up on a diagnosis during a patient’s video visit and from a pediatric emergency physician in New York, struggling with loss that a colleague who died by suicide didn’t live to see “the hopeful part” of the pandemic’s arc “where people can imagine an end.” Several of the clinicians recorded—they also include two medical students, a hospitalist, an adult emergency physician and an ED nurse—touch on the “hero” and “soldier” metaphors so often used now for health care workers. “Nobody signed up for this,” one doctor says. “The metaphors of ‘war’ and ‘heroes’ and ‘fighting the good fight’—that’s not what medicine is. Nobody should be fighting this fight that was totally preventable.”
May 20, 2020
A look at medical training during the pandemic
How are residents and fellows dealing with the onslaught of covid during their training? An article from NPR talks to several physicians-in-training about the effects of the pandemic. Several note that the pandemic has them questioning everything they thought they knew about clinical medicine as they try to keep up with the effects of the virus on their patients. Others note that they are struggling with the emotional toll of seeing so much loss from the pandemic. One emergency medicine resident says he can’t forget talking to patients about to be put on ventilators about their chances for survival—and then listening as they talked to family members on the phone.
What specialties face the highest risk of covid?
New data show that it may not have been a coincidence that the Chinese doctor who died of covid after trying to warn the world about the coming pandemic was not an emergency medicine physician, but an ophthalmologist. A new preprint looking at infection rates among New York City resident physicians in March and April found that three specialties had the highest risk of contracting the virus: anesthesiology, emergency medicine and ophthalmology. A Medscape article says that risk factors for the three specialties are significantly higher than for other physicians. Researchers note that recent data show that the risk for ophthalmologists may be high because the virus can spread through the eyes.
How will academic careers be affected by covid?
Careers for young physicians looking to enter academic medicine may be derailed by the financial stress that is pummeling health care. A MedPage Today article says that academic institutions across the country have instituted hiring freezes, which may limit opportunities for residents hoping to enter academic medicine. While it appears that most existing fellowship offers are being honored, the terms of at least some of those arrangements have changed, with positions that were supposed to focus on teaching or research focusing instead more on clinical care. Analysts worry that the financial stress being felt in health care will hit next year’s residents even harder as they look for opportunities in academic medicine.
May 18, 2020
Which covid patients may become critically ill?
Researchers have published a validated Web-based tool to help calculate at admission whether covid patients will become critically ill. Using hospital records of close to 1,600 patients in China, the authors—writing in JAMA Internal Medicine—assessed more than 70 risk factors. They identified 10 variables associated with increased risk of critical illness, which was defined as needing ICU care or ventilation, or death: chest X-ray abnormality, age, hemoptysis, dyspnea, unconsciousness, number of comorbidities, cancer history, neutrophil-to-lymphocyte ratio, lactate dehydrogenase and direct bilirubin. In other news, Mayo Clinic and the Society of Critical Care Medicine have launched a dashboard with data on thousands of covid patients across more than 100 sites in eight countries. Data tracked include how long patients are being ventilated as well as ICU length of stay.
Here are the states that are the most vulnerable
The CDC has issued guidance on what schools and businesses should do to safely reopen. (The CDC originally proposed more strict draft guidelines.) But which states have the most vulnerable populations? A data analytics firm has ranked states according to more than two dozen medical and economic variables. Those variables include how big are states’ populations of elderly and/or patients with pre-existing medical conditions and of those who lack adequate housing or are living in poverty. According to the analysis, West Virginia is the most vulnerable state due to its large populations of elderly and of patients with chronic diseases, followed by Mississippi, Arkansas and Alabama.
Covid tests dogged by high rates of false negatives
A new study in Annals delivers this bad news: RT-PCR tests have virtually no value in diagnosing patients immediately after they are exposed to coronavirus, with patients continuing to have a high probability of false negatives for several days. Looking at seven previously published studies on both inpatients and outpatients, the authors found a 100% probability of false negatives on the day of exposure. That rate fell to 38% when symptoms began, which was typically four days later. Even three days after symptom onset—around day 8 from exposure—the false-negative rate was 20%. Key takeaways: Don’t rule out coronavirus based on RT-PCR test results alone, and consider waiting to test between one and three days after symptoms begin to minimize the odds of getting a false negative.
May 15, 2020
The next surge may be in noncovid care
While some states cautiously green-light the restart of some elective procedures, a new report suggests how much pent-up demand there may be for hospital services. Issued by a financial analytics firm, the report found that average inpatient census over a two-week period in March and April fell more than 54%. The drop-off was much steeper in specialties that had to halt elective procedures including a 74% reduction in orthopedic services and a 67% decrease in GI. But medical specialties also took an outsized hit with a 57% reduction in cardiology volume and a 37% decrease in cancer care. The report also found a 57% drop in care access for MIs and a 56% decline in stroke volumes. In a new commentary, two hospitalists warn about the coming surge in hospitals of noncovid care. And in new survey results from Premier, health care facilities weigh in with what they believe they need to resume full services: the ability to triple their testing capacity and screen all front-line workers, employees and patients coming for elective procedures.
Data on remdesivir is still MIA
While remdesivir has been the sole medication found to be of some benefit, many questions remain: Which covid patients should get it, and at what point during their illness? Hospitals report that there isn’t enough of the medication to go around. Moreover, clinicians have only an NIAID press release to go on and still don’t have the full study results they need to parse out which patients are more likely to benefit from the drug and at what dose. While distribution of the drug is being worked out, with state health agencies coordinating those efforts within states, individual hospitals trying to create their own remdesivir protocols may have to set up a lottery system to determine which patients get the drug. Clinicians are now calling for the release of full trial results.
Clinicians at risk for their own mental health crisis
During the pandemic, front-line workers have faced grueling days, prolonged stress and, for some, isolation for their families. Modern Healthcare reports that those conditions have been compounded by patient death rates running 10 times the usual number and clinicians being assigned to roles they don’t normally fill. According to experts, clinicians risk potential PTSD and burnout and hospitals need to address those mental health issues. Some hospitals are boosting in-house services and referrals and creating break rooms and outdoor spaces where clinicians can rest. New York’s Mount Sinai, where clinicians have treated thousands of covid patients, has launched a new center to look at the psychological impact of treating coronavirus on front-line workers with research, screening and treatment.
What will medical school look like?
More than three-fourths (77%) of medical schools say they plan to reopen by the end of July, while 15% intend to have students return by the end of this month. That’s according to results of an AAMC survey of more than 100 medical schools. But challenges remain including how much in-person teaching will be available. In areas with a high number of covid cases, for instance, attendings won’t have time to teach, and students will need to steer clear of patients to limit risk and conserve PPE. In mid-March, students were removed from direct patient care and continued with online learning. One interesting note: After postponing this spring’s MCATs, the AAMC plans to ramp up testing again, shortening the exam and offering multiple testing sessions per day to allow testers to maintain a safe distance. Usually, between 10,000 and 12,000 applicants sign up for the MCATs. But when the online scheduling system went live last week, it crashed—as 62,000 people tried to schedule an exam.
Investing in critical care: It makes sense, but it’s wrong
It stands to reason that the pandemic set off a frenzied effort to create more ICU beds and secure more ventilators. But the authors of a new Annals commentary argue that all that time, effort and money could have been better spent elsewhere—and would have produced better covid outcomes, including less mortality. Instead of investing in more “aggressive medical technology,” the writers say that time and money should instead go to resources that are even more scarce than ICU beds and ventilators: ward beds and healthy clinicians. Other resources to invest in to improve care include more widespread testing and contact tracing, PPE, improved public health measures, and training for more health care workers in palliative care communication techniques.
May 13, 2020
How are physicians on the front lines of covid care coping?
A series of recently published articles offers a look at how physicians are doing during the pandemic.
In a series of profiles published by FierceHealthcare, a Houston intensivist describes her experience treating covid patients. She talks about being surprised by how sick covid patients become, and how little clinicians still understand not only about the disease’s effects on patients, but its effects on health care providers.
Another article in the series profiles an ICU physician at Intermountain Healthcare in Utah who talks about her struggles to communicate with the family members—or lack thereof—of covid patients. One hospital went from 36 ICU beds to 150, in part by converting areas like boardrooms into units.
A Medscape article talks to seven clinicians preparing for a day on the front lines of covid care. They talk about their routines before and after their clinical shifts and their struggles to find the PPE that will protect them (and by extension, their families). As one New York emergency physician explained, he’s amazed by “how much of our lives feel under attack by this virus.”
Finally, there’s a somber look at clinicians who have died in the struggle to contain and treat covid. As an article published by Kaiser Health News notes, medical staff account for up to 20% of known coronavirus cases in some states. Its “Lost on the Frontline” series documents the lives of health care workers in the U.S. who have died of covid.
Getting back to “normal” with elective surgeries
As health systems look to return to “normal” after the covid pandemic, a number are starting by slowly bringing back elective surgeries. While orthopedic surgeons said in a recent survey that they expect surgical volumes to mostly rebound within the next three months, analysts predict that more of those surgeries will take place outside of the hospital. (The number of surgeries performed outside of hospitals is expected to rise from 12% to 20% in the next six months.)
Health system administrators, meanwhile, are not nearly as confident that patients will embrace surgery so soon. A report in FierceHealthcare says that patient hesitation to return for surgeries may delay a return to pre-covid volumes for 12 to 18 months. One administrator predicted that flu season in the fall will be a harsh reminder for many patients of the health risks that are still present.
A New York internist describes the changes his practice is making to bring high-risk patients who need to see a physician into the office. Those changes include streamlining the registration process to eliminate as many touchpoints as possible and reducing the amount of time patients spend in the office by allowing them to schedule follow-ups and referrals after they’ve left the office.
May 11, 2020
Roles for interferon, procalcitonin?
A new study in Lancet suggests there may be a role for interferon beta-1b in reducing covid transmission, symptoms and hospital stays. About 125 patients in Hong Kong were randomized to either triple therapy (interferon beta-1b, lopinavir–ritonavir and ribavirin) or lopinavir-ritonavir (controls). Those in the triple therapy cohort received interferon only if they presented within seven days of symptom onset. Patients in the triple therapy group had significantly shorter time to negative nasal swabs (7 vs. 12 days) as well as less time to symptom alleviation (4 vs. 8 days) and lower length of hospital stay (9 vs. 15 days). The lead author notes in a podcast that interferon may be the most important component of the triple therapy. In other news, the authors of recent CAP guidelines weigh in on treating covid-19 pneumonia. They write in Annals that they recommend the same antibiotics in covid pneumonia as in CAP and that procalcitonin may help limit antibiotic overuse.
Palliative care: tough discussions, high demand
While cardiologists’ book of business has been cut in half since the start of the pandemic, one specialty is in high demand, at least in covid hotspots: palliative care. Kaiser Health News reports that palliative care has been transformed by the pandemic as patients and families are thrust into making quick decisions and as family meetings have been replaced by phone calls from the bedside or palliative care hotlines. The pandemic is spurring more widespread end-of-life-care planning discussions, with some hospitals now placing palliative care specialists in the ED for the first time to talk to coronavirus patients at high risk. But talk of hospitals perhaps rationing life-saving resources such as ventilators is worrying some patients, including cancer patients, who are revoking previous DNR orders</a> in case they catch coronavirus.
How is the virus mutating?
Preliminary results from a new research paper claim that the now-dominant strain of coronavirus has mutated and is now more contagious. That report, issued by scientists at the Los Alamos National Laboratory, notes that the mutated strain first appeared in Europe, and that patients with the now dominant strain are not more likely to need to be hospitalized. But other scientists and infectious diseases specialists have pushed back on those preprint results, saying there could be other reasons why a strain could reach dominance besides a mutation that makes it more infectious. In other news, researchers say that New York was the gateway for most of the infections in the U.S. Genetic samples indicate that more infections in the U.S. are linked to the line of virus associated with the New York outbreak—which arrived from Europe—than to the one in Washington state. Travel from the Seattle area has been associated with outbreaks in more than a dozen states.
May 8, 2020
Coronavirus is costing U.S. hospitals $50 billion a month
A new report from the American Hospital Association produces this price tag for how much coronavirus may cost U.S. hospitals: $200 billion, and that’s only for March through June. Calling covid-19 “the greatest financial crisis in history for hospitals and health systems,” the report estimated how much hospitals will spend to care for coronavirus patients and buy PPE as well as the impact of canceled elective procedures, postponed medical care, and the cost of additional staff services that some hospitals are paying for including child care and housing. Another report, this one from a data analytics company, estimates another steep cost of the crisis: The disruptions in U.S. health care caused by coronavirus may lead between April and June to the missed or delayed diagnoses of more than 80,000 cases of five common cancers.
Study: Therapeutic anticoagulation dosing may improve survival
Preliminary results on anticoagulation in patients with severe covid find mortality benefits with therapeutic, not prophylactic, dosing. In their observational study published by JACC, researchers analyzed the medical records of more than 2,700 patients treated over four weeks at one of Mount Sinai’s five hospitals in New York. Among patients not on ventilators, mortality was the same among patients receiving blood thinners and those who didn’t—but those on anticoagulation lived longer, a median of 21 days vs. 14. Mortality did improve among ventilated patients who were anticoagulated: 29% of patients receiving therapeutic dosing died vs. 63% of those who did not. Major bleeding rates were the same across both groups. The algorithm used called for prophylactic subcutaneous enoxaparin for covid patients on the floors, but full therapeutic dosing for those in the ICU. Based on its results, the health system has boosted dosing for patients outside the ICU, giving them intermediate doses. Guidelines from the International Society on Thrombosis and Haemostasis recommend prophylactic dosing. Mount Sinai is launching a randomized trial to test anticoagulation among 5,000 patients.
Who gets remdesivir?
Hospitals are criticizing the seemingly random way the federal government is distributing doses of remdesivir, the experimental drug that’s received emergency use authorization. STAT reports that about two dozen hospitals around the country have been selected to receive vials of the drug, while its manufacturer ramps up production. (Each vial can treat around 170 patients.) However, the decision-making process around those selections is unclear, and some of the hardest-hit hospitals aren’t receiving any. A watchdog group has also weighed in with what it considers a fair price for the drug: $4,460 for one treatment course. FiercePharma reports that the drug’s manufacturer wants to produce enough of the drug to treat 1 million patients by the end of the year.
Covid is linked to an inflammatory syndrome that’s striking children
Their numbers are small, and no children have died. But doctors in New York and the U.K. are sounding the alarm about what they’re calling pediatric multisystem inflammatory syndrome, which has been linked to covid-19. New York Times reports that children are presenting with symptoms that range from reddened tongues to enlarged coronary arteries similar to Kawasaki disease. Unlike most Kawasaki cases, however, some children with the emerging syndrome are in toxic shock. An alert from the New York City Health Department notes that 15 children ages 2 to 15 are in metro ICUs and asks clinicians to report any cases.
UPDATE: New York Gov. Andrew Cuomo on Friday announced that one child has died from the mysterious syndrome that’s linked to coronavirus. Throughout New York state, 73 children have been diagnosed with the syndrome.
Pushing back against “a global infodemic”
An open letter signed by 100 international public health experts and medical societies is making this demand of big tech companies: They need to stop profiting from viral misinformation and to fundamentally change how they share and promote false medical content. According to the letter, medical personnel now have to fight not only coronavirus but “a global infodemic” of false and dangerous cures and medical conspiracies; while medical misinformation has long been a problem on social media—think anti-vaxxers—it is increasingly promoting dangerous medicine, hurting the morale of health care workers and increasing costs. While some tech platforms have started to fact-check medical information, they need to go further, according to the letter, by detoxing the algorithms that determine what people see on their feeds, removing harmful information and blocking repeat offenders, and alerting users who have interacted with harmful misinformation.
May 6, 2020
Audio-only telehealth gets big boost from Medicare
One kink in the use of telemedicine services to care for patients safely—and to potentially bring in revenue for physician practices—may have been resolved. Medicare announced last week that it will increase payments for audio-only virtual visits from $14-$41 to about $46-$110.
Medicare recently began allowing physicians to bill for virtual visits at the same rate as in-person visits, but it was paying significantly less for audio-only visits. One recent survey found that 43% of physician practices said they’re using video for less than 20% of their visits, and 14% said they weren’t using video at all.
More than 100 physician groups recently urged Medicare to support audio-only visits, arguing that many older patients don’t have easy access to video conferencing technology.
Health care’s financial problems spread
The financial stress being felt by health care is accelerating, with hospitals around the country losing huge sums—and physicians feeling the pain. A HealthLeaders article reports that hospitals across the country (excluding New York and San Francisco) collectively are losing about $1.4 billion a day in lost revenue.
Patient volumes at these hospitals has dropped by over 50% since the beginning of March, with inpatient admissions down 30% and ED visits down 40%. The economic pain in medicine is so pervasive, in fact, that analysts say that it is a “driving force” behind the nation’s 4.8% drop in gross domestic product in the first quarter of 2020.
The pain being felt by hospitals and physician practices is also being felt by physicians, who report salary cuts of up to 50%. An article from MD Edge says that such moves may conflict with the terms of physicians’ contracts and offers advice on how to react when employers make unilateral changes to compensation.
May 4, 2020
Expect demand for remdesivir to spike
Given the modest benefits found in an NIH study of remdesivir, the FDA has issued an emergency use authorization for the antiviral. The New York Times reports that the temporary approval is only for covid patients with severe disease, although some clinicians believe the drug may be more effective if administered earlier in patients’ course of illness. Gilead Sciences, the drug’s manufacturer, plans to give away the first 1.5 million doses. That’s good news because clinicians worry that the drug isn’t widely available and that patient and family demands for it will now make that shortage worse.
ID society weighs in on N95s
The IDSA last week released new guidelines on N95 use and reuse, with this caveat: Because there are gaps in the evidence to support the recommendations, those will be updated as new evidence emerges. Moreover, the guidelines tailor recommendations to the availability of supplies with guidance on appropriate use according to conventional, contingency and crisis capacity standards. Among the eight recommendations: Clinicians in a conventional setting may use either a surgical mask, N95, or N99 or PAPR for routine patient care—or either a surgical mask or reprocessed respirator in a contingency or crisis setting. Also in a setting with contingency or crisis capacity: Clinicians should use a reprocessed N95, not a surgical mask, for procedures that generate aerosols, and they can add a face shield or surgical mask to an N95 for extended use. The society didn’t issue any recommendations for the use of shoe coverings or for the use of double vs. single gloves.
New round of CMS changes should boost testing, telehealth pay
The CMS has announced a new wave of regulatory changes, rolling back previous requirements to help increase telehealth payments, accelerate more widespread testing and boost bed capacity for hospitals. Hospitals now have more flexibility to create temporary beds, while the CMS is increasing its payment for telehealth visits, matching reimbursement for similar in-person outpatient care. That payment increase is retroactive to March 1. As for testing, patients no longer need a treating practitioner to order a test. Instead, tests can be ordered by any health care professional authorized by state law, and a written order is no longer needed for Medicare to pay for testing. Further, pharmacists can now team up with clinicians to help collect and assess test specimens, a move that should increase the number of drive-through test sites and allow pharmacy chains to begin to take a major role in testing. The CMS will also now pay for certain antibody and home tests.
May 1, 2020
Modest but real: Remdesivir may improve outcomes
The results haven’t been peer reviewed yet and the effect was only modest. But even Anthony Fauci, MD, said he was “optimistic” about the results of a government-funded trial on remdesivir. The randomized study tested the drug in more than 1,000 covid patients and found that those receiving remdesivir recovered four days faster than those given placebo (median recovery time: 11 vs. 15 days). While the remdesivir arm also showed a mortality benefit, it wasn’t statistically significant. This was the first U.S.-sponsored trial of the agent, although an earlier Chinese study on remdesivir found no benefit. However, the NIH trial enrolled more patients, and the Chinese study has been faulted for giving patients remdesivir later in the course of severe disease.
One in four health care workers at higher risk of poor outcomes
Due to age or chronic conditions, 26.6% of workers who provide direct patient care are at higher risk of poor coronavirus outcomes. That’s according to a new Annals study, which found that 3.7 million out of the nation’s 13.8 million health care workers are either older than age 64 or have chronic conditions like diabetes. Further, among those at high risk, 7.5% are uninsured, mainly among those working in nursing homes and home health. Among all health care workers doing direct patient care, about 29% have no paid sick leave, while 2.5% of hospital workers report family incomes below the poverty line. Researchers based their analysis on both CDC and census survey data.
How to manage pent-up demand for elective surgeries
With most elective surgeries now on hold, experts expect demand to surge once hospitals ramp up procedures once again. Before they do so, a new commentary argues, hospitals need to prioritize those upcoming surgeries, set strategies so their capacity won’t be overwhelmed, and come up with new approaches to surgical scheduling. Hospital leaders must balance the number of surgeries needed and the length of time those patients have been waiting for care against the availability of inpatient beds and PPE. They also need to realize that their traditional block scheduling for surgeries won’t be able to meet the demand. Instead, hospitals and surgeons should consider boosting their daily utilization, moving some procedures such as endoscopies out of surgical suites into procedure rooms, and expanding the hours of OR availability, perhaps into weekends.
“Shark Tank” initiative puts $1.5 billion up for grabs
The NIH this week announced an initiative designed to rapidly boost the development of at-home and point-of-care covid diagnostic tests. STAT reports that the challenge calls on scientists and inventors to develop diagnostic tests and compete for a portion of a $500 million pool; winners will be paired with manufacturers who can scale up production. Technologies will go through a four-phase, highly-competitive process to identify the best candidates. The goal is to make millions of easy-to-use tests available per week by the end of this summer. Experts around the country have pointed out that testing so far has been woefully inadequate. In an April report, an expert panel from Harvard called for the U.S. to conduct five million tests per day</a> by June, ramping up to 20 million per day by late July.
How are your kids?
Much is being written about how worried front-line health care workers are that they may infect their families. The Washington Post this week flipped that focus and interviewed children of doctors and nurses who are treating covid patients. Some of those children have been sent to live with relatives or friends, while others are living at home with parents who are self-isolating in basements or bedrooms or are working longer hours. All parents are struggling with how much to tell their children about the virus and their risk of contracting it. While the children featured in the article know their parents are doing something important, many are anxious or angry.
April 28, 2020
The emerging toll of treating covid patients
If the world didn’t understand the trauma that can come from working in the middle of the covid pandemic, it’s starting to understand. Most recently was the news that a New York City ED physician who had treated covid patients and contracted the disease herself committed suicide. An NPR report on the topic found that half of Chinese health care workers who treated covid now suffer from depression, 44% have anxiety and one-third have insomnia. An article published by Annals of Internal Medicine offers strategies for group leaders and frontline physicians to care for themselves. As the authors point out, “This is a marathon, and endurance is essential.” Finally, a Philadelphia psychiatrist has launched a Facebook group and a physician free support line to help physicians on the front lines of coronavirus care. The COVID-19 Physicians Group features Facebook posts from physicians, and the hotline (888-409-0141) offers free confidential support from volunteer psychiatrists.
What happens to clinicians who speak up about PPE issues?
Physicians and nurses are continuing to speak up about PPE problems, and while some have been disciplined, others have won the battle to be able to speak up when they feel their health is being threatened. An Associated Press article details several instances in which physicians were given N95 masks, but not nurses. In several of those instances, nurses who spoke up and refused to work without N95 masks were fired or suspended.
But there are signs of progress. Several of the hospitals that fired a nurse who refused to work without an N95 masks say they are now providing them to all staff caring for covid patients, and one hospital that had suspended 10 nurses for refusing to work without N95 masks reinstated them and is now providing masks.
“Spot” the robot dog meets the Brigham’s covid unit
You’ve probably seen videos online of Boston Dynamics robot dogs doing difficult tasks like walking up steps. Now, you may see one its robot dogs walking down the halls of a hospital. “Spot” may have a robot body and legs, but its face is a tablet that displays the face of a treating physician. The robot gives physicians a safe way to talk to patients on covid wards. While that’s currently all the robot dog can do—it can’t take patients’ temperature, for example—Brigham and Women’s Hospital hopes the technology can offer even more help on covid wards. According to an article in Wired, patients have been receptive to seeing Spot.
April 27, 2020
Hospitals see a double-digit drop in non-covid cases
It’s a trend that can’t be explained just by the halt in elective procedures: Hospital census, except for covid patients, has plummeted since the pandemic began. Now, new data from Cigna indicate that hospitalizations for common acute problems have indeed gone down. The insurer looked at hospital utilization for seven conditions across the first three months of 2020. It found that hospitalizations for atrial fibrillation among its customers between February and March fell 35%, rates for TIAs dropped 31%, and those for seizures declined 28% and 24% for GI bleeds. Moreover, hospitalizations for aortic aneurysms decreased by 22%, acute appendicitis by 13% and ACS by 11%. Outpatient offices have been even more hard-hit, with a close to 60% decline seen in ambulatory visits in mid-March.
Stroke rates spike among young, middle-age patients
This week, interventional neurologists from New York’s Mount Sinai plan to publish a letter in NEJM about five of their covid patients, all of whom were under age 50 and all had suffered major strokes. Several other U.S. medical centers are publishing on the same phenomenon, according to the Washington Post, as many covid patients having strokes are experiencing LVOs, the deadliest type. With first responders in New York City picking up four times the typical number of patients who have died at home, physicians worry that some of them also suffered strokes. At Mount Sinai, the number of patients with LVOs doubled over the three-week covid surge, while the average age of stroke patients with covid was 15 years younger than of stroke patients who weren’t infected.
Free counseling is now available for front-line physicians
Doctors who need emotional and psychological support can access free counseling seven days a week. More than 600 psychiatrists have volunteered to staff the Physician Support Line (888-409-0141), a hotline that’s open from 8 a.m. to midnight Eastern time. Launched at the end of March, the free confidential hotline has since delivered more than 50 hours of counseling. When callers call in, they can be connected to either a volunteer psychiatrist or to a suicide prevention and disaster distress line. In HealthLeaders Media coverage, the hotline’s founder says the nature of the calls being received has changed from anxiety when the service was first launched to exhaustion as covid caseloads increase and distress as patients are dying. Clinicians don’t need to make an appointment.
April 24, 2020
NIH guidelines recommend against hydroxychloroquine
The NIH has released new coronavirus treatment guidelines that don’t recommend any specific antiviral treatment nor any drug for pre- or post-exposure prophylaxis. They do, however, recommend against using an hydroxychloroquine-azithromycin combination, citing QTc prolongations. (Non-peer reviewed results from the VA released this week indicate that hydroxychloroquine—both with and without azithromycin—didn’t lower covid patients’ risk of needing a ventilator.) The NIH guidelines also came out against using lopinavir/ritonavir or other HIV protease inhibitors and against interferons and Janus kinase inhibitors. Other therapies to steer clear of, according to the NIH: systemic corticosteroids for covid patients on ventilators who don’t have ARDS. As for ventilation, the NIH urges a phased approach to defer ventilator use as long as possible. That caution is also endorsed in a new international analysis, which states: “Severe pneumonia in COVID-19 differs in some important aspects from other causes of severe pneumonia or acute respiratory distress syndrome, and limiting the positive end-expiratory pressure level on the ventilator may be important.”
Congress approves more relief targeting hospitals, testing
Both the House and the Senate this week approved a new coronavirus relief package, this one adding up to about $484 billion. While the bulk of those funds ($310 billion) are earmarked for small business loans, $75 billion is designed for hospitals while $25 billion will support testing. As for the $100 billion for health care included in the first relief package approved last month, FierceHealthcare reports that $30 billion has already been distributed to providers. Of the remaining funds, another $20 billion will go to providers, $10 billion will go to hospitals in areas hit hard by outbreaks, $10 billion will go to rural hospitals, and $400 million will go to Indian Health Services hospitals and clinics. HHS also plans to distribute some funds to SNFs and providers that treat Medicaid patients. The rest will be reserved for more hotspot funding.
Want to restart elective procedures? Take it slow
What would it take to restart elective surgeries? The American College of Surgeons released 10 recommendations for what hospitals and health systems should consider before resuming procedures. No. 1 on that list is knowing your community’s covid prevalence, and hospitals should wait until their number of local covid cases has declined for at least two weeks; No. 2 is knowing your local testing availability. Part of that community awareness, the recommendations state, is setting a threshold of new covid cases that would trigger stopping elective surgeries again. Other recommendations include having a 30-day supply of PPE or a reliable supply chain; considering new sites for elective surgeries, including outpatient settings; and monitoring the stress and fatigue levels of front-line workers treating coronavirus patients. CMS guidance on resuming elective surgeries stresses taking a gradual approach to not threaten hospital capacity or personnel. As for re-starting local economies: Experts say that testing levels need to triple—to between 500,000 and 700,000 a day—to be able to identify and isolate infected patients before business can resume.
Visa constraints keep IMGs out of covid hotspots
While cities and states hard-hit by coronavirus want more health care workers, IMGs including hospitalists who might answer that call say they’re facing constraints. MedPage Today reports that as many as 15,000 IMGs around the country have visas that identify the specific hospital—and sometimes department—where they can work, with no ability to moonlight. Another 65,000 IMGs are living in this country but are not allowed to practice any form of medicine because they didn’t match to a U.S. residency program. Another challenge: Should IMGs become infected and no longer be able to work, they and their families could be deported. The ECFMG recommends easing visa restrictions to allow holders to work in hotspots and to give them and their families permanent waivers from deportation should IMG clinicians become sick.
The byzantine underbelly of PPE deals
It reads like a spy novel or a drug deal: In an NEJM letter titled “In Pursuit of PPE,” a physician executive from Massachusetts’ Baystate Health describes his foray into the bizarre world of trying to purchase PPE for his health system. Many of those deals, he writes, involve big money and many go south when his system is “outbid and outmuscled, sometimes by the federal government” In one convoluted arrangement, he and several members of his team flew to a small airport in the Midatlantic to inspect two semi-trailers—labeled as food service trucks—that contained Chinese face masks and N95s. Before the money could be transferred, FBI agents arrived and homeland security considered redirecting the shipment. The deal proceeded only after a member of Congress intervened. Then there’s this good-news, Philly-proud story: Forty employees of a factory in southeastern Pa. that produces polypropylene, a key ingredient in masks and gowns, just finished their “live-in,” spending 28 days living together in the factory without leaving and working 12-hour shifts around the clock.
April 22, 2020
PPE issues: a look at practical and ethical considerations
Shortages of PPE in health care are roiling providers and health care organizations. Physicians and nurses are being threatened for speaking up when they feel that they and their patients aren’t safe, and physicians worried about the health of themselves and their families are wondering how safe their PPE is keeping them.
A MedPageToday article offers tips on what clinicians can do when faced with shortages of PPE. The advice includes tips on how to extend the use of respirators and how to safely re-use them, along with strategies to decontaminate masks.
A medical ethicist addresses the question of whether clinicians are obligated to care for patients without adequate PPE. He concludes that while a certain amount of risk is inherent in the health care profession, health care workers don’t have an obligation to accept all risks. The comments at the end of the story pick up the debate, so make sure to check them out.
And a podcast by the show Freakonomics looks at the most fair and ethical ways to distribute ventilators. Panelists discuss problems with the first-come-first-served model of distributing ventilators, along with the question of whether health care workers should get special consideration when assigning ventilators to patients
Outpatient practices see financial problems ahead
For physician practices, the bad financial news just keeps on coming. With patient volumes down, many are furloughing or laying off staff. And many see bleak finances for the foreseeable future. Here’s a sampling of the latest surveys of physician practices:
• One-fifth of primary care practices say they could close within a month, and nearly half aren’t sure that they’ll have enough cash to keep their practices open. In the survey of 2,600 physicians, more than two-fifths have already had to lay off or furlough staff.
• In a survey by MGMA, practices report a 60% drop in patient volume and a 55% decrease in revenue since the pandemic began. About 75% of the survey’s 700-plus respondents employ less than 50 FTE physicians.
• In a survey of 160 practices in four states, respondents said that patient volumes are down 65% and will likely be down as much as 12% this time next year. Those practices predicted that by September, patient volumes will probably still be only 76% of normal.
A covid newsletter by—and for—physicians
A covid newsletter written for and by physicians is attempting to help give doctors an edge not only in staying up on new research, but in combatting the slew of information on the Internet about the coronavirus. The Fast Literature Assessment Review, known as FLARE, is produced by eight ICU physicians at Massachusetts General Hospital. According to an article in Wired, the newsletter sprang out of informal e-mail the physicians were exchanging with each other. Its mission is to give updates on the latest covid research and to debunk the newest unproven theories about the pandemic circulating on social media. Recent theories that were debunked included the idea that covid is similar to altitude sickness and the hype around chloroquine.
April 20, 2020
Health care workers converge on NYC
Utah’s Intermountain Healthcare has flown a team of about 100 physicians, nurses and specialists to New York City, while Cleveland Clinic is sending a 20-member team and medical centers in upstate New York are sending busloads. FierceHealthcare reports that the clinical staff from Intermountain who came to help staff New York City hospitals includes hospitalists and intensivists, as well as nurses, an internist, respiratory therapists and a pharmacist. They plan to remain in New York City until the end of this month, giving clinicians on the ground a break. One Intermountain critical care physician highlighted in the article notes that the census in her own ICU in Utah is down 50% and that she’s learning how to treat covid patients, should the surge hit her home hospital. She’s also seeing how clinicians can fill new roles, including a hospital tent for non-covid patients being staffed by second- and third-year family medicine residents.
The latest equipment shortage: dialysis machines
As many patients with severe covid suffer kidney failure, hospitals around the country are scrambling to locate not only enough dialysis machines and supplies but the trained nurses needed to provide the treatment. Nephrologists estimate that between 20% and 40% of covid patients in ICUs need emergency dialysis. According to the New York Times, a department chair from New York’s Mount Sinai Health System notes that the number of patients needing dialysis in her hospital has gone up three-fold. An article in Science details not only the kidney failure occurring with covid but also cardiac and neurological damage.
How many covid patients a day can your hospital manage?
A new, interactive online tool allows health systems and individual hospitals to estimate the maximum number of covid patients they can manage a day, given their acute and critical care resources. Canadian researchers writing in Annals put together model parameters from evolving international data. The tool calculates the maximum daily turnover, given patients’ average length of stay and average time on mechanical ventilation, with separate outputs for the manageable maximum number of acute care beds, critical care beds and ventilators.
April 17, 2020
Treating covid: Standard practices are out, improvisation is in
Now more than a month into treating this disease, doctors report that they’re tossing out standard medical practices and experimenting with the use of different drugs and treatment strategies. One new practice that has emerged: resisting early intubation for patients with oxygen saturation levels as low as in the 40s and opting instead to prone them or have them recline in chairs. The New York Times reports that some hospitals are proning patients—particularly those who are obese—on cut-out mattresses designed for pregnant women to ease their chest pressure. Doctors also note that proning doesn’t seem as effective in older patients. While experts complain about the lack of a centralized research strategy that could identify best practices, the NIH director is forming a partnership among pharmaceutical companies, government agencies both here and abroad, and academic centers. Very preliminary results from one center’s remdesivir trial are encouraging, although other studies on the drug have been inconclusive. Clinical trials are testing the effectiveness of tocilizumab, an immunosuppressive drug. And cardiac associations urge careful monitoring for arrhythmias when using hydroxychloroquine and azithromycin, a drug combo that’s being widely tested.
Three out of four infected health care workers are women
According to CDC data released this week, more than 9,000 health care workers in the U.S. have tested positive for coronavirus and 27 have died. Yet Kaiser Health News reports that commentators believe the true tally is actually far higher, and U.S. officials admit they have no system to provide a comprehensive count. The CDC data, which were based on a sample of only 16% of covid cases in the country, found that the vast majority—73%—of infected health care workers were female with a median age of 42. For a more accurate count, the CDC is studying hospitals in 14 states and reviewing infection surveillance and media reports. Meanwhile, a JAMA editorial proposes this bold response to the pandemic: Suspend the first year of medical school for the 20,000 incoming students slated to begin in July and enlist them instead in a national public health service program. After a month of training in infectious diseases epidemiology and control, those students would be deployed nationwide to help test, trace, track and isolate.
How many times can you decontaminate an N95?
A new study contends that disposable N95s may be safely decontaminated only a few times before their functional integrity starts going downhill. In research supported by the NIH, authors analyzed the efficacy of four common decontamination methods—UV, 70% ethanol, 70C heat and vaporized hydrogen peroxide—and assessed mask function after rounds of decontamination. They found that 70% ethanol degrades mask integrity within 30 minutes so shouldn’t be used. With dry heat, masks could safely be decontaminated two times, while UV and vaporized hydrogen peroxide could be used three times. The study, which wasn’t peer reviewed, was released on the medRxiv preprint server.
Physicians who need to recertify in 2020 get a reprieve
Doctors who are supposed to complete MOC requirements this year are getting a pass from the ABIM, at least through next year. In a letter from its president, the board announced that physicians will have through 2021 to complete any MOC requirements due this year, including assessments, point requirements or attestations, and that diplomates will not lose their certification. Further, doctors in their grace year will receive an additional year. Other boards, including the ABFM, are following suit, as is the American Board of Pediatrics. While the pediatric board hasn’t yet worked out the details of how it will ease deadlines and grant credits, its president said that pediatricians will get credit for the learning curve related to coronavirus and for that specialty’s “huge transformation in practice using telehealth.”
What’s it like to fight coronavirus? 100+ doctors weigh in
A family physician in New Jersey who has his own YouTube channel has posted a video with clips of more than 100 doctors talking about their experiences battling coronavirus. Known on social media as “Dr. Mike,” Mikhail Varshavski, DO, reached out to a wealth of colleagues, asking them what gives them hope, how they’ve been personally affected, what it means to be a doctor during a pandemic, and what about this disease and their efforts fighting it aren’t getting enough attention. Answers ranged from “How is one supposed to date at this point in time?” to maintaining a 30-minute decontamination routine when getting home and “remembering to stay flexible and lean into uncertainty.” Some hospitals are establishing covid wellness teams for their employees, staffing them with psychologists, social workers, hospital leaders and chaplains. And the ranks of the recovered in the U.S. are now at least 44,000, although—like every other figure related to the pandemic in this country—the actual count is believed to be far higher. Some have launched a Survivor Corps Facebook page to share their stories. While some fear being stigmatized for having been infected, many feel an urgent need to help by donating plasma.
April 13, 2020
Coronavirus exacts a terrible emotional toll
It’s not just the long hours and the fears of being infected. Doctors are reporting the high emotional burden of treating severe and dying covid patients who need to be kept isolated from their families. As it falls to doctors to make patients’ final calls to their kin, emergency physicians have rushed to get up to speed with palliative techniques and language, while other specialties—including psychiatrists—are training themselves in palliative care. A commentator who used to be in the military and leads programs in developing physician leadership has published “Ten Tips for a Crisis: Lessons from a Soldier” in the Journal of Hospital Medicine. Among his recommendations: find a battle buddy, get everyone in the fight, take time to huddle, and incorporate rest cycles and rotating teams.
Remdesivir: promising preliminary results
The study was very small and sponsored by industry, and it had no control arm. But researchers testing remdesivir report that more than two-thirds (68%) of 50-plus patients with severe covid who received up to 10 days of the therapy had a reduced need for oxygen support. Among the patients, 57% were intubated, 8% were receiving ECMO, and the rest had oxygen saturation levels of 94% or less. The majority (60%) had some adverse event including diarrhea, rash, and hypotension, as well as elevated hepatic enzymes and renal failure. Remdesivir is now available to hospitals and doctors through expanded access to compassionate use. While several randomized trials on remdesivir are now taking place, the authors write that “the outcomes observed in this compassionate-use program are the best currently available data.” In other news, two critical care doctors write that anxiety is leading clinicians treating patients with severe covid to ventilate and sedate patients too soon and to keep them on ventilators too long. Hospitals also now have to worry about shortages in sedatives for ventilated patients.
What should health care workers do if exposed?
According to the CDC, health care workers potentially exposed to coronavirus may continue to work, as long as they are asymptomatic and adhere to several safety practices. For one, workers who’ve been potentially exposed should continue to monitor their temperature, ideally before they come into the hospital. They should wear a face mask in the workplace at all times for at least 14 days after possible exposure, and remain six feet away from others. But here’s news on that famous six-foot distancing strategy: A CDC study that looked at covid contamination in air and surface samples in Wuhan found that coronavirus can travel up to 13 feet. (Further, one half of the soles on the shoes worn by ICU medical staff tested positive, potentially carrying covid throughout the hospital.) As for health care workers and patients who have recovered from covid, the FDA has released guidance on how to collect and use convalescent plasma.
April 10, 2020
WEEKLY ROUNDUP: “A really hard time”
As the U.S. death toll from coronavirus approached 2,000 a day several days this week, an influential model used to estimate hospital capacity and mortality came in with lower mortality predictions. While the number of hospitalizations in New York has flattened, the hospitalization and death rates among African-Americans and Latinos are, in the areas of the country where those data are being tracked, much higher than among whites. In Detroit, the Henry Ford Health System reports that more than 700 employees have tested positive. The CMS has already paid out close to $34 billion to providers in the form of advance or accelerated payments, with more relief payments to come. Genetic sequencing finds that the virus strain circulating in New York came from Europe, not Asia. And the director of an ICU in Brooklyn reports that as many as 80% of critically ill covid patients have kidney failure, a sign of very poor prognosis. “We’re still having a hard time trying to help everybody through it. A really hard time.”
HHS-watchdog report details hospital shortages
Severe equipment shortages, a lack of tests and a backlog of test results, confusing guidance from federal and state agencies, and a high emotional toll on staff: These are what hospitals are dealing with, according to a report issued this week by the HHS inspector general. Based on a telephone survey conducted March 23-27 of more than 300 hospitals, the report found widespread equipment shortages and hospitals struggling to maintain enough staff. In the report, ventilators were at the top of the list of equipment in short supply; in related news, New York’s Mount Sinai Health System has produced a clinical protocol to convert donated BiPAP machines into ventilators. And some critical care physicians are questioning the use of ventilators (or the early use of ventilators) in a subset of covid patients who, those doctors believe, may do better with noninvasive apnea devices or even nasal cannula.
What anticoagulation do covid patients need?
Thrombosis is increasingly emerging as a marker of severe coronavirus with physicians reporting not only respiratory failure but coagulopathy. Interim guidance from the International Society on Thrombosis and Haemostasis advises measuring D-dimer, prothrombin time, platelet counts and fibrinogin. The guidance also recommends using prophylactic doses of LMWH unless contraindicated in all hospitalized covid patients, including those not in the ICU. But some experts think prophylactic dosing may be too low, and some facilities are starting anticoagulation in covid patients with a D-dimer of more than 1,500 ng/mL and fibrinogen higher than 800 mg/mL. While some experts see advantages to using IV heparin in covid patients, other hospitals are instead choosing to use DOACs to limit the number of times nurses have to enter patients’ rooms.
Large staffing firms cut physician hours
There are signs that several of the larger physician staffing companies are feeling the financial effects of the COVID-19 pandemic. A ProPublica report published by HealthLeaders says that large firms are cutting back the hours of their ED doctors, anesthesiologists and other physicians. Revenue for these companies is dropping as people avoid hospitals for everything but the coronavirus, drying up visits to the ED and cancelling elective procedures. Analysts have complained that cutting ED coverage as hospitals brace for coronavirus could hurt patient care, but the companies insist that they are prepared for a surge in demand. The report comes on the heels of multiple reports of health care organizations furloughing workers.
What’s happened to all the heart attacks?
Hospitalists bracing for a coronavirus surge also report that their regular medical census is way down. In a New York Times article, famed Yale cardiologist Harlan Krumholz, MD, writes that hospitals, besides treating covid patients, are “eerily quiet.” The sharp drop in normal hospital volume can’t be explained by just the suspension of elective procedures; instead, heart attack and stroke patients aren’t showing up. According to an informal Twitter poll, almost half (45.4%) of responding cardiologists said their number of MI/ACS admissions during the pandemic has fallen between 40% and 60%. (Twenty-two percent reported a more than 60% reduction.) The most troubling explanation, Dr. Krumholz writes, is that patients who have symptoms are too afraid to come to a hospital and risk becoming infected. Or social distancing and the adoption of new activity and food behaviors may be reducing MI and stroke triggers. “As we fight coronavirus, we need to combat perceptions that everyone else must stay away from the hospital.”
April 8, 2020
What’s your duty to work when your PPE isn’t keeping you safe?
You’ve seen the stories of physicians and nurses who are being harassed, fined and fired over their refusal to work with PPE they think isn’t safe enough. Whether it’s nurses being outright fired for refusing to wear hospital-issued masks or physicians being left off the schedule because of similar concerns, health care workers are beginning to fight back against equipment that they say is inferior. That raises the question: Are physicians morally obligated to work in conditions in which their safety isn’t being protected? A New York Times article by a New York cardiologist explores whether physicians’ obligation to patient care overrides their obligations to their families. The author concludes that while most physicians will ultimately honor their professional obligation to care for patients, society must also honor its obligation to protect health care workers through measures like social distancing, the maintenance of public health infrastructure—and adequate safety gear. Finally, MedPage Today conducted a survey on the issue and allowed readers to leave comments on the topic.
The personal fallout of COVID-19 for doctors and nurses
• An article in FierceHealthcare quotes two physicians who describe watching patients suffer alone near the end of life because of quarantine conditions in hospitals.
• An article from KevinMD describes how a two-physician couple in New York City made the tough decision to send their daughter to live with her grandparents “for the foreseeable future” so they can fight the virus without fear of infecting her.
• Physicians and nurses who have had breaches in PPE while caring for patients who have tested positive for coronavirus are flocking to RVs, empty condos and whatever other accommodations they can find, all in an effort to protect their families.
A roundup of treatment tips from physicians via Twitter
A New Jersey hospitalist who had to intubate a young (and previously healthy) colleague talks about how he maintained his cool during a trying circumstance. A Michigan hospitalist who has cared for more than 100 COVID patients summarizes the patient presentations he’s seen. And a New Jersey ED physician remarks how patients with oxygen saturation as low as 75% can present with few if any symptoms. All of this comes courtesy of a review of physician Twitter posts from MedPage Today.
April 6, 2020
New York “regionalizes” hospitals in the state
With more than 120,000 covid cases in the state, the 200 hospitals in New York are effectively no longer functioning independently. Instead, state officials have announced that facilities will operate as one state-wide hospital system, sharing supplies, staff and covid patients. Vox reports that the top priority in the state plan is to move doctors and nurses from less affected hospitals upstate to New York City. Patients and resources will also be shared across hospitals throughout the state under the management of the state health department. In hard-hit parts of Europe, covid patients are likewise being transferred out of overwhelmed hospitals via high-speed rail and military planes to facilities with more capacity. New York City’s mayor has called for a national enlistment program for physicians and nurses to be able to deploy medical personnel to covid hotspots around the country. And New York-Presbyterian last week announced that it will pay all front-line staff a $1,250 bonus if they worked at a hospital campus or outpatient site in the system for a week in March providing care or care support to coronavirus patients.
Remdesivir: Docs, hospitals now have expanded access
The manufacturer of remdesivir has announced that it is expanding and streamlining access for hospitals and physicians to the experimental treatment. Remdesivir, an antiviral developed to treat Ebola that isn’t approved by the FDA, is a potential covid treatment that’s been rushed into multiple clinical trials. Its manufacturer Gilead Sciences has now taken the drug’s limited compassionate use program—which will remain in effect for individual pregnant women and children—and is allowing hospitals and doctors to apply for emergency use for multiple covid patients with severe illness at one time. Under its compassionate use program, Gilead has supplied the drug to more than 1,700 patients but has been overwhelmed by individual applications. The company has also ramped up manufacturing and produced 1.5 million doses, enough to treat more than 140,000 patients.
Doing intubations “right next to the nuclear reactor”
For those who haven’t yet treated—or had to intubate—a coronavirus patient, an “as told to” article by a Chicago anesthesiologist is a sobering reminder of how risky treating these patients can be. Cory Deburghgraeve, MD, is an anesthesiologist at the University of Illinois at Chicago who typically spends his workdays doing epidurals and C-sections for women having babies. Now, his full-time job is intubating covid patients in the ICU 14 hours a day, six nights a week. Dr. Deburghgraeve is one of two physicians—one who covers days while he covers nights—who volunteered to be the dedicated providers doing intubations to limit their colleagues’ exposure. While he has asthma, he says he was moved to volunteer because he’s in his early 30s and doesn’t have children. Most covid patients he’s intubated, he reports, are 50 years old or younger and in severe respiratory distress, with oxygen levels as low as 70. When patients’ airway is exposed, which he describes as being “right next to the nuclear reactor,” he sees significant swelling in the upper airway. The ICU has had some successes; one younger patient weaned from a vent was discharged home. But he writes that patients who would typically be on a vent only a few days are staying on for two or three weeks.
April 3, 2020
One million-plus cases worldwide and counting
This morning’s U.S. tally: 245,601 cases, 6,058 deaths. While models cited this week by the administration estimate a death toll in the U.S. between 100,000 and 200,000, epidemiologists question those predictions, saying it’s not clear what those models are based on. A new JAMA perspective provides a framework for rationing ventilators and ICU beds. Organizations are setting up exchanges to allow hospitals to trade supplies. The AMA has issued guidance for retired clinicians coming back to work, given their age-related risk. Recommendations include keeping them away from direct patient care and instead exploring telehealth, filling administrative roles, and doing online teaching or mentoring for medical schools. Data indicate that tests (even if available) may have only a 70% sensitivity, with even lower sensitivity among asymptomatic patients.
What do hospitals need?
What does a surge in covid patients mean for medical supplies? Survey results released this week by Premier indicate what extreme supply demands look like: Covid surges lead to a 17-fold burn rate for N95s, a more than eight-fold in face shields, six-fold for swabs, five-fold for surgical gowns and more than three-fold for surgical masks. Average survey respondents had about three weeks’ worth of N95s on hand. But those with active covid patients had only a three-day supply, and one in four (23%) were going through more than 100 N95s a day. The FDA has approved a machine that can clean 80,000 surgical masks and N95s per day with vaporized hydrogen peroxide. Another machine being marketed claims it can disinfect 500 N95s an hour using UV light. And contradicting some hospital policies, the Joint Commission this week said it supports clinicians bringing protective gear from home to use at work, with evidence suggesting benefits from using personally-owned respirators and masks.
You made the cover of The New Yorker
Tributes to front-line hospital workers have poured in from editorial pages and publications. This week’s New Yorker cover, titled “Bedtime,” shows a gowned-gloved-masked worker in a crowded hospital hallway bidding goodnight to two young children, while a Mike Luckovich cartoon for the Atlanta Journal-Constitution shows doctors, nurses, scientists and first responders in the seminal Iwo Jima pose planting the American flag. One bright note: When New York’s governor sent out a call for reinforcements for his state’s hospitals, 82,000 volunteered for a reserve medical force of recent retirees and health care workers who can leave other jobs. And some humor: GomerBlog points out that a coronavirus vaccine should be ready by 2021 for anti-vaxxers to completely reject and protest against. “At press time, officials noted conspiracy theories about the not-yet-developed vaccine containing mercury were spreading on Twitter.”
April 2, 2020
Why are U.S. masks being sold to foreign buyers?
A Forbes journalist has filed this harrowing news: The U.S. continues to allow medical supplies in this country to be purchased by foreign buyers and shipped overseas. Last week, the author reports, he spent 10 hours listening in on frenzied phone calls between brokers selling N95 masks and potential purchasers from state governments and hospital systems. At day’s end, about 280 million N95s that were warehoused in the U.S. had been sold—that day—to foreign buyers and were about to be exported, while U.S. purchasers were able to secure virtually none of them. The federal administration has at least halted overseas shipments of PPE from the stockpile maintained by the U.S. Agency for International Development, after realizing that two deliveries from that stockpile were being sent to Thailand. News outlets yesterday reported that the U.S. emergency stockpile maintained by the federal government and now being distributed by FEMA is nearly depleted.
One in four infected patients may be asymptomatic
CDC officials are now saying that as many as 25% of patients infected with covid may be completely asymptomatic, a data point leading many officials to consider recommending the use of face masks—for everyone. Such a recommendation, however, would causes a run on face masks just when health care workers are in increasingly dire need. Among passengers on the Diamond Princess cruise ship, 18% of infected patients never developed symptoms, while investigators in Hong Kong have reported that between 20% and 40% of transmissions in China occurred from patients before they developed symptoms. Studies also show that infected patients are most contagious one to three days before any symptoms appear.
Is there a clinical role for immune survivors?
While convalescent plasma is being tested as a possible treatment for serious illness, the issue of potential immunity among surviving covid patients raises this question: Could providers who contract the virus and recover be an important clinical workforce? That’s touched on in an IDSA blog entry written by ID physician and pandemic expert Daniel Lucey, MD, MPH. Dr. Lucey points to many unknowns, including: Are survivors truly immune, and how accurate are antibody tests? How would such tests be developed and distributed, and by whom, and would clinicians need verification of being antibody-positive? “I would be reluctant, or at least very slow initially,” Dr. Lucey wrote, “to recommend that frontline workers who are antibody-positive against the SARS-CoV-2 virus should not wear COVID-19 personal protective equipment.”
April 1, 2020
Hospitalists issue some hard-won guidance
The hospitalists with EvergreenHealth in Kirkland, Wash., have the distinction of treating many of the first covid patients in this country infected through community transmission. As their number of critically ill patients climbed, the clinicians and administration there rapidly worked to create flexible staffing, new ways to cohort patients and negative pressure rooms out of general floors. The physicians were also learning about the disease course as patients developed ARDS, ground-glass opacities, and persistent fevers, and presented with elevated CRP and D-dimers. They also learned to use early intubation—not bridging—once patients’ need for supplemental oxygen start to increase. The EvergreenHealth hospitalists have put their lessons learned into a nine-page PDF of protocols and best practices.
NY wants you! (So does California)
New York’s governor Andrew Cuomo this week issued this plea to health care workers nationwide: “Please come help us in New York.” To try to manage the deepening crisis in New York City and throughout the state, the governor is asking one million health care workers around the country to volunteer their services in New York now. California’s governor Gavin Newsom is also appealing to retired health care workers and those now in training to come join the new California Health Corps. To facilitate that appeal and to help staff the emergency hospitals being built in that state, Gov. Newsom signed an executive order waiving health care staffing ratios. The state is also waiving some licensing and certification requirements.
Doctors be warned: Watch what you say about COVID-19, PPE
A report from Bloomberg says that hospitals are threatening to fire health care workers who talk too much about their working conditions in the age of COVID-19. The report says that a nurse in Chicago was fired after telling a colleague via e-mail that she wanted a more protective mask. And another report from Modern Healthcare says that an ED physician in Washington state claims he was fired after criticizing his hospital’s handling of the coronavirus. A Medscape report notes that hospitals are muzzling physician complaints, particularly when it comes to a lack of personal protective equipment. Hospitals are also forcing physicians to remove online posts and face retribution for speaking out.
Don’t bother bringing your own N95 to work
Talking about issues with PPE isn’t the only fire-able offense. Clinicians who bring their own protective gear to work are discovering trouble. A Medscape report says that physicians at a northern California hospital say they’ve been warned they can be fired for bringing their own N95 mask to work, and that they need a note from her physician to even consider wearing the mask. A Modern Healthcare report says that one nurse who was fired for bringing her own N95 mask to work is suing her employer for more than $50,000 for lost wages and emotional damages. Some hospitals worry that the gear will scare patients.
Competing interests: clinician safety vs. PPE supplies
PPE tops the list of concerns of physicians on the front lines of the COVID-19 outbreak. That includes the head of hospital medicine at Stanford, who talks about her hospital’s efforts to treat coronavirus patients in an article on Medscape, Hospitalist Neera K. Ahuja, MD, talks with noted physician-author Abraham Verghese, MD, about everything from the changing definition of who qualifies for COVID testing to adjusting physician staffing levels to meeting the growing pandemic. Dr. Ahuja says that one of her more difficult moments occurred when a faculty member explained that she wanted to wear a mask everywhere in the hospital, not just while treating patients. Dr. Ahuja says that the conversation illustrates the competing mandates of keeping clinicians safe while simultaneously preserving PPE supplies.
March 31, 2020
The new normal: Experts predict between 100K-200K U.S. dead
Federal experts today plan to release the statistical models they’re using to come up with stunning predictions of expected dead in the U.S.: between 100,000 and 200,000. The New York Times reports that the death toll in the U.S. today surpassed 3,100, with the U.S. having the highest number of confirmed cases in the world: more than 160,000. (With testing so sparse and delayed, many cases remain undetected.) Virus expert Anthony Fauci, MD, discussed those estimates over the weekend, saying he expects the number of cases in the U.S. to eventually be in the millions. Better news: With close to 250 million Americans in 29 states now ordered to stay at home, data on daily fever readings (a tell-tale covid symptom) around the country show a decline.
CMS waives more regulations to boost hospital capacity
The CMS yesterday announced a host of temporary waivers of regulations, all to allow hospitals to quickly ramp up capacity and expand the number of health care workers. Hospitals may now, for instance, contract with ambulatory surgery centers to provide hospital services including trauma surgeries and cancer procedures. Non-hospital buildings and spaces—including hotels and dormitories—may now be used for patient care and quarantine, and ambulances may now transport patients to a wide range of outpatient locations including urgent care centers and physician offices. As for boosting the workforce, the CMS is now allowing hospitals to hire private practice providers, and it is waiving requirements that CRNAs must be supervised by physicians. Hospitals also now have a blanket waiver to provide benefits to staff including meals, laundry service and day care.
Is using hydroxychloroquine “a rush to judgment”?
The FDA has given an emergency green-light to using the anti-malarial hydroxychloroquine to treat covid patients. While the agency acknowledged that the therapy is unproven in coronavirus, it said that deriving any benefit in treating serious covid cases risk may be worth the risk. Experts warn that use of the drug could affect heart rhythms among patients taking certain drugs or those with heart problems, and long-term use is associated with retinopathy. Researchers writing in Annals cautioned against using the drug without further investigation, writing that doing so would be “a rush to judgment” that could endanger supplies for approved uses among patients with lupus and rheumatoid arthritis.
Hospitals develop, deploy their own covid tests
Some good news: More hospitals and academic centers report that they’ve now developed the ability to test covid patients in-house, cutting down on crippling testing delays. While reagent shortages continue to threaten that capability, FierceHealthcare reports that the lab at New York’s Montefiore Medical Center is now running hundreds of tests a day, while the test developed at Baltimore’s Johns Hopkins Hospital is being used for 1,000 daily tests. The stimulus package that Congress passed last week requires insurers to cover the cost of tests developed by hospitals, and the CMS is now asking hospitals to report their daily testing data along with their daily supply needs and bed capacity. JAMA livestream contains more news on managing covid patients.
March 30, 2020
When 911 is overwhelmed
Coronavirus calls are overwhelming the 911 call system in New York City. While EMS in that city typically fields 4,000 calls a day, that number has now risen to more than 7,000. The outsized volume has left paramedics making on-the-spot decisions about who is well enough to stay in place and who needs to be taken to one of the city’s hospitals, with EMS rationing protective gear. Over the past several weeks, the nature of the calls has also changed from reporting fever or respiratory distress to cardiac arrest and organ failure. New York’s governor on Sunday reported that more than 76,000 retired health care workers have now volunteered to work in New York hospitals. And New Yorkers are taking to their balconies and open windows at 7 p.m. to cheer for health care workers and first responders.
How bad is the PPE shortage?
Pretty dire, according to survey results released by APIC. In an online survey of U.S. facilities, the infection control association learned that close to half—48%—are either already or almost out of respirators. Close to half (49%) reported they don’t have enough face shields, and nearly one-third (31%) don’t have enough masks. Even hand sanitizer is in short supply with 25% of facilities saying they are almost out. APIC called on the federal government to help alleviate those shortages, while Science News reports that “carpenters, clothing companies and local sewing circles are stepping up to help.” JAMA put out a call for creative ideas in how to conserve PPE and has received scores of responses.
CMS waives its (loathed) three-day SNF rule
The CMS this month announced that it is waiving its three-day rule for covering SNF care for Medicare beneficiaries, part of the agency’s emergency efforts to make regulations more flexible and allow hospitals to more effectively discharge patients. Inpatients who need SNF care no longer need to first be hospitalized for at least three days. Other changes: The CMS is renewing SNF coverage for some Medicare patients who have exhausted those benefits. It is also waiving its requirement that critical access hospitals can have only 25 beds and that patients’ length of stay much be limited to only 96 hours.
March 27, 2020
U.S.A.: We’re No. 1
The U.S. yesterday surpassed China as the nation with the highest number of confirmed cases. This morning’s Johns Hopkins’ stats: 85,996 cases in the U.S., 542,788 cases worldwide, 24,361 deaths worldwide. The House today may vote on the largest economic relief bill in U.S. history, one that would give hospitals $100 billion to offset the costs of treating covid patients. Early trials on the efficacy of lopinavir-ritonavir and hydroxychloroquine to treat hospitalized covid patients found neither to be effective. Research on patients hospitalized with coronavirus in Wuhan finds that 20% had cardiac injury, making those patients more likely to need noninvasive and invasive ventilation and have much higher mortality. The FDA is allowing clinicians to use alternative respiratory devices, and it has given the green-light to convalescent plasma from covid patients who have recovered as an investigational treatment for those with severe disease. Pediatric hospitals are resisting taking adult patients from other facilities, saying doing so wouldn’t be safe. Instead, they urge hospitals that treat adults and are at capacity to send all pediatric patients to children’s hospitals. An NEJM perspective outlines what the government can do to help alleviate PPE shortages. And hospitals are now debating whether to institute universal do-not-resuscitate orders for coronavirus patients, citing infection-control concerns and the shortage of PPE.
How to stretch ICU staffing
ICUs should switch to a model of tiered staffing that integrates experienced critical care clinicians with others repurposed from other hospital departments. That’s according to pandemic recommendations issued by the SCCM. The suggested model gives a physician who has critical care experience oversight over four teams, with each team managing 24 beds. Further, each team should consist of four staffing tiers. An experienced ICU APC or a reassigned non-ICU physician should be the first tier, while the second tier would consist of both experienced and reassigned physicians, APCs, respiratory therapists, CRNAs and CAAs; personnel in that second tier would concentrate on ventilation. Experienced ICU nurses would make up the third tier and reassigned non-ICU nurses would be in the fourth. To make such staffing possible, the SCCM issued the following recommendations: limit elective surgeries to free up beds, staff and ventilators; train reassigned staff; combine those who have ICU experience with those who don’t; and practice public health measures to minimize transmission. The SCCM also points out that 48% of U.S. hospitals have no intensivists on staff.
Teaching hospitals face visa moratorium
With the State Department putting a temporary halt to issuing visas, the visas of more than 4,000 foreign physicians are now up in the air. Those doctors, most of whom are waiting for J-1 visas, are slated to begin their residencies in U.S. teaching hospitals in July. Earlier this month, the state department sent out guidance to sponsors including the ECFMG to either cancel their programs or postpone their start dates. Among the more than 7,000 IMGs placed in residency programs in last week’s Match, more than 3,000 are already U.S. citizens.
Staffing strategies: All hands on deck
What types of staffing strategies do you need when more than 50% of all your admissions are coronavirus patients? That’s the situation Northwell Health, the largest system in the greater metro New York area with 15 hospitals, now finds itself in. Those hospitals are also dealing with this reality: Between 25% and 35% of those admitted patients need ICU-level care.
Joshua Case, MD, is medical director of Northwell’s hospital medicine program. In an SHM Webinar, Dr. Case discussed the tactics his hospitalist programs are using to increase provider capacity:
• Reach out to outpatient physicians. Talk to the physicians in your community, whether or not they still have hospital privileges, to have them come into the hospital and treat low-acuity patients. Be sure to devise some quick computer training as well as emergency credentialing so onboarding isn’t held up by red tape.
• Bring back the “-ists.” Hospitalists have typically taken on specialists’ admissions to allow those physicians to focus on outpatient procedures and visits. Now that those outpatient options are shut down, give back admissions with those primary diagnoses to the specialists. Pulmonologists, meanwhile, and anesthesiologists can be enlisted to run vents.
Partner any outpatient clinicians who are unfamiliar with the hospital with early-year residents or NPs/PAs. In academic settings, think about how to deploy third-year residents and fellows.
• Figure out who shouldn’t come in. Hospitalists who have been exposed may be in quarantine while they wait for test results. Others—including those who are pregnant or immunocompromised—should likewise work offsite. Have those doctors take cross coverage at night, freeing up the onsite physicians. If your hospital has telemedicine, staff those services with offsite physicians as well.
For hospitals that don’t yet have a big COVID population, some physicians who shouldn’t work with coronavirus patients may still be able to come in and treat other patients
But at Northwell’s sites, “there’s no such thing any longer as a non-COVID unit,” Dr. Case said. If coronavirus patients are still only a minority of admissions, let physicians decide who wants to staff those teams or units.
“Physicians now have a tremendous amount of anxiety,” Dr. Case said.
Instead of work clothes and white coats, clinicians are wearing scrubs. The health system is exploring how to provide onsite showers as well as scrub services so doctors can clean up before they come go and have their work clothes laundered without taking them home.
In the presentation, Dr. Case was joined by Romil Chadha, MD, interim director of the hospital medicine division at the University of Kentucky. That entire state, Dr. Chada pointed out, has only 160 COVID-positive patients, so it is weeks away from being in the same situation as the hospitals in New York.
But the academic center has made essential plans including for child care. “We need child care for between 1,500 and 2,000 children a day,” said Dr. Chadha. Local YMCAs have stepped up to provide that care, while medical students have also volunteered. All the staff—doctors as well as nurses, pharmacists and social workers—are sharing their child-care resources.
Dr. Chadha also noted the tremendous number of volunteer offers that he and his colleagues have received. He mentioned one vascular surgeon—now sidelined—who wanted to know what he could do to help, fi out the hospitalists.
“He said he hadn’t placed a vent in 10 years, but he was willing to do so,” he said. “I’ve been floored by the response.”
Dr. Case agreed. “The only answer to give people is ‘yes,’ ” he said. ” ‘I will find something for you.’ ”
What the stimulus bill could mean for hospitals
The Senate this week approved a $2 trillion economic stimulus bill that, if it becomes law, would deliver $130 billion to hospitals and community heath centers.
Hospitals would receive $100 billion to help offset the costs of treating COVID patients and to make up for lost revenue from suspended surgeries and procedures. That’s good news, given reports that hospitals—because of too low reimbursement rates—might lose an average of $2,800 per COVID patient and have to initiate layoffs within several months.
The bill also includes $16 billion for medical supplies, $11 billion to develop vaccines and diagnostic tests, $250 million to boost hospital capacity, and $275 million to expand capacity for rural hospitals. In addition, $200 million is earmarked for promoting telehealth. The House is expected to vote on the bill this week.
PPE: How to extend the use of N95s
In a new SHM Webinar, Joshua Case, MD, medical director of hospital medicine for Northwell Health in New York, discussed how health care personnel in his system—which is at the epicenter of the epidemic in this country—are extending the use of N95s appropriately and safely.
For one, hospitalists don’t need to use N95s all the time they’re in the hospital or with low-risk patients. Instead, all personnel wear surgical masks in the hospital all the time, as do all suspected or confirmed COVID patients when they’re not alone.
To extend N95 use with high-risk patients, Dr. Case said it’s OK to use the same N95 to go from patient to patient. (For added protection, personnel also put surgical masks over their N95s.) Between patients, perform hand hygiene, remove the gown and gloves you used with one patient, and don a new gown and gloves.
As for reuse, N95s can be stored in a paper bag or “breathable” plastic. How long can an individual N95 be used altogether? According to manufacturer recommendations, there is no specific time limit to N95 use, and the same mask can be used until it’s worn, dirty, damaged or tough to breathe in. In his system, Dr. Case said, they’re using N95s for up to a total of about 100 hours.
That is absolutely not the case when doing aerosolizing procedures such as intubations; in such cases, N95s must be thrown away. To limit the number of such procedures, the health system is no longer doing nebulizer treatments or BiPAP/CPAP. Obtaining a nasopharyngeal swab is not considered an aerosolizing procedure.
As for donning PPE, “use the buddy system,” said Dr. Case. “Have someone else check your equipment as you’re putting it on.” And even if patients are crashing, “always put your equipment on first. It’s like those airplane safety videos that tell you to put on your own oxygen mask before trying to help others.”
Other tips: To limit your exposure, limit your time with COVID patients and visit them only once a day. Take advantage of technology—any telehealth robots or in-room video cameras or tablets, even in-room telephones—for additional communication with patients.
As for making sure your N95 fits properly: Kiss the beards goodbye. “If you have facial hair,” said Dr. Case, “you need to shave.”
Survey finds PCP practices already reeling from COVID-19
A mid-March survey of more than 500 PCPs in 48 states finds that just over half of respondents were already saying that they face a lack of personal protective equipment (PPE); nearly half also reported that they had inadequate testing capabilities. About one-fifth (21%) of respondents reported that the pandemic was already having a “severe impact” on their groups, while 30% said the strain of the pandemic on their practice was “close to severe.” An article in FierceHealthcare says the survey found that physicians are dealing with staff illnesses and a flood of questions via the phone and e-mail. Practices are also reeling from the financial impact of cancelling face-to-face patient appointments and replacing them with lower-paying tele-visits. In related news, a survey of Chinese physicians who treated coronavirus patients found high rates of depression, anxiety, insomnia and distress.
Are these hospital hacks safe or not?
As hospital-based doctors brace for the impact of COVID-19, some have started coming up with workarounds to shortages of supplies. Baby monitors are being rigged to help keep clinicians from having to enter the rooms of infected patients in an effort to preserve personal protective equipment, for example, and physicians are looking at ways to share ventilators among more than one patient. But as an article in Medscape warns, not all hacks are necessarily safe. For a look at other hacks (and a review of the safety of at least one of them), see the article in Medscape.
March 24, 2020
Moving care from the hospital to the community
In a new NEJM perspective, Italian doctors a hospital in Bergamo—the epicenter of the outbreak in Italy where, the physicians write, they are “far beyond the tipping point”—argue that a new model of care must be devised to effectively fight the outbreak. Instead of patient-centered care that revolves around hospitals, community-centered models need to move much more treatment and surveillance out into the community.
What would such a model look like? One that relies on a comprehensive network of home care, mobile clinics, telemedicine, and the delivery of early oxygen, pulse oximeters, and nutrition to the homes of patients with only mild illness or those who are recovering.
Without those robust outpatient resources, the authors argue, hospitals such as their own—which they call “highly contaminated”—as well as medical transport and health care personnel will remain vectors of infection. “The more medicalized and centralized the society, the more widespread the virus.”
March 23, 2020
NY guv to hospitals: Expand capacity now
New York governor Andrew Cuomo this weekend outlined an aggressive emergency agenda to expand hospital capacity in his state. That state, he said in a Sunday briefing, had about 15 times more confirmed cases than any other.
While New York currently has 53,000 hospital beds, more than twice that number—110,000—are needed. To that end, he asked hospitals to devise plans to double their number of beds, and he mandated them developing plans to increase bed capacity by 50%. He also ordered suspending elective surgeries in the state as of Wednesday, discussed repurposing now-empty hotels and school dormitories to take care of patients, and said he was waiving all state regulations on licensed beds.
In the same briefing, the governor asked the Army Corps of Engineers to immediately begin building four temporary hospitals in the greater New York metropolitan area. He also asked FEMA to set up four field hospitals in Manhattan’s Jacob K. Javits Convention Center, each with a capacity of 250 beds.
As for stats on COVID-19: According to Gov. Cuomo, 13% of confirmed cases in the state have needed to be hospitalized.
And speaking of New York: CBS News on Friday reported that 1,000 retired health care workers in New York City volunteered over the course of 24 hours to come back to work.
What worked in Asia?
In a New Yorker article, Atul Gawande, MD, reports on how health care workers in some Asian countries treated COVID-19 patients while keeping themselves infection-free. The article holds out hope of preserving critically important equipment like N95s.
All health care workers in Hong Kong and Singapore wore surgical masks and gloves, practiced hand hygiene, and disinfected all surfaces between consults. Patients with tell-tale symptoms, known contact or a travel history were treated in separate clinics and wards. Doctors stayed six feet away from patients (except during exams) and from each other. N95s were used only for procedures, like intubations, that involved aerosols.
Each country also defined “close contact.” In Hong Kong, that meant spending 15 minutes at a distance of less than six feet without a surgical mask. (The definition was 30 minutes in Singapore.) When clinicians were exposed to suspected or positive patients within six feet for less than 15 minutes but more than two, they could stay on the job wearing a surgical mask and checking their temperature twice daily. Those with only brief contact monitored themselves for symptoms.
“Extraordinary precautions,” Dr. Gawande writes, “don’t seem to be required to stop it,” adding that hospital workers in those Asian countries were able to stay infection-free without strict quarantine policies.
March 20, 2020
“At war with no ammo”: tests, vents, swabs and PPE
This morning’s Johns Hopkins COVID-19 stats: 14,250 U.S. cases, 246,275 cases worldwide, 10,038 deaths worldwide. To address the shortage of doctors, the HHS this week announced that physicians will be able to practice across state lines.
Some health systems are figuring out a role for retired clinicians and medical students. While coronavirus testing is still in very short supply, some providers are suspending testing drive-thrus due to limited test supplies, including swabs, and to conserve tests for critically ill patients. Other systems have decided to preserve tests for high-risk patients and for health care workers.
To shore up hospitals’ stock of protective gear, the CMS this week recommended delaying all elective surgeries and non-essential medical and surgical procedures. Some innovative hospitals are building simpler ventilators themselves.
Car companies offered to begin manufacturing respirators, while the department of defense this week said it will release 2,000 ventilators and five million masks to federal agencies. An ED physician in Detroit demonstrates how to modify a ventilator to accommodate two to four patients at a time. A California surgeon, with only a limited supply of respirator masks in the OR, had this description: “We’re at war with no ammo.” More than 600,000 health care workers have signed onto a letter asking the government, industry, media and general population to help immediately with supplies
Different predictions: How bad will it get?
Among many models released this week predicting possible pandemic outcomes, none contained good news. One model given a great deal of credibility was issued by Britain’s Imperial College. It predicted 2.2 million deaths in the U.S. if no containment or mitigation strategies were pursued, with aggressive mitigation measures cutting that mortality in half.
A Harvard analysis looked at several scenarios, weighing different infection rates across different timelines in the U.S. to gauge where—and how soon—hospitals could run out of beds. A health care analysis company this week also released its model of projected ICU bed shortages, breaking those down by state. According to those predictions, Seattle will hit its ICU capacity at the end of this month, with New York filling its ICU beds in the first week of April. Specialty hospitals, including Cancer Treatment Centers of America, and ambulatory surgery centers are offering to accept acute and critical care patients if hospitals are overwhelmed. The New York Times has compiled a list of bed shortages around the US.
How long does COVID-19 survive in air, on surfaces?
Experimental findings released this week indicate how long the coronavirus can survive in the air and on surfaces, results that have key implications for health care workers. Aerosolized virus (droplets smaller than 5 micrometers) can stay suspended in the air for a half hour before falling onto surfaces.
Such aerosols could infect clinicians who don’t have proper protections while intubating sick patients. Aerosolized virus and droplets could also land on protective equipment and be released into the air when that equipment is being removed. (In their experiments, researchers found that virus remained viable in aerosols for three hours.)
On surfaces, the virus can live the longest on both stainless steel and plastic—for 72 hours, although the amount of viable virus decreases over that time. The virus survives only four hours on copper and up to 24 hours on cardboard.
March 20, 2020
Analysis: Young adults aren’t immune
It’s been known for months that coronavirus is particularly dangerous for elderly patients, and a new CDC analysis of COVID-19 patients in the U.S. between Feb. 12 and March 16 bears that out. But the analysis also finds that the majority of coronavirus patients hospitalized in the U.S. so far—55%—were under age 65, with 20% between the ages of 20 and 44. (Eighteen percent were ages 45–54 and 17% were ages 55–64.) As for ICU admissions, 7% were among patients 85 or older, 46% among ages 65–84 years, 36% among ages 45–64 years and 12% among adults 20–44 years. Twenty percent of the deaths in the U.S. included in the analysis were among patients age 64 or younger.
March 13, 2020
Where are the tests?
With the World Health Organization this week announcing that coronavirus is now a global pandemic, Johns Hopkins yesterday reports that there are more than 127,800 cases worldwide and more than 4,700 deaths. The number of confirmed cases in the U.S. stands at 1,323—a figure assumed to be under-reported, given crippling delays in testing and in test shortages. Testing reports this week indicate that the U.S. has administered five tests per million people vs. 3,692 per million in South Korea.
The Cleveland Clinic announced yesterday that it had started testing for coronavirus in-house, one of perhaps only a dozen institutions in the country that can do so. Other labs in the U.S. worry about supply shortages, while doctors in Italy have <a href=>received guidelines on how to ration ICU beds and ventilators. An article in Annals details how hospitals should prepare to handle rising volumes and protect health care workers.
Hospitals race to get telemedicine up and running
With coronavirus bearing down, the Wall Street Journal reports that hospitals are scrambling to build—or expand—their telemedicine capacity as a potential tool for testing and monitoring COVID-19 patients. Part of what’s driving that rush is the need to allow nonclinical staff to work offsite. In addition to rising demand for telehealth vendors and software upgrades, some hospitals—including New York’s Mount Sinai—are developing coronavirus dashboards in their EHRs so that doctors and nurses can access all patient information related to screening, labs and images in one place. The $8.3 billion coronavirus relief legislation passed last week waives longstanding Medicare restrictions on paying for telemedicine, but challenges remain.
March 6, 2020
States of emergency
With California, Maryland and Washington declaring a state of emergency, coronavirus has now caused 12 deaths with more than 200 confirmed cases in the U.S., and infections reported in 18 states. Internationally, there are nearly 100,000 cases and more than 3,300 deaths, with Johns Hopkins reporting that more than 53,600 patients have recovered from the virus. Both the House and Senate this week passed $8.3 billion in emergency coronavirus aid, with funds earmarked for state and local health departments and for telehealth services for Medicare beneficiaries, among other items.
An online survey done this week of 6,500 nurses found that only 29% reported that their hospitals had a plan to isolate potential coronavirus cases and only 44% had been given guidance on how to manage the virus. Only 30% felt their hospitals had enough protective gear for health care workers. The FDA has approved a policy allowing some labs to create and use their own coronavirus tests; the UW Medicine lab in Seattle, for instance, which covers the UW medical school and hospitals, is now processing 100 coronavirus tests a day, with the capacity to do up to 4,000 a day.
February 28, 2020
First case of community transmission
This week, the CDC reports 60 coronavirus cases in the U.S., 45 of whom were repatriated from either China or a cruise ship docked in Japan. The CDC also suspects that one patient in California may be the first case of community transmission in this country. Coronavirus has now spread to 47 countries outside China, with major outbreaks in South Korea, Italy and Iran. A CDC director this week urged Americans to prepare for a potential outbreak and noted that the CDC will send out modified versions of its faulty virus test kits to state and local governments and commercial labs.
Axios reports that the FDA is maintaining a list of about 150 drugs that might experience shortages if the outbreak worsens in China, a major supplier of raw pharmaceutical ingredients. Meanwhile, researchers are testing HIV medications against the virus as well as an experimental infusion first tested against Ebola, and Emory University plans to begin a trial on a nucleoside analog developed to treat flu. A JAMA infographic breaks down the numbers for COVID-19 and this year’s moderately severe flu season.
February 21, 2020
Panel warns hospitals to have a plan
With the disease toll in China standing at about 75,000 confirmed cases and 2,100 deaths, a new analysis finds that the novel coronavirus is more contagious than the viruses that cause MERS and SARS. Meanwhile, an expert panel at this week’s Society of Critical Care Medicine meeting warned hospitals to prepare now for a possible influx of COVID-19 patients by having a plan to identify and isolate patients as well as to collect and report data on cases.
Experts worry that in the event of an outbreak here, hospitals may run short of ECMO machines and ventilators. Analysts this week also warned that the current outbreak could disrupt the U.S. medical supply chain, which relies on products and components from China. The CDC has begun monitoring some patients with flu-like symptoms for COVID-19 in New York, Los Angeles, San Francisco, Chicago and Seattle. The CDC also released this reality check: This season, the flu has caused 250,000 hospitalizations in the U.S. and 14,000 deaths.
February 14, 2020
Cases in the United States
The CDC announced yesterday that it has confirmed the 15th coronavirus case in the U.S. That patient has been under quarantine in Texas since arriving on a flight from China earlier this month. Meanwhile, China revised up its number of coronavirus cases by 20,000 as the result of new diagnostic criteria that don’t rely on lab tests, according to the Washington Post. The new case total there is more than 63,000, with more than 1,300 deaths reported. That puts the coronavirus death toll higher than that of the 2003 SARS pandemic, although the CDC notes that the mortality rate associated with the novel coronavirus is less than that of SARS: 2% vs. 10%.
While the new virus’ mortality rate may be lower, experts believe it’s more easily transmitted. Researchers are optimistic that they may have a vaccine against the novel coronavirus by this fall. The virus has been given at least two official names: severe acute respiratory syndrome coronavirus 2 and COVID-19.
January 31, 2020
WHO declares coronavirus a global public health emergency
The World Health Organization yesterday declared that the coronavirus outbreak that originated in China is now a global emergency, with more than 8,000 cases reported worldwide. While most of those cases are in China, the virus has spread to many other countries including the U.S. The declaration escalates global response to the disease but leaves it up to individual countries to decide what protective measures to take, including whether to close their borders or screen airport passengers. As of Thursday, officials had confirmed the sixth case of coronavirus in the U.S., the first case in this country of clear human-to-human transmission.
January 24, 2020
The CDC has confirmed that a patient in Washington state is being treated for the 2019-nCoV coronavirus that broke out in China last month, making him the first patient in the U.S. with that diagnosis. The man had recently traveled to Wuhan province, the site of the outbreak in China where at least 17 deaths from the pneumonia-like disease have been reported.
While the CDC announced this week that it would begin screening passengers returning from Wuhan at several U.S. airports, Chinese authorities have since imposed travel restrictions on Wuhan and surrounding municipalities, covering about 25 million people. Cases have been detected around China as well as in Thailand, Japan, South Korea, Singapore and Vietnam, in addition to the U.S.